Improving Perioperative Handoffs: Moving Beyond Standardized Checklists and Protocols

Perioperative handoffs provide critical opportunities for care teams to synthesize vital patient information collectively^1,2 but they are vulnerable to communication gaps that precipitate medical errors and preventable patient harm.^1–3 Patients in the perioperative environment are at high risk for handoff failures due to rapid transitions through phases of perioperative care. Thus, clinical practitioners and researchers have long focused on patient safety and quality improvement during handoffs.

Efforts to improve perioperative handoffs frequently rely on standardization strategies, including process-based protocols and communication checklists.^4–6 However, the impact of these interventions on outcomes has been mixed. Several process outcomes (for example, clinician satisfaction,⁷ information transfer,^8,9 handoff quality^10,11) and clinical outcomes (for example, time to analgesia dosing and postoperative complications¹²) improved significantly, while others (for example, antibiotic delays and realized errors) have not. Furthermore, it has been difficult to sustain improvements in outcomes.^4,13–15

This Special Issue on Perioperative Handoff Safety and Quality presents research beyond rigid, standardized handoff protocols. The articles attempt to advance the field by offering foundational evidence to design, implement, and assess the impact of new handoff models, strategies, and multipronged interventions. This editorial discusses three themes emerging from this new science of handoff safety and calls for a paradigm shift away from rigid standardization of handoff checklists and protocols to tailored implementation of a handoff process that fosters teamwork, customization, and personalization based on clinical context and patient characteristics.^16,17 In other words, we need to standardize the elements for an effective handoff process, including defining a core set of tasks, tools, and teamwork behaviors, while allowing for flexibility in the process based on contextual factors (barriers, enablers) unique to the type of handoff and setting.

First, current research views handoffs as more than information transfer events. Historically, handoff improvements primarily focused on a discrete moment in time (the actual handoff) and were considered a process to structure and standardize, with the primary goals being reliable information transfer and process adherence. Despite its importance, this approach has proven to be too narrowly focused on driving widespread and sustained improvements. Major limiting factors to perioperative handoff improvements include the limited or lack of fit of existing handoff strategies within current workflows and perioperative routines, limited planning for a successful implementation, and lack of educational strategies to build teamwork competencies required for effective handoffs between clinicians/teams. These factors have resulted in significant variability in handoff content, process, and effectiveness.

This information transfer and protocol adherence perspective is giving way to the realization that redesigning perioperative handoffs will require complex sociotechnical change. We need more holistic and balanced handoff solutions integrating social and technical components to promote teamwork and psychological safety.¹⁸ This is particularly true in the surgical setting, where handoffs are frequently interprofessional, involving high-acuity patients and rapid transfers between units. Keebler et al. introduced tenets of how human factors and ergonomics can facilitate sustainable change in postoperative handoffs.¹⁹ They emphasize team dynamics and integration of team training, practice, and debriefing into the change process. This study used a participatory (human-centered) design approach that included a team of subject matter experts (human factors and ergonomics, safety and implementation science, health care education, and team training) that guided unit-based handoff leads and champions through a structured implementation process.^19,20 The association between improved teamwork and sustained conformance to unit-defined best practices suggests that teamwork matters, consistent with a handoff model that identified teamwork as the primary mediator for improved patient, clinician, team, and organizational outcomes.²¹ In other words, considering the interdependencies between work systems, clinician agency, and organizational culture is critical to supporting all teamwork functions underlying safe and reliable handoffs.²² Insights from this study can inform the future design of an implementation toolkit and its steps.

Second, to guide the study of perioperative handoffs (as a teaming and sociotechnical activity), we must innovate or adapt existing theories and frameworks and develop new methodologies to measure handoff effectiveness. In their mixed methods study advancing measurement practices in information transfer during handoff, Busch et al. found that the familiarity of team members engaged in the patient handoff process was a critical factor influencing handoff quality,²³ suggesting that broader organizational dynamics beyond the handoff itself play an important role. Wolf et al. expanded on this point using case studies to contextualize principles from the multiteam system (MTS) literature.²⁴ They focused on the compositional, linkage, and developmental aspects of MTSs. Of particular relevance to perioperative handoffs is the boundary-spanning function that highlights how clinicians across team-level boundaries need to coordinate between their component teams and serve as a boundary spanner between their own team and another component team in the MTS. This work provides an important framework for thinking more broadly about organizational issues that could affect handoff quality and about design requirements for new types of handoff teaming interventions.

