Pediatric Residency Program Handover: Before and After the ACGME Requirement Melissa R. Held, MD; Georgine S. Burke, PhD; Edwin Zalneraitis, MD From the Department of Pediatrics, Connecticut Children’s Medical Center, University of Connecticut School of Medicine, Hartford, Conn The authors declare that they have no conflict of interest. Address correspondence to Melissa R. Held, MD, Department of Pediatrics, Connecticut Children’s Medical Center, University of Connecticut School of Medicine, 282 Washington St, Suite 4H, Medical Education, Hartford, CT 06106 (e-mail: [email protected]). Received for publication December 6, 2013; accepted June 12, 2014.
ABSTRACT OBJECTIVE: To determine what changes occurred in pediatric
Other learners (visiting residents, medical students) also continued to learn handover skills by role modeling (55% vs 56%; P ¼ NS). Lack of feedback and interruptions were recognized as barriers to successful handover by program directors in both survey years. CONCLUSIONS: There is a continued need for handover curricula with didactic and practical components as well as assessment pieces within pediatric residency programs. Barriers to effective handover such as lack of feedback and interruptions continue to be major problems. There is a lack of faculty ownership and interest in learner handover that may affect long-term successes. Because role modeling continues to be the main way in which trainees learn handover, specific attention should be given to teach role-modeling techniques.
residency programs with regards to handover education and assessment before and after the Accreditation Council for Graduate Medical Education (ACGME) requirement mandating monitoring safe handover practices in July 2011. METHODS: We sent surveys at 2 time periods to all pediatric program directors in the United States, as identified from a list provided by the Association of Pediatric Program Directors. Respondents were asked about their program demographics, whether they had handover curricula, how trainees were taught to perform handovers, and perceived barriers to effective handover. RESULTS: Response rates were 58% in both survey years. After the ACGME requirement, only 1 of 3 of programs reported a handover curriculum with goals, objectives, and assessment tools. There was a statistically significant increase in the percentage of those responding that resident handover education primarily occurred by role modeling (66% vs 82%; P < .05).
KEYWORDS: graduate medical education; handover; pediatrics; residency; role modeling ACADEMIC PEDIATRICS 2014;14:610–615
WHAT’S NEW
programs have started to implement standardized verbal handover communication tools such as SIGNOUT? and I-PASS.6,7 Pilot studies of the implementation of a verbal mnemonic and handover protocols for handover communication have shown improvements in patient safety and error rates.6–9 Despite having more programs using a standard verbal handover protocol in 201110 formal education in handover and specific assessments was generally lacking and has become increasingly recognized as important for further ensuring safe patient care.11,12 Studies showing handover communication problems among house staff in a variety of specialties have prompted many to implement even more structured curriculum and evaluation interventions.5,13–18 In addition, the Accreditation Council for Graduate Medical Education (ACGME) revised its common program requirements to include that pediatric residency programs “must ensure and monitor effective, structured handover processes,” thus indicating to residency programs that more comprehensive handover curriculum and evaluation methods were warranted.19 The new standards were implemented in July 2011. To date, to our knowledge, there have not been any national studies looking at the status of handover programs
Pediatric residency programs are still working toward comprehensive educational and assessment tools for performing handovers. Because role modeling is a major way in which all learners are educated in handovers, efforts to teach others how to improve role modeling handovers may help close the gaps in education and feedback for handover.
THE JOINT COMMISSION identified communication as the top contributing factor to medical error, with handover playing a “role in an estimated 80% of serious preventable adverse events.”1 Research from other highly reliable organizations has highlighted the potential consequences of missing or misunderstood information communicated during shift change. These problems include being unaware of important data or events, being unprepared to deal with consequences of previous events, failing to anticipate future issues, lacking knowledge necessary to perform tasks, and reworking activities that are in progress.2,3 With the advent of restricted duty hours, the importance of effective and efficient communication to other caregivers is clear.4,5 Over the past few years, residency ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association
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or curricula before and after the ACGME requirement in 2011 in pediatric residency programs; nor have there been any published examinations of the general state of handover practices, curricula, or barriers since the ACGME requirements were put into place. In this study, we wanted to determine whether curricular and/or program changes occurred after implementation of the new ACGME handover requirements in relation to education and assessment in handovers, including barriers. We hypothesized that there would be changes between the 2 time periods in certain areas, including more formal education and assessment tools for residents on handover, fewer interruptions during handover, and more frequent feedback on handover.
