Instituting electronic hospital handovers ¹

At-A-Glance

Current behavior:

Doctors provide verbal or hand-written handover notes at the end of each shift.

Desired behavior:

Doctors record handover notes in an electronic system at the end of each shift.

Change approach:

Implemented an easy-to-use system with built-in reminders, used mandatory quizzes and pressure from senior doctors to encourage compliance.

Impact:

Non-compliance with the system went down from 6.7% to 1.4% over a seven-month period.

Implications for implementing partners:

Gather user input to design systems that will be as convenient as possible; develop solutions iteratively to test and refine what works in practice.

Implications for supporting partners:

Give implementers the flexibility and resources to test out iterative solutions.

Proper handover of information between doctor shifts is critical for patient safety, and electronic handover systems have been found to reduce errors caused by informal verbal handovers. Singapore General Hospital had tried instituting an electronic handover system in the past, but participation was low and the effort failed due to the additional work it put on doctors. A new team was therefore tasked with figuring out a way to institute electronic handovers.

The team first met with doctors to understand why they had not used the prior system and what would increase compliance. They organized doctor meetings to discuss the new proposed solution and gain buy-in for the changes.

The new system significantly reduced the effort required by doctors, streamlining a long form into four simple fields that could be viewed on a single screen. It was also integrated into the existing Electronic Medical Record platform, as opposed to being in a separate system. Given that some well-intentioned doctors forgot to complete handoffs at the end of a long shift, the hospital created automated reminders to the doctors at the beginning and end of shifts. To increase the incentives for compliance, they mandated quizzes to test doctors’ knowledge of the new system and provided certificates to those who passed. Finally, they enlisted senior doctors to encourage all staff to follow the new protocols.

The ultimately successful solution was developed and improved iteratively, incorporating feedback from doctors who were advising throughout the process.

The ultimately successful solution was developed and improved iteratively. For instance, while reminders were initially provided by calls or text messages from residents, automated reminders in the EMR were found to be more reliable and impactful on compliance. The effort ultimately reduced non-compliance from 6.7% to 1.4% over a seven-month period.