Clinical Handover – How the Role of Allocation of Responsibilities contributes to desired outcome?

Clinical Handover – How the Role of Allocation

of Responsibilities contributes to desired

outcome?

Master thesis, MSc Supply Chain Management

University of Groningen, Faculty of Economics and Business

Eduard Kohout

S3142272

Supervisor: Prof. dr. J. de Vries

Co-assessor: dr. S.A. Carolien de Blok

Word count: 11 181

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Acknowledgements

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Content

Abstract ... 4

1. Introduction ... 5

2. Theoretical Background ... 7

2.1. Clinical Handover Process ... 7

2.2. Types of Information Transmission in Clinical Handover Process ... 8

2.3. Allocation of Responsibilities and Supporting Role of Allocation of Authority in Clinical Handover ... 8

2.4. Electronic Records ... 9

2.5. Quality of Information ... 10

2.6. Conceptual Model ... 11

3. Methodology ... 13

3.1. Introduction of the Focal Hospital ... 13

3.2. Data Collection ... 14 3.3. Data Analysis ... 15 4. Findings ... 18 4.1. Allocation of Responsibilities ... 18 4.2. Usage of ICT ... 20 4.3. Exchange of Data ... 22 4.4. Quality of information ... 24 5. Discussion ... 26 6. Conclusion ... 29

6.1. Limitations of the Research and Further Research ... 30

6.2. Managerial Implication ... 31

References: ... 32

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List of figures

Figure 1 Data quality, RICHARD Y. WANG AND DIANE M. STRONG 1995 (p. 17) ... 11

Figure 2 : Dimension definition, Batini, C., & Scannapieco, M. 2016 (p. 40) ... 11

Figure 3: Conceptual model ... 12

Figure 4: Rich picture ... 29

List of tables

Table 2: Coding tree ... 17

Table 3: Specification of responsibility presented in internal rules ... 19

Table 4: Estimated time spending on non-core activity ... 21

Table 5: Characteristics of ICT system ... 22

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Abstract

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1. Introduction

Communication, as defined by The Merriam-Webster dictionary, is a process where information is exchanged between two entities. Clinical communication plays a key role in patient safety and care continuity since the communication provides information for patient treatment (Johnson, 2015). Clinical communication, as divided by The Australian Commission on Safety and Quality in Healthcare, consists of the clinical handover process and the communication between patients and doctors (Lyhne, 2012). The clinical handover process aims to improve handover communication across hospital settings, as it is not just a mere transfer of information, but also focuses on a transfer of responsibility (Pezzolessi, 2010). The importance of the clinical handover for patient safety and quality of care can be illustrated on the case of an elderly Aboriginal man in Australia who died due to poor communication between the hospital and the community health centre (Jorm et al., 2009). Two-thirds of sentinel events in Australia, involving death or serious physical or psychological injury, are caused by defects in communication in the handover process (Johnson, 2015). As a result, a further investigation on the topic of clinical handover should be made.

6 However, the effect of allocation of responsibilities as determinant in the process has been overlooked in the literature, since researchers are more focused on a particular part of the process. Furthermore, when the setting of process is inefficient, the steps in process cannot be balanced (La Rosa, 2016). As a result the desired outcome cannot be achieved, which remains a main unresolved issue in relationship between the allocation of responsibilities and exchange of data (Chin, 2012). Additionally, inter department data exchange is still prone to errors because the conditions in each department might be different, which exposes the data exchange to a possibility of errors (Bost, 2010). As a result, the aim of this master thesis is focused on the role of allocation of responsibilities and its impact on data exchange between two wards via electronic records. Electronic records present the new manner of communication implemented in the hospital which is related to the trend of computerization of hospital facilities (Benham-Hutchins, 2010). The increasing importance of electronic records over written form requires new capabilities of the employees (Klim, 2013) and brings along new challenges in terms of standardization of the electronic protocol (Habicht, 2015). The objective of the master thesis does not include the exchange of data under emergency conditions (cases like multi-vehicle collision are managed by completely different procedures) but under normal circumstances. As a result of the above, the following research question arose:

RQ: In what way does allocation of responsibilities influence the outcome of clinical handover process in terms of data quality when the patient is transferred from one ward to another using electronic records?

This will be investigated by means of an explorative single case study among doctors and nurses who participate in the process. Semi structured interview is used to gather the data. Findings will be discussed and recommendations will be given. Thus supposed contribution to the theory clarifies in what way has allocation of responsibilities impact on the information quality within the clinical handover process and also contributes to the knowledge in terms of potential barriers. The results derived from this study will also be very useful for hospitals that are trying to improve their own clinical handover process, since it shows some important insights on the process in terms of factors that have an impact on desired outcome of the clinical handover process.

