The document describes the implementation of a morning handover process utilizing the MOSAIQ electronic medical record (EMR) system at the Tweed Cancer Care and Haematology Unit. An evaluation found the EMR handover process improved staff satisfaction, coordination of patient care, and reduced incidents. It was concluded the handover process meets national standards and could benefit other ambulatory care units utilizing EMRs.

2. Brendan Esposito CNS
Cancer Care and Haematology Unit
The Tweed Hospital
October 2015
Handover Utilising
MOSAIQ EMR
Optimising the Model of Care for Patient
Management at The Tweed Cancer Care and
Haematology Unit

3. Where’d he say he’s from?
 The Tweed Cancer Care and Haematology Unit (CC&HU) is an
ambulatory day treatment unit within The Tweed Hospital (TTH).
 An initial implementation of a handover process was attempted
by nursing staff in November 2011.
 Coinciding at this time was the implementation of the dedicated
oncology specific, electronic patient record system (EMR),
MOSAIQ.
 Sequenced process of patient handover utilising MOSAIQ EMR
was begun on 7th May 2012

4. Handover – What’s the big deal
The commonly understood model of shift to shift
nursing handover does not apply to most ambulatory
day treatment units. Most ‘tailor made’ handover
process and checklists are not readily applicable .
None-the-less, ‘handover’ of patient clinical
information remains quintessential to safe clinical
practice.

5. Handover - What’s it got to do with
EMR?
With the recent increased use of computer systems,
electronic medical record keeping and electronic
devices that enable communication, there has been a
corresponding increase in interest concerning how
these innovations are impacting on the transfer of
clinical information and patient handover.

6. MOSAIQ – What is it?
Electronic Medical Record System
Dedicated Multi-Departmental Oncology Management
System
Interfaces with external systems
All patients accessible to all disciplines

7. What does it do?
 EMR-patient notes
 Assessments tools
 Documents, letters, reports
 Chemo orders
 Generates blood test and investigation orders
 Laboratory and investigative results
 Appointment scheduling
 Daily basis-patient ‘queuing’ and staff allocation
 Medicare code capture and billing
 Statistical analysis – crystal reports

8. What’s it look like?

9. CINSW Project Grant
 The aims of the project where seen to be relevant to the
CINSW Strategic Plan 2011-2015
 The project was funded through a successful application
for a CI NSW Cancer Services Development grant

10. Aim of the Project
To demonstrate the effectiveness of morning
handover utilising MOSAIQ EMR within Cancer
Care and Haematology Unit at The Tweed
Hospital and its impact on patient care delivery

11. Methods Used
 A comparison of morning handover using MOSAIQ to
local and national standards
 Benchmarking local handover practices
 Comparison of Essentials of Care observations and Staff
Satisfaction Surveys
 Examination of Incidence Reports
 Interrogative EMR Patient Chart Audit

12. Comparisons to Standards
 National standards (NSQHS standard 6)
 Australian Commission on Safety and Quality in Health Care
 Australian Resource Centre for Healthcare Innovations
 Clinical Excellence Commission
 NSW Safe Clinical Handover Program
 NSW Health Policy directive PD2009_60 Clinical Handover -
Standard Key Principles
 Northern NSW Local Health District Procedure,
Nursing/Midwifery Shift Clinical Handover – Point of
Care/Bedside NC-NNSW-PRO-6361-12

13. Results of this Comparison
Handover utilising MOSAIQ EMR meets local and
national standards with limited exceptions:
No documentation of ‘handover’ present
Patient involvement in the process could be
greater or more explicit

14. Benchmarking
 Six similar ambulatory units in the Northern NSW Local
Health district and geographical proximal to TTH were
canvassed.
 The Nursing Unit Managers of these units were provided a
copy of the SAFE CLINICAL HANDOVER-KEY PRINCIPLES
FOR SAFE AND EFFECTIVE HANDOVER and a modified
questionnaire taken from the same document

15. Results of Benchmarking
 5/6 response rate
 ‘Handover’ practices vary widely locally
 All units experienced similar circumstances and
intrinsic problems
 Standard handover formats devised for ‘shift to shift’
settings did not suit
 Very few units (1/5) document ‘handover’
 4/5 units employ EMR