METHODS STUDY DESIGN This study of 2 cohorts was conducted in January 2011 and again in September 2012, after the ACGME requirements regarding handover education and assessment were in effect. The study population included all members of the Association of Pediatric Program Directors (APPD), a group of pediatric residency leaders, who were members of the APPD electronic mailing list at the time of the survey administration. SURVEY DEVELOPMENT The survey instrument was based on prior studies performed in internal medicine.12,20 The survey was piloted with 5 faculty members at the University of Connecticut School of Medicine who were experienced in survey development and had teaching or administrative responsibilities with pediatric residents. Questions were revised until consensus was reached. The APPD Research and Scholarship Task Force then reviewed and approved the survey (https://www.appd.org/ed_res/ResearchSurvey. cfm). The institutional review board at Connecticut Children’s Medical Center also approved the study. Participants were anonymous, and consent was implied by completion of the survey. The SurveyMonkey Web tool (https://www.surveymonkey.com/) was used to distribute both surveys via e-mail by the APPD. The survey was sent at 2 time periods to all pediatric program directors (PDs) in the United States, as identified from a list provided by the APPD. The initial survey was sent to APPD members in January 2011, with a follow-up e-mail in September 2012 sent directly from the APPD. Two additional e-mail reminders were sent with each survey by the APPD via the electronic mailing list. The final survey instrument consisted of 23 questions, structured as yes/no or Likert-like ranked responses. The online Table (available at www.academicpedsjnl.net) lists the main questions asked in the survey. Respondents were asked about their program setting and size, as well as overnight call schedules. The survey also asked how handover was conducted (setting, participants, communication styles) and how learners were taught handover. Finally, PDs were asked to comment on their concerns with handover and what did they perceive as barriers to
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effective handover. The list of barriers was selected after careful review of the available literature.11,20–22 The 2012 follow-up survey asked the original questions from the 2011 survey, included an additional question about whether the program had a handover curriculum, and further queried PDs about feedback frequency and how nonpediatric/visiting resident (eg, family practice, emergency medicine or residents visiting from another institution), and fourth-year students/subinterns were educated and given feedback on handover. PDs were asked to either complete the survey or forward the survey link to a designee who could best provide information about the program’s handover curricula and education. Each survey cohort (2011 and 2012) represented an independent sample of PDs at that point in time, but no identifiers were collected. Response rates were calculated using the number of respondents and the total number of pediatric residency PDs in the APPD database at that time. DATA ANALYSIS The survey responses from each individual respondent were downloaded from Survey Monkey to a spreadsheet and imported into JMP statistical software (SAS Institute, Cary, NC) for analysis. Results were compared between survey years by the Wilcoxon test for ranked responses or the chi-square test for categorical measures. Alpha was set at 5%.
RESULTS Of the 197 and 199 potential respondents in 2011 and 2012 respectively, response rates were 58% in both cohorts (114 of 197) and (116 of 199). Demographic characteristics of the residency programs who responded in each cohort are shown in Table 1. In the 2011 cohort, 61% of respondents’ programs (n ¼ 69) were in university/academic hospital settings and 33% (n ¼ 38) were in community hospitals that were university affiliated. In 2012, 70% (n ¼ 75) of respondents were in a university/academic hospital, 24% at a community hospital that was university affiliated (n ¼ 26). Responses for both years came from PDs in all regions of the United States, including Puerto Rico. Reported use of a night float system increased from 59% in 2011 to 86% in 2012 (P < .05), and every fourth night call decreased from 37% to 5% (P ¼ NS) from 2011 to 2012. Table 1. Respondent Demographic Characteristics: Pediatric Residency Programs Characteristic Setting University/academic Community hospital/academic affiliate Community hospital/not affiliated Military hospital Other Total no. of residents 60
2011
2012
69 (60.5%) 38 (33.3%)
75 (70%) 26 (24%)
4 (3.5%) 3 (2.6%) 0 (0)
1 (0.9%) 0 (0) 5 (5%)
29 (25%) 57 (50%) 28 (25%)
28 (26%) 42 (39%) 37 (34%)
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HANDOVER CURRICULA After the ACGME requirement was announced in July 2011, the follow-up survey showed that 35% of programs reported a handover curriculum with goals, objectives, and assessment tools, 25% percent reported a curriculum with goals and objectives only, 11% had assessment tools only, 16% reported no curriculum at all, and 13% reported no curriculum but had plans to implement one in the next 12 months. For programs that did not have a curriculum in place, we asked for comments identifying the main barriers to implementing a handover curriculum in their program. The main barriers reported included “not having enough time” (13 comments; eg, for developing a curriculum, time for oversight) and a “lack of faculty interest/ involvement” (7 comments). HANDOVER EDUCATION AND TRAINING OF LEARNERS The reported use of role modeling and observation as a primary approach to resident handover education increased significantly between the 2 survey years. In 2011, 66% of PDs reported that their residents were trained by role modeling and observation of others and 82% in 2012 (P < .05). There was also an increase in the handover training that occurred at PL-1 orientation with 60% as a new PL-1 in 2011 and 75% in 2012 (P < .05). PDs were asked to comment on how nonpediatric or visiting residents (eg, family practice, emergency medicine, residents from other institutions) or subinterns/ fourth-year medical students were trained in handover for their inpatient rotations. For both survey years, there was only informal training or role modeling (54%) or no specific training at all (30%). Formal training in handover was reported 7% of the time in 2011 and only 1% of the time in 2012 for these learners. None of these comparisons was statistically significant. Results are summarized in Figures 1 and 2. Feedback on handover was reported to be provided to residents about 76% of the time in both 2011 and 2012. PDs reported an increase in feedback from faculty, from 36% in 2011 to 55% in 2012 (P ¼ .02). When asked how often feedback was given to learners, nearly 40% reported it was given “only when there was a problem.”
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Figure 2. Methods reported by program directors for teaching handover skills to nonpediatric resident learners (eg, visiting residents, medical students).
BARRIERS TO EFFECTIVE HANDOVER PDs were asked to identify the 3 main barriers to effective and efficient handover at their program. In decreasing response order, these barriers from 2011 were interruptions, lack of feedback on handover, and no standard verbal format. The top 3 barriers in 2012 were lack of feedback, interruptions, and multiple sequential handovers in a day. Results are shown in Table 2. There was a statistically significant difference between years in these barriers with fewer choosing “interruptions” (68% vs 49%, P < .001) in 2012 but more choosing “lack of feedback on handover.” (35% vs 57%, P < .004. We also examined whether handover sessions were considered protected—that is, no nonurgent pages or interruptions. Fifty percent of PD respondents said that handover time was not “protected” in 2011. In 2012, this had decreased to 43% (P ¼ NS). Of those in 2012 who reported that handover was indeed protected, 50% of those respondents reported that interruptions were still a problem during handover sessions. PDs were asked to report their own personal concerns about handover since the ACGME requirement was announced. These reported concerns included: residents not getting enough feedback on handover (65%), a lack of supervision on handover (52%), concerns with patient safety/medical errors (51%), no good way to assess or evaluate resident handover (38%), not enough feedback given Table 2. Top Barriers to Effective Handover 2011
Figure 1. How and when residents are trained in handover.
