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Deliverables

  • Deliverables overview.

    Del. no

    Deliverable name

    WP no

    Lead Beneficiary

    Nature[1]

    Diss. level[2]

    Delivery Date

    D1

    Report on training needs and appropriation guideline per region and category

    4

    OUNL

    R

    PP

    12

    D2

    Report on the likely cost of the various prototype interventions, based on a model of the likely costs

    6

    BHAM

    R

    PU

    13

    D3

    Report on the barriers and facilitators to effective handoffs in the social, linguistic and technological contexts in which they take place in different European settings.

    2

    KI

    R

    PU

    18

    D4

    Periodic EC report first period (Activity report, Management report, report on distribution of EC contribution)

    1

    UMCU

    R

    RE

    19

    D5

    Report on how variations in handoff processes lead to “near misses” and adverse outcomes

    3

    UMCU

    R

    PU

    24

    D6

    Report on specific problems in care provision and on the factors that influence change

    5

    RUNMC

    R

    PU

    24

    D7

    Report quantifying the expected benefits of the interventions that will be implemented

    6

    BHAM

    R

    PU

    25

    D8

    Final EC report (Activity report, Management report, report on distribution of EC contribution)

    1

    UMCU

    R

    RE

    36

    D9

    Evaluation report regarding a) training and b) use of tools

    4

    OUNL

    R

    PU

    36

    D10

    Report on mechanisms and processes responsible for the implementation results and their variation within target groups

    5

    RUNMC

    R

    PU

    36

    D11

    Report quantifying resources actually consumed in each country by type of intervention

    6

    BHAM

    R

    PU

    36

    D12

    HANDOVER final report

    7

    UMCU

    R

    PU

    36



    [1] R = Report, P = Prototype, D = Demonstrator, O = Other

    [2] PU = Public; PP = Restricted to programme participants; RE = Restricted to a group specified by the consortium (incl. Commission services); CO = confidential, only for members of the consortium (incl. Commission services);

     

  • D1. Report on training needs and appropriation guideline per region and category

    Authors:
    Dr. W. Kicken, Dr. M. van der Klink, Dr. S. Stoyanov, Prof. Dr. H.P. A. Boshuizen

    Abstract:
    The HANDOVER project acknowledges that training and learning are important means to encourage the implementation of handover models and tools. This deliverable describes the training needs analysis, which can be considered as the first step in the design and delivery of training in handover. The training needs analysis encompasses the examination of training content, training design and conditions and prerequisites that affect the transfer of training from the training site to the workplace. A literature study and 18 interviews with training specialists working in hospitals in Spain, Poland and The Netherlands were used to collect information concerning the training needs. The report provides practical guidelines in the form of quality indicators that can be applied for decisions on the content of the training, for selecting the most appropriate training design and for establishing favourable conditions that increase the effectiveness of the training. The report concludes with some remarks concerning the further development of the quality indicators and the training in handover.

    Keywords:
    Handover, training needs analysis, training design, transfer of training, quality indicators

  • D2. Report on the likely cost of the various prototype interventions, based on a model of the likely costs

    Authors:
    Prof. Richard J. Lilford, Mr. Peter, J. Chilton, Dr. Karla Hemming, Dr. Celia A. Brown, Mr. Alan J. Girling,  Prof. Paul Barach,  Miss Wendy Fox-Kirk


    Abstract:
    A report providing a model for the assessment of cost effectiveness of organizational interventions such as handover in healthcare settings. The proposed model is an extended Donabedian Chain. Upstream interventions have diffuse effects creating problems with statistical power if downstream end points are measured. The difficulty of measuring the effect of upstream interventions such as that for handover is discussed and the conclusion reached that if an intervention is relatively inexpensive then worthwhile (cost effective) effects will not be detectable at the level of the patient. The importance of assessing the value of information is also discussed with Bayesian techniques suggested as the key methodology to address this issue.