16. EOC and Staff Surveys
 CC&HU began engagement with the EOC program in
October 2010. This cyclic process begins with data
collection. Data is collected in various ways, one of which
is observational studies of ward processes and activities
 This qualitative data consisted of observations of the
environment and staff interactions and also included the
application and interpretation of a Questionnaire about
Clinical Handover (QCH) in August 2012 and Nursing
Workplace Satisfaction Questionnaire (Fairbrother, Jones
and Rivas, 2010) in 2010

17. EOC and Staff Surveys
(Hang in there… He gets interesting in about 3 more slides)
 Aspects of the previously applied QCH (2012) were
compared with results from an expanded QCH in
2014
 Results from the 2014 NWSQ were compared to the
previous results from the same questionnaire
applied in 2010
 A compared sick leave 12 months prior and then
after implementation of handover

18. Results of Surveys and Observations
 EOC observations and staff satisfaction surveys indicate
that handover using MOSAIQ is valued by staff and has
resulted in greater staff satisfaction and a perception of
safer and better co-ordinated patient care.
 A reduction in staff sick leave has also been observed in
the period after the implementation of handover utilising
MOSAIQ.

19. An examination of Incidence Reports
 A total of 61 incident reports (Incident Information
Management System) were examined
 Incidents between 16 Aug 2010 and 24 Jan 2014 were
examined
 Four incidents were noted to concern the communication
of clinical information

20. Results of this Examination
 Two incidents prior to implementation resulted in patients being
treated with low neutrophil counts (despite a checking procedure
being in place) because this clinical information had not been
communicated
 Handover inserts another ‘group’ check into existing procedures. No
further incidents of this nature have been noted
 A third report revealed partially completed chemotherapy orders were
discovered during handover for a patient booked for Tx. The potential
for chemotherapy to be inadvertently administered was detected
 A similar report described incorrect dosages of chemotherapy being
discovered during the handover procedure.
 These incidents lend support to the handover having improving
patient safety

21. Chart Audit
 50 EMR audited: 25 before implementation and 25 after
 Is there evidence a review of blood results by nursing staff occurred on the day of
treatment?
 Has the patient been previously delayed chemotherapy treatment? Was this
because of information discovered during handover?
 Is there evidence the patient received chemotherapy education?
 Is there evidence these orders/plans were acted upon?
• Are there specific medical orders associated with the treatment in place prior
to the scheduled appointment?
• Is there evidence of a nursing plan associated with the treatment in place prior
to scheduled appointment?
• Is there evidence these orders/plans were acted upon?

22. Results of Chart Audit (Nearly there guys…)
 An increase was seen in the nursing assessment of
patient blood results and the number of patients receiving
chemotherapy education, prior to the patient receiving
chemotherapy
 The handover process has resulted in an increase number
of medical instructions being actioned nursing staff
 A similar increase is shown in the number of nursing
plans being actioned nursing staff

23. Conclusions
There now exists a dedicated, formalised, embedded and sequenced
process of patient handover utilising MOSAIQ EMR to review
patients, which is considered essential and valuable to the nursing
practice within the CC&HU. This has positively impacted on the
safety and care of patients and lead to improvements in staff
satisfaction and feelings of collegiality. This process meets National
and local standards and is readily applicable to the local
circumstances within the unit described and may possibly prove
applicable in other ambulatory settings utilising EMR systems.

24. Recommendations
1. NSQHS standard 6.2 Establishing and maintaining structured and
documented processes for clinical handover
2. NSQHS standard 6.5.1 Mechanisms to involve patients and, where
relevant carers in the clinical handover are in use.
3. This report to be made available to other ambulatory care units
4. Develop quantitative measures/KPIs
– Wastage of chemotherapy
– Patients OOS
– Time in motion
– Number of documented ‘handovers’

25. Acknowledgements
 The hard working CC&HU Nursing Team
 Lily Fenech - EOC Coordinator Northern NSW LHD
 Stephen Manley – Cancer Systems Innovations Manager,
CINSW
 Greg Fairchild – Post Doctoral Research Fellow, NaMO
 Sue Brooks - NUM, CC&HU TTH