What is Electronic Handover? 

 At 5pm, Doctor T finishes her shift for the day.   As part of her handover to the on-call doctor, she creates a flag in the computer system for each patient follow-up required. She indicates within the flag a description so that the next doctor can continue the care for the patient. 

Doctor M, the on-call doctor begins his shift by reviewing the flags that Doctor T has created.   With the completion of each task, he then unchecks the flag as an acknowledgement.   A standardised method of handover is very important to ensure that patients receive continuity of care that is safe and appropriate for their needs.

We caught up with Dr Munirah and Dr Orlanda, team leads for the projects:   

1. How does it feel like to be involved in a QI project?
Honestly, before we embarked on this, the topic of QI was quite foreign to us.   This experience has helped us appreciate QI concepts and see how we can change healthcare delivery to patients. It’s important for clinicians to be involved in QI as we are key stakeholders in executing the care for our patients.

2. Any advice to others considering a QI project?
Dr Munirah: I think you have to be passionate about the problem you want to improve.   At the same time, the problem should have some impact on patient safety or patient care. Handover is something that doctors do everyday and hence seeing the difference it made was something very tangible to us.   Healthcare delivery to our patients today has become more complex. Solving a problem requires an appreciation of how different systems work together to bring out the required outcome.   Hence, it is important to involve the right stakeholders so that you can have the support you need to implement the change.

Dr Orlanda: As residents we should keep our eyes open and minds sensitive to the criticism we have for our current practice.   We discuss them during coffee talk as a habit so now let's recognise them as achievable QI targets that we can be passionate about.   Just like everyone has their specialty of interest, there will be pet peeves that we can transform into very well meaning and practical projects.   We are confident in time, that more doctors will feel the same and QI projects will bring good change.   So, QI is definitely desirable.   Feasibility is up to us!

3. Who would you like to thank?
Our entire team, comprising 12 internal medicine residents, administrative and IT support, senior doctors and our Division Chair!   A key ingredient to making this work was that every team member brought with them different areas of expertise.   For example, Desmond Lee and Rachael Wu from the Division of Medicine helped with the data extraction and analysis.   Senior doctors helped to rally support from seniors to ensure compliance among the juniors.   The IHiS team was also very involved in executing the IT changes that we wanted to implement.

About the Project

Electronic handover system has been in place in the Division of Medicine since March 2012 but usage levels were low.   A team of internal medicine residents embarked on QI projects and successfully increased the compliance rate and quality of electronic handovers.  

"In phase 1, we focused on compliance by ensuring that doctors used the flowsheet correctly and safely.   From a survery with the doctors, we gained useful feedback which helped us understand the human and systemic factors affecting the sustainability.   Through several rounds of fine-tuning, we arrived at this version that you see today.

In phase 2, we wanted to address the "quality" of the handover information with focus on adequacy and succinctness of information.   We designed interventions to encourage doctors to use the SBAR (Situation-Background-Assessment-Recommendation) tool as a mental framework to synthesize the information they were handing over.   We wanted to ensure that primary teams documented an adequate impression and plan for their patients."

Residents make a difference
As a testament to the success, the above diagram shows the decrease in the numbers of unacknowledged flags through effective intervention measures.   More doctors are also using the SBAR method to input their handover instructions, thus information is clear and accurate and patient safety is enhanced.

Clinical Handover Team:
IM Residents: Dr Munirah Alhamid, Dr Wong Hei Man, Dr Orlanda Goh, Dr Ng Kangqi, Dr Matthew Chuah, Dr Wong Yu Jun, Dr Kaavya Narasimhalu, Dr Nur Emillia binte Roslan, Dr Nurul Aidah binti Abdul Halim, Dr Vignesh s/o Sivasamy, Dr Wong Ningyan, Dr Justin Sii.

Clinical Services and Improvement Office, Med-ACP: Mr Desmond Lee, Miss Rachael Wu.

Senior clinicians: Dr Low Su Ying, Director for Quality Improvement & Implementation, Med-ACP, Dr Tan Thuan Tong, Director for Clinical Service Enhancement & Integration, Med-ACP and A/Prof Chow Wan Cheng, Academic Chair, Med-ACP.

This article was reproduced from LighterNotes – Stories of SGH Campus and its people. Do you like this story? Tell us at mysgh@sgh.com.sg