Don't interrupt me! development of a handoff education bundle to simulate the real world.

OBJECTIVES: Ineffective nurse-to-nurse handoff communication is associated with information omissions, diagnostic errors, treatment errors, and delays. New nurses report a lack of confidence and ability in handoff communication, which may stem from inadequate training in prelicensure nursing programs. Our objective was to introduce prelicensure nursing students to a standardized, theory-based method for handoff, including behavioral strategies employed by nurses during interrupted handoff. METHODS: A handoff education bundle (HEB) was developed. Kern's six-step curriculum model was utilized to design, implement, and evaluate the handoff curriculum. RESULTS: Student feedback highlighted the importance of integrating multiple, varying distractors during learning cycles and recognition of the impact of distractors on handoff. CONCLUSIONS: Implementing a HEB at the prelicensure nursing level could promote competency in handoff communication for new graduate nurses. IMPLICATIONS FOR INTERNATIONAL AUDIENCE: Handoff is an international patient safety priority, as inadequate communication has been linked to adverse patient events.

Daily handover in surgery: systematic review and a novel taxonomy of interventions and outcomes.

BACKGROUND: Poor-quality handovers lead to adverse outcomes for patients; however, there is a lack of evidence to support safe surgical handovers. This systematic review aims to summarize the interventions available to improve end-of-shift surgical handover. A novel taxonomy of interventions and outcomes and a modified quality assessment tool are also described. METHODS: Ovid MEDLINE®, PubMed, Embase, and Cochrane databases were searched for articles up to April 2023. Comparative studies describing interventions for daily in-hospital surgical handovers between doctors were included. Studies were grouped according to their interventions and outcomes. RESULTS: In total, 6139 citations were retrieved, and 41 studies met the inclusion criteria. The total patient sample sizes in the control and intervention groups were 11 946 and 11 563 patients, respectively. Most studies were pre-/post-intervention cohort studies (92.7%), and most (73.2%) represented level V evidence. The mean quality assessment score was 53.4% (17.1). A taxonomy of handover interventions and outcomes was developed, with interventions including handover tools, process standardization measures, staff education, and the use of mnemonics. More than 25% of studies used a document as the only intervention. Overall, 55 discrete outcomes were assessed in four categories including process (n = 27), staff (n = 14), patient (n = 12) and system-level (n = 2) outcomes. Significant improvements were seen in 51.8%, 78.5%, 58.3% (n = 9761 versus 9312 patients) and 100% of these outcomes, respectively. CONCLUSIONS: Most publications demonstrate that good-quality surgical handover improves outcomes and many interventions appear to be effective; however, studies are methodologically heterogeneous. These novel taxonomies and quality assessment tool will help standardize future studies.

Improving availability and accuracy of the junior doctors' on-call handover through digitalisation.

Clinical handovers from out-of-hours activity are essential for relaying information about events such as new admissions, outstanding or complete investigations, physical health reviews, ward jobs and risk. This information enables the day team to effectively prioritise and follow-up any necessary tasks.Junior doctors at a hospital site in the London Borough of Newham were aware that the existing handover system, constituted of a word document circulated via email, was lacking robustness and that the handover was not sent out reliably on a daily basis.Quality improvement (QI) methods including process mapping, PDSA ('Plan, Do, Study, Act') cycles, driver diagrams and run charts were used to understand the issue, create a more robust process and measure the improvements made, all supported by regular QI project meetings. The change ideas included moving from an informal Microsoft (MS) Word document, which was emailed out, to an Excel spreadsheet stored centrally on MS Teams. Column headers were added for admissions, ward jobs, seclusion reviews, matters relating to mental health law and Accident and Emergency (A&E) assessments, as well as defined columns for outstanding jobs and standard tasks that need to be completed for all admissions. Responsibility for circulating the handover list was given to the incoming day duty doctor if the night doctor was too busy, with admin support to chase the circulation of the handover. Results were studied for the following 18 months.The percentage of handovers being appropriately sent out increased from a median of 80% to 100% during the project period, and the availability of handover data where the data were visible to doctors on MS Teams but had not been sent out also increased from a median of 80% to 100%. The system was deemed safe, effective and easy to use, and has already been replicated at neighbouring hospitals.

