responsibilities, roles and tasks on information exchange Handover in care: influence of stakeholder s’

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Handover in care: influence of stakeholders’

responsibilities, roles and tasks on information exchange

Explorative case study, involving transitions with OR and ED, at the Pediatric Department of Isala Hospital Zwolle

Dual Degree - Master Thesis – Dissertation - 30 ECT / 60 CATS

MSc. Supply Chain Management

MSc. Technology and Operations Management

Supervisor: Co-Assessor:

Prof. Dr. Jan de Vries Dr. Adrian Small Bart Torij

S1843265 / B160697948

Word Count: 18.911

Submission: 01-03-2018, Groningen

University of Groningen, Faculty of Economics and Business Newcastle University Business School

Nettelbosje 2, 9747 AE Groningen 5 Barrack Road, Newcastle upon Tyne, NE1 4SE

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Abstract

There seems to be a lack of information on stakeholder participation in the handover processes in care, and their influence on the handover performance. Previous research found that pre-prepared handover sheets/tools combined with verbal handover maintains the best data integrity. Stakeholder opinions on information exchange during handover have been partly examined before, however the specific influence of stakeholders’ responsibilities, roles and tasks on information exchange is missing. A local non-university affiliated university will give new insights, due to limited barriers and facilitators. An exploratory single-case study research has been performed at the pediatric department of Isala Zwolle involving transitions with OR and ED. The data was mainly obtained through semi-structured interviews, observations, questionnaires and documents. Results are that responsibilities, roles and tasks at Isala are well-developed and clearly defined and executed to a fair degree. In practice, nurses repeatedly found official roles and responsibilities somewhat vague. Pediatricans may neglect standardisation and handover may be rushed. Quality of information is good, however double work is common. Pre-prepared handover sheets/tools with verbal handover does maintain the best data integrity. Handover performance is good and Isala invests in innovation. This is important, looking at fast changing environments and a digital landscape that is prone to errors. This research shows how roles, tasks and responsibilities influence information exchange in a modern era, and give hospitals, health organisations and companies investigating supply chains opportunities for verifying own role, task and responsibility structure in relation to information exchange. Finally, handover performance can be measured through evidence-based audits and deeper relations between variables are examined.

Keywords: handover in care, handoff, sign-out, transitions, medical supply chain, pediatrics, pediatric department, ED, OR, children’s hospital, Isala Zwolle, communication, stakeholder participation, involvement, information exchange, performance, roles, responsibilities, tasks.

Preface

This thesis is the final product of my MSc Technology and Operations Management at the University of Groningen and my MSc Operations and Supply Chain Management at Newcastle University. I am pleased that I got the opportunity to study abroad. It helps to acquire more knowledge, and to learn to participate in two appealing cultures.

I would like to express my profound gratitude to Prof. Dr. Jan de Vries, for his significant support during the completion period of the thesis. He gave helpful advices and was very important for finding the right structure for the thesis. In addition, I would also like to thank my co-assessor Dr. Adrian Small for his effort.

Furthermore, I would like to thank all staff of Isala at the department of pediatrics who helped with observations, interviews, questionnaires and helped me gather all required data.

Lastly, I would like to thank my family (especially my parents) and Hans van Zanten for always giving me their full support during this journey.

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IV

Handover performance is an important and complex (interaction) process as well as an important precondition for the health outcome and safety of the patient (Harvey, 2016; Smith et al., 2015). According to Penninga (2017) there seems to be a lack of information on stakeholder participation in the handover processes, and their influence on the handover performance. This paper will discuss their role and responsibility in the process - focusing on information exchange - and will attempt to fill the gap addressed in earlier literature by conducting case study research at a local and non-academic hospital. Specifically, the influence of role, task and responsibility on information exchange is missing in current literature according to Horwitz et al. (2009), Lee (2017) and Olsen et al. (2013). Explorative case study research has been conducted at the pediatric department of a hospital in the Netherlands, mainly encompassing between-unit research, focusing on transfers between the pediatric department and the operations room (OR). In addition, transitions with the emergency department (ED) have been investigated to obtain a more complete view of the chain. There is currently a paucity of literature on transitions from ED to inpatient transitions (American Academy of Pediatrics, 2016).

Over the decades, there has been conducted significant amounts of research investigating handover issues, however improving handover performance still seems relatively hard to realise (Chenoweth, Kable, & Pond, 2015; Cohen & Hilligoss, 2010; Hesselink, 2014; Manias, Gerdtz, Williams, Mcguiness, & Dooley, 2016; Olsen,Østnor, Enmarker, & Hellzén, 2013; Schoen et al., 2007). This, along with many trends such as an increased complexity and an increased necessity to collaborate between healthcare professionals within or between different organisational units (Meijboom, Schmidt-Bakx, & Westert, 2011; Minkman, Mirella; Vermeulen, Robbert; Ahaus, Kees; Huijsman, 2011; Minkman, 2016), makes it more important for investigating different elements and stages of the handover process while aiming at improving handover performance. Stakeholder relationships can be within-unit, between-unit and between organisational situations. Handover procedures vary considerably, however common components of the procedure of handover are information exchange, coordination of care and communication (Guidet et al., 2016). Since investigating the process of handover possible involves shaping and integration of processes and different chains, the process of handover of care can be seen from a supply chain perspective as a medical process chain (“medical supply chain”) as well (Croom, Romano, & Giannakis, 2000; Dobrzykowski, Saboori Deilami, Hong, & Kim, 2014; Power, 2005). Handover performance is defined as the complete timely transfer of a patient, information, and the professional responsibility (from one person or team to another person or team) (IGZ, 2015). However, a precise performance indicator is often missing, and the term is simply measured by reducing adverse events. Yu et al. (2017) tested evidence-based audits in pediatric settings to measure performance.