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2. Theoretical Background

2.1. Clinical Handover Process

Firstly, clinical handover is defined (Manser, 2011, Lyhne, 2012, Liu, 2012) as a routine process, where information is transmitted among staff in hospital in order to deliver high quality care to patients. However the following definition provided by Pezzolessi (2010) is the most suitable for the purpose of the study and defines the clinical handover as: “the critical component of health-care quality and safety. During their journey throughout the hospital, patients are exposed to several transfers across different areas of diagnosis and levels of care. At each stage of the process, information about their health needs to be communicated among hospital staff at shift changes and within shifts. When patient information is transferred, clinical handover occurs. Achieving high-quality clinical handover requires an understanding of its core elements, which go beyond the simple transfer of information and involve effective communication and a clear transfer of responsibility” (p. 1). Meaning of the definition reflects the focus of the thesis in terms of steps that must be taken in order to deliver accurate information about patient state. First of all, forms of information transmission and types of information transmission in clinical handover process are presented. Then, the particular parts of the handover process are discussed. It should be stated that for this paper, the terms communication, information transmission and exchange of data are used interchangeably.

Forms of Information Transmission in Clinical Handover Process

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2.2. Types of Information Transmission in Clinical Handover Process

Information transmission about patient state occurs in situations that when one provider of care physically leaves the hospital or when the patient is transferred to other locations (Scott et al., 2012). Situations when a provider of care physically leaves are represented by the exchange of information between work shifts (nurse to nurse, nurse to doctor, doctor to nurse and doctor to doctor) (Smeulers et al., 2014). Information transmission occurring during patient transfer consists of two types, either between two wards or between two hospitals. Information transmission between two hospitals occurs due to potential insufficiency of capacity or equipment or specialized ward to provide proper treatment to the patient (Lyhne et al., 2012). Transfer of information between two wards represents a challenge in spite of routine in process (Broekhuis, 2007). Different culture in each ward and the distance between the wards represent the factors that negatively influence the process. Furthermore, distance between the wards decreases the possibility of using face-to-face communication in case of unclear information about the patient’s state as it is possible during the shift handover (Manias et al., 2016).

2.3. Allocation of Responsibilities and Supporting Role of Allocation of Authority in

Clinical Handover

Allocation of responsibility as a determinant of the setup of the clinical handover process (Lee, 2016), is the first step that needs to be clarified in order to achieve the desired outcome of the clinical handover process (accurate information about patient state). Responsibility is in hospital settings defined as being responsible for patient safety and the responsibilities are slightly different for doctors and nurses (Ramassubu et al, 2016). Doctor’s responsibility for patient safety consists of a few partial responsibilities. The first responsibility is taking care of the patient health so the doctor has to make his/her best effort to come up with the right diagnosis and propose the proper treatment. The second responsibility is his/her obligation to inform patient about his/her state and about potential risks related to the treatment. The third responsibility is to update the information about patient state to the system and inform the other doctors about patient state during the handover process. The last responsibility is to take care of the needs of patient e.g. mitigate the pain (Siemsen et al, 2012). Nurse’s responsibilities consist of few partial responsibilities as well. Firstly, taking care about the patients’ needs in terms of medication, nutrition etc. Secondly follow the instruction from the doctors. Thirdly communicate the information about patient to a nurse who is next in a row (Klim, 2013).

9 process but it depends on the quality of settings (Rosa, 2016). If the clinician enters the handover process and it is not clear who is responsible for the transmission of information, it leads to confusion and it might menace the quality of care and the safety of the patient (Lee et al, 2016). Furthermore, information transmission is prone to mistakes and so the proper setting is important to minimize the risk of other factors affecting the information transmission (Ramassubu et al, 2016). Despite the amount of definitions of clinical handover, when transfer of responsibility occurs is still an issue among clinicians (Chin et al., 2012) and “the majority of healthcare organisations do not yet possess explicit structures as to whose responsibility it is, within care teams, to bring patient information to handover” (Jeffcot et all, 2009 p. 4). Some believe that responsibility is supposed to be transferred when information transmission occurs, some say that responsibility is supposed to be transferred when the acknowledgment about receiving the information from the on-coming doctor is provided (Lee et al, 2016).