2012
Barrier
n (%)
Rank
n (%)
Rank
Interruptions during handovers No standard verbal presentation format Lack of feedback on handover Multiple sequential handovers in 1 day Lack of instruction for handover Residents leaving do not have time to prepare
77 (68) 36 (35)
1 2
55 (49) 16 (14)
2 6
36 (35) 26 (26)
3 4
64 (57) 40 (35)
1 3
19 (19) 13 (13)
5 7
17 (15) 23 (20)
5 4
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on handover for other learners (students, visiting residents) (38%), and concerns with miscommunication and missing information from shift to shift (37%).
CONCLUSIONS To our knowledge, this is the first study to examine changes in handover curricula, education and training, and barriers to effective handover since the ACGME requirement was announced in 2011. We found very few programs that reported a comprehensive handover curriculum in place after the requirement, an increase in the use of role modeling as a tool to teach all learners handover, and persistent barriers to successful handover. Professional organizations including the ACGME and the Joint Commission have emphasized the importance of safe handover for learners by mandating the monitoring of effective and structured handover processes. Despite the ACGME requirement that residency programs maintain and monitor formal educational programs in handoffs, only one-third of pediatric residency programs reported a robust handover curriculum with goals, objectives, and assessment tools in 2012. More than a quarter of programs reported that they either did not have a curriculum of any kind or they had plans to implement one within a 12-month period. As with other educational mandates such as education and assessment of ethics and professionalism, programs are often slow in adopting these mandates.23 Since the time of these surveys, the I-PASS study group and the American Medical Association have developed and started to share handover educational materials for other institutions to use.13,24,25 Despite these new materials, it is interesting to note that the Joint Commission has required all health care institutions to “implement a standardized approach to handoff communications” (2006 National Patient Safety Goal 2E, revision 2011) for many years, yet most programs in 2012 still did not have a comprehensive handover curriculum.1 Verbal standardization of handover significantly improved from 2011 to 2012. A scripted verbal tool should communicate details to standardize the handover process and reduce the risk of missing important information.26 Guidelines for safe handover have focused on standardizing the sign-out mechanism and have been utilized in various medical fields.6,16,27 During the study period, we believe more programs had begun implementing standard verbal mnemonics for handover such as I-PASS, SIGNOUT?, and SBAR.5,7,10,27 However, the verbal mnemonic is just one piece of the handover process. Standardization of training and evaluation of handover are also currently being studied. For example, groups have created and are evaluating such tools as a Hand-off CEX to use in evaluation of learner handover skills.28,29 It is likely that because of these new studies on the use of standardized communication and assessment tools, as well as broader access to widely accepted educational initiatives, programs will have the ability to more easily implement handover educational curricula and strategies for evaluation.
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Although more programs were reporting some kind of training in handover in 2012, we found that role modeling and observation of other residents continues to be the major way in which all trainees learned how to handover. In fact, PDs reported a significantly increased use of role modeling for teaching handover techniques in 2012 compared to 2011. What is even more interesting is that nearly half of other noncore pediatric residents on the team (family practice residents, emergency department residents, subinterns, students) are trained in handover by role modeling alone, and 1 of 3 are reportedly not trained at all. Subinterns and visiting residents look to the pediatric residents to model the appropriate handover practices. PDs and others are continuing to rely heavily on their more senior learners to role model handover communication and give feedback on handover practices, yet there is no specific training for how to accomplish this. We know from prior studies that residents overestimate the effectiveness of their handover and that there is little improvement of this communication over time.29 Residents (and most faculty) are not usually taught how to role model handover skills, yet it is known to be a powerful teaching strategy and an integral part of medical education.30,31 Providing appropriate role modeling has also been included in the Pediatric Milestones under patient care.32 Role-modeling skills and behaviors can and should be taught; however, little attention has been spent on teaching these skills. Studies looking at faculty physician role models describe having a role-modeling consciousness, in that they are specifically thinking about being the role model when interacting with other learners.31 We suggest that there be an emphasis on specifically training more senior residents to explicitly model handover practices. This may have a significant impact on the effectiveness of handover sessions and may reduce the need for more constant faculty oversight, which is always a challenge given faculty time constraints. Barriers to effective handover practices continue to exist. Lack of feedback was a persistent problem recognized as one of the main barriers by PDs in both 2011 and 2012. Inadequate handover supervision by faculty has been noted in other studies looking at resident perception of adverse events as a result of poor handover communication.33 There is the notion of an overall lack of faculty interest/involvement in handover and the never-ending issue with faculty time constraints. Despite these concerns, PDs reported that more faculty attendings were giving feedback to residents on handover in 2012 compared to the earlier survey year. The ACGME requirement of monitoring handover likely contributed to this increase, but recruiting faculty to this task is a challenge. One way to promote faculty involvement would be to include those dedicated faculty who are familiar with the patients being signed out and who can be present during most or all handover sessions. Not only would this allow for timely feedback to learners but it could contribute to increased patient safety and quality of hospital stays. Evaluation of handover skills and behaviors can easily be implemented into any evaluation of a resident or student during their