Initiative to improve handover notes in a tertiary psychiatric hospital.

Clinical handover is an important process in hospital settings, but it is often carried out inadequately, posing potentially serious consequences for the patients. This project aimed to increase the effectiveness of handover notes when patients were transferred between a general psychiatric ward and other wards in a tertiary psychiatric hospital. Effective handover notes in this project were defined to have the following five components: brief psychiatric history, reason for the patient to be transferred, significant risk issues, reason for psychotropic medication change and active medical issues. Baseline measurement obtained from audits revealed that the completion rate of effective handover notes was only 27.27%, which could potentially compromise patient safety and staff work efficiency. To address this problem, a series of plan-do-study-act (PDSA) cycles was implemented to improve the handover process. The interventions included education to junior doctors, reminders to complete effective handover notes and implementation of a handover template. Following each PDSA cycle, data were gathered to assess whether an effect had been achieved and to identify ways to enhance interventions to maximise impact. After the final PDSA cycle, the percentage of effective handover notes among all transfer cases reached 90.50%. Postintervention feedback from inpatient team indicated that effective communication between different teams was ensured, and staff satisfaction and time savings were improved. This study highlights the importance of employing PDSA cycles to assess and refine interventions and the usefulness of structuring the content of key components of handover notes to obtain measurable improvements.

Nurses engaging with referral letters and discharge summaries: A qualitative study.

AIMS: To investigate the ways that nurses engage with referral letters and discharge summaries, and the qualities of these documents they find valuable for safe and effective practice. DESIGN: This study comprised a qualitative, case-study design within a constructivist paradigm using convenience sampling. METHODS: Interviews were conducted with nurses to investigate their practices relating to referral letters and discharge summaries. Data collection also involved nurses' examination and evaluation of a diverse range of 10 referral letters and discharge summaries from medical records at two Australian hospitals through focus-group sessions. The data were transcribed and analysed inductively. RESULTS: In all, 67 nurses participated in interviews or focus groups. Nurses indicated they used referral letters and discharge summaries to inform their work when caring for patients at different times throughout their hospitalisation. These documents assisted them with verbal handovers, to enable them to educate patients about their condition and treatment and to provide a high standard of care. The qualities of referral letters and discharge summaries that they most valued were language and communication, an awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. CONCLUSION: Nurses relied on referral letters and discharge summaries to ensure safe and effective patient care. They used these documents to enhance their verbal handovers, contribute to patient care and to educate the patient about their condition and treatment. They identified several qualities of these documents that assisted them in maintaining patient safety including clarity and conciseness of information. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: It is important that referral letters and discharge summaries are written clearly, concisely and comprehensively because nurses use them as key sources of evidence in planning and delivering care, and in communicating with other health professionals in relaying goals of care and implementing treatment plans. IMPACT: Nurses reported that they regularly used referral letters and discharge summaries as valuable sources of evidence throughout their patients' hospitalisation. The qualities of these documents which they most valued were language and communication styles, awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. This research has important impact on the patient experience in relation to encouraging effective referral letter and discharge summary writing. REPORTING METHOD: We have adhered to the relevant EQUATOR guidelines through the SRQR reporting method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Reaching consensus on the definition of person-centred handover practices in emergency departments: A modified online Delphi.

