Saving lives through better hospital communication

Poor communication between staff and departments in hospitals can put patient’s lives at risk, even lead to death. The HANDOVER Research Consortium is an EU-funded project looking at ways to improve patient care during time of transition as well as reducing avoidable and unnecessary treatment. We talk to the project’s principal investigator Paul Barach and other project partners about this important work that is saving lives.

A healthy, 15-year-old boy with a mild chest deformity is taken to hospital one weekend for a routine elective operation. Staffing is low at the teaching hospital and there are a few communication problems among the hospital hierarchy. Physicians in training are reluctant to call their supervisors during the weekend. A few hours later, the boy is dead.

Such incidences are supposedly rare – this one happened in the US - but it is surprising how many of us can report cases of inconvenience, pain, suffering and even death as a result of poor communication between health professionals when a patient is referred to hospital or discharged from it. And as hospitalisations become ever shorter and transitions between hospital and community become more frequent, there are bigger risks - not only to high-risk patients but to all patients, young and old.

An international project called HANDOVER is working to improve how people deliver clinical care during these transitions, to reduce unnecessary and avoidable treatment, medical errors and loss of life. The project aims to identify and study best practices and help to create standard approaches to handover communication, all this while measuring the effectiveness of these practices in terms of cost and the impact on patients.

The work done by the European HANDOVER Research Consortium project (HANDOVER), not only in pointing out where things go wrong but in putting a thorough case as to how they can be put right, won it a $5 million, three-year grant from the EU. The project, the highest scored grant in its class, which began three years ago in October 2008, has been carried out in six countries over five years: the UK, Holland, Spain, Italy, Poland and Sweden. Significantly, the project focuses on the role of patients and their empowerment, and is the first time that the EU has funded a project on co-ordination and transitions of care.

Paul Barach, the principal investigator of HANDOVER is a practicing anesthesiologist and intensive care specialist and a health service researcher trained at the Massachusetts General Hospital, affiliated with Harvard Medical School. “Poor handovers not only cause harm to patients, but also undermine patient trust, cause administrative overwork and cost a great deal of money,” he says. “When a patient’s transition from the hospital to home is less than optimal, the repercussions can be far-reaching – hospital readmission, adverse medical events, and even mortality.”

“Up to 20 per cent of adverse results can be caused by ineffective patient handovers– it is a huge medical problem, and a huge political one,” says Barach – political because those in charge of health authorities have been reluctant to prioritise this as a serious problem and have not allocated the resources to solve the issues.

“It is a process that is so porous and not resistant or reliable,” he says. “The impact of organisational culture on the quality and safety of hospital discharge is fairly unknown. Failures in communication are the most common cause of errors in handovers – a typical scenario involves a sealed note about a patient from a hospital doctor to a GP. “The patient is often unaware of what she is supposed to do and feels helpless, almost like a child given a note from a teacher,” Barach says. “It is important to be honest and transparent with patients. It comes down to the fundamental issue of respect and trust.”

Barach is visiting Professor and Senior Research Fellow at the University of Utrecht in Holland. It was his idea to apply for European funding for a project to study handovers between primary care doctors and hospitals. He reports to Professor Cor Kalkman, an anaesthesiologist at the university’s medical centre, who heads the patient safety centre there and who has seen poor patient care due to ineffective handovers first hand.

“Both from personal experience as a doctor and as the son of parents who have received much hospital care and GP care recently, I have witnessed many avoidable, sometimes very serious, adverse events during patient handovers” says Kalkman. “My 89-year-old father received a drug to treat hiccups while in hospital. That drug was continued after discharge (and long after the hiccups were gone) in a very high dose and caused symptoms akin to Parkinson’s that completely invalidated him. It was only after ‘pushing’ from my end and demanding to know why he received that drug in such high doses that it was discontinued. The symptoms of Parkinsonism disappeared in less than a week. “The chilling fact is that nobody – neither in the hospital nor in the GP practice - could remember why my father was receiving the drug, but still the GP did not dare to discontinue it, because ‘the hospital had prescribed it’. It is our responsibility to try to reduce the number of potentially avoidable adverse events. The EU programme led to a project we have initiated within this hospital in which we use video cameras to support ‘reflexive’ feedback to create awareness among the doctors of the handover problems and to elicit ideas for improvement from frontline healthcare workers. This technique results in very rapid improvement in handovers, engagement and maximum staff buy-in.”

