Doctors’ Handovers in the Acute Medical Assessment Unit: A Hierarchical Task Analysis

1. Doctors’ Handovers in the Acute Medical Assessment Unit: A Hierarchical Task Analysis Michelle A. Raduma1 Supervisors: Prof Rhona Flin1, Dr Steven Yule1, Dr David Williams2 University of Aberdeen1, Aberdeen Royal Infirmary, NHS Scotland2 This work is funded by

2. Handovers can be high-risk • The literature suggests that handovers are a “high –risk” situation that can cause gaps in the continuity of patient care due to communication/ teamwork failures, and can lead to adverse events1 1Cook, R.I., Render, M., & Woods, D.D.(2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320 (7237), 791-794.

3. Piper Alpha ‘I conclude that the leak resulted from steps taken by night-shift maintenance. Unknown to them a pressure safety valve had been removed… the lack of awareness of the removal of the valve resulted in failures in the communication of information at shift handoverearlier in the evening and failure in the operation of the permit to work system in connection with the work which had entailed its removal’ (Cullen, 1990, Ch 1, p 1.)

4. Doctors’ handovers • With the implementation of Working Time Directives regulating the maximum amount of hours doctors can legally work, there has been an increase in doctors’ shift work. • Studies in Patient Safety research show that increased shift work amongst doctors has created problems in relation to safe handover practices, such as: • A lack of good communication between doctors at shift handovers. • A loss/miscommunication of patient information at shift handover • Very idiosyncratic and unsystematic handovers

5. Research study sample • Teams of doctors transferring primary responsibility for their patients to other teams of doctors. • Doctors working within the Acute Medical Assessment Unit (AMAU).

6. Why the AMAU? • AMAUs are: • Complex work environments because patients admitted have a wide range of conditions or may be undiagnosed • They experience a large number of patient transfers • Often where a patient’s journey during their hospital stay begins. It is vital therefore that a continuum of care is maintained, where patients can be moved easily and safely from one point in the system to the next (Royal College of Physicians, 2002). ‘The evidence base for best practice in acute medical care is weaker than it should be and needs to be strengthened. For this to occur, the culture of research and development in acute medical services should be given a higher priority than it has at present.’ (Royal College of Physicians, 2007).

7. Research objectives Objectives: • To understand the doctors’ handover process in hospital settings, specifically in the AMAU by means of a hierarchical task analysis (HTA). • To identify where patient information is at risk in the handover process.

8. Hierarchical task analysis (HTA) To fully describe how a task is done, a detailed account of the activities that are a prerequisite for the successful completion of the task need to be systematically documented. Asystematic analysis of a task that makes it easier to identify where risks and problems in the performance of the task may lie. This enables those specific problems to be targeted for improvement (Shepherd & Stammers, 20032). 2) Shepherd, A. & Stammers, R.B. (2005). In Wilson, J.R. & Cortlett, N (Ed). Evaluation of Human Work 3rd ed. Florida: Taylor & Francis Group

9. HTA: How to use a dance mat

10. Documenting the handover process: Data collection • Raduma, Flin, Yule, & Williams2 identified various methods that have been employed to investigate handovers • Observations (N= 30) • Interviews (N= 20) • Questionnaires • Critical incident reporting • To conduct the HTA, a detailed description of activities pre-handover, at handover, and post-handover will be carried out via observations and interviews. • The result: a hierarchy of steps that represent behaviours that are required to accomplish the task goal. 2) Doctors’ handovers in hospitals: A literature review (Manuscript under review)

11. Documentingthe handover process: Procedure • The study is being carried out in three stages • Stage 1: Identification of the key tasks and goals of the doctors’ shift handover (completed) • Stage 2: Construction of the HTA • Stage 3: Re-evaluation of the HTA

12. Documenting the handover process: Method • An observation checklist and interview schedule developed based on: • previous methods used in other handover studies, • a literature review, • and preliminary observations of doctors’ shift handovers (n = 5)

13. Observation checklist

14. Observation data • Shadow doctors as they prepare handover • Attend handover meetings • Shadow doctors after they have received handover

15. Observation data: Coding

16. Interview schedule

17. Interview data: Coding • Note the main tasks of each handover phase • Categorise these in terms of: • the goal (e.g. to prepare the handover) • the operation (what the person does to move towards the goal) • the plan (the conditions under which to act in order to reach the goal) • Organise these tasks sequentially

18. Interview coding example Goal: What is the first thing you do in preparation for handover? “…making sure I know where the patients are and not handing over people who might have already moved across the other side of the hospital” Operation: How do you find out where the patients are? “you need to go and look at the list of patients in the red book behind the nurses’ desk and see which patients have gone” Plan: Do you do that for every patient in the AMAU before the 4pm handover? “…you do that only if the patient has already been assessed …I tend to do it just before the handover, so about 4pm”

19. Preliminary HTA: Doctors’ handovers in the AMAU

20. Thank you. Please feel free to ask any questions. For more information, please contact me or visit our website michelleraduma@abdn.ac.uk www.abdn.ac.uk/psrg