The transfer of responsibility is partly affected by the allocation of authorities. Allocation of authorities at the ward is the power of employees to give orders to others on how to do the task. The impact of the allocation of authorities on allocation of responsibilities can be positive either negative (Patterson and Wears, 2010). Positive impact is related to the situation, when the allocation of authority enables to force the hospital staff follow the rules. Allocation of authorities determines the role of physicians and ensures an unambiguous transfer of responsibility (Philibert, 2009). At present, there are only a few protocols (in the USA) on how the allocation of authority in a health-care setting is determined in order to clarify an individual’s responsibility (Patterson and Wears, 2010).

2.4. Electronic Records

10 The first step in providing high information quality through electronic records is determined by the standardization of the protocol, in other words a template must be created (Habicht et al., 2015) in which the basic terms are defined (Scott, 2012). The protocol specifies which information should be included and in what order (Manser, 2011). A few concepts of protocol were proposed by the literature, Thompson (2011) in his article mentions a framework called ISBAR (identification, situation, background, assessment, recommendation) created by Canterbury District Health Board, used for reporting about changes in a patient’s status, or in the article by Porteus (2009) another framework called iSoBAR (identify, situation, observation background, agreed plan, read back) was established. Another type of framework is called SHARED (situation, history, assessment, risk, expectation, documentation). This framework is proposed and specially adjusted for maternity care (Hatten-Mastersson, 2009). The advantage of standardized protocols is in identical lay-out of the reports, so when the doctor or the nurse starts reading the protocol they will be able to orientate themselves in the protocol quickly and the quality of care will not the jeopardized (Stead, 2005). Standardization of the protocol makes finding information easier (Boucheix, 2008), safety of patient is improved through the standardized protocol (Matic, 2011) or as is stated in Fealy (2016) standardized protocols improve the clinical handover. Derived from the statements, standardization of protocol facilitates the data exchange.

However, standardization of protocol is not a sufficient approach because some problems still might appear. It mainly depends on the quality of protocol so there is too much or too little information in the electronic system (Manser, 2011) or language used in the electronic records is not understandable so it is not clear what is meant by it (Boucheix, 2008). Similarly, inflexibility affects information transmission. Inflexibility means that the form offered by the software is strict and there is no place to type additional information that does not belong to any category determined by the settings (Ash et al., 2004). Finally, the quality of training for using the IT system is very important as well (Klim, 2013). Factors that are related to the usage of electronic records and have negative impact are regarded as barriers (Jorm, 2009).

2.5. Quality of Information

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Figure 1 Data quality, RICHARD Y. WANG AND DIANE M. STRONG 1995 (p. 17)

The description of each category is provided in Figure 2. Observing when the concrete dimension has not been achieved, will be the trigger used to discover what factors are responsible for inaccurate and incomplete information.

Figure 2 : Dimension definition, Batini, C., & Scannapieco, M. 2016 (p. 40)

2.6. Conceptual Model

12 follows (Lee, 2016, La Rosa, 2016). Building on this, the question arises in exactly what way the allocation influences the other construct and if it is sufficient prerequisite in order to achieve desired outcome of the clinical handover process. In order to investigate the influence of allocation of responsibilities, the conceptual model was depicted to illustrate the relations, as presented in figure 3.

Figure 3: Conceptual model

13 medical state of the patient. Data quality which is crucial in order to provide the best care for the patient (Pirk, 2016).

3. Methodology

The aim of this master thesis was to investigate the impact of allocation of responsibilities on the exchange of data between two wards in terms of data quality. This has been done by executing an explorative case study since the method of case study is the most appropriate to explore the phenomenon in depth (Voss, 2002 in Karlsson, 2016). In addition, the clinical handover process is a complex process, that needs to be studied in its natural settings and that leads to a better understanding of how its mechanisms work (Voss, 2016). Single case study was performed due to the time limits and the scope of the research. Due to the short time that was available for conducting the research, a more thorough understanding of a single case is preferred over a multiple-case study. The unit of analysis of the study is the process of clinical handover within the focal hospital. Finally, according to Bost (2010) most of the studies on clinical handover process were conducted in the Western world so that was the trigger to conduct the study in the Czech Republic.

3.1. Introduction of the Focal Hospital

14 document focuses on physical symptoms like temperature, intensity of pain, etc. From these three documents, the medication chart is derived. This record determines which medicaments the patient is supposed to get. The last is the release report. This report summarizes with which disease the patient came and what the previous treatment was. This report is created when the patients leaves the ward and they are transferred to another ward or hospital or they are just released to go home. Doctors have access into the system for all the patients that have ever been hospitalized in the hospital. Nurses on the other hand have access into the system just for the patients who lie in their own respective ward.