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2 of standardised approaches, and distribution of unnecessary information may disturb effective information exchange. It is expected that in this case study and in most hospital settings a structured approach like pre-prepared handover sheets/tools combined with verbal handover ensures the best data integrity. In many definitions of handover information exchange, responsibilities, roles and tasks turn out to be the most important and main elements (Cohen & Hilligoss, 2009; McDonald et al., 2007) of the handover definition. It is expected that well-developed, clear defined and distinctive responsibilities, roles and tasks will positively influence information exchange. Multiple assigned roles and unclear responsibilities may disturb effective handover and information exchange. Most professionals think they carry a shared responsibility, however in practice they do not (Göbel et al., 2008; Sujan & Spurgeon, 2014). Flink et al. (2012) stated that patients prefer that responsibility for the handover is clear and unambiguous. Findings by Olsen et al (2013) show that home care nurses are sometimes not able to transfer vital information to the hospital, because nobody takes the responsibility to inform them about hospitalisation, neither relatives, nor the hospital informed the nurses. Shifting more responsibility towards patients and their families will be important for closing gaps and reducing shortcomings in the system in the near future (Göbel et al., 2008). Preferences of the patient about their role vary, some patients prefer to be the key actor in charge, others prefer healthcare professionals to be in charge. Gosdin & Vaugh (2012) show that the involvement of all stakeholders is essential.

This case study research will consist of observations during handover, (semi)-structured stakeholder interviews, questionnaires, literature research, documentary research, access to information systems, and internet research. The following questions will be examined:

RS: How do different stakeholders' responsibilities, roles and tasks influence the quality of information exchange in the handover process?

SQ1: Who are the stakeholders in the handover process? SQ2: How do different stakeholders exchange information?

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(between-3 unit and within-unit in this case) at a local hospital and will include the transfer between OR and pediatrics, while also involving the emergency department. There is no within-unit handover in the pediatric department, according to the contact pediatrician. This will secure a better overall-view since all types of patients – as long as they are underage – will come to the pediatric department, having varying types of problems, while investigating transitions with two vital departments, both ED and OR. There is within-unit handover present in OR and ED.

Looking at practical relevance, understanding of factors that influence handover performance during different types of handover is limited. Responsibilities may be vague and research on information exchange at pediatrics is scarce. The hospital should get a clear view of their handover processes at the pediatric department, especially regarding the influence of stakeholders’ roles, responsibilities and tasks on information exchange. The hospital and the involving departments could take proper actions on top of that when imperfections come to surface. Similar hospital settings (especially in the Netherlands) could benefit from the results that have been obtained and could initiate similar initiatives. Lastly, governmental organisations, health organisations and companies investigating (stakeholder participation in) supply chains could benefit from this research as well.

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2. Literature review

The purpose of this literature review is to provide an overview of earlier research conducted on handover in care (especially information exchange) related to responsibilities, roles and tasks of stakeholders. To obtain a complete overview of handover, general information regarding handover will be given and different handover settings will be examined. Emphasis will be put on settings relevant to this case study, such as pediatrics, ED and OR. This literature review will start with general information on medical handover by exploring the handover landscape. Important societal and medical trends will be examined in this section. After this, general information and definitions of important terms in the handover process will be introduced, as well as information on handover communication and information exchange, leading to general recommendations for communication in the handover process given by the World Health Organisation (WHO). Communication and information exchange often overlap. Subsequently, the handover process will be reviewed from a supply chain perspective, sometimes called the “medical supply chain”. The medical supply chain could be regarded applicable when looking at the process of handover, which involves units and departments. The section ends with examples and a handover protocol for ambulance personnel and ED, including their responsibilities and patient information. Ambulance personnel and ED are often at the beginning of the medical chain, and transitions from ED to pediatrics will also be included in this research. Then, previous research conducted on stakeholders’ perspectives and participation in the handover process will be examined. This includes stakeholder opinions and roles such as physician interviews at the acute care of a children’s hospital. Lastly, the final section of the chapter is split in two: the first part examines the research questions and the conceptual model, and the second part explains the model and examines links between literature in a summary.

2.1 Handover landscape

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2.2 Information exchange & communication

As stated, handover in care involves communication and information exchange between stakeholders. Handover, also called handoff and sign-out (in-hospital handover of care), is defined as “the transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm” (TeamSTEPPS, 2006). Transfer of information, responsibility and authority is usually done from one set of caregivers to another set of caregivers (Borowitz et al., 2008). Handover is, according to the Australian Council for Safety and Quality in Health Care (2005), a complex process and it “includes communication between the change of shift, communication between care providers about patient care, handoff, records, and information tools to assist in communication between care providers about patient care”.

As seen in the figure below, handover commonly includes information exchange (the quality of information that is exchanged between healthcare professionals), coordination of care (the quality of assessment, planning, and organisation of diagnostics, treatments, and medications prescribed and provided by different healthcare professionals) and communication (the quality of exchanging information in terms of personal and direct contact, accessibility, and timeliness) (see figure 2.1). Information needs to be accurate, complete, relevant, understandable/clear, on time, and available (Guidet et al., 2016). Before handover, planning and preparation takes place, and after handover the physical transport. The figure gives insights for current research since main elements of handover are included.

Figure 2.1: Model of handover phases and components (Guidet et al., 2016)

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6 more complete exchange of critical information, while handover duration was not significantly prolonged. According to Pothier et al. (2005), reliable handover is indispensable for quality patient care and the continuity of patient care. Note-taking from verbal reports during handover resulted in significant losses of patient data. Purely verbal handovers resulted in deterioration in the integrity of data. Pre-prepared handover sheets combined with verbal handover proved to maintain extremely good data integrity however. Craig et al. (2011) investigated the effects of the implementation of a structured handover for postoperative patients in the intensive care unit of a children’s hospital. This included pre-admission cardiac reports and operating room information. Main findings were improved communication between the operating room and the intensive care, and improved staff perceptions. Pre-patient readiness, pre-handover readiness and information conveyed were significantly bettered. Observer scores such as attentiveness, organisation, information flow and number of interruptions also significantly improved, while total duration time of the handover did not significantly increase.

