Problem

It is essential to ensure the quality of handover notes in medical practice, including psychiatric settings. Despite the emphasis on the importance of effective communications between different teams, the handover notes in our hospital still needed further improvement. Audits in our hospital revealed that handover notes lacked structure and contained varied information selected inconsistently by different doctors. This could risk omission of clinically significant facts, such as reason for change in psychotropic medications and concerns of certain behavioural problems. Feedback from various doctors indicated that extra time, in addition to that spent on reading the suboptimal handover notes, would be needed to check more clinical documents to gain comprehensive understanding of patients’ conditions.

Our hospital, the Institute of Mental Health (IMH), is the only tertiary psychiatric hospital in Singapore and has over 1850 inpatients.1 There are various types of wards in IMH, including general psychiatric ward, mood disorder unit, early psychosis intervention ward, psychogeriatric ward, addiction ward, long-stay inpatient ward and medical care ward. Patients may be transferred between different wards for various reasons, such as treatment of infection diseases in the medical care ward, management of complex mood disorders in the mood disorder unit and substance detoxification in the addiction ward. Written handover notes are required when patients are transferred between different wards in IMH.

This quality improvement project aimed to increase the effectiveness of handover notes when patients were transferred between a general psychiatric ward and other wards in IMH.

Background

Handover in the clinical environment can be defined as ‘the exchange between health professionals of information about a patient accompanying either a transfer of control over, or of responsibility for, the patient’.2 It represents a valuable endeavour and a fundamental component of the processes and workflows within hospital settings.3 It is one of the pivotal stages in a patient’s healthcare journey.4 Inadequate communication in handover process can be one of the primary factors contributing to compromised patient safety and service quality, along with patient dissatisfaction.5 In spite of its significance, clinical handover is frequently carried out inadequately, posing potentially serious consequences for the patients.2 Though there are structured frameworks for clinical handover in the literature,6 individual hospitals in different countries with distinct cultures may employ different systems, resulting in varying levels of effectiveness.

Mental health hospitals are often seen as having lower clinical demand, compared with acute general hospitals, which might explain why they have been slower to adopt formal handover initiatives.7 Psychiatrists have been reported to exhibit a lower tendency than other mental health professionals to engage in face-to-face handovers.8 Junior doctors have shared dissatisfaction with handover arrangements within mental health hospitals.9 Meanwhile, the complexity of psychiatric disorders has been escalating,10–12 and load of physical and mental health comorbidities has been growing.13 14 There arises a necessity to apply equally robust clinical handover practices within inpatient psychiatric settings.

Baseline measurement

The definition of effective handover notes was reached based on the discussion among the project team members and the feedback from several consultant psychiatrists in the hospital, after taking into consideration of several aspects, including clinical efficiency, patient safety, hospital culture and staff preferences. Based on the consensus reached in the end, effective handover notes in this quality improvement project were defined to have the following five components: (1) Brief psychiatric history. Key points of the history of presenting complaints should be summarised. (2) Reason for the patient to be transferred to another ward. For example, the purpose of the transfer from a general psychiatric ward to a medical care ward is to treat an infectious disease. (3) Significant risk issues. Psychiatric risk issues, such as suicide risk or aggression risk, should be stated clearly. (4) Reason for psychotropic medication change, especially due to significant side effects or intolerance. For example, the reason to avoid olanzapine is because the patient is very concerned about weight gain. (5) Significant and active medical issues. Follow-up interventions, such as repeating chest X-ray in 1 month to monitor resolving of pneumonia, should be written in the handover notes.

The results of baseline measurement were obtained from audits in our hospital. The number of effective handover notes was measured every 2 weeks, as there were approximately 10–20 transfer cases between this general psychiatric ward and other wards in our hospital. The completion rate of effective handover notes, defined by the number of effective handover notes divided by the number of all transfer cases, ranged from 9.09% to 42.86% from February 2022 to June 2022, with a median rate of 27.27%.

Opinions about the quality of handover notes were gathered from the inpatient team. Several concerns were shared, such as important clinical information might be missing in some handover notes, longer time would be needed to collect information due to lack of concise handover notes and patient safety might be compromised because of incomprehensive information.

Qualitative feedback, regarding the possible reasons of suboptimal handover notes, was obtained from both psychiatrists and psychiatric trainees. Main topics from the feedback were insufficient time to prepare handover notes due to a large number of transfer cases, no clear guidelines to writing effective handover notes and a lack of reminders to complete the handover notes.

In order to address the aim of improving the effectiveness of handover notes, we planned to continue to record the completion rate of effective handover notes on further months to increase the reliability of the project and monitor the outcome of our interventions.

Design

This project followed established quality improvement methodologies outlined by the WHO,15 including recognising potential deficiencies within the system responsible for ineffective handover notes, brainstorming the underlying causes, ranking primary causes and sequential strategies that aimed at addressing these specific causes. The initial project team consisted of three psychiatrists, three junior doctors, two nurses and one manager from the clinical governance and quality department. The psychiatrists were in charge of the project and provided insightful guidance. The junior doctors in our hospital were those qualified medical practitioners who were working while engaged in postgraduate training and had not become specialists yet. They prepared written handover notes during the handover process. The nurses carried out doctors’ orders and played an important role in the handover process. The manager from the clinical governance and quality department provided information of current hospital policy and facilitated policy change. Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of our research.

