achieving the ‘perfect handoff’ in patient transfers: building teamwork and trust
TRANSCRIPT
Achieving the �perfect handoff� in patient transfers: buildingteamwork and trust
DIANA CLARKE R N , P h D1, KIM WERESTIUK R N
2, ANDREA SCHOFFNER R N3, JUDY GERARD B N ( S t u d e n t )
4,KATIE SWAN R N , B S N
5, BOBBI JACKSON R N6, BETTY STEEVES R N
7 and SHELLEY PROBIZANSKI R N , B S c N8
1Associate Professor, University of Manitoba, 2Unit Manager, Acute Unit – GD4, 3Research Coordinator andGDRN, D5, Health Sciences Centre, 4Research Assistant, University of Manitoba, 5Research Assistant and GDRN,D4, 6Unit Manager, 7Clinical Resource Nurse, Sub-Acute Unit – GD5 and 8Manager, Quality and Critical Risk,Health Science Centre, Winnipeg, MB, Canada
Introduction
Handoffs in patient care are defined as a transfer of
responsibility for a patient�s care from one provider to
another. As patients move from provider to provider, it
is critical that timely, accurate information about a
patient�s care plan, treatment, current condition, and
any recent or anticipated changes goes with them. With
Correspondence
Diana Clarke
317 Helen Glass Centre for
Nursing
University of Manitoba
Winnipeg
MB
Canada
R3T 2N2
E-mail: [email protected]
C L A R K E D . , W E R E S T I U K K . , S C H O F F N E R A . , G E R A R D J . , S W A N K . , J A C K S O N B . , S T E E V E S B . &
P R O B I Z A N S K I S . (2012) Journal of Nursing Management
Achieving the �perfect handoff� in patient transfers: building teamwork and trust
Aims To use the philosophy and methodology of Appreciative Inquiry (AI) in the
investigation of unit to unit transfers to determine aspects which are working welland should be incorporated into standard practice.
Background Handoffs can result in threats to patient safety and an atmosphere of
distrust and blaming among staff can be engendered. As the majority of handoffs
go well, an alternative is to build on successful handoffs.
Evaluation The AI methodology was used to discover what was currently working
well in unit to unit transfers. The data from semi-structured interviews that
were conducted with staff, patients, and family informed structural process
improvements.
Key issues Themes extracted from the interviews focused on the situational vari-
ables necessary for the perfect transfer, the mode and content of transfer-related
communication, and important factors in communication with the patient and
family.
Conclusions This project was successful in demonstrating the usefulness of AI as
both a quality improvement methodology and a strategy to build trust among key
stakeholders.
Implications for nursing management Giving staff members the opportunity to
contribute positively to process improvements and share their ideas for innovation
has the potential to highlight expertise and everyday accomplishments enhancing
morale and reducing conflict.
Keywords: acute care, appreciative inquiry, handoffs, patient transfers
Accepted for publication: 31 January 2012
Journal of Nursing Management, 2012
DOI: 10.1111/j.1365-2834.2012.01400.xª 2012 Blackwell Publishing Ltd 1
each handoff, however, there is the possibility of crucial
information being lost or mis-communicated. These
lapses can result in incidents ranging from lost personal
items and inconvenience to patient injuries and exacer-
bation of the patient�s condition. While our current
culture of patient safety initiatives has tended to focus on
identifying vulnerabilities and recovery from failure, the
vast majority of handoffs go smoothly and are unac-
knowledged. The purpose of this quality improvement
project was to examine what �goes right� in handoffs and
employ the philosophy and methodology of Appreciative
Inquiry (AI) to develop protocols that build on strength
rather than recover from failure.
Background
The tenor of incident reports, focusing on errors in
patient care, has the potential to be one of blame and
culpability, disempowering individual staff and pitting
both individuals and patient care units against one
another resulting in both inter-unit and intra-unit
conflict and mistrust. While the vast majority of
handoffs go smoothly with minimal threat to patient
safety and no untoward events, most research has fo-
cused on the negative consequences of handoffs errors.