AIM: To reach consensus on the definition and attributes of 'person-centred handover practices' in emergency departments. BACKGROUND: Handover practices between emergency care practitioners and healthcare professionals in emergency departments are important and should be conducted meticulously. Person-centred handover practices may enhance the delivery of person-centred care in emergency departments. DESIGN: A three-round online Delphi survey. METHODS: Nine experts participated in a three round Delphi survey. The expert panel comprised experts from nine countries. Quantitative data were descriptively analysed, and qualitative data were thematically analysed. A consensus of 80% had to be reached before an attribute and definition could be accepted. RESULTS: Experts reached a consensus of 79% in round one, 95% in round two and 95% in round three. A final set of six attributes were agreed upon and the final concept definition was formulated. CONCLUSION: Person-centred handover practices have not been implemented in emergency departments. Yet, person-centred handover practices may enhance the delivery of person-centred care, which has multiple benefits for patients and healthcare practitioners. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Person-centred care is not generally implemented in emergency departments. Person-centred handover practices can lead to person-centred care. Handover practices in emergency departments are a high-risk activity. Despite numerous calls to standardise and improve handover practices, they remain a problem. Developing a standardised definition could be a first step towards implementing person-centred handover practices in emergency departments. REPORTING METHOD: The study adhered to the relevant EQUATOR reporting guidelines: Guidance on Conducting and Reporting Delphi Studies (CREDES) checklist. IMPACT (ADDRESSING): Improve handover practices and patient care. Improve person-centred care in emergency departments. PATIENT OR PUBLIC CONTRIBUTION: Emergency care practitioners and nurses experienced in handover practices and/or person-centred care, working in clinical and academic fields, participated in the study by sharing their expert knowledge during each of the Delphi rounds.

Improving Direct Admissions to Internal Medicine Services.

BACKGROUND: Direct admissions from clinic or home to the hospital may improve efficiency and reduce emergency room utilization, but nonoptimized processes may increase the risk of harm during the transition of care. Our multidisciplinary team aimed to understand and improve the process of directly admitting patients to inpatient medicine services at a large academic medical center. METHODS: In this single-institution quality improvement initiative, we identified key communication gaps within the direct admission process and implemented a handoff tool in the form of a templated note and order set to bridge those communication gaps. The primary outcome measure was the monthly utilization rate of the handoff note as a surrogate for handoffs and uptake of the intervention. RESULTS: We launched our intervention in April 2022. We achieved sustained use of the SmartText and a peak of 24% of direct admissions utilizing the SmartText in January 2023. Based on feedback during Plan-Do-Study-Act cycles, we added direct admission instructions for outpatient teams to follow in the order set and reduced text in the handoff note. CONCLUSIONS: This study demonstrates the design and implementation of a quality improvement initiative to identify and address communication gaps for direct admissions of adult medicine patients.

The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members.

OBJECTIVE: To examine time from injury to initiation of surgical care and association with survival in US military casualties. BACKGROUND: Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce. METHODS: This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity. RESULTS: Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67). CONCLUSIONS: Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.

Structured postoperative handover protocol improves efficiency and quality of interdisciplinary communication and nursing care in surgical intensive care unit: a randomized controlled trial.

This study aimed to evaluate the effectiveness of a structured postoperative handover protocol for postoperative transfer to the SICU. This study was a randomized controlled trial conducted in a comprehensive teaching hospital in China. Patients who were transferred to the SICU after surgery were randomly divided into two groups. The intervention group underwent postoperative structured handover protocol, and the control group still applied conventional oral handover. A total of 101 postoperative patients and 50 clinicians were enrolled. Although the intervention group did not shorten the handover duration (6.18 ± 1.66 vs 5.94 ± 1.91; P = 0.505), the handover integrity was significantly improved, mainly reflected in fewer information omissions (1.44 ± 0.97 vs 0.67 ± 0.62; P < 0.001), fewer additional questions raised by ICU physicians (1.06 ± 1.04 vs 0.24 ± 0.43; P < 0.001) and fewer additional handovers via phone call (16% vs 3.9%; P = 0.042). The total score of satisfaction of the intervention group was significantly higher than that of the control group (76.44 ± 7.32 vs 81.24 ± 6.95; P = 0.001). With respect to critical care, the incidence of stage I pressure sore within 24 h was lower in the intervention group than in the control group (20% vs 3.9%, P = 0.029). Structured postoperative handover protocol improves the efficiency and quality of interdisciplinary communication and clinical care in SICU.Trial registration This study was registered in China on January 8th, 2022 at Chinese Clinical Trial Registry (ChiCTR2200055400).

