Innovation Report
Targeting Improvements in Patient Safety at a Large Academic Center: An Institutional Handoff Curriculum for Graduate Medical Education Sarah Allen, MD, Cathryn Caton, MD, Jeffery Cluver, MD, Arch G. Mainous III, PhD, and Benjamin Clyburn, MD
Abstract Problem Handoffs are an integral component of patient care, and the number of handoffs has increased as a result of duty hours restrictions for resident physicians. A structured handoff curriculum improves accuracy and has been shown to decrease medical errors. A standardized approach across all specialties is lacking in the published literature. The authors discuss the development and implementation of an institution-wide handoff curriculum for incoming firstyear residents. Approach An Innovation in Graduate Medical Education committee, including faculty
Problem
Patient handoffs are an integral part of patient care and are especially important in an inpatient setting. Although residents correctly perceive that communication errors lead to problematic handoffs, formal education and training related to patient handoffs has been limited in undergraduate and graduate medical education (GME), and most physicians have never received formal instruction on handoffs and related communication skills.1 Historically, GME programs have relied on an implicit curriculum to teach residents and fellows how to hand off patient information. In 2012, a comprehensive curricular blueprint to improve continuity of care was described in the literature, but it Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Allen, 135 Rutledge Ave., Charleston, SC 29425: telephone: (843) 876-0888; e-mail: [email protected]. Acad Med. 2014;89:1366–1369. First published online August 12, 2014 doi: 10.1097/ACM.0000000000000462
1366
from multiple specialties, identified an educational deficiency in handoffs and selected this as the target for the educational innovation. Meetings were held to develop and implement an extensive handoff curriculum for incoming first-year residents. The designed curriculum included large- and small-group sessions, and a specialtyspecific observed simulated handoff experience. The authors analyzed participants’ pre- and postsurveys using descriptive statistics. Outcomes One hundred and twenty-four participants attended the formalized handoff training day. Following training, residents recognized
has yet to be validated.2 Some academic institutions have developed task forces to improve practices institution-wide but have not focused on formalized education programs as a driver of the process.3 Many programs have implemented specialty-specific curricula,3,4 but we are aware of no reports published to date that address the need for an institution-wide curriculum. The need for formalized training of patient handoffs within GME is becoming readily apparent, and there is a need for standardized and validated approaches that result in the acquisition of the knowledge and skills needed to perform an effective patient handoff. Approach
In 2011, the dean of the Medical University of South Carolina (MUSC) College of Medicine convened an “Innovation in Graduate Medical Education” committee of faculty across multiple specialties, including anesthesia, radiology, internal medicine, pathology, surgery, orthopedics, obstetrics–gynecology, emergency medicine, pediatrics, psychiatry, and otolaryngology. This task force quickly
that dedicated time for verbal exchange, templates for accessing and recording information, interactive handoffs giving priority to ill patients, and highlighting action items were most important for effective handoff. Next Steps Both undergraduate and graduate medical education curricula need to develop formalized training and methods to assess competencies in handoffs. Training incoming residents is a logical starting place, but programs should be systematically disseminated across all specialties, from residents to faculty, in order to be effectively integrated into the culture of an institution.
