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Introduction

Ineffective handover is wasting a significant portion of doctors’ and hospital management staff time in a humanitarian non-governmental organization which delivers medical care worldwide. In the fast-paced environment, with human lives at stake, effective handover is essential. Thousands of handovers are being carried out across the organization annually, in some hospitals 1 handover every 3 months. The organization runs 468 projects across 71 countries, with international staff working across all of these projects. The principal outcome of this project was to maximize staff time in order to save more lives. Our objectives were to develop a more effective hospital handover process, test the process in the field and scale it across the organization.

International staff is specialized medical and management staff from countries across the globe. They travel to countries in times of crisis to support medical care on a temporary basis. High turnover of these staff is inevitable. National staff is the bulk of this organizations workforce, delivering medical care long-term, in their country of origin. The urgent need for better handover between incoming and outgoing international staff was highlighted in the nursing debriefing tool results, with handover consistently scoring low. International staff manage national staff, and currently, that management is compromised when handover is unsuccessful, therefore, improving that handover will have a positive effect on all staff, and the level of hospital care in general.

We have created a new handover process which includes a flexible handover template, which outlines what handover documents should include, field staff simply update links and bullet points when leaving their mission. A living organogram orientates new staff members in the team and a national staff buddy which links incoming international staff with a key member of national staff upon entering the field to understand their new role.

Process

SET UP

The first stage of the project was to define the problem and set up an advisory group of key handover stakeholders. These staff members would be instrumental in steering the project as well as implementing the new process. A kick-off workshop was carried out to understand the current user journey of an international field staff member and highlight key areas for improvement.

DISCOVER

The research was carried out with operational, international and national staff to identify their current handover challenges. In total 5 national staff and 30 international staff contributed their opinions and expertise over the
research and testing of the project. A series of interviews and workshops informed the solutions later on. The user journey developed in the set-up stage was continually put in front of the staff to check whether it was accurate, it was then updated and used to identify solutions.

DEFINE

Data from the research was analyzed, which allowed us to gain insights into how the new handover process should work.

DEVELOP

Workshops with field staff and operational staff were carried out in London and Amsterdam. Ideas on how to improve the handover process were developed, based on the initial research gathered. Staff also evaluated
their ideas on a scale of implementable to not, as well as high to low impact. The ideas which would have the highest impact and were possible to implement were developed into prototypes for people to then give feedback.

TEST

The solutions were developed and could be downloaded on the new handover website we developed. Field staff could download and use the new handover process and give feedback via a form or a video call. The
website was accessed by 145 people across 10 different countries. 27 people viewed the flexible handover template, 18 viewed the living organogram and 14 viewed the national staff buddy system. This
quantitative evidence was captured through Google Analytics and Microsoft Office 365 OneDrive (OneDrive). Qualitative evidence also offered valuable insights into what would work in the field. Testing sessions were carried out in the organization’s London office when field staff members were debriefing post-mission. Handover solutions were continuously iterated based on the feedback. The solutions were also presented at the organization's annual science and innovation conference, through this the solutions began to spread through the organisation: London, Amsterdam, Berlin, Barcelona and Brussels offices were all involved in providing feedback on the solutions.

Methods

An example of a method used during the workshops was a turtle handover activity. Participants were given a scenario: to imagine they were adopting a turtle, what information would they need from the previous turtle owner, and how would they want that information delivered? This allowed participants to generate more lateral ways to share handover information.
Analogous research, inspired by IDEO http://www.designkit.org/methods/6 was carried out. This is the gathering of solutions, research, inspiration from outside of the problem space. We gathered examples of handover best practice with people outside of the organization. This research took the form of interviews and a testing session with people from unrelated industries. This strengthened our understanding of handover best practice, and also highlighted the need for better handover processes across multiple industries.

KEY INSIGHTS 

In-depth, qualitative research was conducted with 38 participants in total. 3 workshops were carried out for maximum buy-in from the people who would use and implement the new handover process. During the Discover
phase, 18 of the participants were international field staff, 16 were operational staff, 2 were members of national staff and 6 were analogous research participants, from outside of the organization.

