Redesigning Hospital Handover A report on the redesign of the handover between international field staff at MĂŠdecins Sans FrontiĂ¨res.
National staff buddy guide
Living organogram template
Copyright: Aurelie Baumel/MSF Photo: MSF
Acknowledgements Advisory board for this project: Debbie Duncan, Healthcare Management Advisor, Public Health Department, Amsterdam. Sylvie Letourneau, Information Solutions Analyst, Information Management, Amsterdam. Pete Masters, Innovation Advisor, Manson Unit, London. Michelle Mays, Coordinator Pool Management, HR, Amsterdam. Duco Roolvink, BI Analyst, Reporting and Analytics, Amsterdam. Vicky Treacy-Wong, Nursing Advisor, Public Health Department, Amsterdam. Janet Vlug, Facilities Management Advisor, LogD Field Support, Amsterdam. Peter Whiskerd, Coordinator, Healthcare Management, Amsterdam. Extra project support from: Natalie Schulz, HR Advisor, Operations Desk, Berlin. Ann Wunderlin, Logistician, Tajikistan/Seattle. Jens Pagotto, Operational Advisor, Operations Desk, Amsterdam. Julia Fedec, Nursing Coordinator, Bentiu/Ontario. We would also like to thank all field and operational staff who participated in the research. Some research participants chose to remain anonymous, in which case pseudonyms have been used.
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Introduction “In my first mission a handover saved my life, without this handover I think I would have probably left the project.”
Médecins Sans Frontières (MSF) is an international humanitarian medical non-governmental organisation which operates in extreme settings: in refugee camps, disease outbreaks, war zones, in the places where people’s medical needs are greatest.
Bart-Yan Bekker, Improvement Lead, UK MSF has multiple operational centres and those centres have missions. Each mission is made up of a number of projects which are organised by a coordination team in the capital city of the country they operate in. For instance, Operational Centre Amsterdam (OCA) coordinates the Democratic Republic of Congo (DRC) missions (North and South Kivu). The coordination team in Bukavu, South Kivu’s capital oversees the projects, one of which is a hospital in Baraka, South Kivu.
This report outlines the six-month project carried out by Charlotte Fountaine, a service designer from the Royal College of Art with Médecins Sans Frontières. Service Design is about creating new services and redesigning existing ones. This is done by carrying out research into what people need, as well as spending time testing and iterating elements of the service until they work. The final stage is to implement the new service in the existing organisation; working with multiple stakeholders to ensure that the service works for them. In this context it is about redesigning the field handover process within MSF. The project was undertaken as part of the Public Health Department’s Hospital Management Improvement Strategy (Amsterdam), in collaboration with the Manson Unit (London).
Brief Due to the extreme nature of MSF field work there will always be a high turnover of field staff. The quality of handover between field staff is often very low (reflected by co-labs input, nurse debriefings and anecdotal evidence). Co-labs was a design workshop to identify challenges within MSF. With in-person handovers far from guaranteed and gaps common, the absence of a well-designed handover process means incoming staff can be less informed, less efficient and under-prepared for their mission. This is especially pertinent in the context of MSF international staff due to the short lengths of the missions. The nature of MSF’s work means that the type of handover that incoming staff receive varies greatly, medical staff can be thrown into new and difficult situations without adequate preparation.
A well-designed hand over process will mean that:
After consultation with public health department specialists, field HR and the information management team, it was understood that no consistent and structured approach has been applied to staff handover processes in the field (although there have been efforts). We applied a service design approach to this challenge focusing on the four field roles that relate to hospital management.
This project looks to improve the handover process, starting with these key roles in a few key hospitals with the intention of then scaling the successful handover process across other roles and missions.
Key hospital positions:
• • • •
Hospital Coordinator Clinical Lead Head Nurse Facility Manager
Some key hospitals: • • • •
Lashkagar, Afghanistan Bentiu, South Sudan Baraka, South Kivu DRC (Democratic Republic of Congo) Bossangoa, CAR (Central African Republic)
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Incoming staff get the information they most need in the best possible format in a timely manner, decreasing the amount of time they need to understand their role and increasing the proportion of useful time during their mission. Outgoing staff will have clear process by which to hand over to their successor, reducing risk of no handover and saving time and effort spent reinventing the wheel. Making handover processes more useful for incoming staff will motivate outgoing staff to put effort into creating their own. More coherence in roles in the field, regardless of who is in them. Improved institutional knowledge across MSF.