    Keywords:
    Handover, cost-effectiveness model, intervention, Bayesian techniques

  • D3. Report on Handovers in European settings

    Authors: Dr. H. Hansagi, Dr. M. Olsson, Dr. S. Bergenbrant, MSW. M. Flink, Dr. P. Barach, Dr. G. Öhlén

    Contributors: UMCU, FAD, BHAM, CMJ/NCQA, ASL 10 FIRENZE, RUNMC, OUNL, KAROLINSKA

    Abstract: The aim of WP2 activities was to identify barriers and facilitators to effective handovers in the primary care - hospital interface. This deliverable reports a prospective, qualitative study performed in The Netherlands, Spain, Poland, Italy and Sweden. Patients with chronic diseases, and discharged home from hospital, and their respective care providers were recruited. Interviews, process mapping, and artifacts were used. Phases and roles in handovers are dependent of the social contexts of the countries. Incomplete information e.g. lack of medication lists, were indentified as barriers. Timeliness of information Is critical in some countries, whereas shared IT-systems, personal contact between care provider, and special transfer nurse are facilitators. Communication, both between professionals, and between care providers and patients could be improved. Since this is qualitative research, and because each European country has its own distinct healthcare system, these empirical findings cannot be statistically generalized or taken as policy documents. Still, these findings are sufficiently evident to be helpful in tailoring future interventions to barriers in handovers and to improve continuity of care.

    Keywords: Handover, barriers, facilitators, primary care/hospital interface, social, linguistic, technological contexts, European settings

  • D4. CP-CSA-NoE Periodic Report

    Authors: Loes Pijnenborg, MD PhD, Paul Barach MD MPH

  • D5. Identify Basic Elements of Effective Communication

    Authors: Paul Barach, MD, MPH; Petra Gademan, MD; Cor Kalkman, MD, PhD; Julie Johnson, MSPH, PhD; Loes Pijnenborg, MD, PhD

    Contributors: UMCU, FAD, CMJ/NCQA, ASL 10 FIRENZE, RUNMC, KAROLINSKA

     

    Abstract: The impact of organizational culture on care coordination and transitions of care in the primary care – hospital interface is critical to patient safety and professional responsibility. The aims of this Deliverable are to: (a) identify referral and discharge barriers and facilitators to effective and safe patient handovers; (b) determine how variations in handover processes lead to “near misses” and adverse outcomes; and, c) explore the roles and responsibilities of healthcare providers as well as patients and their carers. We conducted a prospective, qualitative study in The Netherlands, Spain, Poland, Italy and Sweden. Patients with chronic diseases, discharged home from hospital, and their respective care providers were recruited for individual and focus group interviews.

    We determined the effectiveness and efficiency of various methods and models for integrating and sustaining best practices in improving care processes and patient outcomes. The triangulation of multi modal improvement science methods in this study, including analyses of barriers and facilitators, Ishikawa diagrams, near misses, process maps and analyses of roles and responsibilities is innovative and facilitates cross-country learning. We found that while the prevailing handover practices differ across Europe, many of the identified referral and discharge barriers and facilitators appear to be similar in the different countries and settings. The key themes underpinning the barriers and facilitators for patient discharge and referrals that emerged from the analysis include: communication content, process, and tools; attitudes; organizational factors; community resources; patient awareness, and patient empowerment.

    All stakeholders, including the patients, agree upon the need for an active patient role in the handover process. However, both patients and professionals are concerned about the amount of responsibility to be put upon patients. Family members are perceived as of great importance to facilitate handover, both by patients and professionals. The lack of awareness to different professional perspectives, inherent to primary and secondary professional domains, seems to influence the roles and responsibilities in patient diagnosis and treatment. Though most professionals think they carry a shared responsibility in this respect, in practice there is no shared responsibility. Because of multiple assigned roles and unclear responsibilities, especially with nursing professionals, the time of discharge can create barriers in handover. We demonstrated that it is common that the general practitioner plays an essential part in the coordination of patient care. Multiple factors, such as the lack of direct contact between professionals, involvement of multiple professionals and the lack of feedback, make it difficult for the general practitioner to fulfil this role excellently and be accountable.

    Near miss and vignette analysis suggest that involved professionals facilitate handover because they view patient handover as part of their care process. However, most roles and responsibilities are not clearly defined. Near misses and vignette analysis shed light on the complex process-outcome relationship and enable us to refine methods of handover and other strategies to assure safe, effective, and efficient transitions in given clinical populations. The fragmented delivery care model, misaligned payment styems and cultural differences at the interface between the hospital and primary care play a key role in hindering effective and safe handover practices.