1. Inconsistent process
   There is no consistent process for carrying out a handover at the organization. It is up to the individual members of staff to decide whether to write a handover report and how to pass information over to their successor. Some staff takes the initiative to prepare the national staff that they manage and their colleagues by having meetings or providing written documents. The new process draws on best practice across the organization in order to ensure
   we have a flexible handover process that works in a variety of settings.
   “I didn’t really have a handover I just worked it out when I got there.” Sarah Walpole, Medical Doctor
   “There is no specific handover template.” 
   Wubalem, Human Resources Coordinator
2. Motivation
   Outgoing staff needs to be motivated to carry out the handover. If a staff member isn’t prepared for their handover in advance, they have to gather their knowledge for the successor in their final week. At this point, they are exhausted and eager to return home. The new handover process encourages staff to carry out handover before
   their final weeks.
   “That’s the challenge of handovers. Once you’re done you’re tired, done, fed up. Psychologically you’re done and you want to leave.”
   Jose Hulsenbek, Head of HR, UK
   “I think with handovers it’s to do with luck. How much time and motivation they’ve had to do it.”
   Ivelina Georgeiva, User Researcher Scottish Government, UK (analogous research participant)
3. Responsibility
   Handover between field staff is no one’s responsibility. When a staff member is handing over information to their successor they are aware that it’s their responsibility, but there is often no one holding them to account. The new handover process has clear lines of responsibility to hold people to account.
   “If you don’t send people a template and tell them to do it, people are busy. If there’s not someone following up it won’t happen.”
   Nell Gray, HR Coordinator, UK
   “I arrived about a few days after my predecessor had. She hadn’t written her handover so I received it a week after being here.”
   Julia Fedec, Nursing Coordinator, South Sudan
4. Extreme Context
   Working in extreme conditions means handover is challenging. If the new handover process can’t work in an emergency, when a staff member is tired, or when patients need urgent healthcare, then it will not be effective. The new handover process is designed to be as quick and efficient to carry out as possible.
   “We treat everything like it’s an emergency. There’s no time for jet lag.”
   Jose Hulsenbek, Head of HR, UK
5. Institutional Knowledge
   In this multi-lingual, international organization, there are issues in relation to institutional knowledge. Multiple sharing platforms (intranets, OneDrive, Gdrive, Dropbox) are used to communicate in and outside the field. As staff are often contracted to work on a mission by mission basis, they often don’t have an assigned email
   address, instead, there is an address per role. Long-term knowledge dissipates, which makes continuity of strategy within a field hospital a challenge. By improving the handover process, we have a positive effect on other aspects of institutional knowledge, for instance, if an incoming member of staff is inducted and understands the file naming and sharing systems, this can have a knock-on effect in sharing knowledge more widely.
   “None has told me what to do when there was a cholera outbreak.”
   Eugenia Serbassi, Medical Coordinator
   “Every time a new staff member started they changed the length of shifts. Half the nursing team wanted 8 hours, half the team wanted 12 hours. That shows the importance of having a strong handover and good institutional memory.”
   Jens Pagotto, Operations Advisor
6. National Staff
   National staff is a constant, international staff change. National staff is an asset, they hold institutional memory, as they continue to work in the field while international staff comes and go. In some settings, the international staff is more comfortable seeking management and medical advice from other international staff, instead of their more experienced national colleagues. The new handover process must break down this barrier.
   “We (national staff) felt that international staff didn’t take our word for it. Even though we were locals and understood the culture and had seen particular diseases ourselves [...] National staff is happy to teach you the ropes. Give yourself transition, accept that you could be wrong.”
   Carolyn, Former National Staff Member, Content Manager, UK
   “National staff have experienced so many different managers. They’re the ones with institutional memory. Every expat treats them like ‘We know the best’.”
   Anup, Logistician and Marine Engineer, UK

OUTPUTS

We looked at how handover was already being carried out and created a new handover process with key solutions to add value; quick and easy changes to facilitate smooth transitions between field staff. The new
handover process improves morale for staff, increases staff retention and allows them to provide the best possible patient care. The materials associated with this new process are hosted on OneDrive, which the organization is currently migrating all information to, for maximum buy-in. Through research, we learned handover between staff in the health sector is an issue across the globe, and this leading organization is well placed to demonstrate handover best practice in health and humanitarian sectors.

TESTING

On top of the website testing outlined earlier, 19 staff members gave verbal and written feedback. Out of those 19, 12 were international field staff, 4 were operational staff, 2 were national staff, and 1 was an analogous research participant. The living organogram was tested by staff in Tonkilli, Sierra Leone, and Namfura, Nigeria. Head of Missions in Tonkilli, Sierra Leone and South Kivu, Democratic Republic of Congo adopted the flexible handover template and shared it with their staff.

