Event Review: Safer Handover Rapid Improvement


Beginning in April 2016, Salford partners; Salford Clinical Commissioning Group (CCG), Salford City CouncilSalford Royal NHS Foundation Trust (SRFT), Greater Manchester West Mental Health NHS Foundation Trust and Haelo, embarked on an ambitious improvement programme to make Salford the safest health and social care system in the UK. Over the next 2 years, health and social care partners across Salford will build on learning from the successful Making Safety Visible programme.

As a patient transitions between different care providers and settings, it is critical that there are systems in place to ensure all necessary information is transferred with them. Medical and surgical doctors, GPs, acute and community nurses, carers, radiologists and physiotherapists are but a few examples of the different professionals a patient may meet.

The Safer Handover programme aims to investigate how patients and information used by clinicians involved in providing their care is communicated through the system, with an initial focus on interactions between primary and secondary care.

In order to gain a clearer understanding of the causes of problems in handovers between primary and secondary care, Haelo led a “discovery phase” with clinicians, including 1:1 interviews, a focus group, a clinician survey and review of:

– GP correspondence to SRFT colleagues referencing problems with handover documents
– Audit of clinic and discharge letters (run by the CCG at on GP practice)
– Review of Datix reports relating to medicines

The survey captured views from over 100 clinicians (26 GPs and 84 Consultants) across Salford, and identified the following top two themed issues:

– Better communication and access to advice e.g. Skype, email, telephone
– Clear roles / responsibilities for follow up actions

As a result of these findings, the Safer Handover team brought together frontline clinical staff, professionals allied to medicine (PAMS), management executives, administrators and commissioners from primary and secondary care to create a multi-disciplinary team.   Delegates participated in an intense three day rapid improvement event, with the aim of improving handover in Salford on referral into secondary care, and during transfer of care and follow up actions from secondary to primary care in order to improve patient safety.

Day 1

After initial housekeeping and introductions to the facilitation team by Penny Martin, Chief Operating Officer of Haelo, Francine Thorpe, Director of Quality & Innovation, NHS Salford Clinical Commissioning Group provided an overview of the background to the Safer Salford programme, followed by Dr Pete Turkington and Dr Jeremy Tankel who spoke about what had led up to the Safer Handover Event.

The delegates are then divided into two teams – primary care representatives and secondary care representatives. The teams are then separated into two again to use the Kano tool, which defines ‘what does best look like’, with one team focusing on the patient perspective and the other focusing on the clinician perspective:

  • Primary care teams: What does the best transfer of care and follow up actions from secondary care look like?
  • Secondary care teams: What does the best referral from primary care look like?

After defining what ‘best’ looks like and feeding back to the room, the teams are then split up again to create multi-disciplinary groups of primary and secondary care representatives to analyse the current state of handovers in Salford. The groups were split to focus on the following processes:

  • Referral from primary care into secondary care
  • From the decision to discharge a patient from secondary care up to the point of transferring patient care to primary care
  • From information being sent from secondary care to primary care up to the GPs clinical decision about onward management of patient

During this section of the event, the groups used a variety of Lean tools including process mapping, handoff diagrams, waste logs and process mapping measures to establish the current state of the processes.

A key deliverable for Safer Handover is to reduce waste, inefficiencies and duplication and as the session moves into the afternoon, the teams have begun to critically think about each step and started to create process maps of the existing system, drawing out wastes, unnecessary steps and also variations and complexities within processes.

In the meantime, a subgroup begin working on the Value Statement for the event. After some discussion, the team decide that the statement should encompass both focus areas of the event (referrals and follow up actions) within the same statement and be patient focused. They then present to each of the groups to develop and refine the statement with all of the delegates:

Talking through their process map, the first team who centred on referral from primary care to secondary discussed both clinical and administrative tasks including e-referral, non e-referral and subdivided this further into acute and non-acute settings. The process map highlighted many delays in the process and demonstrated the importance of clinical conversation, with a member of the team commenting that more communication is not necessarily making the system more efficient. Insights included an 8% DNA (do not attend) rate for patients in Salford with patients disclosing the primary reason was that they forgot and secondary reason was that they ‘didn’t hear about it.’ The learning showed a need for reassessment of the communication process in this stage.

Moving to the second team who concentrated on the process from decision to discharge from secondary care up to the transfer of care to primary care, the team described how enlightening the exercise had been as they ‘uncovered more than we thought we would.’ Analysing the current state, the team’s original starting point was when the patient was ready for discharge. However, they had uncovered that due to the ‘actual complexity’, the ‘real’ start was the admissions process and would be patient led. The team identified 32 steps within their process map ‘if you get it right’ and 60+ steps if not. Recognising the ‘systems and processes weren’t robust enough’, the team explored the use of a patient centric process as a quality marker, ‘patients need to be a part of the discharge process.’

