- Led by Plymouth Hospitals NHS Trust with technical support from the University of Warwick.
- The project ran from October 2008 until the end of 2013.
- The project aimed to improve the handover systems within neurology and A&E departments to ensure correct and timely information was being shared about patients.
- The team used various techniques to analyse and diagnose issues with the handover process, and a systems approach to help them redesign it.
The Plymouth Hospitals NHS Trust team wanted to improve handover systems in the neurology and A&E departments. Existing systems were unreliable, and core information about patients was not being passed between clinicians.
Unstructured handovers were leading to delays in decision-making, referrals and treatment.
With technical support from the University of Warwick, the team analysed and diagnosed issues, using techniques such as observing and process mapping systems, in-depth interviews and case studies.
Having defined a framework and core data set, the team created a new handover support tool.
The reliability of handovers – defined as core information being passed on – increased from 35% in June 2009, to more than 80% in September 2010.
Learning points from phase one
- Explicit standards for clinical processes are needed so teams can develop shared understanding and measure success.
- A proactive and explicit focus on improving safety is new and gains instant buy-in from clinicians.
- Simple interventions can have a really big impact. However, just because an intervention is simple, does not mean it will be easy to implement.
- Regular feedback to clinical teams about compliance against agreed standards and progress of the project increased their active participation.
- Clinical autonomy can be a barrier to standardisation.
- Communication is key, but finding time to meet, and ways to communicate with a constantly changing staff team was challenging.
- Reductions in harm are difficult to measure and attribute to a particular intervention, meaning it can be difficult to justify this work in such a financially pressured climate.
Lessons from the second phase of the Safer Clinical Systems programme.
About this programme
A programme that ran in two phases from 2008 to 2013. It helped health care teams to proactively identify potential safety br...
You might also like...
Jennifer Dixon, Chief Executive of the Health Foundation, reflects on the relationship between mental and physical health and...
Health Foundation response to NHS Monthly Performance Statistics for January 2019.
A GP’s perspective on the tough decisions she faces diagnosing cancer.
Health Foundation @HealthFdn
A new scheme for bringing branded medicines to the NHS may benefit patients and provide greater value for money, bu… https://t.co/UEJCHoAZOjFollow us on Twitter
Work with us
We look for talented and passionate individuals as everyone at the Health Foundation has an important role to play.View current vacancies
The Q Community
Q is an initiative connecting people with improvement expertise across the UK.Find out more