identified patient handoffs as an area of focus and opportunity based on the projected increase in number of handoffs with the implementation of new duty hours restrictions. Further, local data indicated that approximately half of residents believed that patient information was lost during shift changes and that problems occurred “often” in the transfer of information across hospital units, including intensive care unit-to-floor, emergency department-to-floor, and between floors/services within the hospital. Task force At first, the task force met monthly, with more frequent meetings as the project matured. Meetings were typically one to two hours and focused initially on problem identification. After some discussion and an extensive literature review, the task force committed to developing a formal handoff curriculum. The task force discussed multiple methods of instruction and assessment, including educational sessions for current house staff and monitoring current patient handoffs. It was ultimately decided that without
Academic Medicine, Vol. 89, No. 10 / October 2014
Innovation Report
additional departmental financial support for faculty time, it would be impractical to monitor real-time patient handoffs. With financial support from the GME office and the College of Medicine dean’s office, the task force decided to provide an educational intervention to incoming first-year residents during GME orientation. GME administrative staff were available to copy materials and arrange packets beforehand and were on hand the day of orientation to administer and collect surveys. The task force considered using outside speakers but ultimately decided to focus on the strengths within the institution. Speakers included MUSC’s current quality and safety officers, designated institutional official, and faculty willing to volunteer time to facilitate discussions and observe a simulated handoff experience. Curriculum The handoff curriculum was included in GME orientation for the first time in June 2012 and took up one of the three days of orientation. In this section we describe the individual components of the curriculum. Basics of good medical communication. This didactic portion of the curriculum ran for 25 minutes and included interactive discussions defining the importance of handoffs, as well as the elements that constitute an effective handoff. Included in this section were links to and discussions regarding the Society of Hospital Medicine’s white paper describing the characteristics of an effective handoff.5 Residents participated in an adapted version of the game of telephone, highlighting the potential issues associated with passing information through serial handoffs. Interprofessional communication skills. Interprofessional communication instruction lasted approximately 20 minutes and was provided by our in-house patient safety managers. It focused on the importance of effective communication with nursing and other ancillary staff. Instructors reminded residents that communication errors are identified as the cause of the majority of sentinel events and that professional behavior, both in interaction with colleagues and with other ancillary staff, is important. Tools for communication and handoffs. During this 15-minute portion of the curriculum, incoming residents were introduced to the mnemonic iCATCH:
Academic Medicine, Vol. 89, No. 10 / October 2014
• i: Identify (name, medical record number, date of admission, code status) • C: Chief complaint or presenting symptoms • A: Active problem list • T: Therapies and interventions (planned for next 24 hours) • C: Clinical trajectory and condition (sick or not sick; response to therapy and help the receiving caregiver anticipate problems) • H: Help me (encourage questions and dialogue) A version of this mnemonic was initially developed by the MUSC Department of Pediatrics for use in communication between the pediatric emergency department and inpatient pediatric services. The task force adapted it to suit all subspecialties, and it was included in the residents’ orientation packets. Some specific examples were provided briefly during larger didactic sessions, but specialty-specific uses of iCATCH were discussed during small-group observed simulated handoff experiences (OSHEs; see description below). Attendees received “badge tags” printed with the iCATCH mnemonic to attach to their identification badges and carry with them for the remainder of the year. Instructors introduced residents to the informatics system for patient handoffs, developed by our local IT department. In standardizing our approach, we were able to establish a uniform electronic handoff system throughout the hospital. As each specialty uses this informatics system, information for each service lies in one secure, centralized location that may be accessed by all services. Small-group sessions: Communication event discussion. Residents were divided into multispecialty groups prior to training to facilitate cross-specialty discussion. Volunteer faculty members were preassigned to groups to serve as moderators. Faculty moderators included participants from the Departments of Internal Medicine and Radiology. The groups were each assigned four scenarios to discuss. The scenarios included samples of communication errors that directly impacted patient care. Moderators met with the medical director for quality and safety prior to
small-group discussions in an effort to standardize desired outcomes among groups. Groups had 20 minutes for discussion. A designated recorder noted areas identified by the groups where breakdowns in communication occurred, and how such breakdowns may have been avoided. This exercise demonstrated that each specialty in the scenario contributed to a portion of the error, and that not one specific specialty was at fault. At the end of the session, each small group reported its findings to the group at large. OSHE. The culmination of our training was this simulated handoff experience in a small-group setting. The goal of this exercise was to provide participants an opportunity to demonstrate a verbal patient handoff, based on simulated patient information. Faculty from each specialty developed three to four patient scenarios that were service-specific. Residents were divided into groups of six based on specialty for a total of 20 groups. Corresponding specialty faculty directly observed each resident giving and receiving handoffs based on the specialty-specific scenarios. Faculty participants included program directors as well as junior and senior core faculty. Each group encounter lasted one hour. Faculty assessed the verbal handoff using a checklist developed by the author of the scenario. This checklist was based on the iCATCH model, thus providing a standardization to evaluate handoffs. Faculty prompted participants to selfevaluate and to constructively critique their peers’ performances in the handoff scenarios. Learners provided feedback regarding their individual performance and areas for improvement. Survey Curriculum participants completed a 21-item pre- and postsurvey to assess perceptions towards and personal skill evaluation of handoffs. Questions were developed from nationally recognized handoff guidelines. Items regarding selfassessment of competency and components of an effective handoff were measured on a five-point Likert-type scale (1 = not very competent/important; 5 = very competent/ important). Questions regarding attitude towards handoffs were measured on a four-point scale (1 = strongly disagree; 4 = strongly agree). We tested the internal validity of the questionnaire prior to survey administration. IRB exemption was obtained for educational purposes.