Thus, little is understood regarding how to achieve
best practices (Riesenberg et al. 2010). Out of between
700 and 1000 transfers per year from acute to sub-
acute medicine units at our tertiary care, inner city
hospital, very few were found to result in incident
reports (37 non-medication related occurrences over a
30-month period that could be directly attributable to
errors in inter-unit handoffs). This suggests that there
are processes in place, albeit perhaps informal and
dependent upon the skills and expertise of selected
staff, which result in successful handoffs. The key is to
uncover these processes, validate them and expand on
them in a constructive manner. Furthermore, having
staff members share their positive experiences in
patient care and their ideas for innovation with one
another and with management has the potential to
highlight expertise and everyday accomplishments thus
enhancing morale.
Appreciative Inquiry
Appreciative Inquiry is both a philosophy and a pro-
cess for creating change that focuses on what is
working well and builds on success. It was developed
in the mid-1980s (Cooperrider & Srivastva 1987) as a
type of action research that focused on a more positive
stance seen as collaborative and participative and more
capable of generating innovative change (Van der
Haar & Hosking 2004). Appreciative Inquiry provides
a structure for inquiry into what is the best of what
already exists in a system, making explicit areas of
good performance, communicating and institutional-
izing that good performance so that it is continued and
replicated (Norum 2001, Coghlan et al. 2003) – a
fundamental premise of AI being that �organizations
move toward what they study� (Cooperrider & Sri-
vastva 1987). It has been found that AI is particularly
effective in conflict settings or settings or situations in
which there can be culpability or blame, as the pro-
cesses inherent in AI promote collaboration. When
individuals are engaged in a positive process, as op-
posed to a blaming, fault-finding process, they are
more willing to share their experiences (Elliot 1999,
Patton 2003, Wright & Baker 2004) and take con-
structive ownership in any processes resulting from the
work (Patton 2003).
Setting
The Health Sciences Centre (HSC) is a tertiary teach-
ing hospital in Winnipeg, Manitoba, Canada affiliated
to the University of Manitoba. It comprises five co-
located hospitals under a central administration. The
issue of unit to unit patient transfers had been identi-
fied as an area of concern through regular �incident
report� audits and brought to the Centre-wide Nursing
Practice Council where the idea for the project was
born. The demonstration project focused on routine
transfers from four acute general medical units to the
subacute, non-teaching unit. The principal investigator
for the project was a faculty member from the affili-
ated university who had a joint appointment with the
centre. Additional research team members included
two managers from participating units, one clinical
resource nurse, two general duty nurses who were
interested in learning more about research, a manager
from the Safety and Quality division, and a research
assistant who was an undergraduate university nursing
student. The four �Ds� of Appreciative Inquiry (dis-
covery, dreaming, design and destiny) informed the
methodology (Norum 2001, Coghlan et al. 2003,
Havens et al. 2006).
Discovery
The discovery phase began with the assumption that
every system has aspects that work well and proceeds
with discovering what those aspects are (Norum
2001). This stage involved conducting interviews with
all stakeholder groups with the aim of describing what
D. Clarke et al.
ª 2012 Blackwell Publishing Ltd2 Journal of Nursing Management
�gives life to the system� (Cooperrider & Srivastva
1987). Identified key stakeholders invited to partici-
pate in the project were: general duty nurses from all
shifts on all participating units; patient care managers
and clinical resource nurses from all units; patients and
family members who had undergone a recent transfer
between selected units; allied nursing personnel (unit
clerks, unit assistants); any other disciplines whose
work may be affected by the transfers (e.g. social
workers, rehabilitation specialists, physicians).
Semi-structured 15- to 20-minute interviews were the
primary data collection strategy. Questions asked of
nurses included: �Recall and describe in detail a time
when you experienced a handoff/transfer that was
nearly perfect�, �What aspects of the current process
should be preserved?� and �What do we need to put in
place so that every transfer could be perfect?�. Non-
nursing staff were asked: �How would a perfect transfer/
handoff impact your work?� Patients and family mem-
bers were asked �What would be your three wishes for a
perfect transfer?�As the project was externally funded, ethical ap-
proval for the project was secured from the University
of Manitoba Education Nursing Ethics Review Board
(protocol #2009:155) and all research access proce-
dures were adhered to. As interviews were conducted
by the general duty nurse volunteers, the schedule was
developed so that they interviewed individuals with
whom they did not work. All data were de-identified
so that managers could not identify individual staff
members. All participants were given an embossed
stainless steel coffee mug as a thank you gift. Inter-
views were tape-recorded and data were transcribed
verbatim and analysed by the research team for themes
that addressed the purpose of the study (Hsieh &
Shannon 2005).
