1. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast Paced World Stephen M. Borowitz, M.D. Linda A. Waggoner-Fountain, M.D., M.Ed. Ellen J. Bass, Ph.D. Justin DeVoge, M.S. University of Virginia

2. l Rick Sledd l Ted Perez l Kim Brantley l Matthew Bolton l Leigh Baumgart l McKinsey Bond l Adam Helms l Luther Bartelt l Mangwi Atia l Tammy Schlag l Peggy Plews-Ogan l George Hoke

3. Sign-Out l a mechanism of transferring information, responsibility and/or authority from one set of care-givers to another l primary objective is the accurate transfer of information about patient’s state and plan of care

4. Sign-Out is a Lifelong Skill l In Academic Health Centers, resident physicians sign-out to one another from the very beginning of residency l Few residency training programs formally teach residents how to sign-out l Few residency training programs assess how well residents’ sign-out to one another l Sign-out is a life-long skill

5. There are Multiple Resident Hand-Offs Every Day

6. l Frequent patient care hand-offs have been associated with: »longer hospital stays »more laboratory tests being ordered »more self-reported preventable adverse events Patient Care Handoffs Can Lead to Omissions and Misunderstandings

7. A Changing Environment l Hospitalized patients are sicker and sicker l Hospital stays are shorter and shorter l The “medical record” has been marginalized as a source of communication between clinicians l There has been an explosion in scientific and medical knowledge l There is an increasing reliance on electronic health records/electronic data sources l In 2003, the ACGME instituted duty hour restrictions for all residency programs

8. Sign-Out l There is scant research on how sign-out is actually conducted, and even less is known about how sign-out should be conducted, or how interventions improve the quality of sign-out »most of the available information comes from other domains, particularly aviation and the military

9. missing info 40 (82%) no missing info 9 (18%) no unexpected event 109 (69%) unexpected event 49 (31%) How often did something happen you weren’t prepared for? In 33 of the 40 (79%) cases where information was missing, the problem/issue should have been anticipated during sign-out

10. Residents Often Miss Key Points During Sign-Out

11. Next Steps l Process l Tool(s) l Education

12. Process l We conducted facilitated sessions with residents, and pediatric and systems engineering faculty during which we: »defined the goals of sign-out »identified barriers to and opportunities for improving sign-out »characterized a desired process and the information that should be exchanged during sign-out

13. Tool l We designed an electronic sign-out tool using an iterative, human centered systems design process

15. Education and Training l Initially, we focused on »the type(s) of patient information that should be exchanged »a training process that emphasized the “giver” of information more than the “receiver” of information

16. Who Gives Good Sign-Out and Why? l We surveyed our residents and three residents of varying levels of experience and medical knowledge were identified as sign-out exemplars »“after signing out with them, I feel well prepared for the next call shift” »“they help me anticipate what might go wrong during my call shift” »“they give me a chance to ask questions”

17. Who Gives Good Sign-Out and Why? l We met with our three “sign-out exemplars” and conducted qualitative research about their sign-out techniques and the following themes emerged: »they always achieve “co-orientation” regardless of whether they are giving or receiving sign-out »they all have high emotional intelligence

18. Education and Training l Over time, we have realized the cognitive tasks of sign-out need to be reframed »much less emphasis on the exchange of information »much more emphasis on the development of a shared understanding and meaning of the situation at hand –situational awareness and co- orientation

19. The Cognitive Tasks of Sign-Out l For a successful sign-out, physicians handing off care and physicians assuming care must assemble a shared mental model of patients they are caring for l This co-orientation is necessary to recognize and analyze problems, to make sense of the situation, and to plan l Co-orientation also provides an opportunity for rescue and recovery (collaborative cross-checking)

20. l Clinicians need more than data to understand a patient’s story and to try and predict future trajectories l During handovers, most high-reliability organizations »exchange few data elements »adhere to the “most important first” heuristic »standardize the handover process »do NOT standardize handover content The Cognitive Tasks of Sign-Out

21. “Music is not just about the notes. Rather it is created by the spaces between the notes” Claude Debussy

22. Sign–out vs Sign Over l Culture change »from “I’m just the cross-cover” to “This is my patient right now” l Care of patients must no longer be viewed as a marathon run by a single runner, but as a relay race run by many runners »each person must run a leg of the race »you must “hand off the baton” when your leg is done »if we drop the baton, the race is lost

23. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast Paced World Stephen M. Borowitz, M.D. Linda A. Waggoner-Fountain, M.D., M.Ed. Ellen J. Bass, Ph.D. Justin DeVoge, M.S. University of Virginia