To support teamwork across the perioperative handoff continuum, Starmer et al. presented a conceptual framework emphasizing theoretical principles to inform hand-off practice and research, including understanding system factors and local context and using data-driven quality improvement and research methods to achieve patient-centered handoff improvement efforts.²⁵ The framework takes a comprehensive approach to designing a multimodal intervention that includes tools (mnemonics, checklists), technological solutions, education, and culture/behavior changes to promote teamwork and reduce preventable medical errors and patient harm. Similarly, patient involvement in the design and development of perioperative handoff interventions has been identified as a critical need for creating safe, usable handoff interventions at all phases of care, particularly the beginning and end of a perioperative journey.²⁶

Given this broader framing of handoffs, it is not surprising that traditional process improvement methods have not met the challenge of improving handoff safety. Samost-Williams et al. reviewed principles of resilience engineering and contrasted them with past approaches to handoff improvement, with critical insights being the need to support adaptability (vs. conformity or adherence) and to learn from success.²⁷ Resilience engineering could inform the development of more robust approaches to handoff improvement. Taken together, these articles are a departure from decades of research and improvement efforts focused primarily on formalizing and adhering to a handoff protocol or checklist.

Furthermore, large-scale adoption and reach of evidence-based handoff strategies should consider the core principles of implementation science.²⁸ Using mixed methods (qualitative, quantitative) measurement systems will be essential to detect and understand the influence of handoff barriers and enablers on implementation strategies and outcomes. Lane-Fall et al. described the novel application of qualitative comparative analysis to explore configurations of work system conditions (in other words, people, tasks, and internal environment) that influence handoff quality.²⁸ This qualitative approach seeks to complement observational thematic analyses by analyzing contextual factors or conditions within the work system and handoff process that led to higher levels of fidelity (or adherence) to handoff protocols. Their findings suggest that there is no single work system factor, but several factors combined influence adherence to the handoff process. A better understanding of the critical work system conditions that allow change teams to focus on fidelity-promoting strategies will likely improve implementation, patient, team, and organizational outcomes.

Third, to promote adaptive team performance, researchers explored the importance of developing education strategies and the potential use of artificial intelligence and machine learning to facilitate team effectiveness in personalized and smart handoffs. Although current standardized tools have improved information transfer during handoffs, they failed to adequately address teamwork functions, such as promoting psychological safety among clinicians during handoffs, building resilience to communication and information errors, and creating a shared team understanding of patient care plans, concerns, and courses of treatment.^4,17 A systematic review of anesthesiology handoff education interventions by Riesenberg et al. revealed high heterogeneity and low quality of educational interventions²⁹ despite previous recommendations.³⁰ They outlined multiple improvement opportunities, beginning with conducting a robust needs assessment prior to designing educational interventions. Future educational strategies must apply sound educational theories, design, and assessments capable of evaluating the relationship between team effectiveness during handoffs and improved patient, clinician, team, and organizational outcomes.²⁹ Given the interprofessional nature of perioperative handoffs, competency-based educational strategies must place greater emphasis on teamwork to build adaptive interprofessional teams versus focusing on technical task-based work.

Sparling et al. reviewed a broad range of handoff information tools and presented a vision of what could be achieved with well-designed informatics tools that support the end user.²⁶ They specifically note the opportunity for technological advancements that leverage artificial intelligence, machine learning, and mobile health to improve the quality and safety of handoff processes.^16,31 Employing human-centered design methods is critical to ensure that these technologies can meet the needs of handoff participants, integrate well with workflow, and ease the overall workload burden of transition events. If realized, this vision of technology-enabled handoffs will move care well beyond current practices of cognitive aids.

Threats to perioperative handoff safety and quality are persistent. Effective, sustainable, and scalable solutions have proven elusive. It is time to rethink how handoffs are designed and supported organizationally and technologically. Toward this goal, Sparling et al., from the Multi-Center Handoff Collaborative, offer evidence-based guidelines and future directions based on their Handoff Effectiveness Research in periOperative environments (HERO) Design Studio representing diverse stakeholders and organizations across the nation.³² The HERO Design Studio discussion moved this paradigm shift toward five clusters—increasing global recognition and harmonization of handoff research; formulating requirements to achieve complex sociotechnical change; identifying and evaluating core work processes involved in perioperative handoffs; augmenting existing cognitive aids and tools to simplify, prompt, and improve handoffs; and emphasizing the central role of interprofessional education and training to develop teamwork competencies needed to enhance the uptake and sustainability of evidence-based handoff best practices. Together, the articles in this Special Issue illustrate an exciting, alternative vision for the design of perioperative handoffs to make them safer and more effective.