Handoffs in Teaching Hospitals: Situation, Background, Assessment, and Recommendation

Abstract

In July 2003, the Accreditation Council on Graduate Medical Education implemented duty hour regulations in all residency training programs. A direct result of these restrictions has been an increase in the discontinuity of care to inpatients in US teaching hospitals. This new model underscored the importance of transfers of care, or handoffs, from physician to physician. In 2007, the Joint Commission placed an additional emphasis on handoffs when it required a standardized handoff process for hospital accreditation. In December 2008, the Institute of Medicine report called for more stringent limits to resident duty hours that may further fragment patient care if implemented.1Ulmer C. Wolman D.M. John M.M. Institute of Medicine: Resident Duty Hours—Enhancing Sleep, Supervision and Safety. National Academies Press, Washington, DC2009Google Scholar This article aims to provide a framework to understand the critical issues embedded within the handoff process in teaching hospitals, highlight what has been learned to date, and make recommendations about where medical educators need to go from here. To provide a frame for content, we use the frequently cited SBAR method (Situation, Background, Assessment, Recommendation) for demonstration.2Haig K.M. Sutton S. Whittington J. SBAR: a shared mental model for improving communication between clinicians.Jt Comm J Qual Patient Saf. 2006; 32: 167-175PubMed Scopus (527) Google ScholarPerspectives Viewpoints•Duty hours regulation has resulted in increased discontinuity of care among inpatients in US teaching hospitals.•Joint Commission regulations require a standardized handoff process for hospital accreditation.•Maintaining continuity of care in the face of regulatory action requires increased relationship building among caretakers, and continuous review and improvement of the systems established for handoffs.SituationA handoff is defined herein as the interaction, communication, and planning required to achieve seamless transition of care from one clinician to another. A handoff transfers information as well as responsibility for the care of the patient from one provider to another. It can occur between nurses, between physicians, or among different health care providers. For teaching hospitals, handoffs overwhelmingly occur within the inpatient hospital setting.The complex work environment in US teaching hospitals includes 5 main competing factors that contribute to the challenges to delivering consistent, reliable, effective handoffs, including duty hours regulation, increased documentation requirements for billing, the hospitalist movement, high bed utilization in hospitals, and the nursing shortage. Each of these issues has a direct influence on the learning environment of teaching hospitals and potentially erodes the team dynamics and relationship component required for best practice care. Lack of teamwork and sense of community in these settings is an important but under-recognized component of the handoff process.BackgroundIn 2003, when the Accreditation Council on Graduate Medical Education mandated duty hours regulation for all postgraduate residency training programs, training programs responded by creating more shift work assignments, including day-float or night-float rotations.3Accreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education website.www.acgme.orgGoogle Scholar As a result, the number of handoffs and the associated risks of poor transitions in care have increased.4Arora V. Johnson J. Lovinger D. et al.Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.Qual Saf Health Care. 2005; 14: 401-407Crossref PubMed Scopus (428) Google Scholar, 5Horwitz L.I. Meredith T. Schuur J.D. et al.Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.Ann Emerg Med. 2009; 53: 701-710Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar The “handoff movement” seems to be a direct result of duty hours regulation, with more literature on the subject in the past 5 years than in the prior 25 years. Studies examining the duty hour effects on patient outcomes have demonstrated mixed results, while less data are available about the regulatory effects on resident learning, ownership and responsibility for patients, and medical professionalism.6Volpp K.G. Rosen A.K. Rosenbaum P.R. et al.Mortality among hospitalized beneficiaries in the first 2 years following ACGME resident duty hour reform.JAMA. 2007; 298: 975-983Crossref PubMed Scopus (261) Google Scholar, 7Volpp K.G. Rosen A.K. Rosenbaum P.R. et al.Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.JAMA. 2007; 298: 984-992Crossref PubMed Scopus (219) Google ScholarAn additional regulatory change occurred in the mid-1990s when the Center for Medicare Services launched administrative standards for billing and coding, with several high-profile fraud cases against prominent teaching hospitals. Strict regulations in documentation for teaching physicians were required to reimburse the hospital for services. Unfortunately, the net effect is more paperwork and charting for teaching physicians to document for billing and coding purposes versus providing the care and the appropriate level of supervision for physicians-in-training. Teaching of residents has suffered with a shift in team dynamics.8Farnan J.N. Johnson J.K. Meltzer D.O. et al.On-call supervision and resident autonomy: from micromanager to absentee attending.Am J Med. 2009; 122: 784-788Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The focus on documentation shifted the teaching attending's time to note-writing instead of bedside teaching. For early adopters of electronic medical records, computerized notes added to the time burden.In 1996, the hospitalist movement gained momentum. The business model of health care requires efficiency, so hospitals hired physicians to streamline throughput with early evidence of success.9Rifkin W.D. Holmboe E. Scherer H. Sierra H. Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics.J Gen Intern Med. 2004; 19: 1127-1132Crossref PubMed Scopus (37) Google Scholar, 10Everett G.D. Anton M.P. Jackson B.K. et al.Comparison of hospital costs and length of stay associated with general internists and hospitalist physicians at a community hospital.Am J Manag Care. 2004; 10: 626-630PubMed Google Scholar Since then, the number of hospitalists has skyrocketed, including nighttime positions in teaching hospitals to provide supervision for learners and to capture the lost billings of nighttime procedures.11Wachter R.M. Reflections: the hospitalist movement a decade later.J Hosp Med. 2006; 1: 248-252Crossref PubMed Scopus (36) Google Scholar, 12Freed D.H. Hospitalists: evolution, evidence, and eventualities.Health Care Manag (Frederick). 2004; 23: 238-256PubMed Google Scholar The hospitalist's high-pace, high-demand job has led to a high rate of turnover and burnout.13Hoff T. Whitcomb W.F. Nelson J.R. Thriving and surviving in a new medical career: the case of hospitalist physicians.J Health Soc Behav. 2002; 43: 72-91Crossref PubMed Scopus (40) Google Scholar To stabilize this work force and improve job satisfaction, hospitalist programs have adopted intermittent schedules (eg, 7 days on/7 days off or 14 days on/14 days off). With shorter shifts and assignments of work, hospitalists have less time to be engaged in hospital improvement processes. In teaching hospitals, they are often enlisted to cover for housestaff absences (eg, postcall days, days off, resident clinic). The frequent hospitalist handoffs generally do not coincide with the residency schedules, so a complex system of multiple handoffs without consistent standardization has emerged as the norm.Hospitals have consolidated beds and nursing units to save money, leading to higher bed utilization (sometimes running at over 90% bed occupancy). Without flexible capacity, assigning patients to geographic units is difficult and requires physicians to manage patients on multiple wards, on multiple floors of the hospital, and with a different care team for each patient. Advances in therapeutic and monitoring device technology compound this problem because patients must be in specialized hospital units to receive the services. Patients are transferred in and out of these beds as their care dictates. The resulting algorithm of bed assignment for patients has a ripple effect on how many times a patient is transferred from one room or unit to another. Each transition of care requires a handoff among nurses, physicians, and other health care personnel.Nursing shortages create further complexity with more float nurses and higher patient-to-nurse ratios. The lack of experienced nurses doing floor work puts greater responsibility on novice nurses who have less-developed clinical judgment. In addition, gaps occur when novice nurses communicate with more seasoned nurses who might use colloquialisms, short cuts, and slang in the handoff process.AssessmentScholarly interest in handoffs has increased substantially since 2004, with much of the effort focusing on creating a standardized process or defining qualities of an effective handoff.14Vidyarthi A.R. Arora V. Schnipper A.L. et al.Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.J Hosp Med. 2006; 1: 257-266Crossref PubMed Scopus (220) Google Scholar, 15Solet D.J. Norvell J.M. Rutan G.H. Frankel R.M. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.Acad Med. 2005; 80: 1094-1099Crossref PubMed Scopus (377) Google Scholar In fields such as nuclear power, recombinant DNA research, and aviation, much research has been done on ways to train and ensure highly reliable handoff processes.16Patterson E.S. Roth E.M. Woods D.D. et al.Handoff strategies in setting with high consequences for failure: lessons for health care operations.Int J Qual Health Care. 2004; 16: 125-132Crossref PubMed Scopus (381) Google ScholarThe authors have facilitated workshops at 2 internal medicine meetings on the topic of handoffs to understand the process within the context of housestaff training and safe patient care. The collected wisdom of the medical educators who attended our workshops provided a thorough discussion of the topic. While standardizing the elements, developing tools (eg, templates and technology), and teaching residents best practices will contribute to high-quality handoffs, they are not the whole story. An additional relationship component requires