Challenge “Understanding the context can take 3 months, then in 6 months you finish and finally understand what you’re supposed to do.” Julia Fedec, Nursing Coordinator, South Sudan
Thousands of handovers are being carried out across MSF annually, in some projects there is more than 1 international staff handover every month (activityreport2016.msf.org). Through qualitative research we learned that ineffective handover can mean a significant portion of international field staff time is wasted, which can have a negative impact on the project. Due to the challenging conditions that people are working in, members of international staff typically stay for 6-12 months at a time. After being involved in the running a hospital in an MSF project, international staff members leave the field to return home to their friends and family for a well-earned rest. Often there is a gap between one member of staff leaving and another starting. Staff might not have time for a face-to-face handover, to explain to new staff the process of running the hospital. Poor handover means it takes longer for management staff to settle into their role, impacting the quality of patient care and the overall strategy of the hospital. Designing a way to share knowledge between incoming and outgoing staff successfully will lead to better medical care, a better staff experience, therefore improving the patient experience.
“I didn’t really make a big deal of not having a handover with my predecessor. I just tried to stay positive and went with the flow. But then...how much I wish I had known.” Julia Fedec, Nursing Coordinator, South Sudan
Photo: Charlotte Fountaine
Photo: Charlotte Fountaine
The first stage of the project was to define the problem and set up an advisory group. Departments related to handover were represented, this included staff from IT, data analytics, HR and the Healthcare Management Team. It was important to gather insights from logistics and medical departments, so these groups were represented. These staff members would be instrumental in steering the project so that the new handover process worked well for field staff and for implementing the new handover process later on. A kick off workshop was carried out to understand the current user journey of an international field staff member. This user journey highlighted key areas for improvement within an international staff memberâ€™s time with MSF.
Research was carried out with operational, international and national staff to identify their current handover challenges. With national staff being primarily field based, it was more challenging to reach this group. In total 5 national staff members and 30 international staff members contributed their opinions and expertise over the duration of the project. We also looked for examples of best practice, when handover works well at MSF as well as in other organisations and industries. A series of interviews and a workshop informed the solutions later on. The user journey developed in the Set Up stage was continually put in front of staff to check whether it was accurate, it was then updated and used to identify solutions.
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Photo: Charlotte Fountaine
Photo: Charlotte Fountaine
Data from the research was analysed, which allowed us to gain insights into how the new handover process should work. We responded to these insights when generating solutions for the new handover process.
The solutions were developed and could be downloaded on a new handover website. Field staff could download and use the new handover process and give feedback via a form or a video call. We found that simply sending around the website was not enough to prompt staff to give feedback, most of the feedback we received was during targeted interviews. Testing sessions were carried out in the London office, when field staff members were debriefing so they could try out the handover solutions and provide feedback. Handover solutions were iterated based on that feedback.
4. Develop Workshops with field staff and operational staff at MSF were carried out in London and Amsterdam. During the workshops, ideas for how to improve the handover process were developed, based on the initial research gathered. Staff also evaluated their ideas on a scale of implementable to not, as well as high to low impact. The ideas which would have the highest impact and were possible to implement were developed into prototypes for people to then give feedback.
Insights Research was conducted with 42 participants in total. 18 of the participants were international field staff, 16 were operational staff, 2 were members of national staff and 6 were people from outside of MSF. Analogous research was carried out, as it was important to look to other industries for examples of best practice when carrying out handover. For contacts details of people involved in project email: firstname.lastname@example.org
Unclear process for carrying out effective handover.
Outgoing staff need to be motivated to carry out handover.
Emergency conditions with patient care at stake.
National staff are a constant, international staff change.
Valuable knowledge is lost when staff change.
Lack of clarity around who is responsible for handover.