The final team explored the point of discharge up to the GPs clinical decision about onward management of patient. The team stated that they were ‘surprised how many human steps were involved in the process’ professing that when you introduced humans into any system then you ultimately reduce the level of accuracy.’ When analysing the current state, the team expressed a desire to challenge assumptions and identified two ‘big things’; ambiguity and repetition of effort. The team also discussed time as wastage.

Francine Thorpe, Director of Quality and Innovation at Salford CCG closes the day by praising the multidisciplinary teams on their ‘real commitment’ to making the system work better and a ‘recognition from everyone that the systems are complex.’

Day 2

Following on from an insightful and eye opening first day, the groups meets with renewed energy and spend some time finalising the work from the first day. Next up, everyone is brought together and Haelo Senior Improvement Advisor Kurt Bramfitt poses the question, ‘Who is feeling creative today?’ Leading a session on thinking creatively, Kurt introduces two tools, Word Association and the SCAMPER technique which forms the foundation for the rest of morning. Using the tools, the teams are encouraged to think about their current processes and come up with potential solutions. The groups reflect on the findings from their creativity methods sessions and present back to the group in a 1 minute timed outcome, with some fantastic suggestions being drawn out.

With the groups now thinking creatively, the focus shifts to creating the ‘ideal state’ of each process, with teams being prompted to think big, as though money is no object and there are no obstacles to creating a perfect system. The teams are supported to explore utopian, idealistic dream states using blue sky thinking, and the teams begin creating their ideal state using pictures not words to conceptualise their visions.

When the two teams feedback, although they had been working completely separately, both of their ideal states showed a move to a more innovative system of care, where the patient is at the centre with health and care services working around them. This completely changes the concept of care from being dependent upon where you are, to instead prioritising what is needed. Changes included highlighting a need for simple solutions which would really revolutionise how different sections of the health and care team communicate with one another, again, putting the patient at the heart of this. After this exercise it was evident how everyone in the event was on the same page and wants to work to a shared vision of patient centred care.

Next, it’s time to bring the focus down to creating the future state. Clearing away the glitter and collage materials, the groups use Lean tools such as the 4Ps, complexity matrices and process mapping again to begin planning the future state. The aim of this session is to develop processes that create a step towards the ideal state, but that still make big changes to improve the current process that are achievable in the immediate timeframe after the event.

As the second day comes to a close, the teams having identified barriers to the future envisaged state are now focussing on what is achievable and how it can be implemented. By the end of the day the Value Statement has been further refined, and all agree that this statement is the clear aim and guiding principle that the delegates will work towards as part of the Safer Handover programme:

All information relevant to my care must be reliably communicated to me and those supporting me in a clear, accurate and unambiguous manner. It must be readily available and ensure that responsibility for actions are clearly set out.

Day 3

We’re in to the third and final day and we begin with an overview and walk through the stages in this event from Sharon Jeffrey, who aims to show the big picture behind using the methods in the order used throughout the event Sharon demonstrates how each activity adds together to facilitate the delegates through the change process.

There’ll be lots of time today for teams to build on existing tools, create our improvement and action plans for immediate use, based on the Model for Improvement (three questions and PDSA cycles). There’s no time to lose. Teams are back in their rooms – let’s get started!

Following a busy morning finalising future state maps, using fishbone diagrams to identify the root cause of barriers to developing the future state and developing action plans, we regroup before teams have their last hour to prepare presentations to the executive team this afternoon. It’s important at this point to remind teams that after these three intensive days are over, this is in no way the end of Haelo’s involvement. Haelo ‘green shirts’ have led the three days and have been the team of experts facilitating all sessions and group work. Going forward, staff will be on hand to offer support from improvement to administrative. Teams will be brought back to Haelo HQ in 6 months and again in 12 months to check in. The key message for delegates: all discussions have been delegate led and follow up actions must be delegate owned, with Haelo providing support to move these actions forward and build on the momentum of the event.

Senior leaders from the CCG have been invited to attend for the afternoon to understand the projects and the result of the past three days. After the groups reconvene, Francine Thorpe reminds the room of the concept behind the day and how Safer Handover is a key work stream of Safer Salford, after handover was identified as a key safety risk back during the Making Safety Visible collaborative.

Francine remembers a sense of frustration about the systems we currently work within and how the system impacts on our workload. This event was to bring primary and secondary care clinicians together to create a seamless process that will underpin the ICO programme. Francine celebrates: “there has been a real willingness in the room to work together to impact change”.

The first team to present begin by reviewing their current state and give three top observations about the referral process: differing GP practice referrals processes, lack of understanding of other internal processes and put simply, “it’s complicated!” The team highlight their waste as: duplication and unnecessary communications, it can take up to 114 days for a standard referral and up to 84 steps in the process (but only three of those are value added to the patient). Their ‘blue-sky thinking’ or ideal state was to put the patient right at the centre. The team said: “If we reach that, it will improve patient safety and satisfaction – as well as clinician satisfaction and capacity”.

