Redesigning the hospital handover process
Participants who took part in the improvement of the hospital handover.
This is the number of staff who piloted the project in the beta stage.
Travel to the field each year, and need to carry out a staff handover.
“I arrived about a few days after my predecessor had left. She hadn’t written her handover so I received it a week after being here.” Jula Fedec, Nursing Coordinator, South Sudan.
Médecins Sans Frontières (MSF) is a humanitarian medical organisation providing support across the world. They deliver medical care in war zones and countries affected by natural disasters.
I worked with MSF for 6 months and improved the handover between international hospital management staff. Thousands of handovers are being carried out across MSF annually. In some hospitals there is more than 1 international staff handover every month (activityreport2016.msf.org). Due to the challenging conditions, members of international staff typically stay for 6-12 months at a time. Often there is a gap between one member of staff leaving and another starting. They might not have time for a face-to-face handover, to explain the process of running the hospital to their successor. Poor handover can mean a significant part of staff time is wasted. It takes longer for management staff to settle into their role. This can impact the quality of patient care and the overall strategy of the hospital.
My role as a Service Designer was to understand what was going wrong with hospital handover, and how it could be improved. I assembled a team of experts at MSF to support the implementation of the new handover service. I led the MSF advisory group with people from the field teams, and together we tested multiple ways of improving hospital handover. The best solutions were implemented in the field. I also produced a report of the findings, and spoke at MSF’s Scientific Innovation Day conference.
I carried out research with 42 participants in total. 18 of the participants were international field staff. 16 were operations staff, 2 were members of national staff and 6 were people from outside of MSF. I also carried out analogous research: it was important to look to other industries for examples of best practice when carrying out handover. These are the insights we uncovered:
“There is no specific handover template” Wubalem, Human Resources Coordinator.
There is no consistent process for carrying out handover at the organisation. 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. Often, due to logistical reasons (like visa restrictions), there is no overlap between outgoing and incoming members of international staff. Some staff take the initiative to prepare their colleagues on an ad-hoc basis.
“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. There’s not that time to accommodate it.” Jose Hulsenbek, Head of HR, UK.
Outgoing staff need to be motivated to carry out handover. If a staff member isn’t prepared for their handover in advance, they have to gather their knowledge for their successor in their final week. At this point they are exhausted and eager to return home.
“We had no electricity most of the day. You get up in the morning in pitch black, couldn’t see anything. Electricity wouldn’t come on until 4/5pm then go off at 11pm” Diane Robertson-Bell, HR Coordinator, UK.
There are technology limitations in the field. For this reason I designed a handover process that would work in environments with intermittent Wi-Fi and electricity access and a limited amount of laptops, phones and computers. As well as these infrastructure limitations, MSF currently has multiple document sharing platforms; OneDrive, Gdrive, Habari, field websites and more.
“They build up a working relationship with national staff. That gets broken every time a new person comes in if you don’t do a proper handover. That’s why I saw, for those positions, that personal handover is also crucial.” Jose Hulsenbek, Head of HR, UK
“Our opinions as national staff were not trusted. We 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 [...] What could help [international staff] is to be open in communication, open to learning but be assertive at the same time. National staff are happy to teach you the ropes but not if you’re depending on them all the time. Give yourself transition time, accept that you could be wrong.” Carolyn, Former National Staff Member, Content Manager, UK.
National staff are constant, international staff change. National staff are an asset because they hold institutional memory, they continue while international staff come and go. Their experience and expertise in regards to how to run a hospital and care for patients can strengthen MSF projects and missions.
“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.
It is often unclear who is responsible for which aspect of the handover. 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, or ensuring that the handover is clear and consistent across roles. Currently handover could sit within the line manager’s duty, or field HR, or staff within the operational centre. The new handover process has clear lines of responsibility to hold people to account.
I developed 3 solutions, which addressed the problems identified in the discovery phase. I went through a process of testing prototypes with MSF staff, before implementing the 3 most effective solutions. The new handover process adds value by building on existing tools and best practice to create a consistent, easy to use handover process which can be used by international staff.
“It’s really good idea with the proviso that it’s flexible. Some prompts as to what you need. Mike, Medical Doctor, Nairobi
The template is a Word document which can be stored on the shared drive, or on the hospital computer. The template is designed to be updated with links and bullet points during the project. Rather than writing a whole new handover report every mission, the flexible template is designed to be updated from your predecessor's handover. We encourage field staff to complete their template 3 months before the end of their mission and send it to their line manager.
“It gives an opportunity to elevate the role of national staff. It’s not uncommon for expats to come in thinking that they’re the experts.National staff are the experts." Ann Wunderlin, Logistician, Tajikistan
A buddy system is recommended for new members of staff to be integrated into the team quickly. The buddy relationship also allows the buddy to develop their communication skills and be recognised for their supportive role. International members of staff should be paired with a national staff member in order to benefit from their experience. A buddy is someone who shows the new staff member how everything works in the project.
"I would love it. It’s so much more personal, it’s welcoming you feel like you’re part of the team when your face is on the wall and you see who composes the team." Julia Fedec, Nursing Coordinator, Bentiu
New staff members felt that understanding their team structure and being able to access an org chart was important. We suggest that the org chart is large, visible to all on the wall in your project. Staff mentioned that images of people on the org chart would be useful.
These two user journey’s show how the old handover process worked, and how it improved afterwards.
"In my first mission a handover saved my life, without this handover I think I would have probably left the project. Bart-Yan Bekker, Improvement Lead, UK
The solutions developed through the project are simple and cost-effective ways to solve the issue of ineffective field handover. The service design approach was new to MSF. Thorough in-depth research highlighted what field staff needed from the new handover process. Then solutions were tested in an agile way, so that only the most useful solutions with the most potential for success reached the field.
Before this project I had no idea what a service designer did! I knew we had a problem with handovers and that we had to try and get people to understand how important that was based on the research we’d done. Having you run us through a service design process to help us move things forward in an environment where change is really hard has been really useful. We narrowed it down from a number of really good ideas which we tested with different people to 3 key areas. Those ideas were pragmatic and improved the handover process.
Check out some of the other projects I've been working on.
