Clinical Handover Policy & Procedures

Application
Effective Date Programme application
July 2013 Allowah Presbyterian Children’s
Hospital including Allowah Disability
Support Services

Approved / Reviewed

Key Policy Writer C Towers, G Farrell

Policy Review ELT,

group members

Approved by Date Review date

S Hurren July 2013 July 2016
ELT Aug 2017 July 2020
LM17.08.46
E McClean May 2021 May 2023

Document Control
Issue Date Author Change Description
1 July 2013 T Szanto
2 May 2017 C Towers Scheduled review
3 May 2021 E McClean Scheduled review and policy
change

Other relevant policies

Discharge Policy and Procedures
Patient Identification Policy and Procedures
Infection Control policy and procedures
Child and family centred framework

Document Summary / Key Points:

• Outlines Allowah’s policy and processes for safe, effective and accurate
clinical handover when patient care is being transferred.

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 Change Summary:
• Policy updated to new format for standardised handovers following Q&S
review

Table of Contents

1 REFERS TO ........................................................................................ 3

2 PURPOSE .......................................................................................... 3

3 POLICY STATEMENT .......................................................................... 3

4 RESPONSIBILITIES .......................................................................... 4

4.1 Who is responsible? Who is accountable? Who needs to be consulted? Who

needs to be consulted? ................................................................................................. 4

4.2 Chief Executive Officer ........................................................................................ 4

4.3 Director of Nursing ............................................................................................. 4

4.4 Registered Nurse in Charge................................................................................. 4

4.5 Nursing Staff ....................................................................................................... 5

4.6 All employees involved in patient care ................................................................ 5

4.7 The Medical Team ............................................................................................... 5

5 INFORMATION .................................................................................. 5

5.1 NSQHS – Standard 6 ........................................................................................... 6

5.2 Definitions .......................................................................................................... 6

6 GOVERNANCE AND LEADERSHIP FOR EFFECTIVE CLINICAL

HANDOVER ............................................................................................ 7

6.1 Measuring performance against our expectations ............................................... 7

6.2 Clinical Handover Training .................................................................................. 7

6.3 Clinical Handover changes .................................................................................. 8

6.4 Clinical Handover records ................................................................................... 8

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 7 CLINICAL HANDOVER PROTOCOL ..................................................... 8

7.1 Our expectations ................................................................................................. 8

7.2 Components of Handover at Allowah .................................................................. 9

7.3 Shift to Shift Handover ........................................................................................ 9

7.4 Nursing Progress Notes ...................................................................................... 9

7.5 Handover protocols ........................................................................................... 10

7.6 Short Break Handover ....................................................................................... 14

7.7 Long break Handover ........................................................................................ 14

7.8 Non- clinical activities ....................................................................................... 14

7.9 Discharge .......................................................................................................... 14

7.10 Parent / carer involvement in Handover ........................................................... 14

8 REFERENCES ................................................................................... 15

9 KEY PERFORMANCE INDICATORS ................................................... 15

10 APPENDIX 1 – STANDARD KEY PRINCIPLES FOR CLINICAL

HANDOVER .......................................................................................... 16

1 REFERS TO
All clinical staff involved with care of children at Allowah.

2 PURPOSE
To provide a framework that ensures best practice when transferring care of patients.

3 POLICY STATEMENT
Clinical Handover is the transfer of professional responsibility and accountability for
some or all aspects of care for a patient to another person or professional group on a
temporary or permanent basis.

Handover is of paramount importance for ensuring patient safety and streamlining

work practices / workloads. The aim of any handover is to achieve the efficient
communication of high-quality clinical information at any time when the responsibility

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 for patient care is transferred. Good handover is at the heart of an effective health care
system, it requires systematic and individual attention and needs education, support,
facilitation and sustained effort to ensure it maintains a position of importance in an
already full working day.

The primary objective of the handover is the accurate transfer of information about a
patient’s state and care plan. The handover should also include an opportunity to ask
and respond to questions. It should also serve to improve communication between and
among caregivers and decrease error. It is necessary for each caregiver to have a
thorough knowledge of patient condition and care needs.

Other handovers occur:

• On the phone to a doctor when the patient’s clinical condition changes

• On transferring a patient to a higher level of care
• In written form in the doctors’ book
• Transition of care – a set of actions designed to ensure co-ordination and
continuity of care as patients transfer between services.

