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A Standardized Handoff Simulation Promotes Recovery From Auditory Distractions in Resident Physicians. Simul Healthc 2018; 13:233-238. [PMID: 29727347 DOI: 10.1097/sih.0000000000000322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Despite the increasing use of training simulations to teach and assess resident handoffs, simulations that approximate realistic hospital conditions with distractions are lacking. This study explores the effects of a novel simulation-based training intervention on resident handoff performance in the face of prevalent hospital interruptions. METHODS After a preliminary educational module, entering postgraduate year 1 residents (interns) completed one of the following three handoff simulations: (1) no interruption, (2) hospital noise, or (3) noise and pager interruptions. Trained receivers rated interns using an evidence-based Handoff Behaviors Checklist and a previously validated Handoff Mini-Clinical Examination Exercise instrument. RESULTS Of 127 eligible interns, 125 (98.4%) completed an online preparatory module and a handoff simulation. Interns receiving auditory interruptions were less likely to be heard adequately (48.8% noise and 71.8% noise + pager vs. 100.0% uninterrupted, P < 0.001) and scored lower on establishing appropriate handoff settings (5.7 ± 2.3 noise and 6.2 ± 1.8 noise + pager vs. 8.0 ± 0.8 uninterrupted, P < 0.001). Interns receiving noise only shared a written sign-out document more effectively (71.1% vs. 30.2% uninterrupted and 43.6% noise + pager, P < 0.001). There were no differences in averaged performance metrics on the Handoff Behaviors Checklist. DISCUSSION While common hospital interruptions created nonideal circumstances for the handoff, interns receiving interruptions were rated similarly and recovered effectively. However, interns exposed to noise only used the written sign-out form more actively. Our findings suggest that this intervention was successful in promoting handoff proficiency despite exposure to common but significant hospital interruptions.
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Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs. J Gen Intern Med 2017; 32:667-672. [PMID: 28197967 PMCID: PMC5442016 DOI: 10.1007/s11606-017-4005-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/30/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern. OBJECTIVES The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country. DESIGN Nationwide survey. PARTICIPANTS All internal medicine program directors registered with APDIM. MAIN MEASURES Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs. KEY RESULTS Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff. CONCLUSIONS Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.
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Yoshida H. Capsule Commentary on Phillips et al., Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs Running Title: National Survey of Year-End Clinic Handoffs. J Gen Intern Med 2017. [PMID: 28255800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Affiliation(s)
- Hirofumi Yoshida
- Department of General Internal Medicine, Rakuwakai Otowa Hospital, Otowachinji-cho 2, Yamashina-ku, Kyoto, Japan.
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Pincavage AT, Donnelly MJ, Young JQ, Arora VM. Year-End Resident Clinic Handoffs: Narrative Review and Recommendations for Improvement. Jt Comm J Qual Patient Saf 2016; 43:71-79. [PMID: 28334565 DOI: 10.1016/j.jcjq.2016.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Year-end clinic handoffs in resident continuity clinics are an important patient safety issue. METHODS Intervention articles addressing the year-end resident clinic handoff were identified in a targeted literature search. These articles were reviewed and abstracted to summarize the current literature. On the basis of these reviews and consensus expert opinion, recommendations to improve year-end clinic handoffs were developed. RESULTS Of 23 identified articles, 10 intervention articles in the fields of internal medicine, internal medicine-pediatrics, psychiatry, and family medicine were ultimately included. The additional 13 nonintervention studies were used as background material. There were 12 clinic handoff recommendations for improvement: (1) focus on patients most at risk during the handoff, (2) educate residents, (3) consider balancing caseloads for the residents, (4) prepare patients for the handoff and perform patient-centered outreach, (5) standardize a written method of sign-out and require verbal communication for a subset of patients, (6) use a standardized template or technology solution for the handoff, (7) identify specific tasks that require follow-up, (8) enhance attending supervision during the handoff, (9) make patient assignments clear after the handoff, (10) have patients establish care with the new provider as soon as possible after the handoff, (11) establish care with telephone contact prior to the first visit, (12) perform safety audits to ensure that sign-out occurs, patients receive appointments, no-shows are rescheduled, and task follow-up is completed. CONCLUSION There is emerging evidence for interventions to improve year-end resident clinic handoffs, and the recommendations provided are a starting point to guide training programs.
