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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.5 Continuity of care

Our practice provides continuity of care for its patients.

Criterion 1.5.2

Clinical handover

Our practice has an effective clinical handover system that ensures safe and continuing healthcare delivery for patients.

Indicators

► A. Our practice team can demonstrate how we ensure an accurate and timely handover of patient care.

Explanation

Key points

  • Clinical handover of patient care occurs frequently in general practice both within the practice to other members of the clinical team and to external care providers
  • Clinical handover communications can be face-to-face, written, via telephone and also by electronic means
  • Failure or inadequate transfer of care is a major risk to patient safety and a common cause of serious adverse patient outcomes. Inadequate handover can also lead to delayed treatment, delayed follow up of significant test results, unnecessary repeat of tests, medication errors and increased risk of medicolegal action
  • Practices and services that provide care outside normal opening hours should have standard and documented processes for timely clinical handover
  • Practices should encourage the reporting of near misses and breakdowns in clinical handover procedures and make improvements to minimise the risk of recurrence.

Defining clinical handover

Clinical handover has been defined by the Australian Medical Association as ‘the transfer of professional responsibility and accountability for some or all aspects of a patient’s or a group of patients’ care to another person or professional group on a temporary or permanent basis’.

Clinical handover needs to occur whenever there is an interface of care by different providers. Examples of clinical handover include:

  • a GP covering for a fellow GP who is on leave or is unexpectedly absent
  • a GP covering for a part time colleague
  • a GP handing over care to another health professional such as a practice nurse, physiotherapist, podiatrist or psychologist
  • a GP referring a patient to a service outside the practice
  • a shared care arrangement (eg. team care of a patient with mental health problems).

Whenever clinical handovers occur, whether external or internal, practices should ensure patients are aware of who will take over their care in the absence of their regular doctor. Patients need to be involved in the decision, particularly when they consult with more than one GP in the practice or a specialist or other care provider.

System for clinical handover

Practices are encouraged to have a documented policy on clinical handover to ensure standard processes are followed. When appropriate, it is prudent to record the clinical handover in the consultation notes and document that the patient has shared in decision making and has been informed (see Criterion 1.6.2 Referral documents).

Clinical handover within the practice

Clinical handover between GPs has become perhaps more common in recent years, with so many GPs now working on a sessional basis at a practice. Handover is important when a GP or other clinical staff member is away because of annual leave or illness. Practices should have a defined method to cover the handover of care of patients who have been under the care of the absent clinical team member. Many practices have a ‘buddy’ system whereby a ‘buddy’ follows up results and correspondence or continues the care of patients on behalf of an absent colleague. If a practitioner has a ‘buddy’ system to hand over care, this should be standardised and previously agreed, rather than ad hoc. Such arrangements do not necessarily have to be documented in the consultation notes, although the identity of the treating GP does need to be recorded. Adequate clinical records, including a health summary, will enable another doctor to safely and effectively continue the routine care of patients. Practitioners should routinely read the patient’s preceding clinical records for the past few consultations.

Clinical handover outside the practice

Clinical handover of a patient’s care outside the practice occurs in many ways. It includes but is not limited to: referral for an investigation, referral to an ancillary healthcare provider, referral to a specialist and referral to a hospital, as an outpatient or as an in patient. Criterion 1.6.2 Referral documents states that referral letters include sufficient information to facilitate optimal patient care including details of ‘the purpose of the referral’. As an example, clarifying, rather than assuming, who will manage the responsibility for follow up of investigations when referring a woman with a breast lump to a breast physician or surgeon.

When shared care ceases

Where a clinical handover involves complex or high risk patient care, such as suicidal patients, or patients on complex medication regimens, it is important for a GP to request that they be notified if the care of the patient ceases. Equally, if the GP stops seeing a patient they are treating on a handover basis, or the patient ceases to attend for treatment, it is important for the GP to notify others in the treating team in the interests of patient safety. This issue has been the subject of several coroners’ recommendations.

