1. Accreditation Council for Graduate Medical Education Patient Hand-offs: A Medical Education Perspective Ingrid Philibert, PhD, MBA, Sr. VP, Field Activities, ACGME The greatest problem with communication is the illusion that it has been accomplished. George Bernard Shaw

2. Why is the Hand-off of Interest? Sentinel Event: Unanticipated event that results in death or serious physical or psychological injury to a patient and is not related to the natural course of the patient’s illness

3. Why is the Hand-off of Interest?(2) Across several studies communication problems implicated in 60 to 75% of all errors and adverse events Communication problems as source of errors, more prominent in teaching settings, larger number of factors implicated in each event (supervision, hand-off, team care) 1 Miscommunication incidence per ICU patient: 100% 2 Adverse effects of being cared for by cross-covering physician 3 Consequence: Reduction in errors from reduced hours may be offset by increased errors from inadequate exchange of information during the patient hand-off 1 Singh et al., Arch Intern Med, 2007 2 Mistry, K et al., University of North Carolina, ACGME Conference 2006 3 Petersen, LA et al. Ann Intern Med, 1994

4. Technology and Strategies from High- Reliability Industries Use of electronic tools improved the hand-off process 1 Use of “sign-out forms” may reduce preventable adverse events 2 End of shift transfers from high-reliability industries may offer helpful models for the patient hand-off 3 Combining hospital IT data with resident-entered details could be a powerful tool to improve hand-offs 4 Yet no practical strategies to date to connect these learnings to every-day teaching of residents 1Parker J, et al. JAMIA. 2000; 7(5): 453-61 2Petersen LA, et al. JCJQI. 1998; 24(2): 77-87 3 Patterson E, et al. Int Journ Qual Hlth Care 2004, 16: 125-132. 4 Van Eaton, E et al. Surgery 2004; 136(1): 14-5

5. 2006-08 Hand-off Study Summary Findings Hand-off is a clinical as well as a communication task Strategies from high-reliability industries are adapted to the mobile, fluid nature of residents’ work and the focus on multiple patients with differing needs for attention and care Results affirmed the importance of the interactive verbal transfer of information Time constraints, working patterns and interpersonal factors such as trust influenced the hand-off Use of short cuts: focus on plans and contingencies (suggests most of the information in current hand-off summaries is not used) Use of technology to support transfer both helpful and problematic

6. Summary Findings (2) Verbal hand-offs increasingly foregone in some settings, replaced with: hand-off by phone, outgoing leaves electronic note or paper, option to page for questions rarely used Current technology to support hand-offs not adapted to filling in for the loss off interactive exchange of information (there are open web-based approaches) After duty hour limits: Almost everything “signed out.” Two exceptions in 2006, largely eroded by 2010: staff consults, communicating with families “Read-back” not used, not effective. Instead, more subtle cueing in conversations to highlight important data Critical role of “others with extensive knowledge of the patient” in recovering information lost in the hand-off Negative effect of cross-cover (replicates Petersen et al. 1994); short shifts not associated with appreciable “loss of continuity”

7. Summary Findings: Resident Learning Process The Intern: “Everything in the hand-off is important, but I cannot remember it all or use it all in patient care.” The Mid-level Resident: “Nothing in the hand-off is important, I get my information from a fresh look at the patient (the Consult Effect).” The Senior Resident: “The information from the outgoing resident AND the patient are important. I look for the comments in the hand-off to determined who needs special vigilance. Both cues are important for sick patients.” Effect of level of training: pronounced from 1 st to 2 nd year, negligible after (handoff is learned somewhere in the first year) At more advanced levels information is evaluated based on the whether it comes from a “trusted source” (assessment based on prior interactions)

8. Odds of Errors under Different Shift Patterns, Other Factors Odds Ratio 95% CIP Value In-House Call.35.195-.630.000 Cross Cover only4.421.99-9.87.001 Call and Cross Cover6.203.106-12.390.000 Any Shift with Cross Cover4.772.416-9.407.000 AY Quarter 11.607.812-3.183.186 ICU.22.087-.558.001 Incoming Low Rating of Quality of Hand-off2.4321.201-4.931.018

9. Consequences of Hand-off “Surprises” and Errors Very Common Not knowing critical information, resulting in feeling unhelpful and loss of credibility with care team or family “Not knowing patient well” and having to look up information when the patient is deteriorating Quite Frequently mentioned Omission of or delay in tests, therapeutic interventions or discharge (“To do list errors of omission) Duplication of tests and therapies resulting in waste of time and resources (“To do list errors of commission) Rare but Concerning “Failure to Rescue” (failing to noticing a patient is deteriorating) Wrong intervention for the patient (e.g., wrong treatment or medication due to outdated or erroneous information, coding patient who is DNR)

10. State of Affairs in 2011 Teaching of hand-offs is episodic, sporadic and not connected to clinical work and teaching, despite sincere, well-meaning efforts to interpret and follow the new ACGME Standards on “Transitions in Care” More hand-off teaching and improvement work in specialties with inpatient based approaches, to address “end of shift” hand-offs Other transitions in care (hand-off from OR to ICU or unit, inter- unit, etc.) not as well addressed ACGME standards seek to address all transitions in care Faculty may not be the ideal teachers in many specialties (lack of training, and a perspective of “I do not need to hand-off, I am available to my patient 24/7”) Added value of near-peer teaching from a pedagogical perspective

11. Proposed Solution: Embedding Hand-off in Clinical Teaching A structured approach to educate residents on hand-offs via a curricular blueprint Activities to learn and improve hand-offs are progressive from internship to the end of resident and continue into the work of clinical faculty View of hand-off as entrustable professional activity (EPA) Supervision of hand-offs (direct or indirect, by more senior residents) until an entrustment decision is made based on an assessment of performance A “milestone” perspective would expect entrustment of common hand-offs in the specialty to occur by end of the first year This embeds teaching of the hand of the hand-off in the process by which other clinical skills are taught Bottom Line: Innovation in handoff education and improvement in hospital systems to support the hand-off are necessary components to adapt to an increasingly complex hospital environment

12. Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Patient Care Medical Knowledge IP & Comm. Skills Profession- alism PBLISBP Educational Lecture / Web Tutorial with Post-Test Interns XXXX Handoff Video with Formal Debriefing and Self-assessment Interns XXX Use of "iSoBAR" Handoff Checklist with Formative Feedback Interns XXXX Personalized Handoff Instruction and Formative Feedback from Senior Residents or Faculty Interns XXXXXX Handoff OSHE with Debriefing and Formative Feedback Interns XXXXXX Direct Supervision and Formative Feedback on Handoffs by Senior Resident or Faculty (until the hand-off is delegated as Entrustable Professional Activity) Interns XXXXXX

13. Competencies Taught/Assessed and Modes of Assessment (recommended assessments are shown in bold) Patient Care Medical Knowledge IP & Comm. Skills Profession- alism PBLISBP Resident-Led Morning Report with Feedback Junior/ Senior Residents XXXX Train the Trainer Session for Supervising Intern Hand-offs Jr/Sr Residents XXXX Quality audits and feedback of written or computerized hand-off notes(with Feedback), Jr/Sr Residents, Faculty XX Adapt Handoff tools and forms to local setting using process Jr/Sr Residents, Faculty XXXXXX Develop local formative and summative evaluation tools, potentially using existing models Jr/Sr Residents, Faculty XXXXXX