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rotations by faculty observation. Furthermore, because one of the Pediatric Milestones is to “provide transfer of care that ensures seamless transitions,” handover sessions may offer a useful environment for the assessment and evaluation of this and other milestones needed for the evaluation of resident learners during residency.32 Observation of handover could allow for evaluation of communication skills, patient care skills, professionalism, and systemsbased practice. Interestingly, one of the barriers identified from the IPASS study group as a potential barrier to long-term success (and also identified as a problem by PDs in our survey) was this lack of faculty ownership and interest in learner handover.34 A successful handover curriculum and educational program at our institution has shown that direct observation and supervision of the handover information by faculty is a vital part of the process. Observation and faculty involvement has been said to be the key to the process improvement of handover.35 Including faculty in the development and oversight of handover will be important for the long-term learning skills of our residents and students. As with many aspects of handover, this requires administrative acknowledgment of the importance of handover and the skill training and evaluations that should accompany any implemented program for learners. Faculty will need to have the time set aside from other clinical and teaching responsibilities in order to observe handover sessions and provide timely feedback. Another barrier to effective handover noted in our study that continues to persist is interruptions. In our survey, this term specifically referred to interruptions that were not urgent or immediately needed for safe handover. Interruptions, when not on task, contribute to handover inefficiency. Prior studies examining some of the barriers to giving effective handover included nonurgent nursing questions, and phone and pager interruptions as being major contributors.14,36,37 It should be noted that interruptions were reported as less of an overall concern to PDs in 2012 even though 95% of handover sessions were reported as either not protected times or were protected but still had interruptions. Although there was a significant decrease in the reporting of interruptions as a barrier in 2012, it was still reported as the second most common barrier to effective handover. Just as in other high-risk settings where consequences of miscommunication can be catastrophic, simple notification to other staff that only urgent interruptions will be tolerated during handover sessions may be a simple intervention that any program could implement and has shown success in other areas such as aviation.2,38 Having a designated resident or attending during handover who handles phone calls, pages, and admissions could also aid in improving the process. There are several limitations in this study. We utilized the APPD electronic mailing list to anonymously distribute and collect survey data, and therefore, we were unable to assess those who did not respond. Specific individual programs or PD responses were anonymous and thus could not be compared directly between survey years, and it is not
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known whether the same programs that responded in 2011 also responded in 2012. However, we analyzed the data years as separate and independent groups, which was a statistically more conservative approach, thus reducing the likelihood of seeing a change. Because the surveys were anonymous, we could not confirm that only 1 PD or designee at each program completed the survey. The 2011 survey did not ask specifically whether residency programs had an explicit handover curriculum with goals, objectives, and assessment tools, so we were unable to compare this information to the 2012 data. Nonetheless, few programs reported a handover curriculum with these elements even after the ACGME requirement was announced in 2011. It would be worth resurveying the programs now, 2 years after the requirement, to see if there has been further implementation of curricula within programs. Results from this study illustrate the complexities involved in implementing and maintaining a handover program. The findings emphasize the continued need for handover curricula with both didactic and practical components as well as an assessment piece within pediatric residency programs. Dedicated faculty to teach and assess handover will likely be a vital component of any program for shortand long-term success. Faculty will need an incentive to change their own handover practices and be willing to provide feedback to trainees. Institutional quality and safety officers as well as graduate medical education leaders should be engaged to promote faculty involvement. This study further adds to the knowledge base that the high utilization of role modeling as an educational tool in this setting reflects a need for educators to spend time teaching this skill to our learners. Educational leaders must also provide handover training and assessment for visiting residents, medical students, and other learners in their pediatric residency programs.
ACKNOWLEDGMENT Supported by the APPD.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.acap.2014.06.005.
REFERENCES 1. Joint Commission. Improving hand-off communications: meeting national patient safety goal 2E. Jt Comm Perspect Patient Saf. 2006;6: 9–15. 2. Patterson ES, Woods DD. Shift changes, updates, and the oncall model in space shuttle mission control. Computer supported cooperative work. J Collab Comput. 2001;10:317–346. 3. Flemming D, Hubner U. How to improve change of shift handovers and collaborative grounding and what role does the electronic patient record system play? Results of a systematic literature review. Int J Med Inform. 2013;82:580–592. 4. Nasca TJ, Day SH, Amis ES Jr. ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363:e3.
ACADEMIC PEDIATRICS 5. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010;19:493–497. 6. Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22: 1470–1474. 7. Starmer AJ, Spector ND, Srivastava R, et al., I-PASS Study Group. IPASS, a mnemonic to standardize verbal handoffs. Pediatrics. 2012; 129(2):201–204. 8. Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310: 2262–2270. 9. Joy BF, Elliott E, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12:304–308. 10. Riesenberg LA. Systematic review of handoff mnemonics literature. Am J Med Qual. 2009;24:196–204. 11. Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200:538–545. 12. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166:1173–1177. 13. MedEdPORTAL. The I-PASS Study: A Multi-Site Effort to Standardize the Handoff Process for Better Handoffs and Safer Care. Available at: https://www.mededportal.org/icollaborative/resource/ 557. Accessed July 7, 2014. 14. McSweeney ME, Lightdale JR, Vinci RJ, Moses J. Patient handoffs: pediatric resident experiences and lessons learned. Clin Pediatr. 2011; 50:57–63. 15. Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168: 1755–1760. 16. Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32:646–655. 17. Pincavage AT, Dahlstrom M, Prochaska M, et al. Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety. Acad Med. 2013;88:795–801. 18. Horwitz LI, Rand D, Staisiunas P, et al. Development of a handoff evaluation tool for shift-to-shift physician handoffs: the handoff CEX. J Hosp Med. 2013;8:191–200. 19. Accreditation Council for Graduate Medical Education. Common program requirements. Available at: http://www.acgme.org/acgme web/Portals/0/PDFs/Common_Program_Requirements_07012011[2]. pdf. Accessed October 2, 2014. 20. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician to physician communication during patient handoffs. Acad Med. 2005;80:1094–1099. 21. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Physician-to-physician communication: methods, practice and misgivings with patient handoffs. J Gen Intern Med. 2004;19(suppl 1):108.
