What drives a good handover?

What can we learn from the Ferrari Formula 1 team and the civil aviation and oil industries? How to perform better handovers, says Dr Ken Catchpole from the University of Oxford, whose research received international acclaim

Safety and quality in healthcare are rarely out of the spotlight. Seven years ago, having worked in a range of industries, I was invited to research errors in surgical care. Since then, progress has been made to understnd why patients do not always receive the most optimal treatment.

By taking a new perspective on every day work and challenges faced by clinicians, my team and I have been able to demonstrate that substantial improvements are possible. Furthermore, if we can take basic lessons and apply them across the healthcare system, fundamental improvements can be achieved in the care of patients, the cost of care delivery, and the working lives of healthcare practitioners.

The reasons why catastrophic errors, or even small ones, happen are identical wherever you find them – a number of everyday problems gather together in a limited time or space, to create situations that predispose injury or catastrophe. Though healthcare differs in many contextual and operational respects, human abilities, in an evolutionary sense, are identical.

We know that success in a motor race, an aircraft, an oil rig or a hospital isn’t just about trying harder – it’s about finding the best situation in which humans can excel. We can’t change our human nature and can only improve on specific abilities, such as surgical skill, through hard and expensive training, which may not always be successful.

However, we can more easily influence the things we do and the places we work in – it is these that we should focus on to generate the best handovers.

Why are good handovers crucial?

If we don’t get it right, our patients simply won’t get the care or attention they need

A handover is a transition of care: either between shifts, where the patients remain in the same place but the care team changes; between phases of care, where both the patient and the care team change, such as a handover between wards; or between community and hospital.

When continuity of care was the responsibility of a small team who knew each other and their patients well, transitions could be easy and ad-hoc. However, as the organisation of healthcare has changed, so have the requirements for effective handover.

If we don’t get it right, our patients simply won’t get the care or attention they need. Though this won’t always lead to disaster, a poor handover can have a significant downstream impact on the management of a patient. Patients can experience many changes in care team over a day, and successive poor handovers can lead to a “Chinese whispers” effect where information becomes continually degraded or changed. Perhaps of less importance for an individual patient, but of enormous importance to clinicians, is how a good or bad handover can make you feel.

It is extremely stressful if you’re not sure whether the information you have been given is correct and, over time and hundreds of patients, this can have an insidious effect on teams and individuals.

Researching handovers

I became involved in handover research at Great Ormond Street hospital, where our work in understanding surgical safety found that the handover of patients from surgery to intensive care was one of the weakest parts of the system. Since a handover is a transfer of responsibility, one of the most important questions we first asked was “who is responsible?”

This was not always clear, even though a handover is a transfer of responsibility. We also recognised that handovers were not consistent, either in what was done – there was a great deal of ad-hoc variation – or in the overall success of the handover. While an acceptable standard was implied by everyone, there appeared to be only a minimal level of agreement on what that was.

We recognised the complexity and detail required for a good transition of care, and the need for that to be efficient and as smooth and error-free as possible, which was made harder by time pressures, staffing, interruptions and distractions.

Identifying the problem

Videoing handovers and then viewing them can be extremely enlightening for everyone

The most important first stage was to stand back and observe handovers, asking “is this the best it can be? And if not why not?” and getting staff to identify the problems they experienced. It is surprising how we accept the everyday hiccups as part of our working lives.

Consequently, videoing handovers and then viewing them can be extremely enlightening for everyone. By getting this new perspective, we were able to focus on the inherent problems in our own work that we could change, rather than helplessly railing against the things we couldn’t.

Finding a solution

However, finding the problem is the easy part. Generating solutions that are acceptable, robust and demonstrably better than before is not an easy task, so we enlisted help from three different sources. To change and evaluate our handovers we:

• enlisted expertise from civil aviation 
• discussed complex technical and team dynamics with the racing lead at the Ferrari Formula 1 team 
• combined our knowledge of human factors with that of clinical experts.

The table below details the lessons we learned and shows how we translated their practices and applied them to healthcare.

By using the principles in the table in our own handovers from surgery to intensive care, we redesigned our process, and introduced it through the help of key clinical champions, presentations and by providing a laminated version of the protocol at each bed. We were able to demonstrate reductions in information errors, equipment problems and time taken. Perhaps most importantly – and the reason why this process has been sustained – is that it dramatically enhanced trust between care teams.

Thinking outside the box

Our work has used analogies and lessons from other high-risk industries to improve handovers by understanding the relationship between people, tasks, technology and the environment. What is perhaps most important about improving the quality of care and our own working lives is to continually examine how we deliver it. Changing an existing process is not easy, but just focusing on one or two things in your handovers might make a lot of difference to you and your patients.

Dr Catchpole has been a human factors research clinician for more than a decade. He led an internationally recognised aviation security research team, before researching errors in surgery at Great Ormond Street Hospital. He now works in the Department of Surgery in Oxford, building the QRSTU research group.