14Resource: mental health clinical handover audit tool (mCHAT)
Christy Pirone, John Walsh and Nayia Cominos
14.1Introduction
The Mental Health Clinical Handover Audit Tool (mCHAT) presented in this chapter is designed to help mental health teams take stock of current handover practice and identify strategies for improvement. The tool has been designed specifically to meet the criteria of the Australian clinical handover standard (ACSQHC 2012b) but may be adapted easily and rapidly to suit other mental health handover standards and contexts. Given the special constraints of mental health care, discussed in chapters 12 and 13, this tool is designed for mental health handovers that do not involve patients directly and are conducted in staff-only areas. We assume that the auditor might well be a member of the handover team, and that the role of auditor might be taken by different members of the team on different occasions. We believe that giving different team members the opportunity to act as observers can help build the team’s awareness of handover issues and may encourage collaborative problem solving.
14.2How to use the mCHAT
The mCHAT tool involves first completing an organizational summary sheet about the handover. Table 14.1 provides a sample summary sheet for carrying out mCHAT. Team members’ names may be noted, but in larger teams, it may be more expedient to use role codes.
Having completed the cover sheet, the auditor then observes and rates the handover or handovers, assessing the following four components of mental health handovers:
- Handover environment: the extent to which the environment is conducive to an effective handover
- Handover organization: the extent to which the handover is clearly constituted as an organized, bounded and comprehensive clinical event
- Informational process and outcomes: the extent to which relevant information is communicated in a systematic and structured way and achieves clear informational outcomes
- Interactional practices: the extent to which the handover leader or leaders and team members participate in and manage the handover effectively as an interactive event.
Tab. 14.1: Sample cover sheet for mCHAT: mental health clinical handover audit tool
The tool’s distinction between informational and interactional components draws on work by Eggins and Slade (2012; 2016; chapters 6 and 7) and by Slade et al. (2015a).
Each of these four components is broken down into elements that are then observed by the auditor during the handover or noted down immediately after the handover if subsequent checking is required. For each element of each component, the auditor ticks ‘yes’ or ‘no’. The rating sheet for each of the handover components (presented below) allows space for comments. The comments section allows auditors to include information about the specific context that may impact on the handover process, for example exceptional circumstances on the day, such as an influx of new patients or a high number of agency staff. At the end of the audit, the auditor collates the results, identifying for the team audit elements for which the team scored a ‘No’. First, however, we briefly review the four handover components and their constituent elements and present the individual rating sheets.
14.3Handover environment
The auditor rates the handover environment against the criteria that our research has indicated is most appropriate for optimal handover communication in the mental health context: dedicated time and space; freedom from interruptions; privacy; and access to relevant supports. Table 14.2 is the rating sheet for the handover environment. The rubric (6) ‘access to written and electronic resources to support clinical handover’ may include journey boards, handouts, electronic health information systems, case notes, patient lists, database printouts or other support tools.
Tab. 14.2: Rating sheet for handover environment
| Handover environment | Yes or No? |
| 1. Time for handover is ‘protected’, e.g. delegation of appropriate cover for patient care | |
| 2. The meeting area is quiet and free of distractions | |
| 3. The meeting area has sufficient space to comfortably accommodate all team members | |
| 4. The area permits team members to see and hear each other | |
| 5. The meeting area offers confidentiality (e.g. curtain for bedside handover) | |
| 6. Access to written and electronic resources to support clinical handover | |
| Comments: | |
| Rating (number of ‘yes’ responses out of 6) |
14.4Handover organization
This component considers the handover as a discrete, identifiable and self-contained event and asks: Is the handover overall framed, supported and managed effectively? Effective organization encompasses the following dimensions:
–Attendance: the right people must be at the handover
–Roles: ideally, a handover leader will be nominated to manage the event
–Scheduling: enough time needs to be allocated for the handover
–Framing: the handover needs to be clearly opened and closed
–Scope: the handover must deal with all patients
–Support: participants must be able to access relevant documents or other supports during the handover.