Also key to the HANDOVER project has been Loes Pijnenborg, a GP who was until recently project manager and is now a senior advisor on quality and safety of care at the Utrecht UMC. She has much experience in writing guidelines for GPs and was programme director of a nationwide programme to improve patient safety and logistics in hospitals in Holland. She says: “After 12 years of working in general practice, and seven years of working with hospitals to improve their care, I know that many organisations and many professionals could do better, and also mostly try to do better. But even if they are doing well, they still can improve.

The HANDOVER programme has five main aims:

• To identify the patterns in hospital discharge and referrals, factors that make patient handovers safe, and those that stand in their way.


• To identify how variations in handover processes lead to “near misses” and adverse outcomes.


• To explore the roles and responsibilities of healthcare providers, patients and their carers.


• To examine the costs and benefits of optimal handover training.


• To develop educational tools to improve patient handovers.

There have been noteworthy attempts in the past decade to address the problem. In 2006 the joint commission set as national patient safety goal: a standardised approach to health communications and the provision of opportunity for staff to ask and respond to questions about a patient’s care.

Another global call for improved handover came two years later when a commission on safety and quality of healthcare in Australia said that teaching programmes should provide proper training on how to hand over patients using effective communications.

HANDOVER project has found the following issues that healthcare professionals and policy makers should take into account in their care of patients:

1. Handovers are highly variable across the EU and remain a time that leaves patients vulnerable.


2. This is mostly still unrecognised as a gap in care; there is little standardisation across disciplines and healthcare organisations in the ways in which handovers are performed, supervised and evaluated;


3. Improving patient handovers should focus on the clinical microsystem rather than the individual, because it directs attention to the processes and outcomes of care without any blaming or shaming of any individuals involved.


4. Interventions are needed that directly address organisational culture as a key factor in enabling or undermining efforts to improve hospital patient discharge. For instance, there can be friction and mistrust between hospital doctors and those in the community; junior hospital staff or those new to the system may lack knowledge and the confidence to question their superiors; immigrants may be self-conscious about their command of the language and reluctant to ask questions.


5. Information tools should be developed and deployed to make information readily accessible, user friendly and transparent.


6. Human factors in thinking and design need to be taken into account and applied to clinical as well as the physical design – for instance, says Barach, handovers can be carried out in designated, quiet rooms rather than in corridors, where clinical teams are distracted by people passing by.


7. To reduce readmissions, hospital staff members need to spend more time with patients. This begins long before each patient is ready to leave the hospital. Staff need to make follow-up phone calls and arrange for home visits. Closing the communication loop prior to the patient being discharged will help reduce significantly patient readmissions.


8. Handover best practices are not being taught to doctors and nurses systematically. For instance, feedback on handover performance is needed about individual handover competencies. By setting performance expectations, inexperienced providers could be coupled with experienced ones so that the latter can demonstrate proper storytelling and methods, or videotaped simulated handovers could be used in training. As


9. Barach puts it, “Capturing the wisdom of an eight-hour shift is more complex than one might assume and difficult to do in a few moments.”


10. Clinical handovers must be designed around the patients. Patients and their families, must be engaged and empowered to speak up to help make patient handovers safer and more respectful of the patient’s needs.


11. When something does go wrong, clinicians should have clear ethical obligations to tell the patient and their families the truth about what has happened to the patient in a sensitive, informative and clear way, Barach points out. “Growing evidence shows that the benefits of disclosure of harm to patients outweighs the burdens, and that effective disclosure can rebuild patient trust and improve patient safety and care as well as reduce costs.”

One of the key strengths of the project is that it is multi-national and includes multiple stakeholders including patients. Kalkman says: “The main achievement of this project is a pan-European awareness that the handover problem exists in all European counties, despite large differences in the way hospital care and primary care is organised and funded. It will lead to new areas of research that should focus on culture and how work is carried out (i.e. physically meeting each other and discussing these issues face to face might already overcome some of the more persistent mutual stereotypes).”