4 RESPONSIBILITIES
4.1 Who is responsible? Who is accountable? Who needs to be
consulted? Who needs to be consulted?

4.2 Chief Executive Officer

The CEO is responsible for ensuring this policy is regularly reviewed and complies with
standards and guidelines for Clinical Handover.

4.3 Director of Nursing

The DON is responsible for ensuring compliance with this policy. The day to day
operational leadership of handover will be undertaken by the Registered Nurse in
Charge.

4.4 Registered Nurse in Charge

The Registered Nurse in Charge is responsible for supervising handover and ensuring
the following principles are applied:

• Patient care (as required) continues while handover is occurring

• Handover documentation is available for staff
• The venue, starting times and duration of the handover are clear
• Staff have a good understanding of their role in the handover

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 • Disruptions are minimised
• All relevant staff attend handover
• ISOBAR is adhered to as the communication tool
• Feedback (both positive and negative) is given to staff about their participation
in handover
• Audits of the handover process are completed as required
• Allocation of patients to suitable competent nurses

4.5 Nursing Staff

The aim is that the nurse providing direct care to a patient will hand over directly to
the nurse who is going to provide care. What this looks like varies depending on which
shift is handing over, and this is explained in more detail in this policy. A nurse who
has had responsibility for the care of a patient will ensure that he/she does not leave
the ward without handing over to the incoming nurse or where that is not possible the
Registered Nurse in Charge.

4.6 All employees involved in patient care

All employees involved in patient care are expected to participate in group handover
and to undertake direct patient handover as and when required during their shift at
Allowah.

4.7 The Medical Team

The Medical Team will:

• Refer to the Doctor’s Book for patient care required (non-urgent)

• Read and sign the Monthly Review Folder for an update on tests and Specialists
reports. Any urgent matters will be phoned through to the relevant Doctor as
they are known, by the Registered Nurse in Charge.
• Speak with the Registered Nurse in Charge about changes made to a patient’s
care.

5 INFORMATION
Effective Clinical Handover can reduce communication errors between health
professionals and improve patient safety and care.

Clinical communication problems are a major contributing factor in 70% of hospital

sentinel events leading to an increased risk for adverse events. Adverse events are
seen to increase particularly during a transition of care, when a patient is transferred
between units, physicians and teams. Poor or absent clinical handover, or a failure to
transfer responsibility and accountability, can have extremely serious consequences for
patients. It can result in a delay or diagnosis or treatment, tests being missed or
duplicated and can lead to the wrong treatment or wrong medication being

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 administered to the patient. Clinical handover is an essential element to ensure a safe
and high quality healthcare delivery. It is important to note that improvement
strategies for clinical handover take time.

5.1 NSQHS – Standard 6

The National Safety and Quality Health Service (NSQHS) Standards have certain
requirements with regard to Clinical Handover. These are largely embedded in
Standard 6: Communicating for Safety.

Standard 6.7 & 6.8 are specifically about Clinical Handover and are as follows:

The health service organisation, in collaboration with clinicians, defines the:

a. Minimum information content to be communicated at clinical handover, based

on best-practice guidelines

b. Risks relevant to the service context and the particular needs of patients,
carers and families

c. Clinicians who are involved in the clinical handover

Clinicians use structured clinical handover processes that include:

a. Preparing and scheduling clinical handover

b. Having the relevant information at clinical handover

c. Organising relevant clinicians and others to participate in clinical handover

d. Being aware of the patient’s goals and preferences

e. Supporting patients, carers and families to be involved in clinical handover, in

accordance with the wishes of the patient

f. Ensuring that clinical handover results in the transfer of responsibility and

accountability for care

5.2 Definitions
Clinical handover: transfer of professional responsibility and accountability for some
or all aspects of care for a patient, or group of patients, to another person / family /
legal guardian or professional group on a temporary or permanent basis.

ISOBAR: acronym that stands for Identification – Situation - Observations –

Background – Agreed Plan – Read back. It is an evidence based communication model
that assists the speaker by providing a framework to organise and convey information.

Short break: any time away from the patient for 10-15 minutes – for example:
transferring of patients from another area, picking up patients from another area,
bathroom break.