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Mohorek M, Webb TP. Establishing a conceptual framework for handoffs using communication theory. JOURNAL OF SURGICAL EDUCATION 2015; 72:402-409. [PMID: 25498882 DOI: 10.1016/j.jsurg.2014.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 09/16/2014] [Accepted: 11/03/2014] [Indexed: 06/04/2023]
Abstract
BACKGROUND A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in patient care handoffs. Ineffective handoffs have been identified as the third most common cause of medical error. However, research into health care handoffs lacks a unifying foundational structure. We sought to identify a conceptual framework that could be used to critically analyze handoffs. METHODS A scholarly review focusing on communication theory as a possible conceptual framework for handoffs was conducted. A PubMed search of published handoff research was also performed, and the literature was analyzed and matched to the most relevant theory for health care handoff models. RESULTS The Shannon-Weaver Linear Model of Communication was identified as the most appropriate conceptual framework for health care handoffs. The Linear Model describes communication as a linear process. A source encodes a message into a signal, the signal is sent through a channel, and the signal is decoded back into a message at the destination, all in the presence of internal and external noise. The Linear Model identifies 3 separate instances in handoff communication where error occurs: the transmitter (message encoding), channel, and receiver (signal decoding). CONCLUSIONS The Linear Model of Communication is a suitable conceptual framework for handoff research and provides a structured approach for describing handoff variables. We propose the Linear Model should be used as a foundation for further research into interventions to improve health care handoffs.
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Affiliation(s)
- Matthew Mohorek
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Travis P Webb
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Pincavage AT, Lee WW, Venable LR, Prochaska M, Staisiunas DD, Beiting KJ, Czerweic MK, Oyler J, Vinci LM, Arora VM. "Ms. B changes doctors": using a comic and patient transition packet to engineer patient-oriented clinic handoffs (EPOCH). J Gen Intern Med 2015; 30:257-60. [PMID: 25186160 PMCID: PMC4314496 DOI: 10.1007/s11606-014-3009-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/14/2014] [Accepted: 07/21/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Few patient-centered interventions exist to improve year-end residency clinic handoffs. AIM Our purpose was to assess the impact of a patient-centered transition packet and comic on clinic handoff outcomes. SETTING The study was conducted at an academic medicine residency clinic. PARTICIPANTS Participants were patients undergoing resident clinic handoff 2011-2013 PROGRAM DESCRIPTION: Two months before the 2012 handoff, patients received a "transition packet" incorporating patient-identified solutions (i.e., a new primary care provider (PCP) welcome letter with photo, certificate of recognition, and visit preparation tool). In 2013, a comic was incorporated to stress the importance of follow-up. PROGRAM EVALUATION Patients were interviewed by phone with response rates of 32 % in 2011, 43 % in 2012 and 36 % in 2013. Most patients who were interviewed were aware of the handoff post-packet (95 %). With the comic, more patients recalled receiving the packet (44 % 2012 vs. 64 % 2013, p< 0.001) and correctly identified their new PCP (77 % 2012 vs. 98 % 2013, p< 0.001). Among patients recalling the packet, most (70 % 2012; 65 % 2013) agreed it helped them establish rapport. Both years, fewer patients missed their first new PCP visit (43 % in 2011, 31 % in 2012 and 26 % in 2013, p< 0.001). DISCUSSION A patient-centered transition packet helped prepare patients for clinic handoffs. The comic was associated with increased packet recall and improved follow-up rates.
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Affiliation(s)
- Amber T Pincavage
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue MC 3051, L326, Chicago, IL, 60637, USA,
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Donnelly MJ, Clauser JM, Tractenberg RE. A multicenter intervention to improve ambulatory care handoffs at the end of residency. J Grad Med Educ 2014; 6:112-6. [PMID: 24701320 PMCID: PMC3963766 DOI: 10.4300/jgme-d-13-00139.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/25/2013] [Accepted: 10/05/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Graduating residents transition their continuity clinic patients to junior colleagues every year, creating a vulnerable transition period for about 1 million patients nationally. OBJECTIVE We examined a standardized, electronic template for handing off high-risk ambulatory patients by outgoing residents from 7 residencies within a large health care system, and compared handoff quantity and provider satisfaction for handoffs with and without that template. METHODS Residents graduating in 2011 from 5 internal medicine, 1 family medicine, and 1 internal medicine-pediatrics residency programs in 1 health care system were randomized to a new electronic handoff process with a standardized intervention template or a free-text handoff. Expert reviewers independently evaluated all handoff notes, and providers were surveyed after follow-up appointments regarding use, helpfulness, and overall satisfaction with the handoffs. RESULTS Fifty-two of 79 residents (66%) participated, performing 278 handoffs. Eighty-four patients (30%, 17 of 57) failed to follow up within the study period. For patients who followed up, providers read 61% (101 of 165) of the handoffs at the time of the visit. No significant difference existed between groups in the satisfaction of the follow up provider or the quality measure of the handoffs in our process. Expert agreement on which features make the handoff "helpful" was fair (κ = 0.34). CONCLUSIONS A standardized template did not improve handoff quantity or satisfaction compared with a free-text handoff. Practical handoff programs can be instituted into diverse residencies within a short time frame, with most residents taking part in creating the handoff formats.
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Donnelly MJ, Clauser JM, Tractenberg RE. Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers. TEACHING AND LEARNING IN MEDICINE 2014; 26:17-26. [PMID: 24405342 DOI: 10.1080/10401334.2013.857334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND It is unclear why systematic training in end-of-residency clinic handoffs is not universal. PURPOSES We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation. METHODS We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems. RESULTS Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04). CONCLUSIONS Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.
