Many studies have shown that the transition of patient care through the handoff process is prone to communication error and inadequate clinical content.1 – 5 The Joint Commission (TJC) identified miscommunication as a root cause in the majority of sentinel events it reviewed between 1995 and 2005.6 As a result, TJC has included standardizing handoff communications among its National Patient Safety Goals since at least 2006.7 Despite this recognition, only 19% of pediatric residents in a recent study reported that written handoffs reflect current clinical information and management plans,8 and sign-out has been reported to accurately predict only 42% of overnight adverse events on a surgical service.9 Despite these data, residents actually seem to overestimate the quality and accuracy of their sign-out.10
In response to both of these concerns11 and to increased reports of cross-coverage problems after the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours restrictions,12 the ACGME revised its Common Program Requirements for training programs effective July 1, 2011, to include specific provisions around transitions of care. In addition to requiring that clinical assignments minimize the number of transitions in patient care (VI.B.1), the ACGME further requires that
(VI.B.2) Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety [and] (VI.B.3) Programs must ensure that residents are competent in communicating with team members in the hand-over process.13
Within the Duke University Health System (DUHS), the response to implementing these new ACGME requirements related to transitions in care has been driven by residents and fellows through the Duke GME Patient Safety and Quality Council (PSQC) and its Handoffs Task Force. Of note, Duke University Hospital (DUH) serves as the sponsoring institution for nearly 1,000 trainees in 76 ACGME-accredited and 57 internally sponsored programs and is one of three hospitals within the overarching DUHS. At a health system level, the PSQC was an outgrowth of the patient safety and quality efforts initially funded by the DUHS Chancellor's Innovation Fund. With the support of the hospital's designated institutional official (DIO), the health system's chief patient safety officer (K.F.), and the hospital's chief medical officer, 40 residents and fellows convened the first PSQC meeting in April 2010.
To provide peer review protection as a DUH standing committee and to create a reporting relationship to the Executive Committee of the Medical Staff (ECMS)—DUH's Organized Medical Staff—the PSQC was formalized as a subcommittee of the Graduate Medical Education Committee (GMEC). The PSQC initially represented 13 clinical departments of the School of Medicine and continues to expand in membership with the goal of universal representation from all of Duke's training programs.
In light of the new ACGME requirements related to transitions in care, the PSQC immediately formed a Handoffs Task Force to develop a comprehensive handoffs program. The group's membership included residents, fellows, and faculty from across the hospital, allowing programs that had already incorporated formal handoff education or evaluation programs into their training to rapidly share their successes. To begin informing its work, the task force chose to perform a focused literature review. Of note, the group's goal was not to conduct a formal meta-analysis with specific inclusion and exclusion criteria. Rather, the task force's main purpose in reviewing the literature was to inform its decision-making process specifically related to the creation of a comprehensive handoff education and evaluation program, as well as to identify best practices and potential challenges and, ideally, avoid sabotage from potentially “predictable” issues previously addressed by other institutions.
Focused Literature Review
The Handoffs Task Force began its focused literature review in the fall of 2010 by searching PubMED Central for the following terms: “handover,” “hand over,” “hand-over,” “handoff,” “hand off,” “hand-off,” “signout,” “sign out,” and “sign-out.” To ensure inclusion of the most up-to-date research, members of the task force repeated the same search monthly through March 25, 2011, producing a grand total 919 results. Of these results, members of the task force reviewed English-language (or English translation) abstracts and articles and selected those that appeared most relevant to the specific task of addressing the new ACGME requirements. The group then used the 102 articles discussed below to help inform its work. Of these, 4 were recent comprehensive reviews (Table 1), whereas the rest were divided among the following three categories: structure, education, and evaluation.
Among the articles that addressed the structure of handoffs, there was a clear divide regarding information exchanged and expectations between verbal and written or electronic handoffs.