A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study.

BACKGROUND: An intraoperative transfer of care from one anesthesia provider to another, or handover, may result in information loss and contribute to adverse patient outcomes. In 2019 the authors undertook a quality improvement effort to increase the use of a structured intraoperative handover tool incorporated in the electronic medical record. The authors hypothesized that intraoperative handovers of anesthesia care would be associated with adverse patient outcomes, and that increased use of a structured tool would attenuate this effect. METHODS: This study included adult patients undergoing noncardiac surgery of at least 1 h duration performed during the period 2016 to 2021. Cases with a handover were identified if either there was a change of attending anesthesiologist or change of nurse anesthetist or resident for more than 35 min. The primary outcome was the occurrence of a composite of postoperative mortality and major postoperative morbidity. The effect of the intervention was analyzed by examining the quarterly change in odds ratio for the primary outcome for cases with and without a handover. RESULTS: A total of 121,077 cases, 40.4% of which had a handover, were included. After weighting, the composite outcome was statistically associated with handovers (3,517 of 48,986 [7.2%] in handover cases vs. 4,470 of 72,091 [6.2%] in nonhandover cases; odds ratio, 1.08; 95% CI, 1.04 to 1.12). Time series analysis showed a marked increase in usage of the structured tool after the initial intervention. The odds ratio for the composite outcome showed a significant decrease over time after the initial intervention (t = -3.97; P < 0.001), with the slope of the odds ratio versus time curve decreasing from 0.002 (95% CI, 0.001 to 0.004; P = 0.018) to -0.011 (95% CI, -0.01 to -0.018; P < 0.001). CONCLUSIONS: Intraoperative handovers are significantly associated with adverse outcomes even after controlling for multiple confounding variables. Use of a structured handover tool during anesthesia care may attenuate the adverse effect.

Implementing bedside handovers in mental health care: Insights from an experience-based co-design.

OBJECTIVES: Bedside handovers have the potential to provide opportunities to increase patient involvement in mental health care. However, limited research has been conducted on this subject. METHODS: In this study, we investigate the suitability of experience-based co-design as a method for designing bedside handover in mental health care. RESULTS: The article discusses the goals of bedside handover, the preferred structure and content of the handover, its location and frequency, and the familiarization involved in it. CONCLUSIONS: EBCD proved to be a suitable method of making recommendations for involving patients in nursing handover in a mental healthcare unit of a general hospital. PRACTICE IMPLICATIONS: Nurses and mental health care patients agreed on the ISBARRT model to structure bedside handovers.

[Handover protocols in the emergency department]. / Übergabe und Übergabeschemata in der Notaufnahme.

Patient handovers are a vital juncture in the flow of medical information, and regardless of the mode of handover-oral, written, or combined-it often poses a risk of information loss. This could potentially jeopardize patient safety and influences subsequent treatment. The exchange of information in emergency care settings between paramedics and emergency personnel is particularly prone to errors due to situational specifics such as high ambient noise, the involvement of multiple disciplines, and the need for urgent decision-making in life-threatening situations. As handover training is not yet universally incorporated into education and ongoing training programs, there is a high degree of variability in how it is carried out in practice. However, strategies aimed at enhancing the handover process carry substantial potential for improving staff satisfaction, process quality, and possibly even having a positive prognostic impact.

Educational interventions for improving nursing shift handovers: A systematic review.

