Communication and handoff failures are among the root causes in nearly two-thirds of “sentinel events,” which are serious, often fatal, preventable adverse events in hospitals.1 In response to this issue, the Accreditation Council for Graduate Medical Education (ACGME) now requires that residency training programs provide formal instruction about patient handoffs and that faculty monitor handoffs and ensure adequate handoff skills through direct observation.2–4 Yet despite these requirements and patient safety concerns, well-established handoff curricula and validated tools to observe and assess trainees’ handoff skills are lacking.5–8
Developing a handoff curriculum is challenging for multiple reasons. Handoffs often involve individuals with varying levels of skill, training, and responsibility. Although various approaches may be used to teach handoff skills (e.g., in-person didactic sessions, simulated clinical scenarios, video- and Web-based teaching modules),6,9–15 prior reports suggest that such skills are not traditionally taught in a formal way and that comprehensive curricular approaches are needed.8,16 Additionally, there is substantial variability across (and sometimes within) institutions regarding preferred formats and processes for verbal and written handoffs.17 Handoff practices may be so deeply entrenched that efforts aiming to improve them require transformational change of an institution’s culture.18,19
In June 2010, the Initiative for Innovation in Pediatric Education–Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study was launched as part of a collaborative effort involving 11 pediatric academic medical centers (1 curriculum pilot site, 1 data coordinating center, and 9 data collection sites) to determine the effectiveness of the I-PASS Handoff Bundle, a package of curricular interventions, in standardizing and improving handoffs of care.20,21 (For a list of participating sites, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A201). This project combined rigorous curricular design, traditional health services research, and quality improvement efforts to standardize the complex process of resident inpatient handoffs, with the goal of improving patient safety.
As members of the I-PASS Study Education Executive Committee (EEC), on behalf of all members of the I-PASS Study Group, we describe here the process we employed from June 2010 through February 2014 to develop, implement, and disseminate the I-PASS Handoff Curriculum. We also report preliminary learner outcomes. We use a logic model to frame our reporting and evaluation of this curriculum, because it offers a systematic and visual way to describe the trajectory from the early stages of planning, to the middle stages of implementation, and through the final stages of comparing intended with actual results.22,23
Approach: Development of Conceptual and Logic Models
To create among I-PASS Study Group members a shared mental model for developing the handoff curriculum, implementation strategies, and assessment methods, we began by creating a conceptual model of high-quality patient handoffs. To this end, a panel of investigators reviewed existing literature and identified the key elements and factors that could influence handoff quality. These items were sorted, categorized, and reduced to common terms through an iterative process. We used these terms to create a graphic depiction of our conceptual model, which served as the overarching guide for the development of the curriculum and assessment tools (Figure 1).
To provide a visual representation of the rationale behind the process we used to develop the I-PASS Handoff Curriculum, we created a logic model (Figure 2). The components of a logic model typically include resources, activities, outputs, and short- and long-term outcomes. These components, when viewed together as a whole, explain the resources available to support activities that, when implemented as intended, should produce outputs (or deliverables) that indicate the curriculum is on target to achieve the intended outcomes and have a lasting impact.24 The advantage of using a logic model to frame the description of our curricular development process is that the model helps highlight the assessment, monitoring, and management of the implementation process. A potential shortcoming of the logic model is its linearity.25 Therefore, other curricular development teams seeking to use a logic model such as ours should remain open to modifying the logic model in response to contextual and environmental factors. In this article, we present a description of each component of the logic model as it relates to our experience developing, implementing, and measuring the impact of the I-PASS Handoff Curriculum.
To initiate the process of curriculum development and address the anticipated complexities, the I-PASS Study Group leaders began by identifying needed resources. They first established the EEC, consisting of individuals with expertise and skills in curricular design, assessment, simulation program development, clinical hospital medicine, health services research, and residency training.