3.2. Data Collection

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Doctor Nurse

Ward Unit of intensive

care

Standardized ward Unit of intensive care

Standardized ward

Interviewee position 1 2 3 4 5 6 7 8 1 2 3 4 5 6

Total recorded time 32 35 37 30 41 28 34 31 25 34 27 39 31 33 Table 1: Interview Table

In addition, two informal interviews took place with 2 other doctors, who work in different hospitals in different departments (oncology and neurology department) about the same topic in order to increase the possibility to generalize the results (Yin, 2009).

For the interviews, an interview protocol was used (see appendix A) in order to increase the reliability of the data. The interview protocol is divided into four parts, each part containing questions concerning each construct of the conceptual model (see figure 3). Case study protocol increases the possibility that the study can be repeated somewhere else (Voss, 2002 in Karlsson, 2016). Before the interview, a brief introduction of the topic of the master thesis was presented. The reason for that was to inform the respondent about the project. The interview consisted of semi-structured questions. The advantage of semi-semi-structured interview lies in the opportunity to ask additional questions and request explanation if necessary (Yin, 2009). This leads to a deeper understanding of the impact of the allocation of responsibilities on exchange of data, which fits the explorative character of the study. Interviews took place in the office of the doctors/nurses. Each interview was recorded and transcribed into the Czech language later that day. Transcripts with the answers were sent to the interviewees for final approval in order to improve the construct validity of the study (Voss, 2002 in Karlsson, 2016). By conducting the interview in Czech, rich data collection was enabled, as it created the possibility for the participants to provide detailed answers to the questions, as they are native Czechs. The data were carefully translated into English before using them for final analysis and final report.

3.3. Data Analysis

16 and the notes about the structure of printed documents. The existence of proper documentation of observations allows establishing a chain of evidence (Voss, 2002 in Karlsson, 2016).

The interviews were analysed by following the three steps suggested by Miles and Huberman (Karlsson, 2016), data reduction, data display and conclusion. Reducing the data was done during the documentation phase, by means of transcribing the interview in terms of quotes that are relevant for this study. Then, those reduced data (quotes) were coded. This coding tree is based on the conceptual model visualized in Figure 3. The reduced data (quotes) were divided into categories and subcategories (Miles and Huberman, 1994 in Karlsson, 2016). Definitions that were used for creating categories and subcategories are depicted in Table 1 and are deductively derived from the concepts presented in the theoretical background. However, some new concepts were inductively derived from the interviews because these new concepts were recognized in the interview as influential factors on the data quality e.g. the role of the accreditation process.

Category Sub-category Explanation

Allocation of responsibilities Responsibility The duty to upload/write down the information to the system. Role of internal rules The role of internal rules for the process of allocation of responsibilities as well as for the usage of ICT system. Allocation of authorities Hierarchy at the ward and the

power of the staff.

Usage of ICT Parameters of the system The details about the ICT system e.g. user friendliness

Advantages Compassion with oral

communication.

Barriers Barriers that are main problem

in relation to using ICT system as a form of communication. Protocol quality The perception of the quality

of protocol.

Exchange of data Handover between shifts Steps that need to be taken during the shifts.

17 Process steps The conditions that need to be

met to transfer the data.

Data quality Dimensions Dimensions of the data quality

that are important for the doctors and nurses.

Role of the data for treatment The importance of data for treatment and the perception of the right information. New category Accreditation process Process that is determines if

the ward gets the accreditation to provide the treatment. Difficult/simple illness Differentiation between

difficult and simple diagnosis.

Table 2: Coding tree

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4. Findings

In this chapter, the findings of the study will be presented. Since the aim of the study is to explore in what way the allocation of responsibility influences outcome of the clinical handover process in terms of data quality, an in-depth observation of the process was performed. In general, it was observed that allocation of responsibilities has positive effect on usage of electronic records as well as on exchange of the data because it provides clear setting. Unfortunately, despite the effective setting set by allocation of responsibilities, the desired quality of information about patient state has not been achieved due to the factors that influence the clinical handover process. Human factor or accreditation process were identified as factors that hinder the desired outcome. Structure of the findings is divided into groups reflecting the conceptual model (see figure 3) and due to the complexity of the issue, detailed impact of each variable is further elaborated in the following paragraphs. Doctors, nurses and management are taken as stakeholders of the clinical handover process. Patients are not considered stakeholders because of their incapability of recognizing the appropriateness of the treatment due to misjudgements of the doctor or insufficient amount of information.