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22. Riesenberg LA, Leitzsch J, Massucci JL. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med. 2009;84:1775–1787. 23. Cook AF, Sobotka SA, Ross LF. Teaching and assessment of ethics and professionalism: a survey of pediatric program directors. Acad Pediatr. 2013;13:570–576. 24. American Medical Association. Patient handoffs. Available at: http:// www.ama-assn.org/ama/pub/about-ama/our-people/member-groupssections/resident-fellow-section/rfs-resources/patient-handoffs.page. Accessed October 2, 2014. 25. DeRienzo CM, Frush K, Barfied ME, et al. Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. Acad Med. 2012;87:403–410. 26. Gregory BS. Standardizing hand-off processes. AORN J. 2006;84: 1059–1061. 27. Telem DA, Buch KE, Ellis S, et al. Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. Arch Surg. 2011;146:89–93. 28. Farnan JM, Paro JAM, Rodriguez RM, et al. Hand-off education and evaluation: piloting the Observed Simulated Hand-off Experience (OSHE). J Gen Intern Med. 2009;25:129–134. 29. Chang VY, Arora VM, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off communication. Pediatrics. 2010; 125:491–496. 30. Cruess SR, Cruess RL, Steinert Y. Role modeling—making the most of a powerful teaching strategy. BMJ. 2008;336:718–721. 31. Wright SM, Carrese JA. Excellence in role-modeling: insight and perspective from the pros. CMAJ. 2002;167:638–643. 32. Accreditation Council for Graduate Medical Education. Pediatric Milestones Project. Available at: http://www.acgme.org/acgmeweb/ Portals/0/PFAssets/ProgramResources/320_PedsMilestonesProject. pdf. Accessed October 2, 2014. 33. Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Intern Med. 2005;165:2607–2613. 34. Available at: https://www.mededportal.org/download/304550/data/ s28.pdf. Accessed April 29, 2014. 35. Frishman WH, Nabors C, Peterson SJ. Faculty supervision of the house staff handoff process: the time has come. Am J Med. 2013; 126:e1–e2. 36. Borowitz SM, Waggoner-Fountain LA, Bass EJ, DeVoge JM. Resident sign-out: a precarious exchange of critical information in a fast-paced world. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2, Culture and Redesign. Rockville, Md: Agency for Healthcare Research and Quality; 2008. 37. Greenstein EA, Arora VM, Staisiunas PG, et al. Characterizing physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf. 2013;22:203–209. 38. Federal Aviation Administration. Flight crew member duties.. Available at: edocket.access.gpo.gov/cfr_2002/janqtr/pdf/14cfr121.539. pdf; 1981. Accessed January 18, 2014.
ABSTRACT OBJECTIVE: To determine what changes occurred in pediatric
Other learners (visiting residents, medical students) also continued to learn handover skills by role modeling (55% vs 56%; P ¼ NS). Lack of feedback and interruptions were recognized as barriers to successful handover by program directors in both survey years. CONCLUSIONS: There is a continued need for handover curricula with didactic and practical components as well as assessment pieces within pediatric residency programs. Barriers to effective handover such as lack of feedback and interruptions continue to be major problems. There is a lack of faculty ownership and interest in learner handover that may affect long-term successes. Because role modeling continues to be the main way in which trainees learn handover, specific attention should be given to teach role-modeling techniques.
residency programs with regards to handover education and assessment before and after the Accreditation Council for Graduate Medical Education (ACGME) requirement mandating monitoring safe handover practices in July 2011. METHODS: We sent surveys at 2 time periods to all pediatric program directors in the United States, as identified from a list provided by the Association of Pediatric Program Directors. Respondents were asked about their program demographics, whether they had handover curricula, how trainees were taught to perform handovers, and perceived barriers to effective handover. RESULTS: Response rates were 58% in both survey years. After the ACGME requirement, only 1 of 3 of programs reported a handover curriculum with goals, objectives, and assessment tools. There was a statistically significant increase in the percentage of those responding that resident handover education primarily occurred by role modeling (66% vs 82%; P < .05).
KEYWORDS: graduate medical education; handover; pediatrics; residency; role modeling ACADEMIC PEDIATRICS 2014;14:610–615
WHAT’S NEW
programs have started to implement standardized verbal handover communication tools such as SIGNOUT? and I-PASS.6,7 Pilot studies of the implementation of a verbal mnemonic and handover protocols for handover communication have shown improvements in patient safety and error rates.6–9 Despite having more programs using a standard verbal handover protocol in 201110 formal education in handover and specific assessments was generally lacking and has become increasingly recognized as important for further ensuring safe patient care.11,12 Studies showing handover communication problems among house staff in a variety of specialties have prompted many to implement even more structured curriculum and evaluation interventions.5,13–18 In addition, the Accreditation Council for Graduate Medical Education (ACGME) revised its common program requirements to include that pediatric residency programs “must ensure and monitor effective, structured handover processes,” thus indicating to residency programs that more comprehensive handover curriculum and evaluation methods were warranted.19 The new standards were implemented in July 2011. To date, to our knowledge, there have not been any national studies looking at the status of handover programs
Pediatric residency programs are still working toward comprehensive educational and assessment tools for performing handovers. Because role modeling is a major way in which all learners are educated in handovers, efforts to teach others how to improve role modeling handovers may help close the gaps in education and feedback for handover.