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18 International Field Staff 16 Operational Staff
6 Analogous Research Participants
2 National Staff 42 Research Participants
There is no consistent process for carrying out handover at the organisation. It is up to the individual members of staff to decide whether to write a handover report, and how to pass information over to their successor. Some parts of the organisation have handover templates, but these are not widely used or readily available to staff. Often, due to logistical reasons (like visa restrictions), there is no overlap between the outgoing and incoming members of international staff. Some staff take the initiative to prepare the national staff that they manage and their colleagues by having meetings or providing written documents. Photo: Wubalem Organogram/MSF
“There is no specific handover template.” Wubalem, Human Resources Coordinator
“I didn’t really have a handover I just worked it out when I got there.” Sarah Walpole, Medical Doctor Photo: MSF/Robin Meldrum
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Photo: MSF/Christophe Da Silva/Hans Lucas
Outgoing staff need to be motivated to carry out handover. If a staff member isn’t prepared for their handover in advance, the have to gather their knowledge for the successor in their final week. At this point they are exhausted and eager to return home. The new handover process takes into consideration the lack of motivation to carry out handover as a staff member is leaving the field. Staff members are encouraged to complete their handover template between 3 months and 3 weeks before their end of mission.
“That’s the challenge of handovers. Once you’re done you’re tired, done, fed up. Psychologically you’re done and you want to leave. There’s not that time to accommodate it.” Jose Hulsenbek, Head of HR, UK
“They’re not so interested in handover they want to sleep and rest and see their family.” Bart-Jan Bekker, Improvement Lead, UK
“I think with handovers it’s to do with luck. How much time and motivation they’ve had to do it.” Ivelina Georgeiva, User Researcher Scottish Government, UK
Insights | 13
Photo: MSF/Frederic NOY/COSMO
Technology limitations of the field. The new handover process is designed for environments with intermittent Wi-Fi and electricity access and a limited amount of laptops, phones and computers. As well as these infrastructure limitations, MSF currently has multiple document sharing platforms; OneDrive, Gdrive, Habari, field websites and more. While there are plans to migrate to OneDrive, on Microsoft Office 365, the handover process must be compatible with multiple platforms and not add complexity to the already complex system. For this reason, lo-fi solutions have been developed; a word document and printable templates.
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“We had no electricity most of the day. You get up in the morning in pitch black, couldn’t see anything. Electricity wouldn’t come on until 4/5pm then go off at 11pm.” Diane Robertson-Bell, HR Coordinator, UK
“You don’t buy smart phones when you run the risk of being looted all the time.” Bart-Jan Bekker, Improvement Lead, UK
Photo: MSF/Vincenzo Livieri
National staff is a constant, international staff change. They are an asset, the national staff members hold institutional memory, as they continue to work in the field while international staff come and go. Their experience and expertise in regards to how to run a hospital and care for patients can strengthen MSF projects and missions.
“Our opinions as national staff were not trusted. We felt that international staff didn’t take our word for it. Even though we were locals and understood the culture and had seen particular diseases ourselves [...] What could help [international staff] is to be open in “They build up a working relationship communication, open to learning but with that national staff. That gets broken be assertive at the same time. National every time a new person comes in if you staff are happy to teach you the ropes don’t do a proper handover. That’s why but not if you’re depending on them all I saw, for those positions, that personal the time. Give yourself transition, accept handover is also crucial.” that you could be wrong." Jose Hulsenbek, Head of HR, UK
“Just remember all these national staff members are very experienced. They’ve experienced so many different managers. They’re the ones with institutional memory. Every expat treats them like ‘We know the best’.”
Carolyn, Former National Staff Member, Content Manager, UK
“National staff members get thoroughly fed up with having to deal with a new boss every 6 months” Sam Tinebeck, Head of Mission, UK
Anup, Logistician and Marine Engineer, UK
Insights | 15
Photo: Ivan Muñoz/MSF
Working in extreme conditions means handover is challenging. If the new handover process can’t work in an emergency, when a staff member is tired, or when patients need urgent healthcare, then it will not be effective. The new handover process is designed to be as quick and efficient to carry out as possible.
“A kiss. You step on the plane and see you predecessor getting off the plane. It’s all done on timings. There’s no time” Bart-Jan Bekker, Improvement Lead, UK
“We treat everything like it’s an emergency. There’s no time for jetlag” Jose Hulsenbek, Head of HR, UK
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Photo: Christophe Da Silva/Hans Lucas/MSF
It is often unclear who is responsible for which aspect of the handover. When a staff member is handing over information to their successor they are aware that it’s their responsibility, but there is often no one holding them to account, or ensuring that the handover is clear and consistent across roles. Currently handover could sit within the line manager’s duty, or field HR, or staff within the operational centre. The new handover process has clear lines of responsibility to hold people to account.