The interview participants were 29 general duty
registered nurses, five ward clerks, two home-care
coordinators, nine allied health clinicians (social work,
speech therapy, rehabilitation), two patients and one
family member. A very strong overriding theme
throughout all interviews was that the welfare of the
patient was of uppermost concern. The word �trust�was found repeatedly in the transcripts implying that
the patients and families trusted the staff to care for
them, the staff understood that trust and that they
needed to trust each other in the provision of that
care. The nurses, especially, were very practical in
their responses relating the details of the perfect
transfer with data focusing on information needed for
the transfer, and practical communication-related
variables.
Information
Information the nurse needed to prepare for the transfer
included, most importantly, knowledge of the patient
and the circumstances of admission, the chronology of
events during the admission, and plans for discharge.
Relevant test results, pending tests or procedures, plans
for rehabilitation, etc., were also crucial pieces of
information. The major challenge for nurses at this
point was finding the time to gather and collate the
relevant information (including finding time to speak
with the patient and the family) and the quiet space to
adequately prepare and organize the information re-
quired for the transfer. The nurses were not short of
suggestions regarding how to accomplish this. One
nurse fantasized having a �cone of silence� that could be
employed for such activities. Another, more practically,
suggested having a brightly coloured safety vest that
staff members who did not want to be disturbed could
put on. Yet others talked about designating a space on
the unit reserved for nurses where they were not to be
disturbed.
Unit clerks were discovered to have designed their
own transfer procedures that worked well in their
particular situation and for their patient population,
especially for gathering information and knowing who
to call about what and when. Much of what appeared
to be going well regarding transfer processes could be
attributed to this often underappreciated group.
Highlighting their contributions was important in
building a sense of teamwork around preparation for
transfer.
Communication
Although nurses indicated that they would prefer
face-to-face handoffs, they understood that it was not
usually practical. They were emphatic in their recom-
mendation that person to person contact be by phone
where there is the opportunity to ask questions (�you
can�t ask a question of a piece of paper�) and the ability
to follow up later if necessary (although to �clarify, not
to blame�) was crucial. Some form of standardized
reporting so that the nurses were �on the same page�(e.g. a checklist) was suggested by the majority of the
respondents. It was clear that the faxed report currently
in use was only exacerbating negative relationships
between some units and should be discontinued.
With respect to communication with patient and
family, the following points were put forward for con-
sideration: Has the move and the reasons for the move
been adequately explained to the patient? Have family
Perfect handoff
ª 2012 Blackwell Publishing LtdJournal of Nursing Management 3
been notified? They suggested that it was important to
keep in mind the fact that the patient/family may not
want to move having gotten to know and trust the staff
on the transferring unit. To decrease anxiety and
uncertainty, they suggested that the rationale for the
transfer be carefully explained. Meeting a staff member
from the new unit prior to the move would also give
staff on both units an opportunity to meet one another
thus building inter-unit collegial relationships. Finally,
waiting for the transfer to occur was a stressor for pa-
tients, suggesting that they needed to be kept informed
regarding delays. Again, time to do this adequately was
often at a premium.
Dream
Armed with the results from the thematic analysis and
quotes from the transcripts, the research team and
staff met in a day-long workshop to �create the com-
pelling vision of the future� (Shendell-Falik et al.
2007). Using various methods such as brainstorming
and storyboards, the group mapped out a �perfect�handoff protocol based on the data collected in the
interviews. Key points for consideration were: a quiet
place to prepare documents; time to find relevant
information and speak with patient and family; a
standardized verbal report; and a transfer checklist.
The notion of trust that the patients and families re-
ported in the course of interviews was reminiscent of a
campaign at Stanford University Hospital in San
Francisco, California, USA (Shelley Young, personal
communication) that employed �A Transfer of Trust� as
the guiding principle in all clinical handoff/transfer
situations. �A Transfer of Trust� then became part of
the �handoffs� team�s advertising with staff along with
the �perfect handoff� phrase.
