Why has effective handover lagged in Australia?
“The reason perhaps it has not yet become popular has been the negligible medico-legal implications….. What is needed is more evidence of poor outcomes that can occur following inadequate handover.”
“Many rosters still require substantial shifts from junior doctors, although these are largely being removed. Even if the shifts are long, there are requirements that a certain number of days each week be off roster and therefore not in the hospital otherwise punitive salary arrangements are brought into place. For this reason, handover is required. The reason perhaps it has not yet become popular has been the negligible medico-legal implications and the fact that the current system largely copes, even in the absence of a good handover. What is needed is more evidence of poor outcomes that can occur following inadequate handover and perhaps a more punitive system that will encourage good practice. Sometimes the stick is just as important as the carrot.”
How are eHealth initiatives supporting effective handover?
“eHealth initiatives do exist for handover, particularly in emergency departments. A number of such systems have now been developed where red flags are attached to unreviewed pathology results or patients who require a regular review. These types of systems could, of course, in time be introduced to ward patients but have not gained large currency, partly because of the cost of implementing them and a lack of motivation from hospital bureaucrats to spend the health dollar on such systems, preferring in the current environment to support activity rather than quality.”
Do you have examples of effective changes to handover processes?
“The handover process remains challenging within the healthcare system. This has been well established in the nursing environment with rosters and appropriate time and processes for handover to occur. Within the medical system, handover has not been part of the traditional patient care. Clinicians took 24 hour, 7 day-a-week responsibility for their patients, meaning that the need for handover was largely redundant, except in settings such as emergency and intensive care where such processes have been well established. The barriers now are, firstly, engaging senior clinicians in such an enterprise and, secondly, enshrining an appropriate process into the junior medical officers. At this stage, many hospitals provide little or inadequate time for handover and even if it’s provided, it’s usually done in a casual and poorly structured environment. The challenge is to develop workable, affordable and reliable handover techniques for the medical staff and to have these interdigitating effectively with the nursing support.”
What are the main barriers to effective teamwork in a healthcare setting?
“…………. usually traditional approaches, a hierarchical structure or individuals unhappy to share the decision making or the responsibility associated with the care of patients.”
Working with Consumers
What is the biggest barrier to effective participation of consumers in their care?
“Probably the biggest barrier to effective participation of consumers is the structures in which to incorporate them. There is, of course, a long history of the doctor and the health team making decisions on behalf of consumers in the mistaken belief they were the best individuals to determine what patients require. This has now been supplanted by an understanding that the patient’s wishes are also important. The problem, however, remains how to access them and engage them in a meaningful and long-term environment.”
What progress have you seen in consumer participation in the last ten years?
“Within the last ten years many hospitals have involved consumer or community groups in advising on the services they deliver. More importantly, consultative groups, particularly relating to broad-based healthcare issues have sought consumer participation. The quality of this participation has also improved with a clear understanding from most of the consumer representation that they are there to take a broad and not a personal view. There is now ready acceptance of consumer input, the difficulty is obtaining it, maintaining it and organising the business of a hospital in such as way as they be meaningfully involved.”
What are the risks for a health service of not collaborating with consumers when planning and delivering care?
“The problem of not involving consumers is to develop systems that have missed important elements that may have been obvious to a consumer but not necessarily to the healthcare professional. Such issues as transportation, frequency of visits, access to testing, follow-up of results, and communication with relevant carers, not just immediate relatives, are examples of issues that are often overlooked. The cost, waste and co-operation of the consumer is often considerable when they have not been engaged in the process.”
What is more important to improving consumer participation; a community shift in thinking or a health industry shift in thinking?
“the health sector itself needs to include consumers in its thinking in the same way as it includes accountants in the costing of a service.”
“I think communities need to understand that their opinions can be used and acted upon within the health sector. However, the health sector itself needs to include consumers in its thinking in the same way as it includes accountants in the costing of a service. No hospital now would introduce a new service without a careful business case and, similarly, no hospital should include a new service without taking on community and consumer views regarding the relevance and importance of such a service in the area. Many examples exist of the community’s view on a new service being somewhat at odds with the hospitals’ view.”
Do recent graduates have different views on consumer participation than more established health service staff? Is there variation depending on specialty / area of a health service?
“It is important that the old hierarchical approach be slowly replaced by a more responsive health service that understands .…. the community and patients that it serves.”
“On the whole, junior medical staff are trained by senior medical staff. The views of the senior medical staff often permeate and influence the junior staff. There is a more ready acceptance from junior staff, particularly freshly out of medical school, to engage with patients and community groups, however unless this is strongly reinforced in the health environment such support and engagement is likely to be dissipated. It is important that the old hierarchical approach be slowly replaced by a more responsive health service that understands not only its healthcare professional needs but also the community and patients that it serves.”