Communication is often related to information exchange during handover since information needs to be communicated (Joint Commission, 2007). The WHO states that handover communication between units and care teams may not include all vital information, or information may be misunderstood. To improve handover communication, thus improving overall effectiveness and performance, the WHO made the following suggestions in 2007:

- Healthcare organisations should implement a standardised approach for handing over communication between staff, change of shift and between different patient care units in the course of a patient transfer. This includes approaches such as the SBAR (Situation, Background, Assessment, and Recommendation) technique, allocation of sufficient time for communicating important information, the provision of patient information, and limiting information exchange to the extent which is necessary. - Implementation of systems which ensure – at the time of hospital discharge – that the

patient and next healthcare provider are given key information such diagnosis, treatment plans, medications, and test results.

- Incorporate training for staff on effective handover communication and continue professional development for healthcare professionals.

- Stimulate communication between organisations that are providing care to the same patient in parallel.

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2.3 A medical supply chain

A supply chain perspective may be interesting for this research, since different departments of a hospital can be seen as supply chains as well, commonly starting at ED. It is assumed that a supply chain perspective of many business organisations is also applicable to the process of handover of care and an important base for enhancing handover performance. Supply chain management has the goal of enhancing connectivity of four perspectives in the supply chain from an holistic point of view. These four perspectives include: shared technology, information and communication sharing, managing integrated chains of processes, and partnerships aimed at trust and collaboration (Power, 2005). The interface function in the medical supply chain is the handover of care, thus it is assumed that the four supply chain perspectives are, as said, also an important base for enhancing handover performance (Dobrzykowski et al., 2014; Power, 2005). In the Netherlands, the following definition is used (IGZ, 2003): “integrated care (Dutch: ‘ketenzorg’) is the total of interconnected care efforts by care providers to one patient suffering from a certain illness, which is characterised by formalised adjustment agreements between care providers”. All types of handover movements – between-unit, within-unit and between different organisational units – can be shown in different ways. Examples that are regularly used are examples involving patients arriving at ED that go through the whole medical chain, which will be also applicable for current research. An example representation of such a handover process which includes all types of handover in one model can be seen below in figure 2.2.

Figure 2.2: Model of possible handover pathway (Guidet et al., 2016)

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8 According to the American College of Emergency Physicians (2014) emergency care begins in the pre-hospital setting, continues at ED, and concludes when responsibility for the patient is transferred to another physician or the patient is discharged. To promote optimal care of emergency patients, this transfer of responsibility should be accomplished in an effective, orderly, and predictable manner. Limpahan et al. (2013) identified best practices for emergency department care transitions, which are believed to establish core expectations for communication with downstream providers. These practices include: 1. obtaining information about patients’ outpatient clinicians, 2. sending summarised clinical information to downstream clinicians, 3. executing modified medication reconciliation. 4. provision of effective education and written discharge instructions for the patient.

Aase et al. (2011) presented a joint patient handover protocol for ensuring information exchange between ambulance personnel and ED is working properly. This includes responsibilities of nurses and ambulance personnel. Results of the implementation of the protocol vary. Both ambulance personnel and ED nurses are more content with the information flow and dialogue after implementation, but there are still challenges, mainly related to the system surrounding the protocol, attitudes regarding usefulness of a formalised protocol, and to the knowledge of the protocol itself. In this thesis, patient information and ED responsibilities will be also investigated, and the protocol table below is therefore a good example of such information. The table will lead to a more complete view of the chains and will give an indication for actual responsibilities and information transfer at OR and ED during this case study.

Purpose Scope Patient information Responsibilities

1) Where does the patient Nurse: Ambulance

come from?

Meet ambulance personnel: 2) What has happened, personnel in the Ensure that nurse why is the patient coming triage area is ready to receive To ensure that All patients to the ED? Wear a red report

essential arriving with an 3) Observations and TRIAGE sign Give the report patient ambulance for measures according to according to given information handover in the A. Airways Receive protocol

from triage area or B. Breathing report at bedside

ambulance directly in the C. Circulation (if possible) Act interested and personnel is emergency room D. Defibrillation

Act interested and forthcoming transferred to

triage2 nurse/ 4) Other physical and forthcoming Ensure patient’s

responsible psychological

Active listening confidentiality

nurse for the observations?

Receive triage patient by _{5) How is the patient’s} Ensure patient’s nurse’s signature

handover in confidentiality on given report

current condition? the emergency

ward Changes? Sign for received

Information on patient’s oral report and _{handover of patient} home, relatives informed? _{responsibility} Ambulance personnel

hand over responsibility when report is given and signed by ED nurse

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2.4 Stakeholders’ perspective

When researching how stakeholder roles, tasks and responsibilities influence information exchange, perspectives of stakeholders could also give interesting insights. The stakeholders’ perspective will be investigated in this case study research as well, therefore making literature research important. Limited literature on stakeholder involvement includes Göbel et al. (2012), which did research on the challenges of the interface between hospital and the primary care setting by conducting semi-structured interviews with many stakeholders. Stakeholders were questioned about general handover information exchange and perceptions of recent patient transitions. The involved (main) stakeholders were the general practitioner, hospital-based provider, patient and nurse. Main findings were that the stakeholders commonly agreed that communication between hospital and primary care was essential, however currently lacking. Proper communication takes time and too many individuals are involved (Göbel et al., 2012). Other research by Göbel et al. (2008) in the hospital-primary care interface in 5 European countries showed that all stakeholders in the handover process agreed that there is a need for an active patient role in order to successfully and safely complete handover processes. However, both patients and health professionals were concerned about the amount of responsibility that should be transferred to the patient. Göbel et al. (2008) discovered that shifting more responsibility towards patients and their families will be important for closing gaps and reducing shortcomings in the system in the near future. In the same research, there was also a certain lack of awareness of different professional perspectives observed. Most professionals think they carry a shared responsibility, however in practice they do not. Because of multiple assigned roles and unclear responsibilities, discharge can create barriers in handover, especially for nurses. One of the conclusions of this research (Göbel et al., 2008) was that effective handover in the hospital-primary care interface is limited due to many barriers and facilitators experienced in the process such as lack of awareness of the handover process, bureaucracy, low patient respect, among others. Lastly, general practitioners are expected to play an essential role in the coordination of patient care (Göbel et al., 2008), however, many factors make it difficult for the general practitioner to fulfil this role, including lack of direct contact between professionals, lack of feedback and the involvement of multiple professionals. Gosdin & Vaugh (2012) and Quin (2009) state that improving and changing handover requires involvement of all stakeholders.