“If you don’t send people a template and tell them to do it, people are busy. If there’s not someone following up it won’t happen.” Nell Gray, HR Coordinator, UK
“I arrived about a few days after my predecessor had left. She hadn’t written her handover so I received it a week after being here.” Julia Fedec, Nursing Coordinator, South Sudan
Insights | 17
Solutions In order for the new handover process to be adopted it needed to build on existing processes and technologies within the organisation. However, these small handover solutions would have a big impact, as MSF has a wide reach and improving handover could transform the staff experience. The new handover process adds key value by building on existing tools and best practice to create a consistent, easy to use handover process which can be used by international staff in a variety of extreme contexts. We looked at how handover was already being carried out and created a new handover process with key solutions to add value; quick and easy changes to facilitate smooth transitions between field staff. While preparing for their mission, field staff receive an up-to-date job description, they have the opportunity to contact their predecessor and they receive the flexible handover template, which includes information about their role and links to other key documents. On entering the field, they are able to view an easy-to-update living organogram on the wall, which orientates them within the team. They also have a national staff buddy who shows them the ropes. On leaving, when they are exhausted from their mission, they simply update their predecessorâ€™s flexible handover template with bullet points and links, contact their successor, and update their job description for the next staff member.
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Principles Based on the research carried out, 6 key principles for designing the new handover process were identified. Each solution was developed in adherence with these principles, for the most beneficial new handover process.
The new handover process builds on existing tools and processes for maximum implementation.
The new handover process takes into account the technology limitations of the field.
Minimal time and effort is needed for outgoing staff member to carry out the new handover process. The process saves field staff time.
The new handover solution must be costeffective, saving time in the field and not costing a lot to implement.
The process works across a variety of projects (hospitals, refugee camps, outreach programmes).
There must be clarity on who is responsible for which aspects of the new handover process.
Solutions | 19
Current Handover Process “I didn’t get very much information from the field, I tried to get in touch with the field and didn’t have much luck.” Sarah Walpole, Medical Doctor
Preparing for mission Receives job description
Briefing in head quarters
Travel to field
Security and other briefings in capital city
Job description is out of date so role is unclear
Gap between staff members
Unsure what to bring and what to expect
Unable to retain information due to jetlag
“I was a paediatrician I was the only doctor there. I was up to here. One of tasks was to calculate on a weekly basis the food for my patients.”
Eugenia Serbassi, Medical Coordinator
Meet hospital team, possibly meet predecessor
Read handover document
Using multiple sharing and communication platforms
Ongoing medical oversight
Unclear on who to ask about what
Not enough time to read unstructured lengthy document
Lack of knowledge of what is stored where
Working in a fast paced, chaotic environment
“The number of people who sit on the last day typing away like mad to get a handover document. Or who say “I’ll write it on the plane I’ll send it to you when I get home.” And then they don’t.”
Jose Hulsenbek, HR Coordinator
Attempting to complete objectives
Writing handover report
No contact with successor
Travel back home
Disappointed at not having achieved goals, demotivated
Unsure what it should contain, large paperwork load
Gap in the field, unsure how to contact successor
Flights booked, de-briefings organised
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New Handover Process
Receives up-to-date job description
Handover document received
Contact with predecessor (over Skype, phone or email)
Travel to field, leaving a day for jetlag
Pool manager sends up-to-date job description from predecessor
Handover written early by predecessor
Put in contact with predecessor
Pool manager and HR coordinator ensure time for jetlag
National staff buddy meet and show around
Prompt to update flexible handover template
Project coordinator matches buddies
Living organogram is updated by field admin
Line manager prompts update of flexible handover template
Update job description for successor
Flexible template goes to successor and line manager
Contact with successor (over Skype, phone or email)
Travel back home
Preparing for mission
Up-to-date job description signed off by line manager
Handover template is updated from predecessor
Put in contact with successor
Flights booked, de-briefings organised
Meet hospital team, possibly meet predecessor
Flexible Handover Template
“Yeah I think it’s really good idea with the proviso that it’s flexible. Some prompts as to what you need.”