Design
In the design phase the dream is operationalized
through attending to specific changes in roles, systems,
structures, ways of working, etc. (Coghlan et al. 2003,
Arora & Johnson 2006).
Quiet time and place
Individual participating units were challenged with the
task of finding a quiet place within the geography and
the �politics� of their units that could be designated for
nurses� preparation of transfers. Although this was
particularly challenging for teaching units where a
multiplicity of disciplines and their students are all
vying for space, this project highlighted the importance
of handoffs and gave nurses �permission� to claim space
for this very important work. Units will be reporting
back to the research team in due course regarding their
experiences and successes with this.
Verbal report
The Safety and Quality Department had been promoting
�SBAR� (Situation, Background, Assessment, Recom-
mendations) as a means of effective communication for
all types of clinical encounters. This format was adopted
by the �handoffs� research team who reinforced it by using
it in all written communication with staff. Educators
were also encouraged to reinforce SBAR in their com-
munication with staff at every possible opportunity.
A transfer checklist
The research staff coordinated a meeting where they
were joined by four additional volunteer general duty
registered nurses. Using the data collected in the dis-
covery phase, it was determined which points were
crucial to a �perfect handoff� and a checklist was de-
signed (Figure 1).
The checklist was trialled over a 4-week period.
Nurses using the form were asked to complete a very
brief evaluation form and completed transfer checklists
were collected and examined for completeness. As it
became apparent that some education, albeit brief and
concise, was going to be necessary for dissemination
and uptake of the checklists, clinical educator involve-
ment was seen as crucial. Units that had a more suc-
cessful uptake of the checklists were found to have unit
clerks who ensured that checklists were placed on the
charts of patients scheduled for transfer.
Destiny
Once the design phase was completed with an accom-
panying process map and milestones, implementation
was planned. Inherent within the destiny phase is
evaluation which for AI takes on a �responsive� format.
The evaluation of the checklist will be ongoing and will
become the responsibility of the research team members
based at HSC. Data collection will include: chart audit
of transfer notes (to determine completeness); audit of
units� locked drawers at 6 months post implementation
(to determine if valuables are indeed being transferred
with the patient); rates of form usage (as indicated by
orders from the warehouse); incident reports (as gath-
ered by Safety and Quality); staff, patient, and family
member feedback. The study team will develop a
questionnaire that will voluntarily and anonymously
survey stakeholders regarding their levels of satisfaction
D. Clarke et al.
ª 2012 Blackwell Publishing Ltd4 Journal of Nursing Management
with the new process, improvements/changes in the
sense of teamwork, and any suggestions for improve-
ment. Finally, the impact of the processes on improving
patient outcomes (Cohen & Hilligoss 2010) will be
tracked through Safety and Quality over time.
Conclusion
Using AI and building on strength, the process of
transferring between units at HSC has been given some
structure and consistency. Examination and evaluation
as to whether this structure promotes the �perfect
handoff� every time will be on-going. More importantly,
the project was an opportunity for staff from various
units and various disciplines to share ideas about
improving patient care and, importantly, reinforcing the
notion all staff are committed to honouring the patient�sand family�s trust in them.
Very recently the clinical resource nurse from the
subacute unit was approached by the family of a patient
who had been recently transferred to the unit. They
stated that they had been very nervous about the
transfer as they had had a good experience on the pre-
vious unit and had come to trust the staff there. Their
Addressograph
In Hospital Patient Transfer Checklist
Documentation□ MARs □ Old chart □ Thinned chart □ Kardex □ Addressograph □ I & O sheets □ Vital sign sheets/Flow sheets □ Care maps □ Room signage/Precaution Sheets:
o Patient Safe Handling o SLP o OT o PT o Risk for Falls o Constant Attendant record
Information □ Head to Toe Assessment/documentation□ ACP level: 1 2 3 4□ Allergies: yes no; comments___________□ Patient advised□ Family notified: yes no; POA, Public Trustee□ Isolation____________□ Risk for falls: yes no; Safe Handling Score_____□ Language other than English_____________□ Escort: yes no; comments_____________□ Interpreter: comments_________________□ Constant Attendant required: yes no
Reason: Violent/aggressive Verbal Wander precautions Suicidal observation
Allied Health Involvement□ Social Work□ Home Care□ Physiotherapy□ Occupational Therapy□ Speech/Language Pathology□ Other _______________
Rental Equipment(alert manager of equipment
transfer) □ Bariatric bed/lifts□ KCI□ Other__________
Hospital Equipment Sent□ Walker/Cane□ Wheelchair□ Cushions□ Braces/Splints□ Stockings□ Other_______________
Things to Pack□ Patient’s personal belongings (ensure well labelled)
□ Dentures □ Hearing Aids □ Glasses □ Clothes/shoes □ Walker/Cane □ Own home medications □ Wheelchair □ Locked drawer items/cashier slips □ Cushions □ Other:_______________ □ Jewelry ___________________ □ C-pap/Bi-pap ___________________
□ Medications not in Pyxis, including:□ Wound care products □ Tube feed solutions □ Aero chambers and puffers □ Antibiotics
□ Notify VETV to transfer/refund T.V./phone rental(s)
Disposition:
Figure 1In-hospital patient transfer checklist.