AIM: This study analyzed the components of educational interventions for handovers among nursing students and nurses. BACKGROUND: A handover is a communication process that occurs when patient care responsibilities and rights are transferred from one nurse to another. This process is important in nursing to ensure the continuity of nursing care and patient safety. DESIGN: A systematic literature review of Korean and international studies was conducted to identify the components of handover educational programs for nursing students and nurses and analyze their effects, thereby providing a basis for the further development of these programs. METHODS: Studies published in English or Korean no later than June 30, 2022, were found via an electronic database search using the MEDLINE, Embase, and CINAHL databases. Three reviewers independently evaluated all the studies. These studies focused on educational interventions for nursing students and nurses regarding covering shift-to-shift nursing handovers. After reviewing 1971 extracted articles, 18 satisfied the inclusion criteria. RESULTS: Nine articles involved nursing students and nine involved nurses. Four articles covered bedside handovers as educational topics. Educational methods included lectures and active practice. Active practice comprised demonstrations, role-play, and feedback. The main content areas of the educational programs were an introduction to handovers; training regarding how to extract important information for handovers; and strategies using informatic and thematic structures, such as mnemonics, and concept mapping. The patient cases for role-play were provided in forms of written scenarios, virtual electronic charts, videos, scenario-based simulated situations, and actual patient cases assigned in clinical practice. The effects of the educational interventions were evaluated regarding knowledge, performance, and self-efficacy. Performance and self-efficacy were significantly higher in a study in which the intervention group was provided additional individual feedback compared to the control group and in a study in which the intervention group received multiple additional practice opportunities. CONCLUSIONS: Handover education for nursing students and nurses should include individual feedback, demonstrations, and opportunities to practice to improve their performance and self-efficacy. Feedback methods should be further developed to increase the effectiveness of educational programs. Sample cases involving patients should be devised to increase these opportunities, and methods for improving educator efficiency should be identified.

The Quest for Excellence: A Quality Improvement Project on the Effects of a Standardized PACU/Phase II Bedside Report in a High Turnover Pediatric Ambulatory Surgery Center.

PURPOSE: To evaluate the impact of an evidence-based standardized bedside report within a pediatric ambulatory surgery center on length of handoff time, registered nurse (RN) workflow, and patient and family satisfaction. DESIGN: Quality improvement project using an evidence-based standardized bedside report intervention with pre- and postimplementation evaluation of process and outcome measures. METHODS: In January 2019, a unit-based task force evaluated ways to improve current report process and consistency of communication between staff and families. Time from admit into Phase II until nursing handoff was measured pre- and postimplementation. Nursing workflow was measured by time to first RN assessment after admit to Phase II and the postimplementation nursing survey. Patient and family satisfaction were measured pre- and postimplementation from National Research Council Health. FINDINGS: Postimplementation, average handoff times decreased by 30%; average time from admit to the Phase II unit until the nursing handoff decreased by 28%. From the postimplementation RN survey, 100% RNs: (1) felt standardized bedside report had a positive impact on their workflow, (2) expressed confidence in giving and receiving reports, and (3) reported they had critical information to safely care for patients. Overall patient satisfaction was measured by How likely would you be to recommend this facility to your family and friends; 11.6% improvement over baseline scores was reported. Improved percentages of score improvement from baseline included: nurses explained things (4.42%), nurses listened carefully (4.3%), patient and family received consistent information (2.46%), care providers explained things (2.22%), and patient and family trusted nurses with care (1.74%). CONCLUSIONS: Implementation of standardized bedside report resulted in (1) more expeditious times to handoff and first RN assessment, (2) overall positive impact on nursing workflow, and (3) improvements in patient and family satisfaction.

Analysis of Military-Civilian Patient Handoff at Vista Forge Multi-Agency Nuclear Disaster Exercise 2022.