Medical deputising services

Many practices hand over care of all their patients to a medical deputising service or other provider outside the normal opening hours of the practice. It is prudent to notify the deputising care provider of patients that you anticipate may need care (eg. a patient with a terminal illness). Deputising services need to have a defined means of timely contact with a GP from the practice when they are deputising, should they need to access more detailed health information about a patient. Deputising services are responsible for handing the care of a patient back to the patient’s regular medical practitioner in a timely and appropriate manner.

Clinical handover to an emergency department

If a GP calls an ambulance from the practice to attend a patient’s home, or if the GP is aware that an ambulance has been called to a patient’s home to take the patient to an emergency department, the handover to the ambulance service should be face-to-face where practical or by telephone. When an ambulance service is not involved, the practice should ensure that sufficient information is provided to the emergency department about the clinical condition of the inbound patient, to facilitate prompt and appropriate care.

Handover of tests and results

Pathology services sometimes need to contact a practice doctor after the practice is closed concerning a serious result (eg. an unexpected result suggesting a patient has acute leukaemia or a raised INR).

General practices need to have arrangements in place to allow abnormal and life threatening results identified by pathology outside normal opening hours to be conveyed to a medical practitioner in a timely way, so the medical practitioner can make an informed and appropriate medical decision that is acted on promptly (see Criterion 1.1.2 Telephone and electronic communications).

There are occasions when the need for a handover process is more critical, such as a patient having a test that is anticipated to be abnormal and may need to be followed up when the referring GP is not on duty; or the review of a child with undifferentiated abdominal pain later in the day to ensure he/she does not have a surgical condition such as acute appendicitis. While most practices do this well, these are occasions of greater risk of harm when failure of adequate handover occurs (see Criterion 1.5.3 System for follow up of tests and results).

Transfer of patient health information

Where the practice produces a summary for transfer to another practice, the practice should keep a copy of the summary in the patient’s health record. It is recommended that only a copy of the patient health information be transferred and that the practice retain the original health information.

Errors in clinical handover

When errors in clinical handover occur, every member of the practice team is encouraged to report them using de-identified data, so the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients (see Criterion 3.1.2 Clinical risk management systems). It is important that the practice nurture a culture of just and open communication to support the resolution of errors in clinical handover.

Useful resources

Standard 1.5 Continuity of care

Our practice provides continuity of care for its patients.

Criterion 1.5.2

Clinical handover

Our practice has an effective clinical handover system that ensures safe and continuing healthcare delivery for patients.

In a nutshell

A missed or inadequate handover can have serious consequences for patients and your service, and increases the risk of legal action. Thus, your service should have documented policies and protocols in place that encourage consistent and effective clinical handover, and that your handover processes and communications are diligently applied and well documented. An important part of successful clinical handovers is your service’s capacity to identify gaps and breakdowns in handover communications and improve them to minimise recurrence.

A key objective of effective clinical handover is for any clinician to be able to look at patient health records and continue appropriate quality care. This requires effective clinical note taking, information entry into the correct sections of the health records and good health summaries and social background information.

Key team members

  • Health service manager
  • Clinical staff
  • Locum clinical staff

Key organisational functions

  • Clinical handover communication systems and protocols, within the health service and external to it (for example, outside health services, pathology services, shared care, medical deputising services)
  • Patient records policies and processes
  • Locum clinical staff orientation
  • Clinical risk-management systems and policy

Indicators and what they mean

Table 1.10 explains each of the indicators for this criterion. Refer to Criterion 1.5.2 Clinical handover of the Standards for general practices for an explanation of concepts referred to in this criterion.