There is extensive nursing literature around the safety and structure of patient handoffs dating back to the early 1980s.11 As evidence that nurses have led the way in improving the handoff process, a 2007 New Zealand study comparing resident and nursing handoffs demonstrated that despite more nursing handoffs than physician handoffs occurring within a 24-hour period, nursing handoffs were of higher quality and resulted in fewer reported clinical problems.14
Developed in the nursing literature and reported across multiple physician specialties as well, SBAR (Situation, Background, Assessment, Recommendation) is the most extensively studied method of structuring verbal handoff communication.15 Though the literature is saturated with other models, only a handful have been studied among physicians,16 – 19 and those that have been studied have only been analyzed once.20 In fact, a 2009 review identified 46 articles describing 24 distinct handoff mnemonics published between 1987 and 2008.21 Given this multitude of mnemonics, the “flexible standardization” concept advocated by the Australian National Clinical Handover Initiative may be the most practical large-scale model to implement across a large institution. The model involves mandating minimum core clinical content in the handoff communication while allowing clinical teams to customize handoff practices to meet local clinical needs.22,23 The implementation of this model was recently reported for both physicians and nurses at the Royal Hobart Hospital in Tasmania.24
An increasing number of reports also analyze the written or electronic handoff document. Handoff documents have been called “a unique sublanguage of medicine”25 and only rarely become an official part of the medical record. They are often used by nonphysician members of health care teams (e.g., nurses, social workers, unit coordinators, administrators, speech/occupational/physical therapists)26 – 28 and are viewed and edited frequently by multiple unique users in a single 24-hour period. They are used throughout the day and are sometimes viewed months to years after their creation.29
Checklists and template forms represent the most common method of standardizing handoff documents and have been shown to increase the accuracy of data elements, the quality of postoperative surgical handoffs, and the quality of handoffs between day teams and night teams.30 – 34 However, as electronic medical records (EMRs) have become more common,27,35 – 44 EMR handoff tools have taken standardization to a new level through autopopulation and real-time updating of clinical and administrative data and centralized, multiuser access. A litany of benefits have been attributed to EMR handoff tools, including assisting residents and fellows to remain within duty hours requirements,45,46 decreasing lab reporting errors,47 increasing the use of voluntary safety reporting systems,48 and decreasing postoperative length of stay.49 Several studies ultimately conclude that EMR tools are now superior to written handoff documents50,51 because they further improve the quality of handoff data (completeness or accuracy), decrease data collection time, and increase the efficiency of the handoff itself.52,53
With improving congruence on the safety and structural issues with handoffs, authors have increasingly turned to evaluating handoff-related teaching interventions. Two recent publications analyzing the effectiveness of teaching handoff strategies to medical students highlight the same critical points. First, Chu et al54 demonstrated significant improvement in students' self-perceived handoff skills and handoff knowledge after a two-week “selective” course combining didactic and practicum handoff experiences. Importantly, students rated the course's role-playing activities more helpful than the didactic component. Fourth-year medical students at the University of Chicago demonstrated similar improvements in self-perceived handoff preparedness after a similar but briefer interactive course on handoffs.55
These points—emphasizing interactive over didactic education and the difficulty in evaluating handoff skills beyond self-perceived improvements—carry through the resident literature as well. Arora and Johnson56 developed an interactive 90-minute “handoff clinic” including both a standardized handoff process and a checklist for critical patient content that was used by seven residency programs at the group's home institution. The authors reported variable baseline handoff practices across disciplines with postimplementation improvement in closed-loop communication. A second, shorter course was developed by Horwitz and colleagues57 and focused on the structured “SIGNOUT” mnemonic (Sick or do not resuscitate, Identifying data, General hospital course, New events of the day, Overall patient condition, Upcoming possibilities with plan/rationale, Tasks to complete overnight with plan/rationale, Questions?), interactive communication, key content, anticipatory guidance, and concrete language. This course significantly improved residents' self-perceived comfort in providing efficient and accurate handoffs, and residents judged the SIGNOUT mnemonic a useful tool to convey the necessary components of an internal medicine patient handoff. Importantly, though each of these studies reports a single-session intervention, the beneficial effects of such sessions seem to persist for months.58
In an era when duty hours restrictions decrease residents' face-to-face training time, even one-time institution-level sessions may be difficult to arrange. With this in mind, online teaching sessions have been reported as a successful replacement method for on-site instruction.59 Arora60 incorporates examples of potential problems with subpar handoffs in a streaming video format publicly available online. Devoge et al61 published their successful development of a Web-based training system, and Duke has previously discussed its online orientation modules as well.59
The biggest challenge with online handoff training is the lack of an interactive component. With interactive education critical to teaching handoffs effectively, simulation represents one possible solution to this limitation. One recent article reported a general Web-based handoff simulation program,62 and a second evaluated the use of simulation to teach postoperative communication.63 Whatever the method, our literature review suggests that to be most successful, institutions and programs will need to incorporate some aspect of interactive practice into their handoff education programs.