INTRODUCTION: The leadership of Vista Forge 2022 requested evaluation of the handoff process between military assets and civilian emergency medical services (EMS) providers by the Beth Israel Deaconess Fellowship in Disaster Medicine (BIDMF). Vista Forge was a multi-agency military-civilian full-scale disaster exercise coordinated by the U.S. Military. The exercise, held in Atlanta, Georgia, simulated response to a nuclear bomb in an urban setting by military and civilian disaster teams. MATERIALS AND METHODS: BIDMF had several two-person teams who monitored handoff procedures between military assets after decontamination and civilian emergency medical services providers during the exercise evaluation. RESULTS: A verbal handoff between military and civilian entities was usually not done. Triage tags placed on mannequins before decontamination remained attached to the bodies and were sent with them to civilian hospitals. Triage tags were generic military forms without specific radiation or chemical exposure information. Not all decontamination groups had the same medical capabilities, and in a disaster it is unclear how these teams would manage medical emergencies. CONCLUSIONS: Future studies should develop a standardized handoff procedure to be used in mass casualty situations, and trial it in future multi-agency disaster exercises. Radiation specific triage tags should be considered.

A Review of Verbal and Written Patient Handoffs Applicable to the U.S. Military's Expeditionary Care System.

INTRODUCTION: Long considered a danger point in patient care, handoffs and patient care transitions contribute to medical errors and adverse events. Without standardization of patient handoffs, communication breakdowns arise and critical patient information is lost. Minimal training and informal learning have led to a lack of understanding the process involved in this vital aspect of patient care. In 2017, the U.S. Army commissioned a report to study the process of patient handoffs and identify training gaps. Our report summarizes that process and makes recommendations for implementation. MATERIALS AND METHODS: Scoping literature review of 139 articles published between 1999 and 2017 using PubMed, CINAHL, Cochrane, and Medline databases. Verbal tools for handoffs were evaluated against 12 criteria including patient ID, history, current situation, contingency planning, ability to ask questions, ownership, and read back. Written tools were evaluated against a matrix of 126 casualty/treatment attributes. RESULTS: Among verbal communication protocols, the highest scoring handoff mnemonics were HAND ME AN ISOBAR, IPASS the BATON, and I-SBARQ. Among written handoff tools, the highest scoring documents were the Special Operations Forces (SOF) Mechanism, Injuries, Signs, and Treatment (MIST) Casualty Treatment Card and the Department of Defense (DD) Form 1380 Tactical Combat Casualty Care (TCCC) Card. Four critical process elements for patient handoffs and transfers were identified: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review any relevant historical data. CONCLUSIONS: The findings in this review highlight the need for standardized tools and techniques for patient handoffs in the U.S. Military's expeditionary care system. Future research is needed to trial verbal and nonverbal handoffs under field conditions to gather observational data to assess effectiveness. The results of our gap analyses may provide researchers insight for determining which handoffs to study. If standardized handoffs are utilized, training programs should incorporate the four critical elements into their curricula.

A Discourse Study on Handover Communication Among Care Providers in a Residential Care Home for Persons with Intellectual Disabilities.

Abundant research has focused on handovers among nurses and/or doctors in hospitals; far less is known about handovers among care providers in non-clinical contexts, such as care homes for the elderly or the disabled. Focusing on handovers in a residential care home for persons with intellectual disabilities (RCHID), this study argues that handover communication in non-clinical settings is equally important. Ineffective handovers can lead to the deterioration of the residents' health conditions, chaotic situations and even injuries to both care providers and care recipients. Staff in RCHIDs rely heavily on handover communication to obtain information about the residents' needs and to offer appropriate care services. Combining discourse analysis with interactional sociolinguistics, this study analyzes written and spoken discourses involved in handover communication among care providers in a typical RCHID in Hong Kong to investigate what and how communicative functions were achieved through the participants' language use. The data were collected by convenience sampling, including handwritten notes and handover recordings of twelve sessions. Then a group interview of seven care providers was conducted to obtain supplementary data. Findings suggest that handover communication includes informational and interpersonal functions. While information delivery is the main purpose, care providers also establish relationships with one another through small talk about care home residents. The results suggest potential drawbacks of the handovers, including illegible notes, inconsistent information collection, and low interactivity. This study proposes a model that elucidates the correlation between discourse, handover communication and healthcare services, and suggests strategies to enhance such communication.