4.1. Allocation of Responsibilities

First of all, allocation of responsibilities is immediately recognizable when the patients enter the hospital because each patient is assigned to one particular doctor and one particular nurse. The doctor is chosen based on the type of injury/disease. Before the patient enters the hospital, the allocation of responsibilities is already framed by internal written rules. As stated by the quality care manager ’’Official framework (settings) of how things will be done before they actually happen, is the key factor in the clinical handover process“. Internal rules specify the responsibilities for the doctors and nurses concerning the data exchange (see Table 2 for more details).

Responsibility Doctor Nurse

Specification doctor is responsible for updating the information in the system of electronic records about patient state during his/her shift, treatment and for safety of the patient

nurse is responsible for taking care of patient in a way typical for nurses (provide patients with medicine, perform physical exams, interpret patient info, etc.)

19 concerning the

data exchange

to the next ward , the doctor is obliged to create a release report summarizing the changes in the patient state

given by doctors

Deadlines concerning the data exchange

update the information about current patient state till the 10:00 next day – daily record of medication

nurses do not have the authority to provide updates, they only have access into the system (they can just view the documentation in the system)

Others In case of sudden indisposition of the personnel (illness, personal reasons, etc.), the responsibility is assigned to the doctor/nurse who is on duty at that moment

Table 3: Specification of responsibility presented in internal rules

20 The allocation of authorities as another variable is closely related to the allocation of responsibility. The allocation of authority represents the functionality of the hierarchy at the ward. The hierarchy at the wards is structured as follows: head of department, senior doctors, and junior doctors. The allocation of authorities influences the allocation of responsibility in terms of how strictly are the rules followed by the doctors/nurses. The compliance with written rules set by the allocation of responsibilities is strengthened by the strong allocation of authorities and it is recognizable in case of the transfer from intensive care unit to standardized medical ward. As a doctor (3) said “The allocation of authority is visible when the patient is transferred from the ward of anaesthesiology to our department, because I can compare it to my ward (intensive unit care) and see the difference. Our head of department strictly insists on updating the information into the system in a brief but accurate way but the head of the next department does not care”. This quote represents the difference between good case and bad case. The negative impact of unstrict allocation of authorities is illustrated on the case of transfer of the patient from the ward of anaesthesiology to standardized medical ward. As doctor (6) said “When we get the patient from this ward (anaesthesiology), we (I mean me and my colleagues) are very careful about completeness of information, because we know that the head of this department is very benevolent about fulfiling the requirements specified in rules set by the allocation of responsibilities”.

Overall, the allocation of responsibility is the first step that determines the pattern of how the data about the patient state are exchanged. It becomes clear that a clear allocation of responsibilities has a positive effect on the outcome (accurate information) of the clinical handover process. In addition, the deadlines for updating the information about patient state provides the continuity of the care. Moreover, derived from answers, allocation of authorities has positive but also negative impact because it depends on the head of the department in terms of his/her will to force the his/her co-workers to follow the rules.

4.2. Usage of ICT

21 stated that the structure of the protocol is clear. However, clear structure of the protocol is not enough because accreditation process was identified as the factor that hinders exploitation of the full potential of the electronic records. As a doctor with a 20 years working experience in the specific hospital stated “The demand from the side of the management concerning how much information needs to be written down is just insane”. In order to get accreditation for ward (e.g. oncological treatment), the information accuracy has to achieve the defined threshold (70%). The accreditation process causes that doctors are forced to write down as much information as possible in order to achieve the threshold. Accreditation process causes the overwhelming of the doctor who is next in the row with the information although the allocation of responsibilities requires brief and accurate information. In addition, accreditation process reduce the given time for treating the patients and forces the doctors spent the time on non-core value activity. The following table shows the estimated time that respondents claimed to spend on activities related to the non-core activity and emphasizes the negative impact of the accreditation process on the time exploitation of the doctors.

Doctors

Respondent 1 2 3 4 5 6 7 8

Hours per day 1 0.5 0.75 1.25 2 0.5 0.5 1

Table 4: Estimated time spending on non-core activity

On the other hand, twelve of fourteen respondents provided similar answers which can be summarized in a quote “Spoken words fly away, written words remain”. It means that in spite of knowing that they (doctors) put too much information and the protocol looks messy, they still do it because they are afraid of prosecution. In case of a trial, the electronic records are used to assess the treatment that was used by the doctor. This is seen as main advantage in comparison to oral communication since the doctors can always check the information in the system. However, 14/14 respondents state that electronic records are not enough and they as well as use the oral communication in order to stretch the most important information (e.g. doctor (1) “I highlight the news about patient state that may threaten the patient’s life”.

Influential factor for electronic records besides the rules set by the allocation of responsibilities, is the setting of the system itself. For the more details about quality of system, see table 4.