    Keyword: Handover, patient safety, near misses, barriers, facilitators, primary care hospital interface, process maps, Ishikawa charts, culture, roles and responsibilities

  • D6. Report on challenges in patient care and the factors that influence change in practice

    Authors: G.Hesselink, MA, MSc; H. Wollersheim, MD, PhD; Paul Barach, MD, MPH; L.Schoonhoven, PhD; Prof. M. Vernooij-Dassen, PhD

    Contributors: UMCU, FAD, BHAM, CMJ/NCQA, ASL 10 FIRENZE, RUNMC, OUNL, KAROLINSKA

    Abstract: The impact of organizational culture on patient handovers in the primary care – hospital interface in Europe has been relatively unknown. The aim of this Deliverable is two-fold: (a) to identify cultural barriers and facilitators to effective and safe patient handovers; and, (b) to provide a closer look into the factors that need to be addressed when developing and implementing best-practice interventions given these cultural findings. A prospective, qualitative study was performed in The Netherlands, Spain, Poland, Italy and Sweden. Patients with chronic diseases, discharged home from hospital, and their respective care providers were recruited. Individual and focus group interviews were used. We found that although the prevailing handover practices differ across Europe, many of the identified cultural barriers and facilitators appear to be similar in the different studied countries and settings. A fragmented delivery care model and culture at the interface between the hospital and primary care, conflicting professional values and, in some countries, the organization’s identity played a key role in hindering effective and safe handover practices. In some of countries studied, the presence of a learning culture and patient-centered culture appeared to facilitate effective handovers. However, as these conditions seemed to lack in most countries, they turned out to be a barrier as well. Finally, the extent to which patients (as well as their family care givers) are aware of their own important role and are empowered enough affects the quality and safety of handovers, both positively and negatively. The results indicate that improving the quality and safety of handover practice in the EU requires more awareness and care for the aspects that make continuity of care possible. Each European country in the study has its own distinct healthcare delivery system, and thus these empirical findings need to be customized to the local constraints. Still, these findings are sufficiently evident to allow the tailoring of future interventions to address and overcome cultural barriers in handovers and to improve the continuity of patient care.

    Keywords: Handover, patient safety, barriers, facilitators, primary care/hospital interface, organizational culture, culture, European Union settings, focus groups, interviews

  • D7. Report quantifying the expected benefits of the planned interventions

    Authors: Nicola Novielli, Yen-Fu Chen, Marcel Van der Klink, Hub Wollersheim, Paul Barach, Richard J. Lilford

    Abstract:

    Aim: The aim of this report is to assess the expected benefit of the proposed Handover interventions and to model the size of a potential trial to measure the effectiveness of this intervention.

    Background: The HandOver project aims to develop a suite of interventions to improve the handover of patients between the hospital and the community. These interventions will be customisable and include several options with a focus on creating a virtual training environment called the Handover Training Toolbox.

    Methods: A literature review identifies readmission rates and adverse event rates among the plausible targets for such an intervention. A team of experts was invited to express their belief on the expected effect of the intervention in terms of expected reduction in the attributable risk in both end points. Such beliefs were quantified using Bayesian prior distributions. An economic model was created to quantify the cost-effectiveness of the proposed intervention contingent on to prior beliefs. The size of a potential trial to measure the effectiveness of the intervention was also modelled. All models included sensitivity analyses.

    Results: The pooled expert opinion suggested an improvement of 25% in the attributable risk of readmission rates and adverse event rates. The modelling exercise showed that such an effect would be cost-effective in a society that was willing to pay up to 20,000€ to avoid one death and obtain one Quality Adjusted Life Year (QALY).

    A future trial to detect a reduced readmission rate would need to be very large to detect cost-effective and plausible effects over most assumptions.

    Discussion: The implementation of the handover toolbox is likely to be cost-effective. The sample size for a trial to evaluate it is very large under most assumptions. Option value analysis and value of information analysis will be considered for deliverable 11 (due 30th Sept 2011).

    Keywords: Handover, patient safety, barriers, facilitators, primary care/ hospital interface, prior beliefs, expected effectiveness, headroom analysis

  • D8. Periodic EC report

    Authors: P. Barach, L. Pijnenborg, A.A. Göbel, C.J. Kalkman

    Abstract:

    When a patient’s transition from the hospital to home is less than optimal, the repercussions can be far-reaching — hospital readmission, an adverse medical event,   and   even   mortality. Project  HANDOVER,   is   the   first   major   European study to assess patient transitions. The goal of the study is to identify and study patient   handover   practices   and   create   standardized   approaches   to   handover communications in 6 European countries (i.e, Sweden, Poland, England, Italy, Spain, Netherlands).

    The policy objective of the HANDOVER project was to assess the continuum of clinical care at the primary care hospital interface by informing EU healthcare policy makers and educators about patient transitions. The project HANDOVER developed a standardized toolkit for improving the handoff processes, that can be tailored to meet local and/or institutional needs. The study included a total of 12 hospitals, and has collected data from hundreds of physicians, nurses, patients and hospital managers.

