NATIONAL CLINICIANS NETWORK
NSW 2012 FORUM – R EPORT
OF
O UTCOMES
C LINI C AL H ANDO VER A CROSS S ECTORS – T HE C LINI CI AN ’ S D ILEMM A
1
CONTENTS
1
Executive Summary
2
2
Background and Purpose
5
3
Clinical Handover in Australia - Key Issues
3.1 The Current Context
5
5
4
Improving Clinical Handover
4.1 Panel Discussion
4.2 Small Group Discussions
4.3 Themes Emerging from Group Discussions
4.4 Possible Solutions
4.5 Next Steps
6
6
6
6
8
10
5
Appendices
5.1 Appendix 1 – National Lead Clinicians Group membership
5.2 Appendix 2 – NSW National Clinicians Network program
11
11
14
1
1
EXECUTIVE SUMMARY
The first National Clinicians Network forum under the auspices of the National Lead
Clinicians Group was held in Sydney on 21 November 2012. Its purpose was to engage
clinicians in improving clinical handover across the patient care pathway in multiple settings.
Objectives
The aim of this report is to summarise the outcomes of the forum and the possible solutions
identified to improve clinical handover. The report will assist in the provision of effective
clinical handover across the different parts of the health system and transfer of care into the
community.
The focus - Clinical Handover
Clinical handover, despite being an integral part of clinical care, remains a high risk area for
patient safety. Clinical handover is the transfer of professional responsibility and
accountability for some or all aspects of care for a patient, or group of patients, to another
person or professional group on a temporary or permanent basis1. This process differs from
discharge where care and treatment is at an end and the person or family assumes
responsibility for ongoing health maintenance.
Poor or absent clinical handover can have serious consequences for patients, leading to a
delay in diagnosis or treatment, discontinuity of care, medical and medication adverse
events, avoidable re-admissions, and inefficiencies in managing patient flow into hospital
and their return to the community setting. Communication problems are a major contributor
to adverse events in hospital with 70% of sentinel events being attributed to communication
errors and approximately one in five patients experiencing an adverse event.
Clinical handover is not a new concept. There has been substantial work undertaken in this
area by various stakeholders, including the development of standards and guides, resources
to support best practice, literature reviews and various projects, including work by the
Australian Commission on Safety and Quality in Health Care, and state and territory
governments. However, there remain a number of substantial challenges with clinical
handover, particularly where handover occurs across different parts of the health system.
The agenda
The Commonwealth Minister for Health, the Hon Tanya Plibersek MP opened the NSW
forum and noted that clinical handover is an area where the health system can be improved.
She also noted that identifying and disseminating ways to improve the handover of
information is absolutely critical as patients, particularly those with chronic and complex
1
Australian Commission on Safety and Quality in Health Care (ACSQHC), September 2011), National Safety
and Quality Health Service Standards, ACSQHC, Sydney.
2
conditions, move between different parts of the health system. The Minister also urged
clinicians to take a broader view of their role, noting the gains from better integration of the
work between sectors and professions across settings.
The forum included both a panel and small work group discussions to deliberate the critical
issues of clinical handover based on ‘Jack’s story’ (ageing patient, chronic morbidities,
multiple medications, Primary Care, acute episode and discharged 10 days later). The forum
was attended by around 180 delegates including clinicians across all health areas; health
executives and managers; representatives from health professional bodies and consumer
representatives. Delegates discussed issues and solutions in small groups about the
“when”, “how” and “what” of effective clinical handover across the different health care
settings.
Outcomes
Participants discussed a number of issues impacting on effective clinical handover.
Participants also agreed that for patients, continuity of care is paramount. Recognising that
acute care is ‘episodic care’, patients should be ‘handed back’ to their General Practitioner
and other primary care providers for continuity of care. Given the new governance
arrangements affecting the health sector, it is important that clinicians, managers, and
executives work together at all levels to influence governments to achieve some of the
outcomes discussed.