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10 Sujan & Spurgeon (2014) conducted 39 interviews with staff from two English ambulance services and three English hospitals. Interviews mainly contained front-line staff, however there was staff with (indirect) senior management responsibilities as well. Results are that there were tensions in the activity of handover and in the flow of information. Written documentation was regarded more important than verbal, however overflow of documents could make localisation harder. Also, practitioners in different chains, for instance the paramedic at the scene and the ED nurse, could have different goals and motivations. The former may document everything, while the latter may find this unnecessary. Furthermore, responsibility should be allocated implicitly, and verbal communication is too dependent on individuals. Individuals dealt with these problems by making trade-offs. They rely on their assessment of the current situation and make decisions based on their experience. Participants described patient and information flow across departmental and organisational boundaries as an important factor that can negatively affect quality and safety of handover. Issues included lack of capacity, lack of collaboration across boundaries and time pressure.

Stakeholders like the patient or the case manager are important for current research as well and will be investigated. In one study (Flink et al., 2012) patients participated in handovers by sharing and conveying information. Results were that patients are more actively involved in handovers when they feel that their involvement is needed. When they feel that their contribution is not necessary or not valued, they usually tend to be less active. Lastly, patients prefer a handover process where the responsibility is clear and unambiguous. An important stakeholder is the case manager. Case managers are first contact points for patients and guide patients through the health chain. If well-implemented, case management improves the patient’s quality of life (Huws et al., 2008). Case managers facilitate the patient’s access to many services and sources. Detailed information on case management and patient empowerment is shown below. Additionally, information on clinical pathways is given. These three factors relate here to the quality of information exchange, coordination of care and communication between healthcare professionals (Debergh, 2015).

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11 Stakeholder influence

& handover elements

2.5a Research questions & conceptual model

The above-mentioned literature from the former paragraphs of chapter two contains important aspects of the handover process and is specifically relevant to current research. This chapter will end with examining the research questions, followed by the conceptual model, hypotheses and explanation of links. Research questions are being supported by the literature research, and specific parts relevant to the questions will be examined below the questions and conceptual model. The conceptual model could be interpreted as a schematic summary of the findings of the literature research earlier given in this paper. Literature research conducted earlier in this chapter (Debergh, 2015; Göbel et al., 2008;2012; Sujan & Spurgeon, 2014) showed that stakeholder influence on handover performance mainly consisted of four variables, which are stakeholder communication, stakeholder information exchange, stakeholder involvement and stakeholder responsibility. These variables can also be derived from the (in this research) mentioned definitions of handover and care coordination and are often overlapping and are therefore (actively or latently) included in the conceptual model.

RS: How do different stakeholders' responsibilities, roles and tasks influence the quality of information exchange in the handover process?

SQ1: Who are the stakeholders in the handover process?

SQ2: How do different stakeholders exchange information?

H2 +

H1 +

Figure 2.3: Conceptual model

H1: Well-developed, clear defined and distinctive responsibilities, roles and tasks will positively influence the quality of information exchange.

H2: Pre-prepared handover sheets/tools combined with verbal handover maintains the best data integrity.

Information exchange

Communication Responsibility, role and task

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2.5b Summary: relevant links between literature and explanation of the model

According to Horwitz et al. (2009), Lee (2017) and Olsen et al. (2013), the influence of role, task and responsibility on information exchange is missing in current literature. The main research question is about how stakeholders’ responsibilities, roles and tasks influence the (ultimate) handover performance, specifically information exchange. Combining responsibilities and roles with information exchange clarifies the core elements of handover. In many definitions of handover information exchange and responsibility and roles are described as the primary elements of handover. An example definition is the element of information exchange in the broad working definition of care coordination: "Organizing care is often managed by the exchange of information among participants responsible for different aspects of care" (McDonald et al., 2007). According to Cohen & Hilligoss (2009), another definition containing these elements is: “handover, or an equivalent term 'handoff', is the exchange between health professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient”.

Multiple assigned roles and unclear responsibilities may disturb effective handover and information exchange (Göbel et al., 2008; Sujan & Spurgeon, 2014). Stakeholders agree that more responsibility should be shifted towards the family of the patient and the patient itself, and roles and responsibilities of different professionals are unclear. Patients opinions on own degree of involvement and responsibility vary largely however. Gosdin & Vaugh (2012) and Quin (2009) show that involvement of all stakeholders is needed for improving and changing handover in general. Olsen et al. (2013) shows that home care nurses are often not able to transfer important information to the hospital, because nobody takes the responsibility to inform them about hospitalisation. The hospital did not give warnings in some occasions. Unclear responsibilities refer to uncertain lines of duties among caregivers regarding the patient (Olsen et al., 2013). Lack of assignment of responsibility, roles and tasks hinders effective handover and information exchange many papers have shown, examples of these are Horwitz et al. (2009) and Olsen et al. (2013). Flink et al. (2012) stated that patients prefer that responsibility for the handover is clear and unambiguous. A joint patient handover protocol for ambulance personnel and ED nurses (table 2.1) was developed at ED of a regional Norwegian hospital. This was created to ensure essential patient information is being transferred properly between ambulance personnel and ED nurses (Aase et al., 2011) and gives an indication of roles and responsibilities influencing information exchange. These emergency situations are vulnerable activity, due to great uncertainty, time pressure and departmental overcrowding (Wong et al., 2008), and interesting for current (ED) research.

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13 umbrella organisation or a national health institution. Distinctive refers to the degree of (observed and perceived) overlap between different responsibilities, roles and tasks.