Once the members of the EEC were identified, we sought support from two organizations with the interest and capacity to foster a multicenter educational improvement effort: the Pediatric Research in Inpatient Settings (PRIS) Network and the Initiative for Innovation in Pediatric Education (IIPE). The PRIS Network conducts large, multi-institutional pediatric research studies with the mission of improving the health of and health care delivered to hospitalized children and their families.26 Its organizational structure and processes provided critical guidance and scientific oversight during the early stages of our protocol design and site team assembly. The IIPE initiates, facilitates, and sustains ongoing innovative change in pediatric education.27 Its support helped raise the profile of this project, as its endorsement was contingent on evidence of high-level institutional support from the participating sites, including letters of support from each hospital’s chief executive officer, department chair, designated institutional official, and residency program director. Additionally, to support effective local implementation of the curriculum, we ensured that each site had study team representation from the residency program and a leader in hospital medicine. The coupling of a dedicated group of educators, clinicians, and investigators with institutional leadership ensured that all participating sites were invested in the project before it began. The EEC also established an early partnership with national leaders from the Agency for Healthcare Research and Quality’s Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) initiative.28 TeamSTEPPS has an established communication and teamwork skills curriculum from which we drew key principles and content for a portion of the I-PASS Handoff Curriculum.
After assembling these foundational resources, we applied for and secured an American Recovery and Reinvestment Act grant from the U.S. Department of Health and Human Services to carry out the work of developing, implementing, and measuring the effect of the I-PASS Handoff Curriculum. To accommodate ancillary studies and involvement of additional sites, this grant was supplemented by funding from the Medical Research Foundation of Oregon, Physician Services Incorporated Foundation (of Ontario, Canada), and the Oregon Comparative Effectiveness Research K12 Program (Agency for Healthcare Research and Quality). In addition, an unrestricted educational grant from the Pfizer Medical Education Grant Program aided in the development of computer-based curricular modules to facilitate independent study.
As previously described,20 to facilitate organization and delegation of tasks, I-PASS Study Group members were organized into several committees and subcommittees (for the full list of study group members and the organizational structure, see Supplemental Digital Appendixes 1 and 2, respectively, at http://links.lww.com/ACADMED/A201). EEC members engaged in several activities to enhance our capacity to work as a team. Face-to-face meetings were organized to foster team cohesiveness, facilitate productivity, and drive consensus on shared purpose and vision. Because individual learning styles have been shown to affect performance in academic and work environments, prior to the first in-person meeting, each EEC member completed a learning styles inventory.29–31 The results of this assessment were shared with the group to encourage reflection regarding working preferences and individual strengths. Given the significant geographic separation of participating study sites and EEC members, Web conferencing was used to facilitate standing weekly meetings to maximize productivity and workflow. A project manager was hired to oversee administrative aspects of both the curriculum development and the research study.
The I-PASS Study Group made it a priority to promote mentorship within the team, both between junior and senior members as well as among peers. With this goal in mind, there was a strategic effort to ensure that the leaders of the subcommittees as well as all teams developing scholarly products included both junior and senior members, who were grouped to facilitate mentorship, support, and guidance.
Educational frameworks and guiding principles
In developing the I-PASS Handoff Curriculum, we used Kern and colleagues’32 six steps of curriculum development for medical education as a framework (see Table 1). We conducted a targeted needs assessment, using one focus group at each of the nine data collection sites, to determine current and preferred handoff practices, tools, and site-specific educational programs and resources. We found considerable variability across sites in both the handoff training that residents received and current handoff practices. Although four of the nine sites had electronic medical record–based written tools to facilitate handoffs, few used a team-based approach for verbal handoffs (two sites) or a supervised handoff process (one site). Most notably, none of the sites employed a formal curriculum to teach residents best handoff practices or used a handoff mnemonic.
A review of the literature indicated that limited data existed to guide adoption of standardized and evidence-based handoff practices in graduate medical education.8 To supplement the literature, we relied on the study group members’ expert opinions, reaching consensus on how to proceed throughout curriculum development and seeking the input of residents and external advisors at each stage. The curriculum was rolled out across participating study sites in three successive waves (July to December 2011, December 2011 to May 2012, and May to October 2012), with two to four sites per wave. After each wave of curriculum implementation, intensive debriefing, evaluation, and feedback occurred; we sought input from site participants as well as EEC leaders. This iterative process allowed for continuous improvement of implementation activities at successive sites and ensured opportunities to improve and refine the curriculum over time.