1367
Innovation Report
Analysis Of the 124 participants in the curriculum, 121 completed the presurvey and 119 completed the postsurvey. We computed descriptive statistics for the responses. We compared items in the pre- and postsurveys through t tests using SAS 9.2 (SAS Institute, Cary, North Carolina). Outcomes
One hundred twenty-four incoming firstyear residents attended the formalized handoff training day. Demographic information is included in Table 1. Survey response rate was 97.6% (121/124) for the presurvey and 96% (119/124) for the postsurvey. Prior to our intervention, 23% (29/124) of participants reported receiving some form of formal training on handoffs. Residents increasingly identified important aspects of the
Table 1 Demographic Information of 124 First-Year Residents Participating in a Formal Handoff Curriculum, Medical University of South Carolina, 2012 Characteristic Level of training PGY-1
No. (%) 124 (100)
Gender Male
64 (52)
Female
60 (48)
Race African American
5 (4)
Asian
9 (8)
Hispanic
2 (2)
Native American White
1 (1) 107 (85)
Specialty Anesthesia Emergency medicine Internal medicine
12 (10)
The institution-wide curriculum and the attention devoted to handoffs emphasize the importance of this topic. The impact on the AHRQ survey, though modest, was higher than anticipated by our institutional leaders based on the impact of prior patient safety initiatives. The majority of our cost was the time devoted by the faculty members who participated in the task force. The iCATCH badge tags, which were given to all residents, added approximately $500. We did not incur any additional costs for auditorium or observation space. Next Steps
For the purposes of this study, we looked to incoming first-year residents only, because of challenges with funding, timing, and availability of upperlevel residents. Faculty from specific departments were charged with returning to their training programs to develop an abbreviated version for the senior residents. Sessions have now occurred in each of the major clinical departments.
6 (5) 31 (25)
Otolaryngology
3 (2)
Neurology
6 (5)
Obstetrics–gynecology
6 (5)
Orthopedics
3 (2)
Pathology
5 (4)
Pediatrics
19 (15)
Psychiatry
12 (10)
Surgery
21 (17)
Prior handoff training Yes
29 (23)
No
95 (77)
Abbreviations: PGY indicates postgraduate year.
1368
handoff, felt more competent in giving handoffs, and identified more previously witnessed clinical errors from poor handoffs after participation in the formal curriculum. In addition, our institution administers the Agency for Healthcare and Research Quality (AHRQ) Culture of Safety Survey annually to both house staff and faculty to monitor the culture of safety at our institution. From 2011 to 2013, responses to this survey demonstrated a statistically significant improvement in participants’ ratings of handoffs and transitions of care as well as their ratings of communication openness.
The resources developed during the innovation are available institution-wide. Medical students currently engage in and attend handoffs as part of their clerkship requirements throughout the university. Furthermore, current fourth-year medical students have the opportunity to participate in an abridged version of this curriculum as part of a capstone course. During the internal medicine core rotation, fourth-year students are instructed in developing an accurate and concise written handoff. We plan to continue offering versions of this training across the institution.
A standardized informatics system is imperative in the implementation of an accurate handoff program. This not only allows each service within the inpatient setting to have access to patient information to facilitate information transfer between units but also affords the opportunity for each member of the team to have an accurate plan of care for each patient. On the basis of feedback from our residents, we are enhancing our electronic handoff system on an ongoing basis. Faculty development sessions, including training regarding the importance of handoffs and teaching resident physicians and medical students how to perform an accurate handoff, are imperative for inte gration into the culture of an institution. We are continuing to explore enhanced faculty development in this regard. At this time, we are in the process of developing methods to assess competency and incorporate handoffs into milestones while also ensuring that effective handoffs take place in day-today clinical activities. At a departmental level, we are exploring methods for assessing competency in participating in an effective handoff, either in a clinical setting or by using a version of the OSHEs described above. The use of observation of “real-time” handoffs was discussed by the task force, and several departments have recently assigned faculty members to observe handoffs. However, because of variable faculty involvement, limited funding, and the timing of handoffs (typically early in the morning and late in the evening), this was not deemed feasible for generalized training. The task force also discussed following residents for six months to one year after orientation to determine whether the educational curriculum yielded any long-term improvement in skills. However, we met resistance by many specialties because of lack of availability of in-house physicians. This long-term follow-up may be feasible for specialties that have in-house faculty at all times. We continue to administer the AHRQ Culture of Safety Survey to all residents on an ongoing basis. Handoffs are not specific to institutions or medical specialties and are a necessary part of medical education to reduce patient errors, improve patient care, and ultimately
Academic Medicine, Vol. 89, No. 10 / October 2014
Innovation Report
improve the practice of medicine in an ever “shifting” environment.