22 exchange of data.

Training 13/14 respondents confirmed that they

participated in the training for using the ICT system. Training is useful in order to provide skills for employees to operate the system with electronic records.

Table 5: Characteristics of ICT system

To sum up, usage of ICT has positive effect on quality of information because of the clear structure and positive effect on exchange of data, since the doctors can always check the information in the system. Furthermore, accreditation process is considered as barrier in usage of ICT because of the bureaucratic burden that brings to process.

4.3. Exchange of Data

Exchange of data is the crucial step in the clinical handover process. This step is mainly responsible for the outcome in terms of data accuracy and it is framed by the allocation of responsibilities. As doctor (2) states “We (doctors) know, what we should do consideration of exchange of data, we know how to use ICT system, but still there when we read the records from previous shift or ward, we can still find mistakes”. Exchange of data is divided into exchange between shifts and exchange between wards. This division is derived from the situation from the researched wards, when the patient in many cases stays in the ward at least for a few days so before the transferring the patient to the next ward, the exchange between the shifts occurs. The following table presents the characteristics of each of them, based on the shadow working.

Exchange of data

Between shifts Between wards

When doctor/nurse finishes their shift (nurses at 6:00 a.m. and at 6:00 p.m., doctors at 7:00 a.m. and at 4:00 p.m.)

when the patient is transferred

Form electronic record (daily record of hospitalization) + face to face communication highlighting the news in patient state, nurse (4) said

23 “Everyone uses own oral structure,

but it is rather intuitive, you know what should be highlighted”.

Specifics data exchange determines the quality for the process. The release report is handed with the patient when s/he is transferred to next ward is derived from the reports that were created during the shift handover. As doctor (1) states “the quality of data exchange between shifts on the other department affects the data quality that I receive, if I am not satisfied I have to spent so much time to find the correct information”

patients are moved both ways, from intensive care unit to the standardized ward when the patient state is getting better, or in case of complication, patient is transferred from standardized ward to the intensive care unit.

Table 6: Types of data exchange

This division is important because the quality of the shift exchange determines the quality of exchange between the wards. Example of this can be illustrated on case of doctor (4) who states ”If the data exchange about the patient state between the shifts just between me and doctor Novak and during the shift of doctor Novak, patient is transferred to next ward, it is more likely that that our data exchange was ok and doctor in the next ward get sufficient info about patient. But if the patient is treated by many doctors within one ward, it is more likely that something would go wrong”. As it was mentioned in the table 6, when the patient is transferred to another ward, the release report is the first document that the doctor in the next ward opens. So the quality of data exchange between the shifts determines the quality of exchange between the wards because release report consists only of information about patient state gained during the data exchange between the shifts.

24 derived from that. Firstly, doctors spent a lot of time writing down the information and secondly, with complex disease/injury it is more probable that information will be inaccurate/incomplete. In both cases doctor and nurse lose the time that might otherwise be used for treating the patient. Last but not least, the most crucial factor for the entire process is the human factor. 14/14 respondents mentioned that human factor is the main barrier for achieving the desired outcome of the clinical handover process. Doctor (8) states ‘’I drew my co-worker’s attention to filling out the record in a more precise way. He said he would do it, but a week later, he did it again in the wrong way”. Nurse (1) claims ‘’The settings of the process can be best of the best but if the people do not follow instructions no matter for what reason it will not be perfect any time soon “. The human factor is represented by the negative human qualities like “laziness” (doctor (5)), “inexperience” (doctor (6)) “no willingness to do it properly” ((nurse (5)) or “incompetence” (nurse (1)). These human qualities represent the reason why there is the difference in setting the rules and following them. It causes that the potential for desired outcome in term of accurate information determined by the rules, has not been fulfilled. However, if the doctor does it properly, it exhibits the advantage of proper allocation of responsibilities. Doctor (7) states “I am not leaving the office before I finish everything concerning the patient including data update”. It means that human factor can have also positive effect. Unfortunately, because of issues with overtime, lack of employees, the negative effect of the human factor is in this particular case more obvious.

Overall, data exchange is divided into handover between shifts and handover between wards. The performance of data exchange between shifts has impact on the handover performance between wards but if the impact will be positive or negative is dependent on impact of human factor and illness’ level of difficulty of illness.