We explicitly employed adult learning principles in the development of the curriculum to ensure that residents have multiple opportunities to learn patient handoff skills in ways that are relevant to their clinical responsibilities.33 For example, we relied extensively on simulation activities to give residents chances to apply the skills they are learning. Learning activities are generally interactive and designed to build on residents’ previously acquired skills. Before participating in the curriculum, residents complete a learning styles inventory; the goal is to increase their awareness of how they learn, how others may learn differently, and how awareness of team members’ preferred learning styles may affect the process of learning new patient information during patient handoffs.
We incorporated quality improvement methods as we refined the curriculum on the basis of lessons learned from the single-site pilot study,34 which occurred at Boston Children’s Hospital in 2009–2010, approximately 12 months before the launch of the multisite I-PASS Study. As project leaders, we did a thorough review of the initial curriculum, using evaluation data and focus groups of residents and faculty who had participated in the pilot study. In this way, we identified gaps in the curriculum as well as potential new ways to implement it. As a result of our improvement cycle, we developed a novel mnemonic for verbal and written handoffs that is shorter and easier to remember than the mnemonic used in the pilot study. The new mnemonic also reflects the name of our study, I-PASS: I, Illness severity; P, Patient summary; A, Action items; S, Situation awareness and contingency planning; S, Synthesis by receiver. This mnemonic has been described previously.21
Development of curricular components
A key activity in the curriculum development process was the creation of the discrete components of the I-PASS Handoff Curriculum (Table 2), which followed the development and refinement of an extensive list of handoff educational goals and objectives for residents and faculty. We used a modified Delphi process to achieve consensus about parts of the curriculum, such as the elements that should appear within a patient summary and the items that should be included on the written handoff document.35 We considered multiple educational strategies as outlined by Kern and colleagues’32 suggested approach to curricular development. We ultimately selected the strategies that we felt had the highest congruence between objectives and educational methods, were feasible with existing resources, and used multiple educational methods to deliver content.32 Below, we provide a brief overview of the process used to develop each of the components of the curriculum.
Core resident workshop.
The core resident workshop is the foundation of the I-PASS Handoff Curriculum.36 This two-hour didactic and interactive session teaches key principles and communication techniques adapted from the TeamSTEPPS curriculum,28 as well as best practices for verbal and written handoffs using the I-PASS mnemonic.21 We developed trigger videos (short film clips to generate discussion and reflection)37 and interactive guides for large-group discussion to encourage active learning. Although residents’ participation in the research study (collection of data from residents) was entirely voluntary, each site expected all pediatric residents to complete the I-PASS training and practice use of I-PASS techniques to comply with ACGME requirements for teaching and monitoring patient handoff skills.
Handoff simulation exercises: Trigger videos and role-plays.
We incorporated illustrative videos and role-play simulations into the curriculum to simulate both ideal and less-than-ideal handoff behaviors. These provide learners with an opportunity to observe a concept and then practice new behaviors.38,39 Simulation has been shown to enhance skill acquisition and behavior change through practice and reflection.40,41
A subcommittee of I-PASS members with expertise in simulation developed the role-play and video simulations42 and revised them on the basis of input from the EEC members and pilot testing. We created short scenarios (approximately five minutes) with relatively simple clinical elements to maintain learners’ attention span, allow enough time for feedback, and encourage participants to focus on key communication and handoff skills rather than clinical issues. The role-plays are delivered in a one-hour simulation session that is ideally scheduled in conjunction with the two-hour core resident workshop. They include a shared mental model role-play scenario as well as three scenarios in which three learners rotate the roles of giving, receiving, and observing (and critiquing) a handoff.
We developed a computer module43 to serve as a resource for learners who cannot attend workshops or who want to refresh their skills independently. The computer module integrates illustrative videos to demonstrate techniques and prompts the learner to answer questions and reflect on the video elements.