Many articles addressing handoff evaluation report either safety and quality data or the self-perceived confidence of participants. One exception is the “Handoff Communication Assessment” from Apker and colleagues.64 The authors reported strong kappa statistics among various evaluators of emergency-physician-to-hospitalist handoffs, but their evaluation tool focused on communication structure (e.g., time spent talking by each party, asking versus answering information) rather than the quality of the handoff data.64 In the absence of a multi-center-validated tool, most institutions continue reporting individually developed written or electronic evaluations.
Incorporating senior-level supervision in a handoff evaluation program also appears to improve both performance and patient safety. Chu et al65 showed that interns reported increased ability to perform both handoffs and read-backs and increased readiness to make contingency plans after a formal handoff instruction program. Critically, more than 85% of interns rated attending supervision “useful or extremely useful.” In another analysis, attending hospitalists reviewed 1,225 intern-generated EMR handoff documents. Their review found errors in 7% of these documents, and 7% of those (6 documents total) had “serious” errors. The mean time required for each review was two minutes, and over 80% of interns believed that attending oversight improved handoff quality.66
Summary of focused literature review
The literature on physician handoff structure, education, and evaluation is growing,15,56,61,64,67 – 99 but sizable gaps in knowledge remain.100 To quote from one review, “There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies.”20 Indeed, even the four recent comprehensive reviews we identified lack congruence on the “best” structure for standardizing patient handoffs.20,101 – 103
Despite conflicting and variable terminology defining a handoff and its content,46,71,72,104 – 110 authors noted consistent support in the literature around three basic principles clearly articulated as early as 2005:
- Physicians need formal didactic and interactive training in handoffs,101
- Face-to-face, uninterrupted communication combining verbal and written or electronic handoff information is best,101 and
- Data must be unambiguous and factually correct.101
Furthermore, given the dueling needs of common structure and customization to local clinical need, we believe the “flexible standardization” concept22 represents the best foundation for an institution-level handoff standardization process. Finally, we believe that our review supports an evaluation program that includes both peer–peer and supervisor–trainee monitoring.
Building on the focused literature findings described above, the Handoffs Task Force convened stakeholders in the winter of 2010 to begin developing institution-wide guidelines as the first step of its comprehensive handoffs program. The core group comprised resident and fellow leaders from the PSQC, multiple faculty and staff leaders, and K.F. as the faculty champion. The task force then invited any interested DUHS physicians at any level of training to participate through broad invitations at GMEC meetings, e-mail invitations, and individual solicitations of program directors. The group identified the principles published by the Society of Hospital Medicine as a conceptual framework77 and circulated several drafts of proposed guidelines among the members of the task force. Ultimately, the entire PSQC reviewed the guidelines in December 2010 and presented the final draft (List 1) for approval at the GMEC meeting in January 2011. With subsequent review and concurrence by the ECMS, these guidelines now form the foundation for resident and fellow handoff content institution-wide.
With the new guidelines for structure, education, and evaluation in place, the Handoffs Task Force expanded its focus to assist programs in teaching and implementing the common structure and developing program-specific modifications to facilitate flexible standardization.
To ensure that every trainee receives basic education in handoff safety and familiarity with Duke's guidelines, the group developed a 20-minute streaming video webinar around handoffs for the GME institutional orientation (required for all ∼300 incoming residents and fellows annually). This webinar-based process has been previously described as one method of presenting trainees with necessary orientation information in a setting of diminished face-to-face teaching time.59 In the handoffs webinar, the narrator (C.D.) walks trainees through an abbreviated discussion of the Handoffs Task Force's literature review results focusing on safety data, structure, education, and evaluation and presents the institution-level expectations for all trainees and programs effective July 1, 2011. Trainees then complete a mandatory posttest to demonstrate understanding of key principles. As a didactic-only teaching session, the orientation module ensures that trainees receive institution-level expectations at the outset of their training, thus allowing programs to tailor their individual training sessions around more interactive and specialty-specific components of handoff education.
To help programs develop specialty-specific educational content, the Handoffs Task Force identified a variety of specialty-specific guidelines during the literature review process and disseminated these articles to programs (Table 2). We also highlighted the work of individual departments to give programs a variety of potential educational pathways. For example, the pediatrics program invited residents to participate in a noon conference discussion around an article on pediatric handoff core content, developed additional pediatric-specific handoff expectations, and followed with a tailored education and monitoring program led by chief residents. Neurosurgery took a different approach, incorporating input from a variety of centers and focusing on introducing handoff concepts early in training. Each of these interactive processes engaged residents and fellows in defining specialty-specific data elements, helping trainees within each program “own” the transition to a more concrete handoff structure.