Handover of patients can be a complex process which is exacerbated when dealing with
more vulnerable patients such as those from low socio-economic backgrounds, the aged,
those with chronic illnesses, patients requiring multiple admissions and/or a combination of
acute, primary, aged care or allied health care. Clinical handover is most important for
vulnerable patients where transfers of care are likely to be ‘high risk’. Identifying these
patients through appropriate processes, acknowledging their higher risk and assigning
greater attention and resources to these transfers will go some way towards addressing the
risk.
Solutions - whether standardised or flexible - need to ensure that those involved in some or
all aspects of care for the patient, or group of patients, are accountable for the care provided
and the transfer of responsibility. Participants noted that the approaches and solutions used
to improve clinical handover vary between different parts of the health sector and their
success is dependent on a number of processes. Many of the solutions suggested by
participants also require policy authorisation and leadership. Some need additional
resourcing. The key themes identified are outlined below.

Effective communication – Accurate information exchange should occur at every
stage of the patient pathway and information must move with the patient.
Professional colleges and organisations need to be included in discussions on the
development of handover policy and processes.

Changing the culture within organisations – Ensuring effective clinical handover will
require a change in the way clinicians and managers work which goes beyond
3
standards, guidelines and protocols. It requires an understanding and acceptance of
responsibility for shared care, supporting clinicians, and building and maintaining
respectful and valuable relationships both among clinicians in different care settings
and between services at an organisational level.

Working protocols and adequate patient information – Implement working protocols
which involve all parts of the health care system and transfer of care into the
community to support the patient continuum of care. As a priority develop Critical
Point Protocols for high risk patients such as frail older people, people with mental
health problems and paediatric patients. Local protocols should be developed to
determine minimum data sets for transfer of care and alternative resources when
general practice is not available.

Care Coordination - Information exchange must be two-way and not limited to the point
of transfer. Ongoing conversations between different clinicians and sectors involved
in patient care should also continue and be supported by care coordinators, liaison
officers and practice nurses. The central role of patients and family/carers in
contributing to effective clinical handover must also be acknowledged and supported.

Relationships between different parts of the health system - Medicare Locals and
Local Health Networks2 can work together and with non-government organisations or
providers on all aspects of transfer of care across the health care system or into the
community. It requires an understanding and acceptance of responsibility for shared
care, supporting clinicians, and building and maintaining respectful and valuable
relationships both among clinicians in different care settings and between services at
an organisational level.
Next steps
The National Lead Clinicians Group will consider follow up actions to build consensus
around possible solutions to clinical handover, and who may be involved in delivering these
solutions. The Group will also discuss other options to address the various solutions and
who should lead and participate in their implementation. The Group will be developing a
matrix of issues, solutions and implementers arising from the various NCN forums, to
prioritise actions and provide a roadmap for implementation. This will require the Group’s
engagement with other stakeholders across the health system, and its use of networks and
partners to ensure the solutions identified ultimately flow through to systemic changes that
result in improved outcomes for patients.
2
In NSW, Local Health Networks are referred to as Local Health Districts.
4
2
BACKGROUND AND PURPOSE
The National Clinicians Network (NCN) has been established under the auspices of the
National Lead Clinicians Group (see Appendix 1 for membership of Group) – a body formed
to advise the Federal Minister for Health on clinical issues. Working in conjunction with
jurisdictional clinical bodies, the National Clinicians Network brings together clinicians to
enhance multidisciplinary clinical leadership and engagement in the Australian health
system.
The National Lead Clinicians Group is conducting a series of state and territory NCN forums
around Australia, culminating in a National NCN forum to be held in mid-2013. The forums
will be held every year. The purpose of the NSW forum was to engage clinicians in
improving clinical handover to strengthen the quality and safety of care, make the patient
journey more streamlined and to consider these aspects across a range of situations and
settings. It also aimed to stimulate personal reflection on how each clinician could contribute
to improvements in clinical handover in their practice settings (see Appendix 2 for forum
program).