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Affiliation(s)
- Michael J Donnelly
- a Department of Medicine and Pediatrics, Medstar Georgetown University Hospital , Washington , DC , USA
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Pincavage AT, Prochaska M, Dahlstrom M, Lee WW, Beiting KJ, Ratner S, Oyler J, Vinci LM, Arora VM. Patient safety outcomes after two years of an enhanced internal medicine residency clinic handoff. Am J Med 2014; 127:96-9. [PMID: 24384104 DOI: 10.1016/j.amjmed.2013.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 09/30/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Megan Prochaska
- Internal Medicine Residency Training Program, University of Chicago, Ill
| | - Marcus Dahlstrom
- Internal Medicine Residency Training Program, University of California San Francisco
| | - Wei Wei Lee
- Department of Medicine, University of Chicago, Ill
| | | | - Shana Ratner
- Division of General Internal Medicine and Epidemiology, University of North Carolina, Chapel Hill
| | - Julie Oyler
- Department of Medicine, University of Chicago, Ill
| | - Lisa M Vinci
- Department of Medicine, University of Chicago, Ill
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Abstract
BACKGROUND Although Internal Medicine year-end resident clinic handoffs affect numerous patients, little research has described patients' perspectives of the experience. OBJECTIVE To describe patients' perceptions of positive and negative experiences pertaining to the year-end clinic handoff; to rate patient satisfaction with aspects of the clinic handoff and identify whether or not patients could name their new physicians. DESIGN Qualitative study design using semi-structured interviews. PARTICIPANTS High-risk patients who underwent a year-end clinic handoff in July 2011. MEASUREMENTS Three months post-handoff, telephone interviews were conducted with patients to elicit their perceptions of positive and negative experiences. An initial coding classification was developed and applied to transcripts. Patients were also asked to name their primary care physician (PCP) and rate their satisfaction with the handoff. RESULTS In all, 103 telephone interviews were completed. Patient experiences regarding clinic handoffs were categorized into four themes: (1) doctor-patient relationships (i.e. difficulty building rapport); (2) clinic logistics (i.e. difficulty rescheduling appointments); (3) process of the care transition (i.e. patient unaware transition occurred); and (4) patient safety-related issues (i.e. missed tests). Only 59 % of patients could correctly name their new PCP. Patients who reported that they were informed of the clinic transition by letter or by telephone call from their new PCP were more likely to correctly name them (65 % vs. 32 % p = 0.007), report that their new doctor assumed care for them immediately (81 % [68/84] vs. 53 % [10/19], p = 0.009) and report satisfaction with communication between their old and new doctors (80 % [67/84] vs. 58 % [11/19], p = 0.04). Patients reported positive experiences such as learning more about their new physician through personal sharing, which helped them build rapport. Patients who reported being aware of the medical education mission of the clinic tended to be more understanding of the handoff process. CONCLUSIONS Patients face unique challenges during year-end clinic handoffs and provide insights into areas of improvement for a patient-centered handoff.
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Pincavage AT, Dahlstrom M, Prochaska M, Ratner S, Beiting KJ, Oyler J, Vinci LM, Arora VM. Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:795-801. [PMID: 23619066 DOI: 10.1097/acm.0b013e31828fd3c4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. METHOD In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. RESULTS Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06). CONCLUSIONS Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.
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Affiliation(s)
- Amber T Pincavage
- Department of Medicine, University of Chicago, Chicago, Illinois 60637, USA.
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Donnelly MJ, Clauser JM, Tractenberg RE. Current Practice in End-of-Residency Handoffs: A Survey of Internal Medicine-Pediatrics Program Directors. J Grad Med Educ 2013; 5:93-7. [PMID: 24404234 PMCID: PMC3613327 DOI: 10.4300/jgme-d-12-00183.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/20/2012] [Accepted: 09/09/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND End-of-residency outpatient handoffs affect at least 1 million patients per year, yet there is no consensus on best practices. OBJECTIVE To explore the use of formal systems for end-of-residency clinic handoffs in internal medicine-pediatrics residency (Med-Peds) programs, and their associated categorical internal medicine and pediatrics programs. METHODS We surveyed Med-Peds program directors about their programs' system for handing off ambulatory continuity patients. RESULTS Our response rate was 85% (67 of 79 programs). Thirty-one programs (46%) reported having a system for end-of-residency handoffs. Of the 30 that offered detailed information, 22 (73%) formally introduced the program to residents, 12 (40%) standardized the handoff, and 14 (47%) used multiple methods for information exchange, with the electronic health record and oral transfer of information (15 of 30, 50%) the most common. Six programs (20%) indicated they did not offer residents protected time to complete end-of-residency handoffs, and 13 programs (43%) did not identify a specific postgraduate year level for residents to whom patients were handed off. Programs were more likely to have a system for end-of-residency handoffs if another categorical program at their institution also had one (P < .001). CONCLUSIONS Fewer than half of responding Med-Peds programs have outpatient handoff systems in place. Inclusion of end-of-residency handoff information in the electronic health record may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.
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