A standard operating protocol (SOP) and minimum data set (MDS) for nursing and medical handover: considerations for flexible standardization in developing electronic tools.

As part of Australia's participation in the World Health Organization, the Australian Commission on Safety and Quality in Health Care (ACSQHC) is the leading federal government technical agency involved in the area of clinical handover improvement. The ACSQHC has funded a range of handover improvement projects in Australia including one at the Royal Hobart Hospital (RHH), Tasmania. The RHH project aims to investigate the potential for generalizable and transferable clinical handover solutions throughout the medical and nursing disciplines. More specifically, this project produced an over-arching minimum data set (MDS) and over-arching standardized operating protocol (SOP) based on research work on nursing and medical shift-to-shift clinical handover in general medicine, general surgery and emergency medicine. The over-arching MDS consists of five headings: situational awareness, patient identification, history and information, responsibility and tasks and accountability. The over-arching SOP has five phases: preparation; design; implementation; evaluation; and maintenance. This paper provides an overview of the project and the approach taken. It considers the implications of these standardized operating protocols and minimum data sets for developing electronic clinical handover support tools. Significantly, the paper highlights a human-centred design approach that actively involves medical and nursing staff in data collection, analysis, interpretation, and systems design. This approach reveals the dangers of info-centrism when considering electronic tools, as information emerges as the only factor amongst many others that influence the efficiency and effectiveness of clinical handover.