Faculty development resources.
We reasoned that faculty champions would be essential for successful implementation of the I-PASS curriculum; however, most faculty members had never received formal instruction in patient handoffs. To address this issue, we created a set of faculty development resources44 to teach handoff skills to faculty and to train faculty to teach these skills to residents, assess residents’ performance, and deliver feedback effectively. The resources include a faculty champions guide, which serves as a blueprint for faculty and is complemented by a faculty development module. Similar to the core resident workshop, the faculty module uses interactive didactics, illustrative videos, and simulation exercises. This module is also available in a computer-based format for independent study. To receive the title of I-PASS faculty champion, a faculty member at one of the study sites had to complete the one-hour I-PASS faculty development training module, and then either (1) serve as a facilitator during the two-hour I-PASS resident training workshop and one-hour simulation session or (2) conduct live observations of resident handoffs and give feedback using a direct observation tool (described below). Although the number of observations conducted by each faculty member varied, faculty members were asked to commit to a 30-minute observation period, to complete the assessment tools, and to provide verbal or written feedback to the residents they observed.
Faculty observation tools.
We developed direct observation assessment tools for preparing a written handoff, giving a verbal handoff, and receiving a verbal handoff.45 Our conceptual model (Figure 1) informed the items assessed in each of the three tools. Items and response scales with behavioral anchors describing early-learner through expert behaviors were developed in an iterative fashion. The tools address how well those involved in handoffs determine illness severity, adhere to the components of the I-PASS handoff mnemonic, and engage with one another. In addition, the tools allow the observer to note miscommunications, erroneous information, omissions, the presence of tangential or unrelated conversation, and pace (of verbal handoff).
We pilot tested the initial draft versions of the tools at one institution (Boston Children’s Hospital), but the tools lacked interrater agreement. We attributed this to the difficulty in writing valid behavioral anchor response scales for each item that could be rated by a faculty observer in real time. To address this issue, we created a new set of items that describe the expert or desired behavior and are rated on the frequency with which the behavior is observed during the handoff. Pilot testing indicated that this version of the tool was much easier for faculty observers to use. Validity and reliability testing of these observation tools is ongoing.
Early in the curriculum development process, we recognized that successful implementation of the I-PASS Handoff Curriculum would require fundamental changes to the ways in which providers communicate about patients. After reviewing literature on transformational change efforts,19 we identified communicating our vision and institutionalizing our intervention as key components in this transformation. We created a Campaign Subcommittee, which was charged with “branding” I-PASS to support the communication, implementation, and sustainability of the curriculum.
Recognizing the importance of local agents of change,46 we conducted a focus group with chief residents and other stakeholders from seven institutions to develop “advertising” strategies. On the basis of feedback from this group, we developed the I-PASS campaign toolkit,47 which includes multiple elements. We chose a slogan—”Better Handoffs. Safer Care”—and designed a logo to represent and brand the curriculum as well as to illustrate its purpose. To communicate and remind providers about key I-PASS concepts, we created point-of-care references, including pocket reference cards and computer monitor frames with I-PASS details. We designed posters and wrote I-PASS “tips of the day” to further reinforce key curricular elements. We formatted these tips in innovative ways to engage residents and encourage review, including fortune cookies and flip books for use by team leaders on daily rounds. We also created a condensed version of the core resident workshop, as a just-in-time presentation, to reinforce key training elements at the start of each inpatient rotation and to orient medical students and visiting residents who may not receive the full curriculum.
Finally, we provided guidelines for the implementation of the campaign toolkit elements. As the I-PASS curriculum was implemented at the nine data collection sites, site investigators kept logs of the extent to which various campaign elements were implemented.
The I-PASS Study was designed to facilitate multiple outputs at multiple time points during the curriculum development and implementation phases. These “deliverables” have provided early evidence that we are on target to achieve our intended outcomes and impact. Our strategy of recruiting teams of faculty champions—respected faculty members actively involved in patient care and resident education—at each of the nine data collection sites has enabled rapid and early adoption of the I-PASS curriculum. Ethical approval for the I-PASS Study was granted by the institutional review board of Boston Children’s Hospital, which served as the study’s primary site and coordinating center. Additional approval was granted by the institutional review boards at each participating study site.