Adjunct Professor Russell Stitz, Chair of the National Lead Clinicians Group, welcomed over
170 clinicians and health professionals to the Sydney Convention and Exhibition Centre and
encouraged participants to focus on solutions from both system and personal perspectives.
Lynette Glendinning of Tempo Strategies facilitated the forum.
3
CLINICAL HANDOVER IN AUSTRALIA - KEY ISSUES
3.1
THE CURRENT CONTEXT
Issues related to clinical handover in Australia were discussed from the perspectives of
government, safety and quality, and clinicians working in diverse sectors and settings.
The Hon Tanya Plibersek MP, Minister for Health, acknowledged the innovative work being
undertaken in clinical handover and noted the importance of focusing on system
improvement. She urged clinicians to take a broader view of their role noting that there was
a lot to gain from better integration between sectors and professions. In considering
improvements Minister Plibersek urged a focus on patient needs to guide thinking and noted
that it was important that health professionals from a range of settings contribute to the
thinking and participate in the design of change.
Professor Debora Picone, Chief Executive Officer, Australian Commission on Safety and
Quality in Health Care, provided a rationale for serious focus on issues related to clinical
handover, noting that 70 per cent of adverse events are due to communication issues and
that one in five patients experiences an adverse event. Of these, one third are preventable
5
and one third are ameliorable. Transitions in care at admission, referral and discharge are
high risk for discontinuity of care and for medical and medication adverse events.
Professor Picone referred participants to the OSSIE Guide to Clinical Handover
Improvement Implementation Toolkit3 and Chapter 6 of the National Safety and Quality
Health Service Standards4. She urged participants to reduce risks and improve personal and
system effectiveness by using current opportunities, including the use of Personally
Controlled Electronic Health Records (PCEHR) as they become available, and participating
in the work of the National Lead Clinicians Group.
4
IMPROVING CLINICAL HANDOVER
4.1
PANEL DISCUSSION
A panel discussion, facilitated by Lynette Glendinning, explored perspectives related to a
range of clinical fields and settings. The panel was asked to comment on a case study of an
elderly patient with very complex needs to prompt the more detailed group discussions to
follow. The participants in the panel discussion were Dr Anett Wegerhoff, General
Practitioner; Dr Marian Lee, Emergency Physician; Professor Kate White, Chair of Cancer
Nursing, NSW Cancer Institute; Dr Ken Mackey, General Practitioner; and Mr Ian Richards,
Clinical Services Redesign Manager, NSW Agency for Clinical Innovation.
4.2
SMALL GROUP DISCUSSIONS
Forum participants were divided into three working groups and asked to consider clinical
handover issues from the perspective of different settings (including general practice,
hospital, medical and nursing specialists, allied health, community and aged care). The
working groups also considered three questions applying to each of the different settings:
when should clinical handover occur?; how should clinical handover occur? and; what
information should clinical handover include? A further question emerged when the issue of
'who' is to be involved in clinical handover was put to one of the groups.
4.3
THEMES EMERGING FROM GROUP DISCUSSIONS
Following the small group discussions, the chairs of the groups reported back in the plenary
session on the issues that had been discussed. Outcomes of panel and small group
discussions were clustered in three key areas: organisational/system approach to implement
effective clinical handover; documented and structured clinical handover processes and;
patient and carer involvement in clinical handover. The issues which emerged from these
discussions are presented under the three areas below.
3
OSSIE guide to clinical handover improvement: for clinicians, leaders and managers/ Australian Commission on
Safety and Quality in Health Care
http://www.health.gov.au/internet/safety/publishing.nsf/Content/D0CEDF80C4623FF2CA25757D007F7828/%2
4file/OSSIE.pdf
4
Australian Commission on Safety and Quality in Health Care ((ACSQHC) (September 2011), National Safety
and Quality Health Service Standards, ACSQHC, Sydney.