The template is a Word document which can be stored on the shared drive, or on the project computer. The template is designed to be updated with links and bullet points during the project. Rather than writing a whole new handover report every mission, the flexible template is designed to be updated from your predecessor's handover. We encourage field staff to complete their template 3 months before the end of their mission and send it to their line manager. It is not advisable to leave your template to your final week, when you will be busy getting ready to go home. The line manager, field HR coordinator and pool manager are responsible for ensuring that the flexible handover template is completed and sent to the incoming member of staff. Download the flexible handover template: bit.ly/2Ijv2Ow
Mike, Medical Doctor, Nairobi
Photo: Charlotte Fountaine
“I would love it. It’s so much more personal, it’s welcoming you feel like you’re part of the team when your face is on the wall and you see who composes the team.”
New staff members felt that understanding their team structure and being able to access an organogram was important. We suggest that the organogram is large, visible to all on the wall in your project. Staff mentioned that images of people on the organogram would be useful. If the project has more than 50 staff members, then the organogram should be kept digitally (using Powerpoint, Viso or Excel), or an organogram of each team can be kept on the wall. A wall organogram means that it's easy for the new staff member to find. The field admin and the project coordinator are responsible for updating it. Living Organogram template available in this report.
Julia Fedec, Nursing Coordinator, Bentiu
National Staff Buddies
“It gives an opportunity to elevate the role of national staff. It’s not uncommon for expats to come in thinking that they’re the experts. National staff are the experts.” Ann Wunderlin, Logistician, Tajikistan
A buddy system is recommended for new members of staff to be integrated into the team quickly. The buddy relationship also allows the buddy to develop their communication skills and be recognised for their supportive role. International members of staff should be paired with a national staff member in order to benefit from their experience. A buddy is someone who shows the new staff member how everything works in the project. On starting, the buddy will give the new staff member a tour, explaining different parts of equipment and systems. The buddy will arrange a meeting to discuss the new staff member’s role and invite questions. They will also be available for further questions while the new staff member settles in. The project or hospital coordinator is responsible for linking a willing national staff member with an incoming staff member. National Staff Buddy guide included in this report.
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Contact between outgoing and incoming staff “Connect someone to share what to expect about daily living. That’s the question for a first missioner. You’re very curious – clothes, culture, housing. How many people at the project. What the various roles are of the people. Internet access. Security of area and freedom to move. Exercise. Social life.” Ann Wunderlin, Logistician, Tajikistan
A Skype, email or phone call between the incoming and outgoing member of staff can improve the incoming staff's experience, making them more likely to settle in quickly and understand their role. This contact can be informal, giving the incoming staff member a chance to ask questions about their new role as well as their living conditions. Pool managers are responsible for connecting incoming and outgoing members of staff.
Updated job descriptions “To a degree my job description was useful but didn’t give an awful lot of information about what my job was going to be day-to-day. It had a bit of an understanding of what the mission was hoping to achieve in general but it definitely could have more about my specific role.” Mike, Medical Doctor, London
Field staff members at MSF consistently mentioned that a clear, up-to-date job description is important to prepare them for their role. On leaving, a staff member should have an opportunity to review and confirm/update their job description as appropriate for their successor. HR coordinators and line managers should prompt the staff member to do this.
Leave a day for jetlag “This is one of the complaints we get they are tired from the long flight and then they jump into the briefing process. Each and every department we schedule only one day for briefing. When they go back to the project you can see that they didn’t get the idea of the briefing. They ask questions which were covered during the briefing.” Wubalem, Human Resources Coordinator, Ethiopia
Staff often arrive in the capital city of their mission jetlagged after a long journey. Key security briefings an information on the project are then wasted, as staff members are not able to absorb information. Leaving a day for jetlag will save time later on, and not absorbing key security information is dangerous. Ensuring enough time for jet-lag recovery is the responsibility of the field HR coordinator.
Solutions | 23
National Staff Buddy Guide A guide for the national staff buddy system, which helps to quickly integrate international staff into their roles. Why buddy up? We have a buddy system for new members of staff to integrate them into the team as fast as possible. In a high-pressure environment such as a hospital, it’s important to know how everything works. The buddy relationship also allows the buddy to develop their communication skills. We recommend international members of staff are paired with a national member of staff. It is important to learn from the experience and expertise of the national staff, as well as understand the culture when starting the new role.
What is a buddy? Someone who shows the new staff member how everything works in their mission. On starting, the buddy will give the new staff member a tour, explaining different parts of equipment and how the project works. The buddy will arrange a meeting to discuss the new staff member’s role and give an opportunity to ask questions. They will also be available for further questions while the new staff member settles in.
