Managing competing organizational priorities in clinical handover across organizational boundaries

Abstract

Objectives: Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine). Methods: A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically. Results: The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other's goals and constraints as possible ways towards more sustainable improvement. Conclusion: Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patientcentred care.

Learning from incidents in health care: Critique from a Safety-II perspective

“…incidents), but rather as the presence of something -the ability to make dynamic trade-offs and to adjust performance in order to meet changing demands and deal with disturbances and surprises (Fairbanks et al, 2014, Hollnagel, 2014b, Hollnagel, 2014a, Sujan et al, 2015c, Sujan et al, 2015a.…”

“…Modern health care systems are characterised by changing demands and finite resources giving rise to competing organisational priorities, such as the management of patient flows and time-related performance targets (Sujan et al, 2015c). As argued above, health care systems might be regarded more appropriately as Systems of Systems (Harvey and Stanton, 2014) or Complex Adaptive Systems , Leveson et al, 2009, Robson, 2015.…”

“…The paper aims to make suggestions for the policy and practice of learning from incidents in health care by offering a critique based on a Safety-II perspective. In Safety-II thinking safety is defined as an ability -to make dynamic trade-offs and to adjust performance in order to meet changing demands and to deal with disturbances and surprises (Fairbanks et al, 2014, Hollnagel, 2014b, Hollnagel, 2014a, Sujan et al, 2015c, Sujan et al, 2015a. The paper argues that health care organisations might improve their ability to learn from past experience by studying not only what goes wrong (i.e.…”

Implementing Healthcare Improvement

“…This is because healthcare professionals are able to make dynamic trade-offs and to adjust their performance in order to meet changing demands and deal with disturbances and surprises [18,24,43,46,50]. Empirical studies of everyday clinical work provide a diverse range of examples of such performance adjustments in practice [51][52][53].…”

“…Healthcare systems are characterised by changing demands and finite resources giving rise to competing organisational priorities, such as the management of patient flows and time-related performance targets [43]. Healthcare systems might be regarded more appropriately as Systems of Systems [44] or Complex Adaptive Systems [45].…”