4.4. Quality of information

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5. Discussion

Starting with the conceptual model (see figure 3), findings confirm the relationships among the constructs presented in the research model. Moreover findings determine the influence of other constructs in terms of positive or negative impact on the other constructs. Study shows positive effect of the allocation of responsibilities on data quality because it set the rules for transferring the patient to another ward through specifying the procedure of data exchange. In addition, new constructs were observed, namely the accreditation process and human mistakes and illness’ level of difficulty. These three constructs were identified as main factors that hinder the clinical handover process from achieving the desired outcome. Therefore, these three constructs can be considered as barriers and can be added to barriers mentioned in the literature like lack of standardization (Fealy, 2016), insufficient training (Liu, 2012) or unclear responsibility (Lee, 2016). Their role and their interaction with the proposed constructs in the conceptual model is explained and linked to theory in more detail below.

First, as was previously indicated by Lee (2016) and Chin (2012), this study confirms that the allocation of responsibilities is a determinant factor of the clinical handover process. The written rules clearly specify the responsibilities for data exchange and the setting for usage of electronic records as it was stated by 7 respondents. This confirms the relationship between the allocation of responsibilities and the data exchange using the electronic records as tool for communication. In addition, it is with the accordance to article of Rosa (2016) which states that proper settings of the process are a key factor for successful process. Importance of clear allocation of responsibilities as mentioned in Lee (2016) is supported by the finding that for the doctors is very important to know what to do regarding the data exchange. However, setting the rule and following the rule are two different things. This can be illustrated on the example of the human factor that disrupts data exchange. Namely, unwillingness of the doctor that after the warning from his co-worker has still not changed his attitude towards filling the electronic records following the rules.

27 responsibilities is not unknown effect in the hospital settings. This was found before by Patterson and Wears (2010) and it indicates that allocation of authorities depends on individualities.

Thirdly, despite the satisfaction of the respondents with the quality of protocol which follows the structure of ISBAR, a framework mentioned in Thompson (2011) and participation in regular training which enables to overcome potential barriers in terms of not knowing how to use the system mentioned in Klim (2013) the usage of ICT itself remains itself the influential factor. In addition, in spite of rules how to use the electronic records set by the allocation of responsibilities, it is still exposed to problems. Problems are mainly caused by the accreditation process which forces doctors to write as much as possible which leads to too much information in the system as doctor (8) said “The amount of information in the system is enormous”. In Manser (2011) overloading the system with meaningless information is seen as issue because too much information in the system is in contradiction with what the doctors/nurses request from the electronic records. For doctor/nurse brief, accurate information is the most desired outcome of the clinical handover process (Pirk, 2014). This indicates that the bureaucratic burden is also an issue for hospitals and that leads to problem that hospital staff is forced to spend their time on non-core activities that are not related to the patient treatment. Moreover it implies increasing needs of finding the equilibrium between requirements from official entities like ministry of health and the requirements from the hospital staff who have to cope with the administrative requirements on daily basis.

Furthermore, the findings are in contradiction with the prediction in Manser (2011), that electronic records will eventually replace the verbal communication. Based on the interviews, where each respondent stretches that s/he uses verbal communication every day in order to highlight important changes during his/her shift. It seems logical because verbal communication is not tied down with the rules as the data exchange via electronic records which are determined by the rules set by the allocation of responsibilities and for verbal communication it is rather intuitive what information should be highlighted. In addition, almost half of the respondents even said that they prefer verbal communication because it is a quicker way of getting the information. This is with accordance to Jorm (2009) and Johnson (2015) who identified verbal communication as quicker and more comfortable way of communication for hospital staff.

28 information between the wards, the release report is still prone to the mistakes. Mainly because it is created from the previous records so it is with accordance with the Manias (2016), who states that if the setting at the ward is satisfactory, the information transferred to the other ward has predisposition to have higher quality. Although findings in this study works in the opposite direction in terms of bad setting and worse quality in the ward of anaesthesiology. Also in spite of routine process (Broekhuis, 2007), the inefficiency still remains. In general, it is obvious from the findings that human factor has the biggest impact on data exchange. This influence is known from articles by (Pezzolesi, 2013, Weinger, 2010 and Siemens, 2012) who identifies the human factor as the factor that will be always an issue because it is related to the substance of human being. Going more in-depth, negative impact of the human factor can be reduced by more intuitive system or more detailed instructions followed by penalties.

29 assessment of data quality in hospital settings. Data dimensions fit to the needs of hospital in order to identify the factors causing the inaccuracy of transferred data. The first step to discover the factor that stands behind this is to define the dimension and then ask which factor stands behind e.g. “What is the reason for incomplete data in system?”. Definition of the dimension enable easier tracking of the factor which is responsible for incomplete data. The findings confirm that behind the incomplete and inaccurate information stands mainly the human factor but behind the too much information in the system stands the accreditation process.