To meet the evaluation goals set by both the GMEC and the ACGME, the Handoffs Task Force sought to develop a common handoff monitoring tool to be used by more senior physicians (e.g., program directors, attending physicians, chief or senior residents) to evaluate their junior colleagues. Building on an existing “Handoffs CEX” (clinical examination) assessment tool developed by the Duke Internal Medicine Handoff Quality Improvement Group, the Handoffs Task Force worked with Duke's GME IT experts to create a new handoff evaluation template within the existing MedHub (Ann Arbor, Michigan) evaluation infrastructure used throughout DUHS. The handoff evaluation tool is formatted in the same manner as other evaluations that residents, fellows, and faculty already perform in the MedHub system and can be completed either as a scheduled evaluation or on-the-fly.
The evaluation template includes both free-text and multiple-choice questions and prepopulates all relevant demographic data (e.g., name, program, postgraduate year) as well as the name and title of the evaluator (if the evaluator is more senior than the resident being evaluated). The baseline handoff template includes six general questions (e.g., total handoff time, number of patients, number of interruptions), seven questions specifically related to GMEC-approved core content, and a free-text overall assessment of the handoff process. Each residency program coordinator has the ability to add or remove questions from the template, creating program-specific questions or entirely new sections (e.g., an optional section developed by Internal Medicine includes questions about discussions of Do Not Attempt Resuscitation orders). Finally, as part of the existing MedHub evaluation system, the handoff monitoring tool can be used to track both program and institution-level compliance with evaluation guidelines and to monitor trainees' progression to achieving full competency in transitioning care.
To add an additional layer of institution-level monitoring, the Handoffs Task Force successfully petitioned our DIO to incorporate four questions about handoff structure and education in the annual winter GME DIO housestaff survey beginning in January 2011. These questions address the experience of residents and fellows across the institution with handoff training and their impression of handoff quality (both delivered and received). Though these data provide broad, top-level responses on self-reported scales, we believe that repeating them annually will help monitor changes over time, allow for comparisons across programs, and enable the task force to provide targeted assistance to programs with lagging or sinking responses as needed.
As we assess our program through the Handoffs Task Force's continued work, periodic monitoring of trainee handoff evaluations in MedHub, and tracking changes in the GME DIO survey, we hope to be able to demonstrate improvement toward multiple goals, including (1) more residents and fellows receiving formal instruction and training, (2) greater comfort during sign-out across postgraduate year levels, (3) fewer inadequate handoff situations, and (4) the progressive development of handoff competency at both the program and trainee levels.
Compliance Through Innovation
We believe that the new ACGME guidelines related to transitions in care represent a major opportunity for both sponsoring institutions and training programs to improve the safety and quality of patient care. Although changes in duty hours and supervision requirements may capture the most attention from leaders in GME, it will be critical for GME leaders across the country to develop comprehensive plans for handoff structure, education, and evaluation. We believe that our approach represents one strategy to meet the ACGME requirements through a resident- and fellow-driven process and that it may serve as a model for incorporating both institution-level guidelines and program-level customization.
The authors wish to thank Dr. John Weinerth for his unending support of residents and fellows at Duke University; Dr. Victor Dzau, Dr. William Fulkerson, Mr. Kevin Sowers, Dr. Thomas Owens, Dr. William Richardson, and Mrs. Judy Milne for their executive support; Chuck Rodgers and Chrystal Stancil for their IT support; the members of the Patient Safety and Quality Council, including Dr. Mark Anderson and Dr. Charles Wood; the members of the Handoffs Task Force; Drs. Aimee Zaas, Aubrey Jolly-Graham, Michael Haglund, Betty Staples, and Kathleen Bartlett for their work on program-level projects; and physicians across Duke who have embraced our efforts at improving handoff safety and quality. Dr. DeRienzo also wishes to thank the Division of Neonatal–Perinatal Medicine, including Drs. Ronald Goldberg and Jeffrey Ferranti, for supporting his work on this project.
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The Graduate Medical Education DIO Housestaff Survey (Pro00028767) has been deemed exempt by the Duke IRB (45CFR46.101(b)(2)).
An earlier version of these materials was presented in part at the 2011 Accreditation Council for Graduate Medical Education Conference in Nashville, Tennessee, on March 5, 2011.