What's Ideal? A case study exploring handoff routines in practice

Background Handoffs of care in the healthcare system between responsible providers have traditionally been conceptualized and studied at the point of patient transfer. Thus, clinical practice and associated information systems are designed with the concept of the handoff as a solitary event. This viewpoint does not consider the routine activities necessary for a successful handoff. We propose expanding the analysis of the handoff beyond the single point of transfer to include a routine of interrelated activities leading up to the transfer of responsibility. We used this expanded definition of handoffs to identify exceptions from standard practice as identified by ideal-type handoff routines. Method We used an ethnographic case method to study handoffs in an interventional cardiology unit in a Midwestern community hospital. This involved examining handoffs and their supporting routines. We conducted thematic analysis of the handoffs using NVivo, a qualitative software analysis program. These analyses include categorization of the types and causes of differences in practice and exceptions from ideal-type handoffs. Results Observed handoffs that took place within the clinical unit did not consistently align with the ideal-type routine, yet this variation did not necessarily lead to exceptions. However, for handoffs between clinical units, although more likely to follow the ideal-type routine, differences from the standardized routine more often led to exceptions. We found that problems with performing the routine activities leading up to the handoff and the context in which the handoff occurred affected whether the handoff was successful. Conclusions Considering the handoff as a routine rather than simply the point of transition gives broader insight about how care transitions function. Such consideration helps clinicians better understand how variations occur and how differences from ideal-type handoffs can lead to potential exceptions such as missing information. This analysis can be used to develop information systems that better support handoffs.