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Instructions for line managers When a new member of staff is entering the field, find a national staff members who is willing to be a buddy. Ensure that they have enough time to show the new staff member around the hospital, and show them where important equipment is, and make introductions to the rest of the team. A member of national staff who is enthusiastic, experienced, and ideally a similar level or peer to the new staff member. Highlight the benefits of being a buddy to the member of national staff: increased communication skills, a positive work environment. As well as this, the buddy can make a positive first impression of the project, demonstrate leadership, and be the team’s project ambassador.
Instructions for international staff buddies Meet your buddy, you can ask them questions about your role, get shown around the facilities, and be introduced to the rest of the staff team. Ongoing, you can go to them with any questions you have about your role. Make sure you listen and ask questions of your buddy, they have experience in your project and hold a lot of valuable knowledge. When you are settled in to your role, think about what you can do for your buddy. For example, help your buddy work on their own skills, reflect the buddy’s responsibilities in the next staff appraisal.
Instructions for national staff buddies Your line manager will pair you with a new member of staff to show them around the facilities, answer any questions they may have and introduce them to the rest of the team. Arrange a one-to-one meeting with your new buddy about their role. Your responsibility as a buddy is to make the new member of staff feel welcome and help them to understand their new role. Being a buddy means you are actively working on your communication skills, and helping the project run smoothly. As well as supporting the new staff member settle in, you can think about how the buddy system can help you – are there any skills you would like to work on with your buddy's help? Do you want your buddy duties to be reflected in the next staff evaluation?
First Meeting Outline Welcome Sharing • Buddy shares his/her experience and background with incoming staff member • Expat shares his/her experience and background with buddy Discuss project activities • Successes – what works well • Challenges – what we can improve • Short term goals • Longer term goals Tour facilities • Share facilities map (if possible) • Introduce staff Name, Title, Team • Share who to go for what (eg. computer support) • Share ways units/staff collaborate • Show where supplies are stored and how to request Wrap up • Discuss project culture, including informal norms (e.g. in Tajikistan we greet each other every day with either a handshake (men) or three kisses on cheeks (women) • Questions and answers • Plan for follow up meetings Have lunch together
National Staff Buddies | 25
Living Organogram How to use Cut out the organogram cards. Add peopleâ€™s roles and photos (where possible), and which team they are in. These can go on the wall, and be updated when necessary. See image below for example.
Photo: Charlotte Fountaine
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Living Organogram | 27
Testing The handover process was tested with 13 international field staff, the primary users of the new handover process. 5 members of operational staff tested it and many more gave their feedback through the advisory group and MSFâ€™s scientific day (where the project was presented to MSF staff ). As well as this, 2 national staff members and 1 analogous research participant gave feedback. In total 21 people gave verbal feedback. The process was also tested online, with 145 people visiting the site from 10 different countries.
13 International Field Staff 145 Page views 10 Countries 5
2 National Staff 1 Analogous Research Participants
21 Testing Participants
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Testing mock ups of solutions at MSF London and RCA
Getting verbal feedback on 9+ solutions verbally with 9 staff members
Mock ups of solutions put up online, available for download and use
Live Selected solutions in use in Sierra Leone and Nigeria for feedback
All solutions in use in key missions - not yet achieved
Testing | 29
Photo: Charlotte Fountaine
Photo: Charlotte Fountaine
The alpha testing stage was about quickly developing rough solutions for feedback, then iterating and narrowing down the solutions. We started with 9 different solutions to test. All ideas were prototyped; hospital signage was put up in the MSF London office and around the Royal College of Art. Other ideas such as the handover poster, handover wallet information were created. Those solutions were presented to field staff for feedback. It was clear that some of the printed materials (poster and wallet information) were impractical, contact information and WiFi codes could not be shared due to the volatile environment. Equally, WiFi codes must be confidential so that the bandwidth isn’t compromised by lots of people logging on. Hospital signage provided information on who to speak to about key equipment – but the feedback we received was that logistics staff felt this would give them extra work. Other members of staff said key equipment moved too quickly for this to be relevant.