Medical Colleges Group on Resident Affairs Spring Meeting, Savannah, Georgia, 2013.
Acknowledgments: The authors wish to thank the following participants of the Innovations Committee for their time, efforts, and contributions to graduate medical education: Dr. Will Hand, Dr. Marques Bradshaw, Dr. Diann Krwyko, Dr. Krishna Patel, Dr. Ashlyn Savage, Dr. Michael Bowman, Dr. Doug Norcross, Dr. David Lewin, Dr. Meghan Cummins, Dr. Dee Ford, Dr. Joseph Calandra, and Dr. Danielle Scheurer.
Dr. Allen is assistant professor, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, South Carolina.
Funding/Support: None reported. Other disclosures: None reported. Ethical approval: IRB exemption was obtained from the Medical University of South Carolina IRB body on the grounds that research was strictly for educational and quality improvement purposes, and used only deidentified information in survey tools. Previous presentations: Data from this manuscript were presented at the Association of American
Academic Medicine, Vol. 89, No. 10 / October 2014
Dr. Caton is assistant professor, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, South Carolina. Dr. Cluver is vice chair for education and training, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Dr. Mainous is director, Department of Health Services Research, Management, and Policy, and professor, Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida. Dr. Clyburn is associate dean for medical education, associate professor, designated institutional official for graduate medical education, and internal medicine program director, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, South Carolina.
References 1 Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: A survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34:563–570. 2 Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I; Handoff Education and Assessment for Residents (HEAR) Computer Supported Cooperative Workgroup. The patient handoff: A comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87:411–418. 3 Horwitz LI, Schuster KM, Thung SF, et al. An institution-wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21:863–871. 4 Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Integration of a formalized handoff system into the surgical curriculum: Resident perspectives and early results. Arch Surg. 2011;146:89–93. 5 Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: A systematic review and task force recommendations. J Hosp Med. 2009;4:433–440.
1369
Targeting Improvements in Patient Safety at a Large Academic Center: An Institutional Handoff Curriculum for Graduate Medical Education Sarah Allen, MD, Cathryn Caton, MD, Jeffery Cluver, MD, Arch G. Mainous III, PhD, and Benjamin Clyburn, MD
Abstract Problem Handoffs are an integral component of patient care, and the number of handoffs has increased as a result of duty hours restrictions for resident physicians. A structured handoff curriculum improves accuracy and has been shown to decrease medical errors. A standardized approach across all specialties is lacking in the published literature. The authors discuss the development and implementation of an institution-wide handoff curriculum for incoming firstyear residents. Approach An Innovation in Graduate Medical Education committee, including faculty
Problem
Patient handoffs are an integral part of patient care and are especially important in an inpatient setting. Although residents correctly perceive that communication errors lead to problematic handoffs, formal education and training related to patient handoffs has been limited in undergraduate and graduate medical education (GME), and most physicians have never received formal instruction on handoffs and related communication skills.1 Historically, GME programs have relied on an implicit curriculum to teach residents and fellows how to hand off patient information. In 2012, a comprehensive curricular blueprint to improve continuity of care was described in the literature, but it Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Allen, 135 Rutledge Ave., Charleston, SC 29425: telephone: (843) 876-0888; e-mail: [email protected]. Acad Med. 2014;89:1366–1369. First published online August 12, 2014 doi: 10.1097/ACM.0000000000000462
1366
from multiple specialties, identified an educational deficiency in handoffs and selected this as the target for the educational innovation. Meetings were held to develop and implement an extensive handoff curriculum for incoming first-year residents. The designed curriculum included large- and small-group sessions, and a specialtyspecific observed simulated handoff experience. The authors analyzed participants’ pre- and postsurveys using descriptive statistics. Outcomes One hundred and twenty-four participants attended the formalized handoff training day. Following training, residents recognized
has yet to be validated.2 Some academic institutions have developed task forces to improve practices institution-wide but have not focused on formalized education programs as a driver of the process.3 Many programs have implemented specialty-specific curricula,3,4 but we are aware of no reports published to date that address the need for an institution-wide curriculum. The need for formalized training of patient handoffs within GME is becoming readily apparent, and there is a need for standardized and validated approaches that result in the acquisition of the knowledge and skills needed to perform an effective patient handoff. Approach
In 2011, the dean of the Medical University of South Carolina (MUSC) College of Medicine convened an “Innovation in Graduate Medical Education” committee of faculty across multiple specialties, including anesthesia, radiology, internal medicine, pathology, surgery, orthopedics, obstetrics–gynecology, emergency medicine, pediatrics, psychiatry, and otolaryngology. This task force quickly
that dedicated time for verbal exchange, templates for accessing and recording information, interactive handoffs giving priority to ill patients, and highlighting action items were most important for effective handoff. Next Steps Both undergraduate and graduate medical education curricula need to develop formalized training and methods to assess competencies in handoffs. Training incoming residents is a logical starting place, but programs should be systematically disseminated across all specialties, from residents to faculty, in order to be effectively integrated into the culture of an institution.