THE JOINT COMMISSION identified communication as the top contributing factor to medical error, with handover playing a “role in an estimated 80% of serious preventable adverse events.”1 Research from other highly reliable organizations has highlighted the potential consequences of missing or misunderstood information communicated during shift change. These problems include being unaware of important data or events, being unprepared to deal with consequences of previous events, failing to anticipate future issues, lacking knowledge necessary to perform tasks, and reworking activities that are in progress.2,3 With the advent of restricted duty hours, the importance of effective and efficient communication to other caregivers is clear.4,5 Over the past few years, residency ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association
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Volume 14, Number 6 November–December 2014
ACADEMIC PEDIATRICS
PEDIATRIC RESIDENCY PROGRAM HANDOVER
or curricula before and after the ACGME requirement in 2011 in pediatric residency programs; nor have there been any published examinations of the general state of handover practices, curricula, or barriers since the ACGME requirements were put into place. In this study, we wanted to determine whether curricular and/or program changes occurred after implementation of the new ACGME handover requirements in relation to education and assessment in handovers, including barriers. We hypothesized that there would be changes between the 2 time periods in certain areas, including more formal education and assessment tools for residents on handover, fewer interruptions during handover, and more frequent feedback on handover.
METHODS STUDY DESIGN This study of 2 cohorts was conducted in January 2011 and again in September 2012, after the ACGME requirements regarding handover education and assessment were in effect. The study population included all members of the Association of Pediatric Program Directors (APPD), a group of pediatric residency leaders, who were members of the APPD electronic mailing list at the time of the survey administration. SURVEY DEVELOPMENT The survey instrument was based on prior studies performed in internal medicine.12,20 The survey was piloted with 5 faculty members at the University of Connecticut School of Medicine who were experienced in survey development and had teaching or administrative responsibilities with pediatric residents. Questions were revised until consensus was reached. The APPD Research and Scholarship Task Force then reviewed and approved the survey (https://www.appd.org/ed_res/ResearchSurvey. cfm). The institutional review board at Connecticut Children’s Medical Center also approved the study. Participants were anonymous, and consent was implied by completion of the survey. The SurveyMonkey Web tool (https://www.surveymonkey.com/) was used to distribute both surveys via e-mail by the APPD. The survey was sent at 2 time periods to all pediatric program directors (PDs) in the United States, as identified from a list provided by the APPD. The initial survey was sent to APPD members in January 2011, with a follow-up e-mail in September 2012 sent directly from the APPD. Two additional e-mail reminders were sent with each survey by the APPD via the electronic mailing list. The final survey instrument consisted of 23 questions, structured as yes/no or Likert-like ranked responses. The online Table (available at www.academicpedsjnl.net) lists the main questions asked in the survey. Respondents were asked about their program setting and size, as well as overnight call schedules. The survey also asked how handover was conducted (setting, participants, communication styles) and how learners were taught handover. Finally, PDs were asked to comment on their concerns with handover and what did they perceive as barriers to
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effective handover. The list of barriers was selected after careful review of the available literature.11,20–22 The 2012 follow-up survey asked the original questions from the 2011 survey, included an additional question about whether the program had a handover curriculum, and further queried PDs about feedback frequency and how nonpediatric/visiting resident (eg, family practice, emergency medicine or residents visiting from another institution), and fourth-year students/subinterns were educated and given feedback on handover. PDs were asked to either complete the survey or forward the survey link to a designee who could best provide information about the program’s handover curricula and education. Each survey cohort (2011 and 2012) represented an independent sample of PDs at that point in time, but no identifiers were collected. Response rates were calculated using the number of respondents and the total number of pediatric residency PDs in the APPD database at that time. DATA ANALYSIS The survey responses from each individual respondent were downloaded from Survey Monkey to a spreadsheet and imported into JMP statistical software (SAS Institute, Cary, NC) for analysis. Results were compared between survey years by the Wilcoxon test for ranked responses or the chi-square test for categorical measures. Alpha was set at 5%.
RESULTS Of the 197 and 199 potential respondents in 2011 and 2012 respectively, response rates were 58% in both cohorts (114 of 197) and (116 of 199). Demographic characteristics of the residency programs who responded in each cohort are shown in Table 1. In the 2011 cohort, 61% of respondents’ programs (n ¼ 69) were in university/academic hospital settings and 33% (n ¼ 38) were in community hospitals that were university affiliated. In 2012, 70% (n ¼ 75) of respondents were in a university/academic hospital, 24% at a community hospital that was university affiliated (n ¼ 26). Responses for both years came from PDs in all regions of the United States, including Puerto Rico. Reported use of a night float system increased from 59% in 2011 to 86% in 2012 (P < .05), and every fourth night call decreased from 37% to 5% (P ¼ NS) from 2011 to 2012. Table 1. Respondent Demographic Characteristics: Pediatric Residency Programs Characteristic Setting University/academic Community hospital/academic affiliate Community hospital/not affiliated Military hospital Other Total no. of residents 60
2011
2012
69 (60.5%) 38 (33.3%)
75 (70%) 26 (24%)
4 (3.5%) 3 (2.6%) 0 (0)
1 (0.9%) 0 (0) 5 (5%)
29 (25%) 57 (50%) 28 (25%)
28 (26%) 42 (39%) 37 (34%)
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HANDOVER CURRICULA After the ACGME requirement was announced in July 2011, the follow-up survey showed that 35% of programs reported a handover curriculum with goals, objectives, and assessment tools, 25% percent reported a curriculum with goals and objectives only, 11% had assessment tools only, 16% reported no curriculum at all, and 13% reported no curriculum but had plans to implement one in the next 12 months. For programs that did not have a curriculum in place, we asked for comments identifying the main barriers to implementing a handover curriculum in their program. The main barriers reported included “not having enough time” (13 comments; eg, for developing a curriculum, time for oversight) and a “lack of faculty interest/ involvement” (7 comments). HANDOVER EDUCATION AND TRAINING OF LEARNERS The reported use of role modeling and observation as a primary approach to resident handover education increased significantly between the 2 survey years. In 2011, 66% of PDs reported that their residents were trained by role modeling and observation of others and 82% in 2012 (P < .05). There was also an increase in the handover training that occurred at PL-1 orientation with 60% as a new PL-1 in 2011 and 75% in 2012 (P < .05). PDs were asked to comment on how nonpediatric or visiting residents (eg, family practice, emergency medicine, residents from other institutions) or subinterns/ fourth-year medical students were trained in handover for their inpatient rotations. For both survey years, there was only informal training or role modeling (54%) or no specific training at all (30%). Formal training in handover was reported 7% of the time in 2011 and only 1% of the time in 2012 for these learners. None of these comparisons was statistically significant. Results are summarized in Figures 1 and 2. Feedback on handover was reported to be provided to residents about 76% of the time in both 2011 and 2012. PDs reported an increase in feedback from faculty, from 36% in 2011 to 55% in 2012 (P ¼ .02). When asked how often feedback was given to learners, nearly 40% reported it was given “only when there was a problem.”
