Developing and implementing an organisational system for structured clinical handover
that is relevant to the healthcare setting and specialties, including:
• documented policy, procedures and/or protocols
• agreed tools and guides
6.1.1 Clinical
handover policies,
procedures and/or
protocols are used
by the workforce and
regularly monitored
Key tasks:
• Identify the situations within the organisation requiring clinical handover
• Establish and/or review policy, procedures and/or protocols
• Train and monitor the clinical workforce in the use of policy, procedure and/or
protocols surrounding clinical handover
Suggested strategies:
A key role of the governance framework for a clinical handover system is the development,
implementation, evaluation and revision of policies surrounding management, structure
and minimum data sets used in clinical handover situations. The core principle of clinical
handover policy is a flexible standardised approach to suit local environments.
Health service organisations should identify the situations for clinical handover based
on the points of patient transitions of care within their service. This information will help
to identify what structured clinical handover policies, procedures and/or protocols are
relevant to and required for the healthcare setting. Improvement strategies surrounding
clinical handover should be linked to your organisation’s governance and accountability
arrangements for effectiveness and sustainability.7
When developing your organisational clinical handover policy, you should consider related
principles of other National Standards; including Standard 1: Governance for Safety
and Quality Health Service Organisations; Standard 2: Partnering with Consumers;
Standard 3: Preventing and Controlling Healthcare Associated Infections; Standard 4:
Medication Safety; Standard 5: Patient Identification and Procedure Matching;
Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care.
The Commission has developed, through extensive research and pilot programs,
a change management guide with various resources (OSSIE Guide7
, The Toolkit5).
These resources aim to assist the development and implementation of structured clinical
handover policies and improvement in organisations. All tools and resources are available
through the Commission’s web site, on the Clinical Handover page13:
www.safetyandquality.gov.au/our-work/clinical-communications/clinical-handover/
Although the Commission provides a range of resources, organisations are free to create
their own policies, procedures and/or protocols based on national tools in order to
support effective clinical handover in their organisational environment.
Policies surrounding clinical handover should include:
• details of the relevant committee or meeting regarding governance arrangements
• situations when clinical handover should occur
• structure and method (including minimum data set) relevant to the particular type
of handover situation
• clinical workforce with defined roles and responsibilities
• available support, resources and tools to facilitate structured
communication processes
• mandatory education and training sessions for clinical workforce
• evaluation, audit and feedback processes on current handover procedures.