Table 14.3 is our suggested rating sheet for handover organization. The items are self-explanatory.
Tab. 14.3: Rating sheet for handover organization
| Handover organization | Yes or No? | |
| 1. | The handover meeting has a clear beginning and end | |
| 2. | All team members are punctual and present at handover | |
| 3. | All team members have a copy of the worksheet/patient list | |
| 4. | The team has access to any necessary additional information as required during the handover, e.g. electronic or paper medical record | |
| 5. | There is an identifiable team leader(s) for the handover meeting | |
| 6. | The handover commences and finishes within the allocated time | |
| 7. | Each patient is handed over | |
| 8. | Within the unit/team/organization, there exists a written procedure outlining how handovers should be performed | |
| 9. | The handover of each patient has a clear beginning and end | |
| 10. | The written handover procedure is followed | |
| Comments: | ||
| Rating (number of ‘yes’ responses out of 10) | ||
14.5Informational process and outcomes
In rating this third component of the handover, the auditor assesses two dimensions: the extent to which the giver of the handover follows a systematic and structured process; and the extent to which the team attains clear informational outcomes.
14.5.1Informational process
Informational process is based around use of iSBAR, the structured handover protocol already discussed at many points in this book. By following the iSBAR stages in sequence, the giver of the handover is guided to select relevant information and sequence it logically and concisely. Table 14.4 explains the clinical content of each stage and provides de-identified examples from actual mental health handovers recorded in an emergency department.
Table 14.5 is the mCHAT rating chart the auditor can use to track the use of iSBAR.
14.5.2Informational outcomes
As well as auditing the extent to which the handover giver satisfies the minimum iSBAR dataset, the mCHAT auditor also rates the perceived informational outcomes of the handover: that is, the extent to which those receiving the handover are clear about follow-up tasks, and whether the team has achieved an explicit transfer of responsibility for patients. Table 14.6 presents the rating sheet for informational outcomes. The components are self-explanatory. It may be appropriate to also verify outcomes 2 and 4 with the individual team members.
14.6Interactional practices
This section of the audit rates the effectiveness of the communication strategies used by the leader(s) of the handover and the team members. Effective interactional practices build good team rapport and facilitate the exchange of relevant clinical information about the patient. Team leader(s) and team members’ communication strategies are rated separately.
14.6.1Team leader’s communication
The role of the handover leader(s) may be designated or implicit in their clinical role, but should be identifiable in the meeting. Table 14.7 lists and exemplifies effective team leader communication strategies.
Tab. 14.4: Informational process: iSBAR stages exemplified for mental health handovers
Tab. 14.5: Rating sheet for informational process: use of iSBAR
| Informational process: iSBAR | Yes or No? | |
| i | 1.Each patient has been identified with a minimum of three identifiers | |
| S | 2.For each patient the giver provides the reason for presentation, patient’s current state and, if relevant, patient’s current legal status | |
| B | 3.Giver provides clear statement of patient’s clinical background including any co-morbidities and substance abuse, clinicians and carers involvement, care plan, medication, and relevant social factors. | |
| A | 4.Giver provides clear statement of patient’s medical and psychiatric assessment, including patient and carer concerns, risks to self or others and relevant protective factors. | |
| R | 5.Giver sets out clearly the suggested or actual care plan and indicates how it addresses the patient’s and carer’s concerns | |
| Comments | ||
| Rating (number of ‘yes’ responses out of 5) |
Tab. 14.6: Rating sheet for informational outcomes
| Clear handover outcomes | Yes or No? | |
| 1. | Each patient has been accounted for and discussed | |
| 2. | All team members are aware of the plan for each patient for that period | |
| 3. | Patients at risk have been identified and a plan established to address their risk | |
| 4. | All team members know the tasks they have been allocated and if/when they need to report back | |
| 5. | The handover recipient(s) has/have acknowledged/accepted responsibility for the patient(s) | |
| Comments | ||
| Rating (number of ‘yes’ responses out of 5) | ||
Tab. 14.7: Handover interaction: effective team leader communication strategies