Table 1.10 Criterion 1.5.2 Clinical handover
IndicatorWhat this means and handy hints
▶ A. Our practice team can demonstrate how we ensure an accurate and timely handover of patient care. It’s a good start for your service to have a comprehensive clinical handover communication policy and protocol, and to ensure that it is known to clinical staff, including locums. Handover communications can be face-to-face, written, verbal (telephone) and electronic (email).Comprehensiveness means considering different situations in which handovers occur and having written policies, protocols or guidelines that set out the best way of achieving effective handovers for these situations. The policies and protocols could include:
  • a clear definition of the term clinical handover
  • provisions for timely, standardised and consistent practices by relevant clinical staff, such as:
    • recording handovers in consultation notes
    • routinely reading patient records prior to consultation
    • noting and processing urgent follow-ups
    • clear guidelines for:
    • handovers among clinical staff within your service
    • handovers outside your service, such as standardised referral methods to other service providers; standardised referral information details; and clarification of who has responsibility for care
    • handling shared-care patients, such as standardised requests for notification of other providers’ cessation of shared care, or standardised alerts for when your service ceases care of a shared-care patient
    • clinical handovers with medical deputising services, providing for when handovers are made, how often (for example, in a ‘timely and appropriate manner’) and who is responsible for the handover
    • handovers to emergency departments, such as face-to-face to the ambulance service, followed by telephone handover to the emergency department. If a patient does not require an ambulance, your service needs to ensure that sufficient information (including language and/or cultural information) is provided to the emergency department in order to facilitate prompt and appropriate care
    • handovers from urgent pathology results, especially in out-of-hours situations. If abnormal or life-threatening results are identified, your health service should have an arrangement in place for quick access to the relevant GP by the pathology provider. The arrangement should allow for timely access to GPs so they can make informed and appropriate medical decisions. Similarly, guidelines should be established for follow-up of urgent and critical pathology results, especially where the GP is not on duty
  • provisions for identifying breakdowns and gaps in clinical handover systems. This means your staff are encouraged to report breakdowns in systems through a culture of trust and open communication. You can achieve this through a clear process of how reporting is done, who is responsible for investigation and analysis, and a clear understanding of the consequences of reporting (changed processes rather than blaming staff)
  • appropriate cultural safety resources for health services that operate in culturally diverse contexts, especially for locum clinical staff with limited experience of the cultural and community contexts.
An essential part of demonstrating this indicator is found in the written policies, protocols and guidelines that accompany practice and behaviour. Most health services generally have good clinical handover systems and communication practices, and it is essential that these practices are documented in writing. This encourages consistency in practices and behaviour, and allows for the easy identification of gaps and breakdowns in the system and for the necessary improvements to be made.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure effective clinical handover for its patients. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The service’s policy and procedure manual clearly identifies the requirements for both internal and external clinical handover and includes examples of template forms to be used.

The service uses a standardised form based on iSoBAR utilising the following: Identification of patient; Situation & status; Observations; Background & history; Assessment & Actions; Responsibility & risk management. This may be modified when required to Identification; Situation; Observation; Background; Agree a plan; Read back.

Staff members providing clinical care access the same resources and information to make sure patients receive consistent advice. Staff members can describe the process used to handover to another practitioner in the practice, or to a locum or external health provider.

Patient feedback indicates that the service’s handover protocols between it and external providers, including hospitals, work effectively.

A register of slips, lapses and mistakes is maintained and staff discuss the documented issues at clinical staff meetings, where they identify actions for improvement.

If a doctor employed by the service is retiring, leaving or taking extended leave, patients are told at least 4 weeks before this happens. They are also told who will take over their care while their usual doctor is away. A clinical handover, either written, face-to-face or via telephone, is done by the doctor to the replacement doctor.

Showing how you meet Criterion 1.5.2

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Have a written policy regarding handover, both internal and external, including to locum doctors or other doctors in the practice.
  • Ensure health files contain copies of referral letters to allied health services, other doctors, specialists and ambulance or Royal Flying Doctor Service staff.
  • Maintain service-level agreements with medical deputising services or after-hours cooperative arrangements, setting out the responsibilities of all parties.
  • Show that you aim for face-to-face handovers, where possible.
  • Have a standardised form for ambulance transfers.
  • Have a shared-care arrangement (for example, team care of a patient with mental health problems).
  • Keep a register of slips, lapses and mistakes.
  • Provide examples of how any breakdown in the clinical handover system was identified and addressed.
  • Use a clinical software program to generate referral letters that are automatically populated with the requirements listed in Criterion 1.6.1 Engaging with other services

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