identified patient handoffs as an area of focus and opportunity based on the projected increase in number of handoffs with the implementation of new duty hours restrictions. Further, local data indicated that approximately half of residents believed that patient information was lost during shift changes and that problems occurred “often” in the transfer of information across hospital units, including intensive care unit-to-floor, emergency department-to-floor, and between floors/services within the hospital. Task force At first, the task force met monthly, with more frequent meetings as the project matured. Meetings were typically one to two hours and focused initially on problem identification. After some discussion and an extensive literature review, the task force committed to developing a formal handoff curriculum. The task force discussed multiple methods of instruction and assessment, including educational sessions for current house staff and monitoring current patient handoffs. It was ultimately decided that without
Academic Medicine, Vol. 89, No. 10 / October 2014
Innovation Report
additional departmental financial support for faculty time, it would be impractical to monitor real-time patient handoffs. With financial support from the GME office and the College of Medicine dean’s office, the task force decided to provide an educational intervention to incoming first-year residents during GME orientation. GME administrative staff were available to copy materials and arrange packets beforehand and were on hand the day of orientation to administer and collect surveys. The task force considered using outside speakers but ultimately decided to focus on the strengths within the institution. Speakers included MUSC’s current quality and safety officers, designated institutional official, and faculty willing to volunteer time to facilitate discussions and observe a simulated handoff experience. Curriculum The handoff curriculum was included in GME orientation for the first time in June 2012 and took up one of the three days of orientation. In this section we describe the individual components of the curriculum. Basics of good medical communication. This didactic portion of the curriculum ran for 25 minutes and included interactive discussions defining the importance of handoffs, as well as the elements that constitute an effective handoff. Included in this section were links to and discussions regarding the Society of Hospital Medicine’s white paper describing the characteristics of an effective handoff.5 Residents participated in an adapted version of the game of telephone, highlighting the potential issues associated with passing information through serial handoffs. Interprofessional communication skills. Interprofessional communication instruction lasted approximately 20 minutes and was provided by our in-house patient safety managers. It focused on the importance of effective communication with nursing and other ancillary staff. Instructors reminded residents that communication errors are identified as the cause of the majority of sentinel events and that professional behavior, both in interaction with colleagues and with other ancillary staff, is important. Tools for communication and handoffs. During this 15-minute portion of the curriculum, incoming residents were introduced to the mnemonic iCATCH:
Academic Medicine, Vol. 89, No. 10 / October 2014
• i: Identify (name, medical record number, date of admission, code status) • C: Chief complaint or presenting symptoms • A: Active problem list • T: Therapies and interventions (planned for next 24 hours) • C: Clinical trajectory and condition (sick or not sick; response to therapy and help the receiving caregiver anticipate problems) • H: Help me (encourage questions and dialogue) A version of this mnemonic was initially developed by the MUSC Department of Pediatrics for use in communication between the pediatric emergency department and inpatient pediatric services. The task force adapted it to suit all subspecialties, and it was included in the residents’ orientation packets. Some specific examples were provided briefly during larger didactic sessions, but specialty-specific uses of iCATCH were discussed during small-group observed simulated handoff experiences (OSHEs; see description below). Attendees received “badge tags” printed with the iCATCH mnemonic to attach to their identification badges and carry with them for the remainder of the year. Instructors introduced residents to the informatics system for patient handoffs, developed by our local IT department. In standardizing our approach, we were able to establish a uniform electronic handoff system throughout the hospital. As each specialty uses this informatics system, information for each service lies in one secure, centralized location that may be accessed by all services. Small-group sessions: Communication event discussion. Residents were divided into multispecialty groups prior to training to facilitate cross-specialty discussion. Volunteer faculty members were preassigned to groups to serve as moderators. Faculty moderators included participants from the Departments of Internal Medicine and Radiology. The groups were each assigned four scenarios to discuss. The scenarios included samples of communication errors that directly impacted patient care. Moderators met with the medical director for quality and safety prior to