| Team leader communication strategy | Example |
| The leader ensures that team members know one another’s names and roles | This is Margaret. She’s just started as the new RMO today. Would you all just quickly give your name and role in the team? |
| S/he begins and ends the formal business of the meeting | OK. Let’s get going. Are we all ready? Right. |
| S/he ensures that the handover process is followed | That’s good, but let’s start at the top of the list. We just need to deal with Henry first, because there’s a code black, then we’ll go through the list. Has everyone got a copy of the patient list? What about Jessica Bean? Have we heard from her mother? Have we covered everyone? |
| S/he models professional and respectful behaviors towards patients and clinicians | Good work. That would be great if you could go with her. Freya is really struggling at the moment. |
| S/he supports team members to actively participate | You saw Georgina, what were your impressions? What do we think of this as a team? |
| S/he keeps the handover topics on track | [smiles at joke]. Sure. Now what about his medication? Can we discuss that in more detail later? |
| S/he allocates tasks as needed and confirms that they are understood using checkback questions. | Which of you is going to call the ward? Would you mind doing that assessment? We might need to check that. Is that clear? |
Table 14.8 provides a sample rating sheet for these team leader communication strategies.
14.6.2Team members’ communication
Team members need to be active participants in the handover. Table 14.9 lists and exemplifies the key communication strategies team members can use to ensure that they listen actively but respectfully, contribute, accept responsibility and resolve any confusions or gaps in information before they leave the handover.
Table 14.10 presents a rating sheet for auditing team members’ communication strategies.
Tab. 14.8: Rating sheet for the team leader’s communication strategies
| Leadership (there may be more than one leader during the handover) | Yes or No? | |
| 1. | The leader ensures that team members know one another’s names and roles | |
| 2. | S/he begins and ends the formal business of the meeting | |
| 3. | S/he ensures that the handover process is followed | |
| 4. | S/he models professional and respectful behaviors in relation to team members and in referring to patients | |
| 5. | S/he ensures that patient and carer concerns and needs are represented respectfully and appropriately during the handover. | |
| 6. | S/he supports team members to actively participate | |
| 7. | S/he allocates tasks as needed and confirms that they are understood using checkback questions | |
| Comments: | ||
| Rating (number of ‘yes’ responses out of 7) | ||
Tab. 14.9: Handover interaction: effective team member communication strategies
Tab. 14.10: Rating sheet for team member communication and interactional strategies
| Team communication | Yes or No? | |
| 1. | The giver of handover is prepared and has up-to-date information | |
| 2. | The giver of handover is able to present an uninterrupted initial report | |
| 3. | The giver of handover indicates when general discussion can begin | |
| 4. | Team members contribute at appropriate points in handover with brief, clear, specific and timely information | |
| 5. | Team members seek clarity through checkback questions | |
| 6. | Team members use inclusive language | |
| 7. | The giver of handover indicates the end of the handover of the patient | |
| 8. | There are opportunities for professional learning and critical review of the plan | |
| 9. | There are opportunities for morale-building, debriefing, team building | |
| Comments: | ||
| Rating (number of ‘yes’ responses out of 9) | ||
14.7Collating and reflecting on the audit results
Having completed the audit, the auditor shares the results with the team in a formal meeting, drawing attention to all items for which the team scored a ‘no’. The audit assumes that all elements in all components are necessary to ensure safe and effective handovers – in clinical handover it is not a matter of ‘near enough is good enough’. Any element for which a ‘no’ response is recorded therefore needs the team’s attention. The team then collaborates to identify strategies to improve these weak points. Ideally, the team sets a timeframe to implement agreed strategies and schedules a follow-up audit to evaluate their effectiveness.
While mCHAT is specifically designed for mental health handovers, these contexts share many commonalities with medical and nursing handovers. Use of mCHAT can be usefully complemented by application of the iCARE3 model and the clinical handover assessment and risk matrix set out in the next chapter.