Figure 4: Rich picture

6. Conclusion

30 sufficient condition to achieve desired outcome from the clinical handover process because the clinical handover process is too complex in order to identify all the factors that might influence the outcome so it indicates that the data quality is still an issue in the hospitals.

In general, this study contributes to more in-depth insights on how the allocation of responsibilities creates the setting for data exchange between wards as was partly indicated in literature (Patterson and Wears, 2010, Jeffcot et al, 2009, Chin et al., 2012, Lee et al, 2016). In addition, in the findings, the damaging role of the bureaucratic burden can be seen in new perspective and contributes to theory in terms of barriers. This effect was not highlighted in literature; however, it seems logical that the bureaucratic burden is also an issue in the hospital environment regarding the characteristic of the hospitals where the patient’s health is treated and this sector needs to be regulated. The bureaucratic burden creates the paradox situation between the management of the hospital and the doctors. On the one hand, the management requires information as detailed as possible in order to fulfil the criteria set for accreditation; on the other hand doctors/nurses require brief information for two reasons. To decrease the time that they have to spent writing down the information into the system and the second reason lies in the clarity of the content of electronic records.

Hence, for future research it is important to take into account different perceptions of data quality from different stakeholders. Emphasizing the role of the bureaucratic burden might be seen as the main contribution to the literature. Influence of the bureaucratic burden should be taken into account in the next studies. Overall, this study implies some new insights related to the concept of the clinical handover process that should be investigated in other facilities in order to increase the generalizability of the phenomenon.

6.1. Limitations of the Research and Further Research

31 However, the explorative case study provides a useful insight which might be used in further research related to the transfer of responsibilities and its relationship with the usage of ICT within the clinical handover process. For the further research, a survey involving more respondents would be interesting in order to compare if the results in terms of satisfaction and critical remarks would be the same for other hospitals since the legislation is the same for other hospitals and they need to cope with same issues such as lack of employees, bureaucracy and insufficient funding. Also further research by means of a survey would provide more generalizable results. In addition, as study implies, new factors should be analysed in more depth. Especially research regarding the influence of the bureaucratic burden can be interesting to study since the difficulties related to the accreditation process that were present in the previous parts. It would be useful to provide deeper insight about the strength of the influence of this factor and eventually propose how to decrease the negative impact of this factor on the clinical handover process.

6.2. Managerial Implication

Next to the theoretical implications, the study also provides implication for quality care managers in hospitals. With the system of accreditation and the system of international certification the pressure on the quality of care is increasing from the top management of the hospitals representing the interest of the owners. As this study demonstrates, the managers in the hospitals need to find an equilibrium between what needs to be achieved in terms of obtaining the certificate and the lowest demand in terms of bureaucratic stress. The steps should be proposed in close cooperation with doctors because they daily participate in the process. In addition, quality care managers should choose the ward where the allocation of authorities works the best and apply the same scheme in other wards in order to increase the quality of the data that are the outcome of the clinical handover.

32

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36

Appendix

Appendix A: Protocol for interview

Allocation of responsibilities and allocation of authorities

1. Could you please describe how would you define handover process and what is the role of yours in it?

2. How often you participate during the handover?

3. Do you have some protocols (framework) that adjust what needs to be fulfil during the handover? How does it specify your responsibility?

4. It is a complex process. What are the requirements (rules) that you need to follow?

5. What is the influence of the allocation of authorities in the ward? Do you think that hierarchy plays the role?

6. What are the steps during the transfer of responsibility in case of emergency? I mean in case of sudden absence of doctor?

ICT

1. How the system of electronic records works for you? Can you describe how you use the electronic records to write down the information about patient state?

2. Do you feel that the standardization of protocol is ok? What are the advantages and disadvantages in your point of view?

3. Have you been trained for usage of ICT system? Was the training useful? Could you describe the training?

4. Do you use just electronic records? If not, what other form of communication do you use and could you describe how?

5. How often do you update the information about patient state? Do you consider it as an important part of your job?

6. What are the main problems with electronic records?

__________________________________________________________________________________ Exchange of data

1. Which one of the handover types (shifts x wards) is less prone to mistakes?

2. What are the differences? Could you be more specific in terms of difficulties which causes to you?

37 Information quality

1. How would you assess the quality of information that you receive? Do you have any tools to do so?

2. How important is quality of data for you work?

3. How much time to you spend with the procedure of finding the missing information? Could you make an estimation in hours per week?

4. What are the main barriers for handover process? Could you describe each in more detail? 5. If you have this opportunity, what would be your propositions how to improve the whole

process?