6
Organisational/system approach to implement effective clinical handover
●
Patients should be ‘handed back’ to their General Practitioner (GP), community health
nurses and other primary care providers for continuity of care, recognising that acute
care is ‘episodic care’. Patients with complex or chronic conditions need a ‘medical
home’ where their care information is centralised.
●
The concept of acute care ‘in-reach’, where primary care is genuinely involved in
discharge planning, is important.
●
The language used by different professional groups increases the risk of
misunderstanding. Clarity and legibility across the care continuum is critical.
●
Different professionals (specialists, GPs, nurses, community/acute allied health) have
different areas of focus and clinical experience requiring reciprocal inter-professional
appreciation and respect.
●
Culture change and leadership is a high priority in order to strengthen the focus on
patient and carer needs across the continuum of care and multidisciplinary teamwork.
This is particularly important where there is no real medical home or nominated primary
care provider.
●
The terminology ‘transfer of care’ or ‘hand back’ should replace ‘clinical handover’ as
these terms support primary care as the mainstay of health care and encourage
clinician culture to acknowledge this.
●
The need for Medicare Locals and Local Health Networks to work together and include
Non-Government Organisations (NGOs), which provide many community services, was
raised throughout the discussion. Of note, the National Health Reform Agreement
requires both Medicare Locals and Local Health Networks to engage with each other, as
well as other local clinicians when making decisions on service delivery, particularly
involving matters of safety and quality.
Documented and structured clinical handover processes
●
The timing of clinical handover from acute care settings should take into account all the
supports which need to be in place for a patient and their family. Many community
services are not available out of regular business hours, presenting a risk to patients
discharged out-of-hours.
●
A system of local protocols should be developed which includes a requirement for
timely, accurate information to support planning for transfer of care. Issues to be
considered include arrangements for medication management, care information for the
patient and their family, including what to do if something goes wrong, and
arrangements for other services required.
●
Patients admitted to hospital or seen in the Emergency Department frequently do not
carry essential information such as their medications. Critical information must be
accessible at all times and not dependent on GP practising hours.
7
●
Care coordinators and case conferencing can help bridge the gap between different
sectors of the health system, particularly for people with chronic or complex health
problems.
●
Critical point protocols should be developed as a priority for higher risk patient/acute
care interfaces involving those most vulnerable - including frail older people, people with
mental health problems and complex paediatric patients. Protocols need to suit the
setting and local care arrangements and involve patients and/or carers. There are
benefits and risk associated with different modes of clinical handover
●
The quality and accuracy of handover information is vital. There is an opportunity to
improve the use of electronic data as the Personally Controlled Electronic Health
Record (PCEHR) becomes available. This will also enhance the engagement of patients
and carers in clinical handover and continuing care.
Patient and carer involvement in clinical handover
●
Patient needs should be the focus of clinical handover. Understanding the patient’s
needs requires genuine involvement of the patient and/or the patient’s carer in the plan
of care. Consideration of psychosocial needs must also be considered and this is
particularly important in aged and community care settings.
In summary, clinical handover across sectors could be improved by ensuring that all
clinicians involved with the patient listen carefully to the patient and/or carer, have a sound
understanding of patient and family needs, a strong focus on interdisciplinary care,
knowledge of who is involved in continuing care and the nature of the respective roles, and
better access to more comprehensive and accurate information and communication between
all parties. Protocols should be developed to support care in the local context, and should be
adhered to by all professionals involved in care.
4.4
POSSIBLE SOLUTIONS
The approaches and solutions used to improve clinical handover vary between different
parts of the health system and their success is dependent on a number of processes.
Handover of patients can be a complex process which is exacerbated when dealing with
patients with chronic illnesses, multiple admissions and those requiring a combination of
acute, primary, aged care or allied health care. Solutions - whether standardised or flexible need to ensure that those involved in some or all aspects of care for the patient, or group of
patients, are accountable for the care provided and the transfer of responsibility.
Participants discussed a number of issues impacting on effective clinical handover.