small-group discussions in an effort to standardize desired outcomes among groups. Groups had 20 minutes for discussion. A designated recorder noted areas identified by the groups where breakdowns in communication occurred, and how such breakdowns may have been avoided. This exercise demonstrated that each specialty in the scenario contributed to a portion of the error, and that not one specific specialty was at fault. At the end of the session, each small group reported its findings to the group at large. OSHE. The culmination of our training was this simulated handoff experience in a small-group setting. The goal of this exercise was to provide participants an opportunity to demonstrate a verbal patient handoff, based on simulated patient information. Faculty from each specialty developed three to four patient scenarios that were service-specific. Residents were divided into groups of six based on specialty for a total of 20 groups. Corresponding specialty faculty directly observed each resident giving and receiving handoffs based on the specialty-specific scenarios. Faculty participants included program directors as well as junior and senior core faculty. Each group encounter lasted one hour. Faculty assessed the verbal handoff using a checklist developed by the author of the scenario. This checklist was based on the iCATCH model, thus providing a standardization to evaluate handoffs. Faculty prompted participants to selfevaluate and to constructively critique their peers’ performances in the handoff scenarios. Learners provided feedback regarding their individual performance and areas for improvement. Survey Curriculum participants completed a 21-item pre- and postsurvey to assess perceptions towards and personal skill evaluation of handoffs. Questions were developed from nationally recognized handoff guidelines. Items regarding selfassessment of competency and components of an effective handoff were measured on a five-point Likert-type scale (1 = not very competent/important; 5 = very competent/ important). Questions regarding attitude towards handoffs were measured on a four-point scale (1 = strongly disagree; 4 = strongly agree). We tested the internal validity of the questionnaire prior to survey administration. IRB exemption was obtained for educational purposes.
1367
Innovation Report
Analysis Of the 124 participants in the curriculum, 121 completed the presurvey and 119 completed the postsurvey. We computed descriptive statistics for the responses. We compared items in the pre- and postsurveys through t tests using SAS 9.2 (SAS Institute, Cary, North Carolina). Outcomes
One hundred twenty-four incoming firstyear residents attended the formalized handoff training day. Demographic information is included in Table 1. Survey response rate was 97.6% (121/124) for the presurvey and 96% (119/124) for the postsurvey. Prior to our intervention, 23% (29/124) of participants reported receiving some form of formal training on handoffs. Residents increasingly identified important aspects of the
Table 1 Demographic Information of 124 First-Year Residents Participating in a Formal Handoff Curriculum, Medical University of South Carolina, 2012 Characteristic Level of training PGY-1
No. (%) 124 (100)
Gender Male
64 (52)
Female
60 (48)
Race African American
5 (4)
Asian
9 (8)
Hispanic
2 (2)
Native American White
1 (1) 107 (85)
Specialty Anesthesia Emergency medicine Internal medicine
12 (10)
The institution-wide curriculum and the attention devoted to handoffs emphasize the importance of this topic. The impact on the AHRQ survey, though modest, was higher than anticipated by our institutional leaders based on the impact of prior patient safety initiatives. The majority of our cost was the time devoted by the faculty members who participated in the task force. The iCATCH badge tags, which were given to all residents, added approximately $500. We did not incur any additional costs for auditorium or observation space. Next Steps
For the purposes of this study, we looked to incoming first-year residents only, because of challenges with funding, timing, and availability of upperlevel residents. Faculty from specific departments were charged with returning to their training programs to develop an abbreviated version for the senior residents. Sessions have now occurred in each of the major clinical departments.
6 (5) 31 (25)
Otolaryngology
3 (2)
Neurology
6 (5)
Obstetrics–gynecology
6 (5)
Orthopedics
3 (2)
Pathology
5 (4)
Pediatrics
19 (15)
Psychiatry
12 (10)
Surgery
21 (17)
Prior handoff training Yes
29 (23)
No
95 (77)
Abbreviations: PGY indicates postgraduate year.