ACADEMIC PEDIATRICS
Figure 2. Methods reported by program directors for teaching handover skills to nonpediatric resident learners (eg, visiting residents, medical students).
BARRIERS TO EFFECTIVE HANDOVER PDs were asked to identify the 3 main barriers to effective and efficient handover at their program. In decreasing response order, these barriers from 2011 were interruptions, lack of feedback on handover, and no standard verbal format. The top 3 barriers in 2012 were lack of feedback, interruptions, and multiple sequential handovers in a day. Results are shown in Table 2. There was a statistically significant difference between years in these barriers with fewer choosing “interruptions” (68% vs 49%, P < .001) in 2012 but more choosing “lack of feedback on handover.” (35% vs 57%, P < .004. We also examined whether handover sessions were considered protected—that is, no nonurgent pages or interruptions. Fifty percent of PD respondents said that handover time was not “protected” in 2011. In 2012, this had decreased to 43% (P ¼ NS). Of those in 2012 who reported that handover was indeed protected, 50% of those respondents reported that interruptions were still a problem during handover sessions. PDs were asked to report their own personal concerns about handover since the ACGME requirement was announced. These reported concerns included: residents not getting enough feedback on handover (65%), a lack of supervision on handover (52%), concerns with patient safety/medical errors (51%), no good way to assess or evaluate resident handover (38%), not enough feedback given Table 2. Top Barriers to Effective Handover 2011
Figure 1. How and when residents are trained in handover.
2012
Barrier
n (%)
Rank
n (%)
Rank
Interruptions during handovers No standard verbal presentation format Lack of feedback on handover Multiple sequential handovers in 1 day Lack of instruction for handover Residents leaving do not have time to prepare
77 (68) 36 (35)
1 2
55 (49) 16 (14)
2 6
36 (35) 26 (26)
3 4
64 (57) 40 (35)
1 3
19 (19) 13 (13)
5 7
17 (15) 23 (20)
5 4
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on handover for other learners (students, visiting residents) (38%), and concerns with miscommunication and missing information from shift to shift (37%).
CONCLUSIONS To our knowledge, this is the first study to examine changes in handover curricula, education and training, and barriers to effective handover since the ACGME requirement was announced in 2011. We found very few programs that reported a comprehensive handover curriculum in place after the requirement, an increase in the use of role modeling as a tool to teach all learners handover, and persistent barriers to successful handover. Professional organizations including the ACGME and the Joint Commission have emphasized the importance of safe handover for learners by mandating the monitoring of effective and structured handover processes. Despite the ACGME requirement that residency programs maintain and monitor formal educational programs in handoffs, only one-third of pediatric residency programs reported a robust handover curriculum with goals, objectives, and assessment tools in 2012. More than a quarter of programs reported that they either did not have a curriculum of any kind or they had plans to implement one within a 12-month period. As with other educational mandates such as education and assessment of ethics and professionalism, programs are often slow in adopting these mandates.23 Since the time of these surveys, the I-PASS study group and the American Medical Association have developed and started to share handover educational materials for other institutions to use.13,24,25 Despite these new materials, it is interesting to note that the Joint Commission has required all health care institutions to “implement a standardized approach to handoff communications” (2006 National Patient Safety Goal 2E, revision 2011) for many years, yet most programs in 2012 still did not have a comprehensive handover curriculum.1 Verbal standardization of handover significantly improved from 2011 to 2012. A scripted verbal tool should communicate details to standardize the handover process and reduce the risk of missing important information.26 Guidelines for safe handover have focused on standardizing the sign-out mechanism and have been utilized in various medical fields.6,16,27 During the study period, we believe more programs had begun implementing standard verbal mnemonics for handover such as I-PASS, SIGNOUT?, and SBAR.5,7,10,27 However, the verbal mnemonic is just one piece of the handover process. Standardization of training and evaluation of handover are also currently being studied. For example, groups have created and are evaluating such tools as a Hand-off CEX to use in evaluation of learner handover skills.28,29 It is likely that because of these new studies on the use of standardized communication and assessment tools, as well as broader access to widely accepted educational initiatives, programs will have the ability to more easily implement handover educational curricula and strategies for evaluation.