The next stage of the testing process was to create a website for the solutions which could be shared and downloaded by field staff. This way, any member of field staff in the world could download and use the prototypes and provide feedback. MSF is currently in the process of moving data over to Microsoft Office 365, so the prototypes (the living organogram, the national staff buddy system and the flexible handover template) were hosted on OneDrive. This platform was chosen for maximum integration with MSF systems. Google analytics were set up on the page, from this we were able to see that 145 staff members from 10 different countries visited the site. By using Office 365 we could see how many people clicked on each solution. The flexible handover template was most popular, with 27 people accessing the document. 18 people viewed the living organogram and 14 viewed the national staff buddy system. This data is limited in what it tells us but blended with the qualitative data we learned which solutions would work and why. New ideas emerged – all staff felt it was important to have contact with their predecessor. During initial research the majority of staff said that they would favour a face-to-face handover. However, there are often gaps between staff members in the field. Staff members were sometimes able to Skype, email or call their predecessor – all who did said that they felt better prepared and had more clarity on their role. However, this contact was made on an ad-hoc basis. Mostly staff who knew each other or had mutual acquaintances took the initiative to get in contact. Using their discretion, pool managers, ISSOs and HR coordinators should put field staff in contact for a smooth handover. There are instances where it would be inappropriate for staff to be put in contact, for instance, when the staff member in the project is suffering from stress.
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Live Live testing (when solutions are used in the field by staff ) of the solutions was a challenge. It was not possible to visit the field, due to the time constraints of the project. Testing remotely was logical, as the handover solutions would be implemented remotely. The difficulty came in persuading multiple people within the MSF structure that testing these solutions was a priority. Field staff are concentrating on providing medical care, so the project was seen as a distraction. We live tested the living organogram in 2 locations, and the flexible template was completed by 3 members of field staff. Hana, a field admin in Namfura, Nigeria tried out the living organogram in her project. She felt that the organogram was very important, but that their existing system of updating a spreadsheet and printing it out was working well. For this reason, we encourage projects to have an up-to-date organogram on the wall, using whichever system they are most comfortable with (Excel, or the template provided).
The living organogram was also tested by Natalie Schulz, from Berlin operations, in Tonkolili, Sierra Leone. The flexible template was tested and received feedback from: Richard, the facilities manager in Baraka, Democratic Republic of Congo; Julia Fedec the head nurse in Bentiu, South Sudan and Amy-Leah Potter, Sierra Leone. Detailed feedback was collected on which headings should be changed, which sections were relevant, and which werenâ€™t. Creating a template which was both thorough, but not too intimidating to fill out, was key. The national staff buddy system was a popular idea, receiving almost all positive feedback from field staff. However, it involves at least 3 members of staff being willing to test: a project coordinator to match the incoming staff member with their national staff buddy. For this reason, this idea has not been live tested in the field. However, we did find instances of informal buddy systems which worked well. One of the advantages of creating a formal buddy system is to recognise the invaluable role that national staff play in ensuring that international staff members understand and are able to carry out their new roles.
Testing | 31
• • •
MSF is a large organisation, which comes with large organisational challenges. Handover is one example of institutional knowledge being lost at a key moment in the field. The potential for improvement is great, solving some of the issues associated with handover could mean that other instances of knowledge being lost could be addressed. For instance, if clear information on where and how files should be stored and shared was communicated during handover, this would have a positive effect on the way knowledge is stored and shared at MSF more widely.
Living organogram template, tested with field staff Flexible handover template, tested with field staff National staff buddy guide, tested in theory (verbal feedback rather than live tested) with field staff Report on findings Best practice guide
Outcome measurement Recent data from the newly developed nursing debriefing tool currently scores handover quality at 2 out of 5 on average. This score will now act as an indicator of change, although it cannot reflect any meaningful results inside of the 6-month timeline of this project. The nursing debriefing tool asks 'How well did you handover period with your predecessor prepare you for your mission?'. This question gives insight into whether handover is working. We also suggest the question: 'Did you feel prepared for your role upon entering the project?'. As this covers the quality of onboarding in general. Qualitative evidence is also a key way of measuring handover, to identify whether or people were prepared on entering the field. If not, why? If so, how can this be replicated across missions? These are the questions we asked during this process and we advocate that these questions continue to be asked during debriefings.
32 | Redesigning Hospital Handover
Due to the field being a busy environment, testing at MSF is a challenge. The support of an advisory group was key to accessing field staff to understand their handover barriers and get their feedback on the prototyped solutions. However, without the support of a Head of Mission, it was not possible to fully test the solutions in a project. The next step in improving handover is to try the flexible template, living organogram and national staff buddy system live in a project. Only then can the new handover process be adapted then scaled across MSF’s projects.