How will they do this? By streamlining, simplifying and standardising processes. Also adding that IT infrastructure is critical to meet the ideal state. This leads us to their future state – what they will be working towards after the event! Their key messages were to reduce unnecessary handover and minimise the risk of harm. To do this the team will “take out the noise and clutter in the system, whilst having a much better shared understanding of the system, for both clinician and patient”.

Post event key actions ranged from setting up an information transfer group, testing a world café style event and setting up a process to collect data. Finally in their key learning segment the team said after the three days that “It’s a miracle that patients ever get what they need! But it happens in spite of the system because people work harder not smarter.” It is important to note there is a huge commitment required from all, technology must enable safe handover and there’s recognition that silo working is no longer efficient, reliable or safe.

In the same presentation layout, the second team begin with their top observations about the transfer of care on discharge process, these include: duplication of work, lack of visibility and unknown ownership. The waste was identified as: duplication of communications, delays in planning and amount of time spent investigating clinical information.

Gaps in the system were caused by the high number of records, unnecessary handover and culture – specifically the lack of collaboration.

The ideal state, what the team want to see in the future, will feature real time sharing of e-records and improved sharing between primary, secondary and community services. This again would result in improved patient and staff satisfaction in addition to improved confidence and trust in the system. The team go on to say they have to be realistic about what they can actually achieve for their future state: “we don’t want to be overly ambitious and get nowhere”. Their plan includes a change in culture to a shared responsibility for patients and resources and to develop a system to share tasks with lean communications.

Key actions were simple for the team – they looked at what was feasible from the future state and delegated tasks! Together they learnt it’s good to talk as there’re too many assumptions made and misunderstandings in the system. They found so much value in sitting down face to face and achieved a lot more than we ever would have alone.

That’s it from our teams. Dr Peter Turkington, Medical Director at SRFT, as a member of the executive team takes to the front to talk about what his team needs to do to support the collaborative with the key messages and challenges presented.

Pete urges “Safer Handover is a priority for everyone”. In summary, the process needs to be simplified, and there’s an overwhelming view that this has to be a joined up system to reduce the number of handovers and therefore the risk. He adds: “it’s been a great few days and a pleasure working with you all. We need to work on this momentum. It would be a disaster if all the fantastic work of these three days goes to waste.” He stresses that teams should hold the executive team to account to make sure this happens. Salford has a reputation for safety and being the best, but if we don’t work together and move forward we’re going to be passed. Collaborative working is the key. There is undoubtedly absolute heart and energy in the room to work together as ‘one team’.”

Dr Jeremy Tankel, Salford CCG Clinical Lead for Quality and Safety/Medical Director, follows Pete to the front and reminds attendees of the quote he found at the start of the event: “we must respect the past, trust the present, if we wish to provide for the safety of the future.” This quote stills stands.

From the team presentations, Jeremy pulls out the key themes to take home, 4Ss and 3Cs

  • Safety
  • Streamline
  • Simplify
  • Standardise
  • Commitment
  • Collaboration
  • Culture

He adds these are “the seven most important words I’ve heard (aside from unambiguous!). “I’ve learnt so much from you and about you. I wanted to understand the problem from your perspective – I walk away wiser and humbler.” The past three days have helped us to create a bigger picture and a road map going forward. Pete concludes that the executive team will continue to provide momentum; they owe the teams and the system to do that.

Anthony Hassall, Salford CCG Chief Accountable Officer, echoes Pete’s words on “what sounds like such a brilliant event”. Anthony explains that the outputs presented today chime with what the CCG are striving for, “I live in this great city, as does the majority of my family, we access health care and social care and therefore I have a personal responsibility to make us work together in a strong and robust way.”

There’s nothing like being a patient to experience what a system is actually like. Fortunately or unfortunately, Anthony walked in the shoes of a patient recently. He encountered some amazing things but some things we could be doing better. Anthony thanks the teams before passing to James Sumner, Chief Officer, SRFT to close the event. He describes the event as “an enabler, but we must not let it stop here.”

And with that, the Rapid Improvement Event draws to a close. What a fantastic three days! Penny and the team offer a huge thank you to everyone for their personal commitment, their enthusiasm and drive to make a difference.

Thanks must also go to Sharon Jeffrey, our facilitator and Clinical System Improvement Consultant and the fabulous green shirts from Haelo. Until next time!

Follow or continue the conversation on Twitter using @SaferSalford and #SaferHandover


Creative Thinking: SCAMPER film
PDSA Template
Process Mapping Guide

Outbrief Presentation
3 day process overview