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 Long break: any time away from the patient that is greater than 15 minutes – for
example: meal breaks, multidisciplinary patient meetings, education sessions.

6 GOVERNANCE AND LEADERSHIP FOR EFFECTIVE

CLINICAL HANDOVER
6.1 Measuring performance against our expectations
We will measure performance against our expectations via:

• All Care Team staff & AH to have read the Documentation Policy within the first
week of employment and then on an annual basis

• All staff to have completed LeeCare training within the first week of employment

• All Care Team staff & AH to have completed Documentation competency within the
first week of employment

• Audits of clinical handovers will result in < 5% variance from procedure

• Audits of documentation completion will result in < 5% from procedure

• Audit of documentation engagement (red folder / progress notes / MDT) at

beginning of shift will result in < 5% variance

• When errors occur, follow up action to be taken by the Patient Safety Officer within
5 days of the incident

• Training audits

The regular audits of clinical handover are conducted and reviewed by the Clinical
Governance Unit. These are then reported to the Executive Leadership Team (ELT) as
part of the ongoing quality improvement program.

Incidents and complaints are reviewed by the Director of Clinical Governance and the
ELT. The DCG is responsible for any immediate actions required. Staff involved with the
complaint or incident are spoken with at the time or as soon as appropriate. All staff
are informed as part of the handover process.

6.2 Clinical Handover Training

On orientation staff are introduced to Clinical Handovers and undertake Clinical
Handover training.

Posters outlining the handover process are available at the nurses’ station and in the
medication room as posters and information is regularly given using staff
communication tools.

Our training path is as follows:

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 The ISOBAR acronym is also outlined on the front page of the handover sheet.

Short videos of ISOBAR training are available on the computer at the nurses’ station.
Staff have been encouraged to take time to watch these and improve on the handover
process.

6.3 Clinical Handover changes

Changes to handover procedures are communicated as part of a quality and safety
process. Changes to the procedures are approved in advance by the ELT.

6.4 Clinical Handover records

Paper copies of the Clinical Handover sheets are kept in a folder and then filed and
archived over time. Copies of discharge summaries are kept in patients’ medical
records.

7 CLINICAL HANDOVER PROTOCOL

7.1 Our expectations

At Allowah, we expect:

• All clinical handovers to be conducted in exactly the same way on every shift
• All staff involved in handover / engagement with documentation to reach our KPI of
< 5% variance from protocol on audit
• All staff who participate in clinical handover (Allied Health/AIN/SW/EN/RNs) to know
and follow the policy and procedure
• All staff who write in records to know and follow the policy and procedure
• All staff who engage with clinical records as part of care delivery read the red
folder, progress notes in black folder and MDT at the beginning of their shift for all
children in the care of their team
• Documentation - All AINs / SWs must achieve Level 1 training, RNs/EENs/AH must
achieve at least Level 2 training, CNEs must achieve at least Expert Level

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 • Documentation - All AINs / SWs must achieve Level 1 training, RNs/EENs/AH must
achieve at least Level 2 training, CNEs must achieve at least Expert Level
• The CNE will achieve > 95% Compliance against training audits

7.2 Components of Handover at Allowah

The components of Handover at Allowah are:

• MDT – This is a high-level oversight safety conversation

• Shift to Shift Handover
• “Time out” – will be implemented as part of Team Care in 2021

7.3 Shift to Shift Handover

The Key element to Handover is that staff who have been caring for a particular child
get to hand over their clinical information to the staff who will be caring for a child.

Therefore, not all Shift to Shift Handover’s at Allowah will look the same, because we
have different shaped teams on different shifts and different things will be going on at
Allowah at different shift change times.