He adds that the project has shown that a good use of “shared” ICT platforms can help to improve timely information of patient critical information. “It is my impression that Sweden is the leading country in this respect. ICT integration between hospitals and GPs alone could be the topic of a separate new European project. We found that the patient was very often used as the sole messenger between the hospital and the GP after discharge in many other countries. This is a vulnerable solution for post discharge communication.” In Sweden the principal co-ordinator is Dr Gunnar Ohlen, head of the department of emergency medicine at Karolinska University in Stockholm. “Every day we encounter medical risks due to poor information transfer within the medical care network,” he says. “This is especially apparent in the field of medication, in which we have shown that 20 per cent of the hospital’s acute care patients above the age of 65 are admitted due to adverse drug reactions. The population in Sweden is getting older, he says, but his attitude is pragmatic: “We can do more and more with the resources we have, but resources are getting scarcer so everything we can do to make the right things happen from the start will save resources for other patients.”

Professor Rosa Sunol, Spanish Coordinator, and Director of the Spanish Avedis Donabedian Research Institute, eloquently summarized the project’s impact by saying, “We have learnt the weakness of the process between primary and specialized care, and what kind of different factors may be involved as “root causes” for adverse events.”

As to the future, people involved in the project are adamant that a lot of work needs to be done and there is an urgent need for more funding across the EU to support evaluation of the tools and solutions developed by HANDOVER. Pijnenborg says: “Nowadays lots of improvements are being made within primary care [general practice] or within secondary care [hospitals]. But the handover care between primary and secondary care is still a mostly neglected area. So much more attention and research into this field is needed. This project has developed a new framework and tools to improve handover between primary and secondary care.”

Gijs Hesselink, PhD student from the Radboud University Medical Center in Nijmegen, Holland, one of 3 PhD’s supported by the project, was involved in HANDOVER’s large qualitative study of over 200 individuals, including patients, and in conducting focus group interviews in five EU countries. “Our focus was to study the impact of organisational culture on the quality and safety of handovers, in particular at hospital discharge,” he says.

The group’s findings were new, and show how much work needs to be done. “Many healthcare providers, especially within the hospital, demonstrate a strong focus on self, professional ‘here and now’ work and give less priority to ensuring proper patient follow-up,” says Hesselink. “Also, there is scepticism towards the value of feedback and integrating new practices, and handover practice is often ruled by informal habits. Consequently, community care providers are often not sufficiently informed about patient problems and outcomes, and handover problems often remain unspoken, with opportunities for improvement missed.”

Julie Johnson, a lead expert in systems improvement in charge of ensuring the study methods were applied in same way, has also played a key role in the programme. “The EU project is very ambitious because of the multiple sites, multiple languages, and diverse clinical focuses, --- understanding the process of handover through process mapping, individual interviews and focus group interviews with key stakeholders, and artifact analysis is a landmark opportunity.”

It does not help to demonise the people involved in patient care. Johnson says: “Our healthcare system(s), regardless of the country we are talking about, are full of hard-working, dedicated professionals who do their very best to provide patient care in systems that are flawed. Ultimately, the focus on this grant has to be how we can improve systems of care to make it easier for our healthcare providers to do their work and provide excellent care.”

Barbara Kutryba, President of the European Society of Quality in Healthcare, and the Polish Coordinator, stressed that this is the first time the topic has been studied so thoroughly internationally in Europe: “All countries can and will learn from the outcomes of this project. We will roll out our final results at the final meeting in Florence, which will be visited by key stakeholders (patient representatives, professionals, managers, board of directors, politicians, EU delegates, researchers) from over 20 countries.”

Sunol talks about the lasting impact of the project: “The project will offer the EU the opportunity to learn about how to improve communication processes and how to develop effective handovers in health care organisations across the EU and bring the opportunity of learning from others’ experiences.”

Barach concludes: “Continuity of care is essential in ensuring safe and high-quality care transitions across Europe. It is our ethical duty to make this a priority. Patients and their families deserve better.”

Good transitions, says Barach, are the HANDOVER programme’s ultimate goal: “If you look at what our patients really want from us, they don’t want to be here at the hospital. “They want to be at home safely and with their loved ones.”

Click here to access the project website.

Published: Thursday, 8th December 2011