Overall, we recruited 267 faculty participants, an average of nearly 30 faculty members per data collection site. During the I-PASS Study’s intervention period (July 2011 to May 2013), through 32 three-hour sessions (two-hour workshops followed by one-hour simulation sessions), a total of 855 residents (91% of all pediatric residents at the nine study institutions) were trained in the I-PASS handoff process. Over the same period, 20 faculty development training sessions were conducted, and faculty carried out 888 observations of resident handoffs. As an incentive, faculty champions received 25 points of maintenance of certification (MOC) credit from the American Board of Pediatrics if they met the following requirements: (1) attended I-PASS resident and faculty training activities; (2) participated in at least four monthly site MOC team meetings and plan–do–study–act (PDSA) activities aimed at improving resident utilization of the I-PASS handoff process; and (3) completed 12 resident handoff observations and provided feedback on the direct observation forms.
Once the curriculum was fully developed, EEC members managed a process of curricular dissemination that began with the launch of the I-PASS Study Web site (http://www.ipasshandoffstudy.com/), from which curricular materials can be obtained free of charge by any interested individual or institution. Additionally, the curricular materials have been published at MedEdPORTAL.36,42–45,47 To further facilitate dissemination beyond the initial nine data collection sites and the pilot intervention site, study leaders have participated in national and international presentations and workshops. For example, from May 2012 to February 2014, we completed 48 academic presentations (13 workshops, 3 plenary presentations, 1 platform presentation, 26 invited grand rounds and other lectures, 4 posters, and 1 webinar).
By monitoring requests for our curricular materials on both MedEdPORTAL and the I-PASS Study Web site from May 2012 to February 2014, we found that 1,007 individuals requested access to the materials, representing 517 unique institutions and organizations (noninclusive of study sites) in 48 states and the District of Columbia and 20 countries outside the United States. Individuals requesting the curricular materials indicated an interest in applying them across a range of provider types (physicians, 69.6%; nurses, 10.3%, medical students, 5.1%) and clinical settings (pediatrics, 33.4%; internal medicine, 11.4%; intensive care, 11.6%; emergency medicine, 7.3%; surgery, 7.1%; family medicine, 6.5%; obstetrics–gynecology, 4.9%; and several other subspecialties). On the basis of the early success of this dissemination plan, we believe it provides a model by which educational curricula can be disseminated rapidly to training programs involving medical students, residents, and fellows in the United States and beyond.
Short-Term and Long-Term Outcomes
We collected evaluation data from resident participants and faculty facilitators following the I-PASS Handoff Curriculum Resident Workshops and Simulation Sessions at each of the nine data collection sites participating in the I-PASS Study’s intervention period (July 2011 to May 2013). With regard to learner outcomes, the main results of our preliminary assessment of the I-PASS Handoff Curriculum are as follows:
* High levels of self-reported ability: 91% to 99% of residents agreed or strongly agreed that they were able to perform all aspects of a standardized handoff process following the workshop (Table 3).
* Effectiveness of the curriculum: 81% to 96% of residents agreed or strongly agreed that the workshop promoted the acquisition of relevant skills for patient care activities (Table 3).
Notably, in open-ended questions asking participants to list the most effective elements of the workshop, the elements of the curriculum most often cited were the use of trigger videos and the opportunity to practice giving and receiving handoffs using new skills in simulation exercises.
At present, we are encouraged that the implementation of a standardized approach to handoffs appears to have spread within our study sites and has been incorporated into the existing systems of care. At some sites, the I-PASS handoff process has been adopted by other disciplines, provider types, and units to become the preferred method of standardized communication for handoffs, demonstrating the potential for adaptations and use beyond pediatrics. In the future, we will address the critical step of linking the assessment of the impact of the I-PASS Handoff Curriculum with the direct measurement of patient outcomes by analyzing rates of medical errors. We will also assess rates of verbal and written miscommunications and use time motion data to examine resident workflow before and after the intervention. We also plan to examine how the quality of I-PASS Handoff Bundle adoption and its impact are modified by key hospital-level and patient-level factors. However, until we have analyzed these data in detail, we will not be able to describe the long-term outcomes of the I-PASS Resident Handoff Bundle.