Participants also agreed that for patients, continuity of care is paramount and given the new
governance arrangements in the public health system, it is important that clinicians,
managers, and executives work together at all levels to influence governments (where
necessary) to achieve some of the outcomes discussed. Clinical handover is most important
for vulnerable patients where transfers of care are likely to be ‘high risk’. Acknowledging
higher risk and assigning greater attention and resources to these transfers is likely to
produce the most significant patient gains in the short term.
8
Other key themes for solutions identified included:
 effective communication;
 changing the culture within organisations including empowering younger clinicians;
 implementing working protocols;
 establishing or identifying care coordination roles;
 adequate patient information with an appropriate minimum set of information and;
 establishing and ensuring working relationships Among clinicians and between services
across the health system.
These key themes are outlined further below.
Effective communication
Make two-way information exchange central to each point of transfer of care. Information
should be collected at every stage of the patient pathway and must move with the patient.
The quality and accuracy of handover information is vital. In addition to involving the patient
in clinical handover processes there is value in exchanging information between clinicians
and family or carers who have ongoing care responsibility. Ideally, the information should be
transferred via standardised (ie template-based) paper and electronic documents for
consistency across sectors and organisations. Professional colleges and organisations
need to be included in discussions in the development of handover policy and processes.
Changing the culture within organisations
Facilitating effective clinical handover will require a change in the way clinicians and
managers work, which goes beyond standards, guidelines and protocols. It requires an
acceptance of responsibility for shared care. To facilitate the change in the culture of quality
clinical transfer of care, clinicians will need: continued support through various built in
mechanisms for managing transfer of care; education on the value and impact of good
handover practices; education, coaching and mentoring and; leadership at the local, state
and national levels. The culture within organisations can be changed as part of continuous
quality improvement activities. Consideration should also be given to increasing
opportunities for general practitioners to be involved in hospital process relating to their
patients, strengthening a respectful and valuable relationship between the clinicians,
enabling each to better understand and work together to overcome barriers to effective
clinical handover.
Working protocols and adequate patient information
Implement working protocols which involve all sectors to support the patient continuum of
care. As a priority, develop Critical Point Protocols for high risk patient populations such as
frail older people, people with mental health problems, and complex paediatric patients.
Local protocols should be developed to determine minimum data sets for clinical handover
which include, but are not limited to: social and functional information as well as medical
information; reason for admission; events of admission; advanced care directive; short term
plan; longer term goals or plan; information pathways including key groups involved and the
9
relationships that need to be established. Local protocols may include alternative resources
when general practice is unavailable or when transfer of care is into the community.
Mechanisms such as Personally Controlled Electronic Health Records have strong potential
to provide a readily accessible source of centralised information. Both Medicare Locals and
Local Health Districts will need to play an equal role in this by encouraging participation as
part of the consent to treatment process.
Care Coordination
Information exchange must be two-way and not limited to the point of transfer. Ongoing
conversations between different clinicians and sectors involved in patient care should also
continue and be supported by care coordinators, liaison officers and practice nurses.
Establishing or identifying care coordination roles especially for those with complex or
chronic conditions, such as a nurse in aged care settings, a practice nurse in general
practice settings, and family carers in the home settings. The central role of patients and
carers in contributing to effective clinical handover must also be acknowledged and
supported.
Relationships between different parts of the health system
Medicare Locals and Local Health Networks play a core role in organising and providing
health services and having a well-established relationship, beyond that required by the
National Health Reform Agreement, is critical. Medicare Locals and Local Health Networks
must work together and with non-government organisations or providers on all aspects of
transfer of care across the health care system or into the community. Equally important is
building the relationships between clinicians across the different health services.
4.5
NEXT STEPS
The National Lead Clinicians Group will consider follow up actions to build consensus
around possible solutions to clinical handover, and who may be involved in delivering these
solutions. The Group will also discuss other options and address the various solutions to
facilitate their implementation. It is expected that future NCN forums to be conducted in
2012-13 will test and build on this work. The Group will be developing a spreadsheet of
issues, solutions and implementers arising from the various NCN forums, to prioritise actions
and provide a roadmap for implementation. This will require the Group’s engagement with
other stakeholders across the health system, and its use of networks and partners to ensure
the solutions identified ultimately flow through to systemic changes that result in improved
outcomes for patients. Suggestions from this workshop and other state/territory workshops
will be considered by the National Lead Clinicians Group in their work, and will provide input
to a National forum in 2013.