1368
handoff, felt more competent in giving handoffs, and identified more previously witnessed clinical errors from poor handoffs after participation in the formal curriculum. In addition, our institution administers the Agency for Healthcare and Research Quality (AHRQ) Culture of Safety Survey annually to both house staff and faculty to monitor the culture of safety at our institution. From 2011 to 2013, responses to this survey demonstrated a statistically significant improvement in participants’ ratings of handoffs and transitions of care as well as their ratings of communication openness.
The resources developed during the innovation are available institution-wide. Medical students currently engage in and attend handoffs as part of their clerkship requirements throughout the university. Furthermore, current fourth-year medical students have the opportunity to participate in an abridged version of this curriculum as part of a capstone course. During the internal medicine core rotation, fourth-year students are instructed in developing an accurate and concise written handoff. We plan to continue offering versions of this training across the institution.
A standardized informatics system is imperative in the implementation of an accurate handoff program. This not only allows each service within the inpatient setting to have access to patient information to facilitate information transfer between units but also affords the opportunity for each member of the team to have an accurate plan of care for each patient. On the basis of feedback from our residents, we are enhancing our electronic handoff system on an ongoing basis. Faculty development sessions, including training regarding the importance of handoffs and teaching resident physicians and medical students how to perform an accurate handoff, are imperative for inte gration into the culture of an institution. We are continuing to explore enhanced faculty development in this regard. At this time, we are in the process of developing methods to assess competency and incorporate handoffs into milestones while also ensuring that effective handoffs take place in day-today clinical activities. At a departmental level, we are exploring methods for assessing competency in participating in an effective handoff, either in a clinical setting or by using a version of the OSHEs described above. The use of observation of “real-time” handoffs was discussed by the task force, and several departments have recently assigned faculty members to observe handoffs. However, because of variable faculty involvement, limited funding, and the timing of handoffs (typically early in the morning and late in the evening), this was not deemed feasible for generalized training. The task force also discussed following residents for six months to one year after orientation to determine whether the educational curriculum yielded any long-term improvement in skills. However, we met resistance by many specialties because of lack of availability of in-house physicians. This long-term follow-up may be feasible for specialties that have in-house faculty at all times. We continue to administer the AHRQ Culture of Safety Survey to all residents on an ongoing basis. Handoffs are not specific to institutions or medical specialties and are a necessary part of medical education to reduce patient errors, improve patient care, and ultimately
Academic Medicine, Vol. 89, No. 10 / October 2014
Innovation Report
improve the practice of medicine in an ever “shifting” environment.
Medical Colleges Group on Resident Affairs Spring Meeting, Savannah, Georgia, 2013.
Acknowledgments: The authors wish to thank the following participants of the Innovations Committee for their time, efforts, and contributions to graduate medical education: Dr. Will Hand, Dr. Marques Bradshaw, Dr. Diann Krwyko, Dr. Krishna Patel, Dr. Ashlyn Savage, Dr. Michael Bowman, Dr. Doug Norcross, Dr. David Lewin, Dr. Meghan Cummins, Dr. Dee Ford, Dr. Joseph Calandra, and Dr. Danielle Scheurer.
Dr. Allen is assistant professor, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, South Carolina.
Funding/Support: None reported. Other disclosures: None reported. Ethical approval: IRB exemption was obtained from the Medical University of South Carolina IRB body on the grounds that research was strictly for educational and quality improvement purposes, and used only deidentified information in survey tools. Previous presentations: Data from this manuscript were presented at the Association of American
Academic Medicine, Vol. 89, No. 10 / October 2014
Dr. Caton is assistant professor, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, South Carolina. Dr. Cluver is vice chair for education and training, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina. Dr. Mainous is director, Department of Health Services Research, Management, and Policy, and professor, Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida. Dr. Clyburn is associate dean for medical education, associate professor, designated institutional official for graduate medical education, and internal medicine program director, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, South Carolina.
References 1 Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: A survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34:563–570. 2 Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I; Handoff Education and Assessment for Residents (HEAR) Computer Supported Cooperative Workgroup. The patient handoff: A comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87:411–418. 3 Horwitz LI, Schuster KM, Thung SF, et al. An institution-wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21:863–871. 4 Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Integration of a formalized handoff system into the surgical curriculum: Resident perspectives and early results. Arch Surg. 2011;146:89–93. 5 Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: A systematic review and task force recommendations. J Hosp Med. 2009;4:433–440.
1369