The comprehensive I-PASS Handoff Curriculum offers a standardized approach to teaching and monitoring verbal and written patient handoff skills. The development and implementation of this curriculum offers an example of a large-scale collaborative quality improvement effort in which a diverse group—junior and senior faculty, educators, hospitalists, and health services researchers—contributed their creativity, expertise, and energy to design and implement an educational intervention with the goal of improving patient outcomes. As no handoff curriculum previously existed at any of the participating study sites, faculty and residents had to be trained simultaneously, making the I-PASS curriculum implementation a transformational change effort in each institution.46 In this article, we have provided a logic model for the development, implementation, and dissemination of a large-scale curricular innovation that could serve as an example for others. Moreover, our rigorous process of curriculum development and implementation has positioned us well to study the impact of this intervention on patient outcomes when the main I-PASS Study outcomes data become available for analysis.
We envision a future health care environment in which there is a shared common language for patient handoff communications across provider types, practice settings, and handoff types. We believe the I-PASS Handoff Curriculum will be an option that residency programs can adopt to comply with the ACGME’s requirements to provide formal instruction about patient handoffs and to ensure and monitor adequate handoffs through direct observation.
I-PASS Study Education Executive Committee: Boston Children’s Hospital/Harvard Medical School (primary site): Christopher P. Landrigan, MD, MPH, Theodore C. Sectish, MD, Amy J. Starmer, MD, MPH; Boston Children’s Hospital: Elizabeth L. Noble, Lisa L. Tse; Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine: Jennifer K. O’Toole, MD, MEd; Hospital for Sick Children/University of Toronto: Zia Bismilla, MD, FRCPC, Maitreya Coffey, MD, FRCPC; Lucile Packard Children’s Hospital/Stanford University School of Medicine: Lauren A. Destino, MD, Jennifer L. Everhart, MD, Shilpa J. Patel, MD (currently at Kapi‘olani Children’s Medical Center for Women and Children/University of Hawai‘i at Mānoa John A. Burns School of Medicine); OHSU Doernbecher Children’s Hospital/Oregon Health and Science University: Amy J. Starmer, MD, MPH; Primary Children’s Hospital/Intermountain Healthcare/University of Utah School of Medicine: James F. Bale, Jr., MD, Rajendu Srivastava, MD, MPH, FRCPC Adam T. Stevenson, MD; St. Louis Children’s Hospital/Washington University School of Medicine in St. Louis: F. Sessions Cole, MD; St. Christopher’s Hospital for Children/Drexel University College of Medicine: Sharon Calaman, MD, Nancy D. Spector, MD; UCSF Benioff Children’s Hospital/University of California, San Francisco, School of Medicine: Glenn Rosenbluth, MD, Daniel C. West, MD; Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences: Jennifer H. Hepps, MD, Joseph O. Lopreiato, MD, MPH, Clifton E. Yu, MD.
I-PASS Study Group contributors: Additional I-PASS Study Group members who contributed to this article include April D. Allen, MPA, MA (Heller School for Social Policy and Management, Brandeis University, previously affiliated with Boston Children’s Hospital); Madelyn D. Kahana, MD (Children’s Hospital at Montefiore/Albert Einstein College of Medicine of Yeshiva University, previously affiliated with Lucile Packard Children’s Hospital/Stanford University School of Medicine); Robert S. McGregor, MD (Akron Children’s Hospital/Northeast Ohio Medical University, previously affiliated with St. Christopher’s Hospital for Children/Drexel University College of Medicine), and John S. Webster, MD, MBA, MS (Webster Healthcare Consulting Inc, formerly of the U.S. Department of Defense). A full list of I-PASS Study Group members and participating sites is available as Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A201.
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