The first sub question explores the main involved stakeholders. A full list of healthcare stakeholders and corresponding perspectives can be found in appendix A (AHRQ, 2014). According to Ballard (2003) broad societal stakeholders ensuring patient’s safety consist of the society in general; patients; individual nurses; nursing educators, administrators, and researchers; physicians; governments including legislative bodies and regulators; professional associations; and accrediting agencies. As Göbel et al. (2008) stated in earlier research, stakeholders in the hospital-primary care situation are hospital physicians, hospital nurses, community nurses and GPs, patients and families. Relevant stakeholder types and categories for the handover process at the hospital have been identified after contact with the hospital was established. Front-line employees have been thoroughly explored and investigated.

The second sub question is about how stakeholders exchange information. Research (Debergh, 2015; Göbel et al., 2008;2012; Sujan & Spurgeon, 2014) underlines that differences in individual and department cultures, lack of standardised approaches, and unnecessary information may disturb effective information exchange. According to Guidet et al. (2016) information exchange in a healthcare setting refers to the quality of information that is exchanged between healthcare professionals and needs to be accurate, complete, relevant, understandable/clear, on time and available to ensure continuity of care. Looking at research conducted by Pothier et al. (2005) and Zavalkoff et al. (2011), pre-prepared handover sheets combined with verbal handover maintains the best data integrity. This will be hypothesis two.

Research conducted by Borowitz et al. (2008) in a children’s hospital at the acute ward showed that – although handover between physicians is a frequent activity – in many cases important information is not being transmitted. Analysis of these “missed opportunities” could be used for developing an educational programme for physicians how to deal with the handover process more effectively. According to Borowitz et al. (2008), handover remains an informal unstructured process, that comes with great variation and little standardisation in type and extent of information exchange between care providers. Even in microenvironments handovers of care can vary tremendously, such as in within-unit settings. Different types of settings for handover may give different results on handover performance and effectiveness. As said, the mixing up of research results of within-unit, between-unit, and between different organisational units may disturb drawing clear conclusions, something which Penninga (2017) also affirms. Therefore, handover settings involving within-unit handover (OR and ED) and between-unit (ED-ward, ward-OR) will be considered in this research.

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3. Methodology

The methodology part starts with the chosen research design, which includes the case selection terms. This is followed by the data collection, data analysis and measurements. The paragraph will end with the quality criteria. The beginning of the research design part is rather general, this will diminish in the course of the research design and methodology.

3.1 Research design

The methodology of this research consists of qualitative research, specifically case study research combined with other subtypes of research when considered desired during the execution of the research. There is a certain lack of research done on the involvement of stakeholders influencing handover performance, especially at non-university affiliated hospitals. Therefore, case study research at a local hospital could provide new interesting insights, more specifically by conducting between-unit research between the pediatric department and ED and OR. Within-unit research is present in the ladder two. Nurses have been interviewed during chain observation and pediatricians completed questionnaires.

This research consists of a single case study, which has the benefit of exploring problems in-depth (Karlsson, 2009). A health organisation like Isala hospital in Zwolle is preferred, due to its limited bureaucracy and good accessibility. Effective patient handover was largely influenced by a large variety of barriers and facilitators according to earlier research conducted by Göbel et al. (2008). In this research, large university-affiliated hospitals-primary care handover settings were investigated in five European countries. The concerned hospital could give new insights, considering the fact that it is one of the largest non-academic hospitals in the Netherlands, and plays a large role in serving medical needs in the surroundings of Zwolle. As said, the benefit of case study is that it allows people to gather a lot of (in-depth) information on a specific subject. This could be useful for a pediatric department in a hospital like Isala. Pediatrics has the advantage to not have within-unit handover, thus gives a possibility to focus solely on transitions with ED and OR. There is within-unit handover present at ED and OR, in addition. Case study is usually reliable and gives the opportunity to ask extra questions when considered desired during open interviews. Interviews were combined with observations, documentation and questionnaires: before and during chain observation, nurses have been interviewed. Additionally, pediatricians have been given a questionnaire. Another benefit of case study is that it could give the organisation the opportunity to view their own processes and generate new ideas applicable and specifically for the organisation that is being investigated. Small sample sizes are common for case study research and have also been used in this research. One problem of research on handover in care is the mixing up of research results of within-unit, between-unit, and between different organisational units (Bertrand & Wijngaard, 1986; Cohen & Hilligoss, 2010; Ebel et al., 2011; Hilligoss & Cohen, 2013; Lillrank et al., 2011). By carefully focusing on within- and between-unit research at the mentioned departments and chains the mixing up of results could be eliminated.

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15 internet and literature research. Different sources and interviewing different people could be a reliable addition obtaining an answer on questions. In this research, there has been made use of interviews with stakeholders, documentary research, literature research, access to information systems, direct observations during handover processes and questionnaires. Survey lacks observation and needs a large a number of respondents, which are not available. Survey, archival analysis, experiment and historical research are generally less suitable for this research, since the possibility of a combination of different sources is limited, as well as a structured in-depth analysis of a case.

A completed ethics form has been checked and approved by the university. At the hospital, a contract has been signed, to ensure data will not be disseminated without permission. Potential sensitive data has been communicated with stakeholders. Stakeholders have been informed about the research in advance (informed consent) and stakeholders will be treated anonymously. After thesis completion, a copy of the results will be sent to the hospital.

Limited amounts of chains have been observed and the number of nurses (interviews) and pediatricians (questionnaires) that have been questioned may be limited as well. Inspection results are good, but only a limited number of patient files can be checked. This may affect generalisability and reliability, however the variety of sources that have been used is high. This is often related to case study research; more detailed limitations are given in chapter 5.1.

3.2 Data collection

The sample consists of researching the handover process at the department of pediatrics at Isala Zwolle. The type of sampling is theoretical sampling. Current research has been examined, and a local non-academic hospital involving all stakeholders of the concerned department is likely to extend the current theory. Research could theoretically contain within-unit, between-unit and between organisational situations. This research has focused on between-unit and within-unit research, involving ED, OR, OR (treatment centre) and the pediatric department. All front-line employees (with direct patient contact) have been identified, discussing roles, tasks and responsibilities. Furthermore, every type of stakeholder has been extensively investigated as well. Stakeholders have been mainly selected on their type of stakeholder, although individual characteristics such as age, gender, and experience have been considered, additionally. Questionnaires have been given to pediatricians. Handover situations of all involved chains have been observed, and nurses have been interviewed during the observation. Lastly, documents containing directives have been examined. First, primary data has been considered: data collected by the reviewer itself. This includes semi-structured interviews with stakeholders and other people working at the hospital and questionnaires. Staff meetings have been attended to see the team interact and exchange information and life handover situations have been observed as well. Lastly, documents have been examined. Data collected by other persons have been used in addition, also called secondary data. This can include archival analysis, articles, internet research and data provided by local desks. Lastly, access to the hospital’s information systems has been established.