    The project aimed to improve patient care in EU member states and in relation to patient mobility and cross border care among European countries. A major outcome of the research was a deeper understanding of how variations in communication, culture, and technology use in nursing and medicine leads to ineffective or suboptimal handoffs.

    The discontinuity and variation of care across these EU settings leads to increased handovers poses danger to patients. The handovers we explored and studied are often characterized by communication failures, environmental barriers and adverse care.

    The study was a multi-method study (i.e., process maps, surveys, interviews, focus groups, observations) to directly assess patient handovers and shadow physicians and nurses providing care following patient handovers. Our aims were to: (1) Identify the barriers and facilitators in the medical, social and technological contexts where patient handovers takes place; (2) Determine how variations in handoff processes lead to "near misses" and adverse outcomes; (3) Develop and assess tools and training programmes that are needed for implementation of a handoff training program; and, (4) Assess the cost effectiveness of future handover interventions.

    We mapped out the patient care handover processes in the different countries (process maps, artefact analysis), developed standardized tools to conduct interviews, focus groups, artefact analyses and develop a shared taxonomy of near miss and adverse patient events.

    We interviewed over 192 healthcare providers, and discovered that important and intricate relationships exist among the people, processes, technology, and clinical settings in which handovers occur. Significant differences were seen in the patient discharge, transfer, and rehabilitation processes in each of the 6 countries. We found great variation in practice and a lack of systems appreciation. These relationships have the potential to facilitate or impede the hand-off process and directly impact patient outcomes.

    We focused the 2nd part of the study on developing a series of interventions including clinical practice guidelines, best practice indicators and an educational toolbox for under- and postgraduate healthcare trainees. During the second period of the project we continued our work on identification and validation of factors that would constitute the optimal patient care system continuum, and training tools to assist a successful implementation.

    The lack of awareness of different professional perspectives, inherent to primary and secondary professional domains, seems to influence the roles and responsibilities in patient diagnosis and treatment. Though most professionals think they carry a shared responsibility in this respect, in practice they do not. Because of multiple assigned roles and unclear responsibilities, especially for nursing professionals, discharge can create barriers in handover as well. We demonstrated that it is common for the general practitioner to play an essential part in the coordination of patient care. Multiple factors, such as the lack of direct contact between professionals, involvement of multiple professionals and the lack of feedback, make it difficult for the general practitioner to fulfil this role excellently and be accountable.

    We found that current interventions aimed at improving patient handovers at the hospital-primary care interface fall short in addressing the barriers and facilitators. Effective patient handovers at the hospital-primary care interface are influenced by a large variety of barriers and facilitators. However, effective handover interventions are mostly aimed at improving organizational and technical aspects of the handover process.

    The HANDOVER website www.handover.eu was developed with the support and involvement of the whole HANDOVER project team. The site presents the functionalities that were requested by and expected of the group and provides a compendium of information on handover, both in Europe and globally. Information is available in English but also in the native languages of project partners.

    The Handover Toolbox www.handover.ou.nl is an interactive platform and a compendium of knowledge about education and training in handovers as well as a library of practices, tools and techniques related to patient handovers. The interactivity of the handover network facilitates the sharing of experiences and practices in handovers. The added value of the toolbox is to emphasize the importance of handovers in the process of care and the significance of education in the field.

    Keywords:

    Handover, patient safety, results, impact, dissemination, quality improvement

     

  • D9. Evaluation report of training and the use of training tools

    Authors: M. van der Klink, W. Kicken, H. Drachsler, S. Stoyanov, H.P. A. Boshuizen

    Abstract:

    Training contributes to improving handover practices. Deliverable 9 describes the design of a Handover toolbox to support trainers and others involved in improving handover practices. The deliverable describes the design of the blueprint, the development into a first and second prototype and the final toolbox version. The development process used a design-based approach in which evaluation and development were closely intertwined.  We used conventional methods for data collection including interviews and questionnaires, but also innovative methods including Writing Personas, PMI evaluation and Group Concept Mapping. The toolbox offers advanced pportunities to become an appealing and leading on-line!network that enables members to contribute actively to the body of knowledge stored in the toolbox. The network becomes the place for all healthcare providers to be involved in improving handover practices. Evaluation findings indicate that the final version of the Handover toolbox sufficiently meets the needs of users and the toolbox has sufficient quality and content to allow further implementation. The deliverable concludes with suggestions for further implementation of the Handover toolbox.