A flow chart of the current system was created to visualise the transfer process (figure 1). When a patient was planned to transfer to another ward, the receiving ward would be informed to assess suitability of the transfer and check bed vacancy. If the patient could be accepted to the receiving ward, doctors and nurses in the transferring ward would prepare the transfer documents. Transfer would then be completed.

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Figure 1

Flowchart of the transfer process.

Based on the flow chart of the transfer process, brainstorming was performed among project team members to identify possible underlying causes. The possible causes were identified to be from areas related to doctors, nurses, allied health professionals, patients and healthcare systems. The details of possible causes are listed in figure 2.

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Figure 2

Cause & effect diagram of ineffective handover notes.

Applying the Pareto principle, which posits that 80% of a problem arises from 20% of its identifiable causes, we focused on the most impactful factors and pinpointed the following four root causes as potential targets for interventions: there were no formal standards for handover notes, there were no clear guidelines on who and when to complete handover notes, there was lack of awareness from doctors about the importance of handover, and doctors forgot to complete handover notes. Three plan-do-study-act (PDSA) cycles were carried out to address the root causes.

Strategy

The first PDSA cycle involved three interventions: emails to junior doctors, presentations during junior doctor orientation meeting and small group discussions with selected junior doctors. During each intervention, the importance of handover notes was emphasised, guidelines to include key components in handover notes were described and responsibility of primary team to complete handover notes within one working day was stated. The project team then realised that junior doctors in the hospital would rotate between different hospitals or departments every 3–6 months, so the team would need to repeatedly send emails and have meetings with new junior doctors. Due to manpower limitations of the project team, discussion among our project team members confirmed that these interventions were not sustainable.

The second PDSA cycle included three interventions: ward nurses reminded doctors to document in medical records that handover notes would be completed, doctors changed their desktop images on their computers to remind them to complete handover notes and doctors put reminder stickers on their working laptops. These interventions targeted the root cause that doctors would forget to complete handover notes sometimes. These interventions maintained the increased completion rate of effective handover notes. However, we noticed that there were some unintended consequences. One nurse in the project team gathered feedback from other nurses on the ward via face-to-face sessions and found that nurses had difficulty reminding doctors sometimes due to their busy schedule, and it was not easy to track the reminders. One junior doctor in the project team talked to other junior doctors and realised that some junior doctors were not keen to use the reminding desktop images all the time due to lack of personal preferences. Thus, we decided to implement further interventions to improve the outcome.

The third PDSA cycle provided a handover template, which included the five key components, namely brief history, reason for transfer, reason for psychotropic medication change, risk issues and active medical conditions. The handover template was improved based on the feedback from junior doctors and was then sent to all junior doctors to follow when preparing handover notes. We thought about how we could integrate the reminder into the doctor’s medical notes. We, therefore, designed a handover template based on our local healthcare settings. This template was revised a few times based on suggestions and feedback from various doctors. After this PDSA cycle, the use of effective handover notes increased to a satisfactory level.

Lessons and limitations

The project aim was to improve the effectiveness of handover notes when patients were transferred between different wards, with the key focus of implementing sustainable solutions, rather than short term interventions. To achieve this, it was necessary to devise a system that could be accepted by the doctors involved in the transfer process, and could offer a lasting solution rather than a temporary fix. This project improved the completion rate of effective handover notes to 90.50% in the end. Nonetheless, despites all the efforts, the goal of 100% implementation was difficult to achieve, possibly due to the time limitations of care aspects in a busy psychiatric hospital burdened by high caseloads.

A valuable lesson learnt during the process was recognising the importance of employing PDSA cycles. PDSA cycles enable the team to observe the impact of each intervention on the outcomes and allow for appropriate preparation for subsequent PDSA cycles. PDSA cycles have been proved to be useful in various quality improvement projects.16 17 Through the PDSA cycles in our project, we found that some interventions, such as sending instructional emails to doctors, were not effective or able to maintain the effect due to limited manpower, so we designed new interventions to achieve our goals.

In this project, we defined the key components in effective handover notes based on our local work environment and the consensus of consultant psychiatrists in our hospital, rather than applying an existing template from another country or hospital. There are various handover tools in the literature, such as the nursing handover tool based on the Identification-Situation-Background-Assessment-Recommendation framework.18 Valuable ideas can be learnt from the existing tools. However, there are many factors which may affect the applicability in our local setting, such as the differences in healthcare environment, culture, manpower and existing hospital protocols. Thus, it is essential to develop a handover tool which is individualised to a local setting, after learning from existing tools in the literature.

We also learnt that structured notes could transform into practical and meaningful clinical actions. In our project the structure provided by the handover template resulted in significant outcome. This corroborates with other prefilled clinical templates in the literature, which demonstrate lasting impact.19 20 We will consider the option of implementing structured notes to improve clinical outcome in future quality improvement projects. With the development of information technology in our hospital, digital handover methods may also be considered in the future to enhance the handover process.

In terms of limitations, the number of transfer cases was relatively small during each assessment period. This could lead to fluctuations of the completion rate of effective handover notes. However, the outcome was generally trending upwards after interventions over a reasonable observation period. Besides, this project was conducted in a general psychiatric ward. The outcome may not be generalisable to other types of subspecialty psychiatric wards, but it may be used to inform the development of handover tools in other wards or other hospitals. Lastly, our results might be affected by performance bias. During the project, junior doctors were aware that the quality of their handover notes would be monitored, so they might put in extra efforts to complete the work. Nonetheless, even after the quality improvement project, the quality of junior doctors’ work will continue to be monitored intermittently by senior doctors.