title: Managing competing organizational priorities in clinical handover across organizational boundaries.
abstract: OBJECTIVE
  Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine).
  
  
  METHODS
  A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically.
  
  
  RESULTS
  The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other's goals and constraints as possible ways towards more sustainable improvement.
  
  
  CONCLUSIONS
  Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patient-centred care.
authors.affiliation: Associate Professor of Patient Safety, Warwick Medical School, University of Warwick, UK m-a.sujan@warwick.ac.uk.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Sujan
authors.affiliation: Lead Advanced Clinical Practitioner, Heart of England NHS Foundation Trust, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Chessum
authors.affiliation: Consultant Nurse Emergency Care, United Lincolnshire Hospitals NHS Trust, UK.
authors.forename: Michelle
authors.initials: M
authors.lastname: Rudd
authors.affiliation: Consultant in Emergency Care, Oxford Radcliffe Hospitals NHS Trust, UK.
authors.forename: Laurence
authors.initials: L
authors.lastname: Fitton
authors.affiliation: Consultant in Acute Medicine, Hampshire Hospitals NHS Foundation Trust, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Inada-Kim
authors.affiliation: Professor of Emergency Medicine, Warwick Medical School, University of Warwick, UK.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Cooke
authors.affiliation: Professor of Clinical Healthcare Management, Warwick Medical School, University of Warwick, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Spurgeon
mesh_terms: D001291:Attitude of Health Personnel; D003142:Communication; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003299:Cooperative Behavior; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D007400:Interprofessional Relations; D015279:Organizational Culture; D010360:Patient Transfer / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration; D013222:State Medicine / Q000458:organization & administration; D013997:Time Factors; D061665:Time-to-Treatment; D006113:United Kingdom
keywords: emergency medical services; handover; patient safety