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16 Main targets of the questionnaires were inquired about hospital-specific aspects and experience on handover regarding the concerned chains. In addition, six nurses have been interviewed during handover chain observation. During the interviewed it became clear that this was a good choice: nurses have limited knowledge on theoretical aspects of handover (the more on practical aspects), and are therefore more fit to be interviewed during, before and after transition observations, instead of being given a questionnaire. Pediatricians, in turn, may have more theoretical knowledge, which corresponds with conditions for questionnaire targets for this case (see appendix C). Through interviewing nurses while observing transitions, it was expected to obtain the best view of handover at Isala, since observation captures the primary topic of this research, namely handover between departments, while interviews would capture unclear elements, general information and earlier experience.

One pediatrician has been contacted at the start of this research and was interviewed shortly. This was the contact person. This person has sent the questionnaires to other pediatricians. Five pediatricians have completed the questionnaire. Questionnaires were sent by email. The contact person also hosted the observation day. During observation, interviews have been conducted with nurses. The same day, access to the information system of the hospital has been made. Lastly, general questions have been asked to the main nurse and the desk assistant. Documentary and internet research has been done independently from Isala.

Data collection

method/Stakeholder

Interview

Questionnaire

Observation

Nurses

√

Pediatricians

√

Table 3.1: Main data collection methods used per stakeholder group

Papers from (mainly) the last decade have been considered and keywords such as “handover”, “handover stakeholders”, “handover hospital”, “information exchange handover care” have been entered in search engines such as Google Scholar, SmartCat and Business Source Premier. Due to the rapidly changing nature of the subject, specific information older than ten years may not be very reliable anymore, except for specific and rare information. Also, a concept paper by Penninga (2017) has been used for gathering some general information and finding gap-related information. Many recent papers have been examined.

3.3 Data analysis

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17 General information described in the first two paragraphs of chapter 4 has been obtained through internet research, and to a lesser extent through interviews. Results from note-taking during observation and interviews have been put on paper later and consistency was perfected later. Since interviews were solely based on catchwords, and were performed during observations, results have been described per chain in different paragraphs of chapter 4. After these paragraphs, a paragraph with questionnaire results has been created. Five pediatricians have completed the questionnaire. This is too small an amount for an extensive statistical analysis. During analysis, questionnaire results have been put next to each other and have been compared. Answers were categorised, and similarities were identified, which have been explained in paragraph 4.6. Questionnaire results have been subsequently compared with interview results, observation results, output from internet research and documentation. This leads to the analysis part of the thesis, consisting of answering the different links in the conceptual model. Eventually, a cause and effect scheme has been created to gain better insight in relations of the conceptual model and results, which can be found in the discussion.

3.4 Measurements

This section will include general definitions and discuss possible stakeholders that may be involved. In case study research, constructs are sometimes not predefined, however in this research important definitions are given at the end of chapter 2 and in this measurement section. To get a complete view of main terms, definitions will be given of the following variables: handover, stakeholders, responsibility, care coordination and handover (combined with information exchange and communication).

- “Stakeholders are any group or individual who can affect, or is affected by, the

achievement of a corporation’s purpose” (Freeman, 1984)

- “Handover is the transfer of information (along with authority and responsibility) during

transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm” (TeamSTEPPS, 2006).

- “Handover is a complex process and it includes communication between the change

of shift, communication between care providers about patient care, handoff, records, and information tools to assist in communication between care providers about patient care” (Australian Council for Safety and Quality in Health Care, 2005).

- "Care coordination is the deliberate organisation of patient care activities between two

or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care" (McDonald et al., 2007).

- “Handover, or an equivalent term 'handoff', is the exchange between health

professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient” (Cohen & Hilligoss, 2009).

- Communication is the quality of exchanging information in terms of personal and direct

contact, accessibility, and timeliness (Guidet et al., 2016).

- Handover performance is the complete timely transfer of a patient, information, and

professional responsibility (IGZ,2015). (A precise performance indicator is usually missing, and the term is usually simply measured by reducing adverse events)

- Stakeholder involvement is an integral part of a stepwise process of decision making:

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18 The AHRQ (Agency for Healthcare Research and Quality) has defined "stakeholders" in healthcare as persons or groups that have a vested interest in a clinical decision and the evidence that supports that decision. Stakeholders could be patients, caregivers, clinicians, researchers, advocacy groups, professional societies, businesses, policymakers, or others (AHRQ, 2014). A full list of healthcare stakeholders and corresponding perspectives can be found in appendix A. Stakeholders in the handover process could be divided into direct stakeholders and indirect stakeholders and primary, secondary and tertiary stakeholders. According to Ballard (2003) broad societal stakeholders ensuring patients safety consist of the society in general; patients; individual nurses; nursing educators, administrators, and researchers; physicians; governments including legislative bodies and regulators; professional associations; and accrediting agencies. Earlier research done in five European countries (Sweden, Poland, the Netherlands, Italy and Spain) mentioned the following stakeholders in hospital-primary care handover: hospital physicians and nurses, community nurses and GPs, patients and families (Göbel et al., 2008). Stakeholders in this hospital case study setting have been derived from a smaller scope, involving mainly more direct stakeholders. The exact list was drafted after contact with the hospital was established (for results see the conclusion).

3.5 Quality criteria

Based on the book of Karlsson (2009), quality criteria of four tests have to be met. Construct validity, internal validity, external validity and reliability have been investigated.