7.4 Nursing Progress Notes

Nursing Progress Notes are the backbone of all Handovers at Allowah. All staff are to
view the Nursing Progress Notes to gain greater understanding of the child. The
purpose of the Nursing Progress Notes is to:

(i) Provide a structure for documenting handover items

(ii) Empower all care team staff to participate in handover

(iii) Improve staff competency in handover

(iv) Provide a historical understanding of processes of care and outcomes from

shift to shift

Outgoing staff will:

• Present data from Nursing Progress Notes to incoming staff member/s caring for
that child.
• Present Critical Information
• Store completed Nursing Progress Notes in black folder

Incoming staff will:

• Use reflective questions

• Read previous shift Nursing Progress Notes and initial new Nursing Progress
Notes
• Use Nursing Progress Notes to document during shift
• Store completed Nursing Progress Notes in black folder

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 The RN in Charge is responsible for ensuring Handover is conducted as set out in our
protocol. Team Leaders (and RN in Charge of Night shift) are responsible for:

• Ensure Handover is completed and all staff are involved

• Ensure any staff who are late receive a handover
• Ensure all staff read all the outgoing Nursing Progress Notes and initial/use the
new NPNs

7.5 Handover protocols

In the following diagrams Handover is highlighted in blue. There are a number of other
conversations that will take place around Handover and these are noted as well, but
they are not Handover itself.

REMEMBER: It is essential that staff who have been caring for a child handover to the
staff who will be caring for a child – we don’t want to go through a “second set of
hands” to get the information to where it needs to be.

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Clinical Handover Policy and Procedures – 25 May 2021 Page 11
Clinical Handover Policy and Procedures – 25 May 2021 Page 12
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7.6 Short Break Handover
• Occurs between the nurse responsible for the patient and the nurse who is assuming
responsibility for the patient.
• Comprises of a short verbal handover focusing on the greatest risk for the patient.

7.7 Long break Handover

• Occurs between nurse responsible for the patient and the nurse who is assuming
responsibility for the patient.
• Comprises of a verbal handover in ISOBAR format (ISR) – identification of patient;
current situation and any risks or recommendations for break interval
• Documentation of handover and transfer of professional care needs to be recorded in
the medical record.

7.8 Non- clinical activities

Parents, carers, drivers, volunteers etc. may escort patients from the hospital / ward if they
have been assessed as safe to leave the ward without a nurse escort e.g. children going to
school, going for a walk with volunteers. These activities are to be documented in the medical
record.

7.9 Discharge
Allowah’s policy and procedures related to handover at the time of Discharge are outlined in
the Discharge Policy and Procedures.

7.10 Parent / carer involvement in Handover

• Parents and carers are part of the pre-admission meeting to review the care needs and
help establish an individual care plan for their child.
• Parents / carers are asked at each admission if there have been any changes for their
child. Parents / carers are requested to provide updated medical reports and
medication changes. The RN in charge will update this information on the handover
sheet and through verbal handover to any relevant staff.
• During admission, parents / carers can discuss the child’s care and inform staff of any
important changes they would like to be and these are added to the clinical handover
sheet.
• Patient Care Reviews are conducted as requested or as required and give parents /
carers opportunity for input about the care of their child.
• A discharge summary is provided outlining what has happened during the admission
and any important information for ongoing care following the admission. At discharge
parents / carers also have the opportunity to discuss any issues they would like to be
included in the child’s care on their next admission. After discharge parents / carers

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 can contact Allowah by phone, email or using the feedback form on the website to
inform staff of changes in their child’s care

8 REFERENCES
NSW Health Clinical Handover – Standard Key Principles PD 2009_60 28.9.2009

Safe Handover: Safe Patients Guidance on Clinical Handover for Clinicians and Managers –
AMA 2006

iSoBAR – a concept and handover checklist: The National Clinical Handover Initiative; JM
Porteous, EG Stewart-Wynne, M Connolly and PF Crommelin; MJA Volume 190 Number 11;
June 2009

Transfer of patients between Public Hospitals; NSW Department of Health 27/1/2005

Transfer of patients from public to private Hospital – NSW Department of Health 25/05

NSW Health: Children and Adolescents – Inter-Facility Tranfers; PD 2010_031; 2 June 2010

NSW Health: Recognition and Management of a Patient who is Clinically Deteriorating;

PD2010_026; 10 May 2010

Royal Children’s Hospital Melbourne: Clinical Guidelines: Nursing Clinical Handover- revised
December 2015.

9 KEY PERFORMANCE INDICATORS

Area KPI
Clinical Handover < 5% deviance from policy and procedure on
observation audit
CNE > 95% compliance on audit

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10 APPENDIX 1 – STANDARD KEY PRINCIPLES FOR
CLINICAL HANDOVER

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