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Although more programs were reporting some kind of training in handover in 2012, we found that role modeling and observation of other residents continues to be the major way in which all trainees learned how to handover. In fact, PDs reported a significantly increased use of role modeling for teaching handover techniques in 2012 compared to 2011. What is even more interesting is that nearly half of other noncore pediatric residents on the team (family practice residents, emergency department residents, subinterns, students) are trained in handover by role modeling alone, and 1 of 3 are reportedly not trained at all. Subinterns and visiting residents look to the pediatric residents to model the appropriate handover practices. PDs and others are continuing to rely heavily on their more senior learners to role model handover communication and give feedback on handover practices, yet there is no specific training for how to accomplish this. We know from prior studies that residents overestimate the effectiveness of their handover and that there is little improvement of this communication over time.29 Residents (and most faculty) are not usually taught how to role model handover skills, yet it is known to be a powerful teaching strategy and an integral part of medical education.30,31 Providing appropriate role modeling has also been included in the Pediatric Milestones under patient care.32 Role-modeling skills and behaviors can and should be taught; however, little attention has been spent on teaching these skills. Studies looking at faculty physician role models describe having a role-modeling consciousness, in that they are specifically thinking about being the role model when interacting with other learners.31 We suggest that there be an emphasis on specifically training more senior residents to explicitly model handover practices. This may have a significant impact on the effectiveness of handover sessions and may reduce the need for more constant faculty oversight, which is always a challenge given faculty time constraints. Barriers to effective handover practices continue to exist. Lack of feedback was a persistent problem recognized as one of the main barriers by PDs in both 2011 and 2012. Inadequate handover supervision by faculty has been noted in other studies looking at resident perception of adverse events as a result of poor handover communication.33 There is the notion of an overall lack of faculty interest/involvement in handover and the never-ending issue with faculty time constraints. Despite these concerns, PDs reported that more faculty attendings were giving feedback to residents on handover in 2012 compared to the earlier survey year. The ACGME requirement of monitoring handover likely contributed to this increase, but recruiting faculty to this task is a challenge. One way to promote faculty involvement would be to include those dedicated faculty who are familiar with the patients being signed out and who can be present during most or all handover sessions. Not only would this allow for timely feedback to learners but it could contribute to increased patient safety and quality of hospital stays. Evaluation of handover skills and behaviors can easily be implemented into any evaluation of a resident or student during their
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rotations by faculty observation. Furthermore, because one of the Pediatric Milestones is to “provide transfer of care that ensures seamless transitions,” handover sessions may offer a useful environment for the assessment and evaluation of this and other milestones needed for the evaluation of resident learners during residency.32 Observation of handover could allow for evaluation of communication skills, patient care skills, professionalism, and systemsbased practice. Interestingly, one of the barriers identified from the IPASS study group as a potential barrier to long-term success (and also identified as a problem by PDs in our survey) was this lack of faculty ownership and interest in learner handover.34 A successful handover curriculum and educational program at our institution has shown that direct observation and supervision of the handover information by faculty is a vital part of the process. Observation and faculty involvement has been said to be the key to the process improvement of handover.35 Including faculty in the development and oversight of handover will be important for the long-term learning skills of our residents and students. As with many aspects of handover, this requires administrative acknowledgment of the importance of handover and the skill training and evaluations that should accompany any implemented program for learners. Faculty will need to have the time set aside from other clinical and teaching responsibilities in order to observe handover sessions and provide timely feedback. Another barrier to effective handover noted in our study that continues to persist is interruptions. In our survey, this term specifically referred to interruptions that were not urgent or immediately needed for safe handover. Interruptions, when not on task, contribute to handover inefficiency. Prior studies examining some of the barriers to giving effective handover included nonurgent nursing questions, and phone and pager interruptions as being major contributors.14,36,37 It should be noted that interruptions were reported as less of an overall concern to PDs in 2012 even though 95% of handover sessions were reported as either not protected times or were protected but still had interruptions. Although there was a significant decrease in the reporting of interruptions as a barrier in 2012, it was still reported as the second most common barrier to effective handover. Just as in other high-risk settings where consequences of miscommunication can be catastrophic, simple notification to other staff that only urgent interruptions will be tolerated during handover sessions may be a simple intervention that any program could implement and has shown success in other areas such as aviation.2,38 Having a designated resident or attending during handover who handles phone calls, pages, and admissions could also aid in improving the process. There are several limitations in this study. We utilized the APPD electronic mailing list to anonymously distribute and collect survey data, and therefore, we were unable to assess those who did not respond. Specific individual programs or PD responses were anonymous and thus could not be compared directly between survey years, and it is not
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known whether the same programs that responded in 2011 also responded in 2012. However, we analyzed the data years as separate and independent groups, which was a statistically more conservative approach, thus reducing the likelihood of seeing a change. Because the surveys were anonymous, we could not confirm that only 1 PD or designee at each program completed the survey. The 2011 survey did not ask specifically whether residency programs had an explicit handover curriculum with goals, objectives, and assessment tools, so we were unable to compare this information to the 2012 data. Nonetheless, few programs reported a handover curriculum with these elements even after the ACGME requirement was announced in 2011. It would be worth resurveying the programs now, 2 years after the requirement, to see if there has been further implementation of curricula within programs. Results from this study illustrate the complexities involved in implementing and maintaining a handover program. The findings emphasize the continued need for handover curricula with both didactic and practical components as well as an assessment piece within pediatric residency programs. Dedicated faculty to teach and assess handover will likely be a vital component of any program for shortand long-term success. Faculty will need an incentive to change their own handover practices and be willing to provide feedback to trainees. Institutional quality and safety officers as well as graduate medical education leaders should be engaged to promote faculty involvement. This study further adds to the knowledge base that the high utilization of role modeling as an educational tool in this setting reflects a need for educators to spend time teaching this skill to our learners. Educational leaders must also provide handover training and assessment for visiting residents, medical students, and other learners in their pediatric residency programs.
ACKNOWLEDGMENT Supported by the APPD.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.acap.2014.06.005.
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