Regarding construct validity, data triangulation has been used, containing observations, interviews, questionnaires, documentation, internet research and access to information systems. Furthermore, peer debriefing has been used and people with broad knowhow (in the hospital) have been contacted to verify and confirm data. Different papers and sources have been considered before something has been classified as being trustworthy or correct.

There has been taken care of the internal and external validity as well. Reasoning and research styles have been adapted to current research. Different types of stakeholders have been interviewed and investigated multiple times. Analysis and comparison of similar processes repeatedly contributes to better quality. Furthermore, quality of single case study is usually higher and more specific. Laying focus on information exchange in combination with clearly distinguishing the type of handover has contributed to more detailed research results.

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4. Results

The result section will start with a brief overview of Isala hospital. This information has mainly been acquired through internet research, and interviews of desk assistants, main nurse and contact person (pediatrician). This is followed by information concerning the pediatric department and possible handover routes. Subsequently, results of the researched different chains will be given, which consist of observation and interview results from nurses. This has been supplemented and completed with internet research and documentation. After this, questionnaire results will be given, which have been gathered from pediatricians. Ultimately, the paragraph will end with the analysis of results, by describing the different links in the conceptual model. Results in the analysis section have been retrieved from interviews, observations, questionnaires, internet research and documentation. Based on this info and mentioned relations, a cause and effect scheme can be found in the discussion.

4.1 Isala

Isala is a hospital group, which has a large location in Zwolle, and a minor one in Meppel. It also has three small locations for outpatient care in Heerde, Kampen and Steenwijk. When enquiring for general information such as maps and flyers at the central desk of the hospital, the desk assistant solely refers the website of the hospital, Isala.nl. Isala was formed after a merger of the former catholic hospital “De Weezenlanden” and the protestant Sophia hospital. Both hospitals were slowly being demolished and replaced by a new larger hospital building from around 2009 at the location of the old Sophia building. The official opening of the new hospital building was in October 2013.

Besides basic care, Isala also offers top clinical care, which means it has overlap with academic hospitals, when looking at size and quality. Isala is the largest top clinical hospital of the Netherlands, according to STZ, which also makes it the largest non-academic hospital of the Netherlands. Isala participates in innovative projects, research and education as well. Educational activities are bundled in the Isala Academy. Almost all medical specialties are present at Isala. According to its website, Isala had 1116 available beds in 2016, and had 6521 employees. The location in Zwolle has fourteen clinical operation rooms.

According to the website of Isala, all staff members of Isala should communicate information through the SBAR(R) (last “R” stands for “repeat”) method when accepting information and handing over information. Aim of this communication method is preventing harm to patients as a result of (process) errors. Classroom training sessions are being offered by the Isala Academy on regular base, explaining the SBAR(R) method. According to Mannix et al. (2017) nurses agree that written guidelines, video’s and instructions could improve their use of SBAR and handover in general.

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4.2 Pediatric department

This research will be done at the pediatric department of the Isala location in Zwolle, investigating handover processes with ED and OR. The assistant of the desk at the pediatric department referred to the website for general information, like the assistant at the central desk did.

The department of pediatrics looks modern, and there are parents regularly walking through the department, from one location, to another. There are different wards, each with a number of beds. There are entertainment rooms for the children, and the hospital staff tries to offer family friendly quality. There are also facilities for parents, such as a room for parents and sleeping facilities. Parent participation is being fostered during the hospitalisation, there are special visiting hours and children can be accompanied during examinations or operations (until the holding room or just until the operation).

At pediatrics of Isala, there are regularly innovative projects to promote and equalise communication and information between pediatrician, parent and child. The children’s department of Isala recently (2016) developed a “daily planner” and was awarded a price for it. Parents and children can view important deadlines or write information on it that is important to them, such as operation dates. Pediatricians also find the daily planner a useful tool for detecting patients’ needs and wants and can theoretically also write on it themselves. Other departments and hospitals have shown interest in the idea of a daily planner.

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4.2.1 Possible handover routes involving pediatrics

The pediatric department is divided into three sections: the children’s department (hospitalisation for children for at least one night), nursery care (children’s unit for examinations, small operations and small surgery) and medium- and high care neonatology (for sick or too early born new-borns). Additionally, there is a unit for children in the treatment centre (building W) involving hospitalisation for children for a diverse range of specialties. Visualisation of a possible elementary between-unit hospital handover path for children by looking at the gathered data results in the following scheme:

GP Ambulance / Walk-in / GP GP / Specialist

Figure 4.1: Possible handover routes for a child at Isala hospital

Many path combinations of chains children can go through are possible (figure 4.1). Children come from ED or report themselves at the desk of the pediatric department, usually sent by their GP. From ED, children can be sent directly to OR, IC or the ward. In turn, children can be sent to OR or IC from the ward as well. One of the most important processes of a hospital are being performed at OR. That’s why two chains involving children and OR have been observed. In addition, to get a more complete view of the chain, transitions of ED to pediatrics have been reviewed as well. During, before and after chain observations, nurses were interviewed (six in total). The following three chains have been described in the following paragraphs, followed by questionnaire results obtained from pediatricians:

4.3 From ED to pediatrics (observation, interviews, internet and documentation) 4.4 From pediatrics to OR (observation, interviews, internet and documentation) 4.5 Treatment centre handover (observation, interviews, internet, documentation and HIE)

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4.3 Chain 1: From ED to pediatrics

Children arriving at ED could come from the general practitioner, the out-of-hours service, on their own initiative or by ambulance. Isala was the first hospital in the Netherlands that has made it possible to directly send information measured and gathered in the ambulance to the HIE, thus making it available for ED before arriving. This can give the doctors and nurses the opportunity for giving advice and preparing for the handover and next steps. Handing over and gathering and receiving information could take a lot of effort, especially when the patient is not conscious. In the past a caregiver had to hand over information at arrival, which could cost valuable time in case of emergency.

A process diagram of arrival at ED can be seen in figure 4.2. Patients will be assigned one out of five colours, depending on the degree of emergency, according to the Manchester Triage System. Children get priority when being assigned the same colour as an adult. The PEWS has been successfully tested for children arriving at ED and may be used in the future.