Perfect handoff
ª 2012 Blackwell Publishing LtdJournal of Nursing Management 5
fears, it turned out, had been unfounded: �We didn�thave to tell them (the staff on the receiving unit) any-
thing (about the particulars of their family member�scare); they just knew!� That is the essence of the perfect
handoff – apparent seamlessness of the process for the
patient and family. The challenge will be to achieve that
every time for every patient.
Implications for nursing management
Smooth, efficient, and complete patient transfers be-
tween units contribute to improvements in safety and
patient satisfaction through reducing the possibility of
error but also through reducing conflict and improving
working relationships among staff. It was clear in the
data that continuity of care and maintaining an envi-
ronment of trust were of utmost importance for staff.
Furthermore, when patients and family were asked to
contribute from their point of view, the conceptualiza-
tion of the process as a �transfer of trust� between
healthcare providers was strengthened.
The philosophy underlying AI is building on strength –
that much of what is already being done is of value and
needs to be preserved. Of note was how much work in
successful transferring was already being done by nurses
and unit clerks and how many of them had their own
processes in place to ensure efficiency and accuracy.
Bringing some of these innovations and processes to
light and validating them within the overall context of
safety and continuity of care encouraged staff to
understand how what they do fits into the bigger picture
of quality patient care. The notion of �teamwork� and
how that contributes to successful transfers of trust was
not specifically examined in this study but was implicit
in much of the data gathered and merits more explicit
investigation.
Importantly, this project demonstrated the practicality
and usefulness of AI as a research and process improve-
ment methodology. Staff were engaged and participated
in the process enthusiastically in all phases of the study.
In contrast with the usual lag between data collection
and outcomes in quality improvement projects, they
were able to see immediate results from their participa-
tion. The simultaneous nature of inquiry and interven-
tion in AI (Cooperrider et al. 2008) employed in this
study mirrored the PDSA (Plan/Do/Study/Act) method-
ology for quality improvement recommended by the
Institute for Healthcare Improvement (Langley et al.
2009). When the rigours of research design are adhered
to, functional relationships between process changes in
systems of health care and variation in outcomes can be
demonstrated using a PDSA structure (Speroff &
O�Connor 2004), with the additional benefits of faster
implementation.
This study specifically examined the inter-unit trans-
fer. However, �transfers of trust� occur many times a day
for each patient, for example, shift to shift handoffs,
handing off responsibility for care when covering
breaks, etc. How much of what has developed as a re-
sult of this project can be translated to these other
transfers remains to be seen. Certainly, the process for
inquiry, the hospital-based �champions� at all levels of
the organization, and the staff�s demonstrated confi-
dence in AI as an effective strategy are in place and can
be deployed for extensions of this project.
Source of funding
University of Manitoba Paul T. Thorlakson Foundation
Fund with partial in-kind salary support from the
Health Sciences Centre, Winnipeg.
Ethical approval
University of Manitoba Education Nursing Research EthicsBoard Protocol #E2009:105.
Acknowledgements
The authors wish to thank Ms Helga Bryant and Mr
Patrick Griffith, Chief Nursing Officers of Health Sci-
ences Centre, and Ms Heather Shortridge, Director of
Patient Services, for their support of this project.
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