Bridging gaps in handoffs: a continuity of care based approach

Handoff among healthcare providers has been recognized as a major source of medical errors. Most prior research has often focused on the communication aspects of handoff, with limited emphasis on the overall handoff process, especially from a clinician workflow perspective. Such a workflow perspective that is based on the continuity of care model provides a framework required to identify and support an interconnected trajectory of care events affecting handoff communication. To this end, we propose a new methodology, referred to as the clinician-centered approach that allows us to investigate and represent the entire clinician workflow prior to, during and, after handoff communication. This representation of clinician activities supports a comprehensive analysis of the interdependencies in the handoff process across the care continuum, as opposed to a single discrete, information sharing activity. The clinician-centered approach is supported by multifaceted methods for data collection such as observations, shadowing of clinicians, audio recording of handoff communication, semi-structured interviews and artifact identification and collection. The analysis followed a two-stage mixed inductive-deductive method. The iterative development of clinician-centered approach was realized using a multi-faceted study conducted in the Medical Intensive Care Unit (MICU) of an academic hospital. Using the clinician-centered approach, we (a) identify the nature, inherent characteristics and the interdependencies between three phases of the handoff process and (b) develop a descriptive framework of handoff communication in critical care that captures the non-linear, recursive and interactive nature of collaboration and decision-making. The results reported in this paper serve as a "proof of concept" of our approach, emphasizing the importance of capturing a coordinated and uninterrupted succession of clinician information management and transfer activities in relation to patient care events.