10
5
APPENDICES
5.1
APPENDIX 1 – NATIONAL LEAD CLINICIANS GROUP MEMBERSHIP
Adjunct Prof Russell Stitz, AM RFD (Chair)
Commissioner at the Queensland Health quality and Complaints Commission, senior
surgeon at the Royal Brisbane and Women’s Hospital and has been Professor of Clinical
Surgery and Head of the Discipline of Surgery for the University of Queensland. He is past
President of the Royal Australasian College of Surgeons and past Chairman of the
Committee of Presidents of Medical Colleges. He is also a Director of the Australian Medical
Council.
Adjunct Associate Professor Melissa Locke (Deputy Chair)
A practising specialist paediatric physiotherapist (Fellow of the Australian College of
Physiotherapists), sessional lecturer at Griffith University and National President of the
Australian Physiotherapy Association.
Mr Tim Benson
An experienced senior health consumer representative and a member of both the national
and state peak consumer health bodies, as well as the North Metropolitan Area Health
Service Governing Council in WA.
Dr Mark Bowman
A practising dentist in Victoria, federal and state councillor of the Australian Dental
Association and President of the Australian Society of Periodontology.
Professor David Clarke
Clinical Director of Community, Access and Partnerships, Mental Health Program at
Southern Health in Victoria, and Head of Psychiatry within the School of Psychology and
Psychiatry at Monash University.
Professor Nicholas Glasgow
A practising palliative medicine specialist and General Practitioner in the ACT, and Dean of
the Australian National University Medical School.
11
Ms Helen Gosby
A nurse practitioner in the emergency department at the Children’s Hospital at Westmead,
NSW, and President of the Australian College of Nurse Practitioners.
Dr Alasdair MacDonald
Director of Medicine, Clinical Integration, Reform and Stroke Care within the Tasmanian
Northern Area Health Service and active in Education and Policy within the Royal
Australasian College of Physicians.
Dr Jennifer May
A practising general practitioner in rural NSW, GP Academic at the University of Newcastle
Rural Clinical School, immediate past Chair of the National Rural Health Alliance and the
Chair of the Rural Doctors Association Female Doctor’s Group.
Professor Tracey McDonald
An aged care research professor who holds the RSL LifeCare Clinical Research Chair of
Ageing at the Australian Catholic University.
Dr Ameeta Patel
A practising rural general practitioner and clinical educator in the Northern Territory.
Dr Andrew Pesce
A practising obstetrician and gynaecologist, currently appointed as Clinical Director in
Women’s Health in Western Sydney Local Health District and a member of the Local Health
District Board, as well as the immediate past President of the Australian Medical
Association.
Ms Toni Riley
A practising pharmacist in a regional Victorian pharmacy providing opiate replacement,
primary care services and services to residential care facilities.
Professor Christobel Saunders
Winthrop Professor and Head of Unit for Surgery (QEII Medical Centre) and Academic SubDean, University of Western Australia - responsible for conducting a large number of clinical
research projects in cancer, and a prime teacher of surgery to undergraduate and
postgraduate students at the University of Western Australia.
12
Dr Mark Wenitong
A founder and past President of the Australian Indigenous Doctors Association, and the
senior medical officer for Apunipima Cape York Health Council, an Aboriginal communitycontrolled health service delivering primary care to remote Cape York communities.
Associate Professor Craig Whitehead
A practising geriatrician at Repatriation General Hospital and the Regional Clinical Director
for Rehabilitation and Aged Care.
13
5.2
APPENDIX 2 – NSW NATIONAL CLINICIANS NETWORK PROGRAM
14