Arrival/ pre announcement of the patient Start systematic triage Urgency classification and registration Communication with doctor Patients back in

A Rertriage

A Patients back in

treatment room waiting room

3 Start of treatment

A: Two decision criteria 1. Condition of patient 2. Expiry of target time:

conform system or local agreements

Figure 4.2: Process diagram triage (directives triage at ED, NVSHA, 2008) Additional activities directed to the patient:

- Provision of information on urgency classification and corresponding waiting time. Verbal information is being supported with additional information data like posters in the waiting room and information maps.

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23 When not arriving by ambulance, the above-mentioned process diagram is applicable. A desk clerk will register the patient and required information will be processed in the digital system. Furthermore, the patient will be asked to fill in a form and asked to go to the waiting room. Subsequently, a nurse will bring the patient to the treatment room and ask for the form. According to a pediatrician, all nurses at ED are authorised to treat children when they arrive at ED, however their experience on nursing children may vary; ranging from a high level of experience and specialised education to little experience and no specialised education. In the treatment room, the doctor and nurse will perform an inspection and treat the patient accordingly. When there’s no doctor or treatment room available, the urgency of the emergency will be determined by the nurse through questioning and inspecting the patient, resulting in an expected waiting time ranging from zero minutes to four hours, divided in five groups. However, the policy is to help children as soon as possible. Parents are advised to inform their children why they are being admitted to hospital, and what is going to happen. Obviously, actual degree of realisation depends on the child’s age. The hospital states on its website: “Children from about the age of six have a good sense of time. Depending on your child’s reaction you can determine whether you need to provide him or her with any more information”.

Around 1 pm the pediatric department received a warning that an under-aged patient had to be hospitalised and transferred from ED to pediatrics. This was in fact a relatively elementary handover execution. When arriving at ED, the ED nurses and doctor signalled that the patient could be picked up from a room. When arrived, the pediatric nurse asked questions regarding identity and about what actually happened. Extensive attention was given to the patient and the parents. The patient explained the situation, while the parents gave some additional details (and hints). There were no ED nurses present during the actual handover moment. Subsequently, the patient was transferred to the pediatric department. During the transfer, the patient’s medical history was discussed between the parents and the nurse. When arriving at the pediatric department the patient was given general information regarding the department and information regarding expectations on waiting time and treatment. After the handover, the pediatric nurse told that all patient information is being transferred from ED to pediatrics through the HIE systems.

During earlier research (Bahous & Shadmi, 2016) at a pediatric emergency department most informative turned out to be the patient’s medical history (patients/parents), covering 73,5% of the information, followed by the HIE, covering 54,1% and the referral letter, covering 43,9%. Main sources at Isala are discussed in chapter 4.6.

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4.4 Chain 2: From the pediatric ward to the OR (and back)

The health inspection checks the processes of handover at Dutch hospitals on regular base. Most non-academic hospitals like Isala use directives of the Dutch Association for Anesthesiology / Dutch Association for Surgery (NVA/NVvH). To ensure the safety of the handover process, Isala – as well as many other Dutch non-academic hospitals – use the so called “stop moments”. This consist of seven moments, the first three can be found in appendix D (in Dutch). The last stop moment is when the patient is being discharged from hospital. Stop moments are meant to check certain moments and activities, in order to responsibly and safely continue to the next phase. The complete assessment framework for inspection can be found in appendix E (in Dutch), including the seven official stops conforming the health inspection directives. All other stages of the operative process are also included, including stages from the pre-, peri- and postoperative process. The guides with directives what works out all steps completely can be found in the references. This includes detailed descriptions of (ultimate) responsibilities, roles and tasks and all sort of details regarding prescribed medications, capturing and exchanging information, documenting, consultations, agreements and checks. Following these directives ensures a structured handover of information exchange, according to the health inspection of the Ministry of Health, Welfare and Sport in the Netherlands.

When arriving at the children’s department for handover observations, questions could be asked before the first actual handover was going to take place, while waiting in a waiting room. When questioning about the SBAR(R) method there seemed to be some confusion what it meant, at least regarding the degree to which it is implemented. According to one nurse they should use it, but the degree of (personal) implementation and knowledge varied. As usual, the patient was waiting in a bed in a ward room at the pediatric department, when the nurse arrived and the observation of the handover to OR started. One of the patient’s parents was also present. General questions such as the identity of the patient were verified and there was certain additional formal and informal verbal interaction. Verification of date of birth and name took place repeatedly, for security measures. The nurse had filled in a couple of papers. After this, the patient was transferred to the holding room at the operations room department. When arriving at the holding room, the nurses of the holding room took the papers and did the actual handover of the patient. They asked the patient some general questions such as age and name and told the patient that he could ask questions in the next stages (e.g. to nurses, the anesthesiologist, the surgeon and assistants). A checklist is regularly being checked in this process. After leaving the holding room with the nurse from the pediatric department, she told that it is officially her job to do the formal talking and questioning when performing the handover at the holding room, but the nurses of OR actually did it. According to her, this had to do with the informal relations nurses have with each other. She stated that they know each other very well, however she did not look very satisfied. Furthermore, she explained that the hospital is in the process of digitising all handover information but has not finished this yet. However, she added that when patients go from OR to the pediatric department, information is actually already being transferred digitally.

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25 Usual steps for in the pre-, peri- and postoperative sections of the operative process of the patient for hospitals using NVA/NVvH directives consist of:

No No No No Yes No No 0. Patient is being referred

1. Patient is being seen by the operator

Operation? No operation

Back to referrer

2. Preoperative screening by anesthesiologist and nurse

Stop 1: GO?

3. Patient is being planned for operation

Consult between operator and anesthesiologist

Stop 2: GO?

4. Hospitalisation and operation preparation

Stop 3: GO?

5. Patient called and arriving at the OR-complex

Invasive

preparation Stop 4a: GO?

6. Patient entering the operations room

responsibilities, roles and tasks on information exchange Handover in care: influence of stakeholder s’

Handover in care: influence of stakeholders’