    Keywords:

    Patient safety, Handover, Training, Competencies, Quality, Toolbox, online network

     

  • D10. Mechanisms and Processes Responsible For Implementing Results and Addressing Variation within Target Groups

     

    Authors: G. Hesselink, M. Zegers, L. Schoonhoven, M. Vernooij-Dassen, H. Wollersheim

    Abstract:

    There is a lack of sufficient evidence-base insight into solutions to handover problems. A systematic approach is needed for translating handover challenges into tailored solutions. The aim of this Deliverable is to provide a systematic framework in which a tailored, effective intervention program and implementation strategy can be developed to improve patient handovers from the hospital to the community in the EU. We used a transparent and comprehensive method consisting of six steps, called Intervention Mapping (IM). First, we conducted a problemanalysis and identified determinants of effective and safe handovers. By crossing these determinants with performance objectives in matrix tables we were able to propose desired change objectives in handover performance. Theory-based methods and practical applications were identified based on a literature review and brainstorm sessions that matched with the determinants and the proposed change objectives. Finally, we offered input for developing a local-tailored intervention program and provided suggestions for the implementation and the evaluation of an intervention program. Our main finding was that current handover interventions do not target all the identified determinants and the related performance objectives. Effective handover interventions are mostly aimed at improving organizational and technical aspects of the handover process. However, there is a lack of evidence-based interventions that focus on handover training that relate to organizational culture. However, the problem-analysis indicated that attitudes, knowledge and awareness of those involved are key determinants for improving patient handover and supporting quality improvement efforts. A literature review and brainstorm sessions indicated a variety of available theory-based methods and practical strategies suitable for improving handover training as well as the organizational culture. There is a great opportunity for designing quality improvement interventions that address these objectives.

    Keywords:

    Handover, patient safety, barriers, facilitators, primary care/hospital interface, intervention mapping, systematic review, effectiveness, European Union settings.

  • D11. Report quantifying the resources consumed in each country by by type of intervention.

     

    Authors: Nicola Novielli, Marcel Van der Klink, Semira Manaseki-Holland, Richard J. Lilford

    Abstract:

    Aim: The aim of this report is to estimate the costs of implementing the toolbox in European countries and compare these with the potential benefits that it might bring.

    Background: A cost effectiveness analysis can be performed if a measure of the benefit and a measure of net costs is available. The benefit of the proposed intervention was estimated, on the basis of a Bayesian exercise, in deliverable D7. This report focuses on the net costs of the implementation of the toolbox.

    Methods: The implementation of the toolbox is based on a number of training modules based on the toolbox, their resources and relative costs in different EU countries. Results: Four training modules at different intensities of resource use were defined: S1. Community of Learners; S2. Facilitated community of learners; S3. Conventional training in a classroom; S4. Technology enhanced learning in a virtual environment. For every country, the highest estimate of the cost is below 40,000€ per 10,000 admissions, while the expected benefit, including the expected savings, is around € 6 million for every 10,000 admissions using adverse events as an end point.

    Discussion: The expected benefits of the intervention seems favourable relatively to its likely cost. However, it should be acknowledged that while costs can be anticipated with reasonable certainty, the benefits are little more than an informed guess. The size of effect necessary to justify this relatively low cost intervention is small, and it is unlikely that a rigorously designed study could be large enough to detect such an effect at the patient level. Nevertheless, we recommend phased introduction of the technology with decision gates where formal roll?out would depend on favourable effects in surrogate endpoints upstream of the patient.

    Keywords:

    Handover, patient safety, barriers, facilitators, primary care/hospital interface, prior beliefs, expected effectiveness, expected cost

  • D12. Dissemination of the HANDOVER Project - Final Report

    Authors: B. Kutryba, E. Dudzik-Urbaniak, A.A. Göbel, L. Pijnenborg, P. Barach

    Abstract:

    When a patient’s transition from the hospital to home is less than optimal, the repercussions can be far-reaching – hospital readmission, adverse medical events, and even mortality (www.handover.eu). This discontinuity of care (i.e., the responsibility for the patient is handed over from one caregiver to another) can lead, if not acted upon properly, to severe adverse events to the patient and enhanced costs to the system. Deliverable 12 is the final report of workpackage 7 and the last deliverable of the European FP7 project. The deliverable provides a summary of the development of the HANDOVER Toolbox (Chapter 2), the HANDOVER website (Chapter 3) and the Expert Meetings (Chapter 4). Chapter 5 provides information on the final Expert meeting in Florence (Sept. 23rd, 2011). The deliverable ends with recommendations for policy makers at all levels of the European Union to improve and oversee handover policy.

    Keywords:

    Handover, recommendation about handover, patient safety, barriers, facilitators, primary care/hospital interface, intervention mapping, systematic review, effectiveness, European Union.