MSF has long been a place where innovation thrives. The staff members which the organisation attracts in the field and operations are natural problem solvers, as they constantly have to think quickly in extreme environments. Life threatening issues arise in the field, so staff rapidly learn to problem solve.
Improving hospital handovers is a key element of the hospital improvement strategy, so the continued testing and implementation of this new handover process will fall under the responsibility of the healthcare management team within Operational Centre Amsterdam’s Public Health Department. A key mission will be used as a test bed for live testing the new handover process. The advisory board formed during this project will continue to meet, including a staff member from operations, in order to support the implementation of the new handover process.
Blogging about the project was key in gaining buy-in from staff across MSF. As planned this project was undertaken with support from MSF in London and Amsterdam and publishing an article about the project on the innovation blog led to a connection with the Berlin Operational Centre. This meant that more field staff could be reached, so the project could have a larger impact. The solutions developed through the project were not ground-breaking, they are simple and cost-effective ways to solve the issue of ineffective field handover. However the service design approach was new to MSF. Too often, forms and new processes are imposed on field staff with little research into what they need and little explanation of why they need do extra work. This project focussed on responding to the needs of field staff. It began in response to the nursing debriefing survey carried out by Vicky Treacy Wong, Health Advisor in Amsterdam. Thorough in-depth research highlighted what field staff needed from the new handover process. Then solutions were tested in an agile way, so that only the most useful solutions with the most potential for success reached the field.
The project was presented at MSF’s Innovation Day, which is part of Scientific Day, where projects and discoveries are shared. Field staff were keen to use the new handover process, with many people being keen to see the best practice guide and templates disseminated. For this reason the new handover process should be available on OneDrive, and other sharing platforms used by MSF. Disseminating via email is also encouraged. Suggested implementation of new handover process January 2018 – June 2018 • • •
Research Development of solutions Testing
June 2018 – June 2019 • •
Implementation of handover process by hospital management team in key hospitals Continuation of advisory group
June 2019 – December 2019 • •
Ongoing evaluation of handover process, during debrief and through the debriefing tool Solutions evolve based on this feedback (Is flexible template still fit for purpose? Is it well disseminated and easy to find?)
December 2019 – June 2020 •
Roll out to other projects within the Operational Centre Amsterdam remit and beyond
Conclusion | 33
Conclusion Over the last 6 months we have gathered qualitative data on what effective handover should look like, understood what is already working in the field and understood some of the challenges in relation to handover and institutional knowledge. The new handover process builds on this knowledge and the existing good practice being carried out in MSF’s field projects.
Elements of the new handover process, tested with 19 staff members: •
• Research carried out with 38 participants highlighted • •
• • • •
Motivation, outgoing staff need to be motivated to carry out handover. This led us to design a process which was quick and easy to carry out, ultimately saving staff time. Infrastructure, the extreme field conditions were taken into account. The handover process utilises Office 365 as MSF progresses to one system. National Staff, ultimately national staff hold MSF’s knowledge and expertise and ways to involve and elevate their role are important. Context, the new handover process must be quick and easy to work in extreme contexts. Responsibility, there is a lack of clarity around who is responsible for handover. We created a best practice guide for handover, which outlines who should be responsible for which element.
• • •
Flexible template, staff members use their predecessor’s handover report and simply update links and bullet points, carried out before their final week and shared with their successor before they travel to the field. Living organogram, we recommend organograms are regularly updated and kept on the wall for all to see. National staff buddies, national and international staff are formally paired for maximum collaboration in the project. Contact with predecessor, incoming and outgoing staff are connected via email, phone or Skype to understand the day-to-day role. Up-to-date job descriptions, outgoing staff are encouraged to update their job description for their successor. Leave a day for jetlag, incoming staff are given time to catch up on sleep, so that they are able to absorb their briefing information.
The next challenge is to disseminate this new handover process, while continually testing and evaluating its use. A suggestion would be to inform heads of mission of the new handover process at the next co-days event in Amsterdam. The new handover process makes handover quicker and easier, rather than creating more paperwork in an already busy field setting. Feedback and questions on this project are welcome and should be directed to: email@example.com, or firstname.lastname@example.org
34 | Redesigning Hospital Handover
A report on the redesign of the handover between international eld staff at Me?decins Sans Frontie?res.