The flexible template was then completed and received feedback from: Richard, the facilities manager in Baraka, Democratic Republic of Congo; Julia Fedec the head nurse in Bentiu, South Sudan, Anne Wunderlin, field admin, Seattle and Amy-Leah Potter, field admin, Sierra Leone. Detailed feedback was collected on which headings should be changed, which sections were relevant, and which weren’t. The national staff buddy system was a popular idea, receiving almost all positive feedback from field staff. However, it involves at least 3
members of staff being willing to test: a project coordinator to match the incoming staff member with their national staff buddy. This idea has not been live tested in the view but, we did find instances of informal buddy systems which worked well. One of the advantages of creating a formal buddy system is to recognize the invaluable role that national staff plays in ensuring that international staff members understand and are able to carry out their new roles. Hana, a field admin in Namfura, Nigeria tried out the living organogram in her project. She felt that the organogram was very important for incoming staff, but that their existing system of updating a spreadsheet and printing it out was working well in this particular hospital. For this reason, we encourage projects to have an up-to-date organogram on the wall, using whichever system they are most comfortable with. The living organogram was also tested by Natalie Schulz, from Berlin operations, in Tonkolili, Sierra Leone. At the time of writing this report, we have yet to gather her feedback.

DELIVERABLES

Best practice guide
A best practice guide outlining the new handover process, including templates and tips on how to carry out the new handover process for Heads of Mission delivered to the organization, for dissemination to key field staff.

Living organogram template
A template for a living organogram which could be put on the wall. This was delivered to the organization on a website and on their OneDrive, as well as to key field staff members who used this in their hospitals.

Flexible handover template
Delivered as a word document for maximum flexibility, on OneDrive and the handover website, used by multiple field staff to aid handover.

National staff buddies guide
A simple .pdf guide which is hosted on OneDrive and the handover website. This was tested in theory (verbal feedback rather than live tested) with field staff.

Report, Film, and Website
A report of all findings from the project was written and will be shared by the project’s advisory group. A film outlining the outcomes of the project, as well as the website where key templates could be downloaded was delivered.

Impact
“In terms of impact, it’s very difficult to quantify at this stage, but we do know that half of the people we put into our missions we lose after 1 mission. That’s the sheer reality of what these places are like. If we can improve handover between the outgoing person and the
incoming person I certainly think that can have an impact on retaining people.”
Peter Whiskerd, Healthcare Management Team, Holland

The initial objective was to improve the hospital handover process for international staff, which would have a positive effect on the staff they manage, and ultimately on patient care. As mentioned in the introduction, the nursing debriefing tool identified handover as a key challenge, with handover consistently scoring 2 out of 5 on the Likert scale and staff commenting that they felt unprepared when starting their role. Therefore, the hospital management team have agreed that the nursing debriefing tool will be used to measure the success of the new handover process. The potential impact of effective handover is great; if staff settle into their roles quicker, up to
one-third of all international field staff time could be saved. Julia Fedec, an international staff member stated: “understanding the context can take 3 months, then in 6 months you finish and you finally understand what you’re supposed to do.” Due to the length of the project, it is not possible to draw strong conclusions about the impact of
the solutions yet. However, we obtained qualitative feedback, with international staff being grateful that their views had been heard and the new process addressed their concerns. As well as the improved handover process, the service design approach was unfamiliar to the Hospital Management Team as well as to the wider organization. Too often forms and new processes are imposed on field staff with little research into what they need and little explanation of why they need do extra work. This project responded to the needs of field staff. Peter Masters, Innovation Advisor stated:
“The service design approach took us back to the basics to say what are the needs and requirements built a body of evidence on which designs and prototypes could be based. I’m optimistic for the outcome of this project because it’s been through that process.”

CONCLUSION

This new handover process makes simple, cost-effective changes in a large organization to increase the time that field staff can spend saving the lives of people in need due to war, famine, and disease. The flexible template, living organogram, and national staff buddy system are key touchpoints in a handover process that can be adopted by staff members across this complex and varied landscape to transform staff relationships for the better. The next challenge is to disseminate this new handover process across the 468 projects, while continually testing and evaluating its use. Improving hospital handovers is a key element of the hospital improvement strategy, so the continued testing and implementation of this new handover process will fall under the responsibility of the healthcare management team within operational center Amsterdam’s Public Health Department. A key hospital will be used as a testbed for live testing the new handover process. The advisory board formed during this project will continue to meet, in order to support with the implementation of the new handover process.