some attention.A handoff is an organized dialogue in which authority and responsibility for the care of patients is transferred from one individual to another, yet in videotapes collected by the authors of almost 20 handoffs involving over 100 different patients, few involved a 2-way conversation. The person receiving the handoff rarely interjected or questioned the giver, and only occasionally clarified a detail in the process. The dialogue has somehow become a monologue, with minimization of the relationship between giver and receiver. The fragmented shifts, wide geographic distribution of patients in the hospital, and transient assignment of nurses and physicians to specific units has created considerable uncertainty and unfamiliarity in health care. Improving teamwork and building relationships is an additional strategy for improving handoffs.The authors provide the following framework for other teaching hospitals and training programs to consider in their efforts to address the handoff competency. Four major domains to the handoff process can be simply remembered with the mnemonic TEAM: time, elements, anticipation, and mutual trust.Time barriers clearly inhibit effective handoffs. Competing demands create constant interruptions and can introduce geographic distance between the giver and receiver of information. For example, the inpatient physician leaving the hospital may need to hand off to a provider in a distant outpatient continuity clinic who is on call for the evening but has not completed office hours. As an important component of work, distinct time for the handoff process should be allocated.Identifying the specific elements has been a frequent approach to improving handoffs. A number of different mnemonics have been proposed in the literature.17Riesenberg L.A. Leitzsch J. Little B.W. Systematic review of handoff mnemonics literature.Am J Med Qual. 2009; 24: 196-204Crossref PubMed Scopus (233) Google Scholar There is no “one-size-fits-all” solution for this problem, given the variety of electronic medical record systems and information technology solutions that health care systems have adopted. The standardization and organization of information must be agreed upon by local consensus and accurately reflect the content that providers value for the specific venue.The third component, anticipatory management, includes understanding a patient's condition and severity, coupled with good clinical judgment to anticipate what might occur during an upcoming shift. Physicians should be trained in handoffs just as they are in medical content. The focus of such training should be for outgoing providers to predict and prioritize patient care needs to help the receiver of the information plan accordingly.Mutual trust is the last component. Mutual trust includes shared accountability and exchange of information that adjusts for different levels of expertise and provides a level platform for teaching and learning. It requires an open, honest exchange of information without hierarchy that allows frank questions to be asked without fear of embarrassment or humiliation.RecommendationThese 4 domains describing the TEAM components are outlined in detail in the Table, with suggested strategies to target each one to improve the handoff process. Each unique teaching hospital might prioritize one element over another, but collectively, the framework is quite transferable to different systems. Handoffs are more than just tools; they should provide an opportunity for relationship-centered care and teamwork. Teamwork around handoffs, as described in the nursing literature, is required for effective, safe, and patient-centered coordination of care.18Shendell-Falid N. Feinson M. Mohr B.J. Enhancing patient safety: improving the patient handoff process through appreciative inquiry.J Nurs Adm. 2007; 37: 95-104Crossref PubMed Scopus (53) Google Scholar Effective handoffs require both trust and confidence in the reliability of the information received. Trust demands a relationship, a connection between the giver and receiver of information, while confidence implies a reliance on the integrity of the information. Trust and confidence must therefore be firmly rooted in the bond between the 2 parties. Handoffs can represent an Achilles' heel for hospital care in the 21st century because relationships are the element most at risk in today's complex health care environment. Efforts to reinforce rapport among health care providers working together might be the secret ingredient to overcoming this challenge.TableSpecific Handoff Barriers and Proposed Suggestions to Eliminate BarriersHandoff BarriersProposed SuggestionsTime barriers Time pressuresPart of work flow not added on InterruptionsEnsure designated face-to-face handoff time Competing demandsEfficient and sustainable Too many other patientsCaps for total number of patients per physician Efficiency related to information Efficiency related to workWalk rounds in patient rooms for handoffElements/required information Outdated informationIT solutions for dynamic updated information (share between RN/MD) Lack of standardizationStandardization for purpose No agreement on required elementsAgreed upon templatesContent-specific (ICU vs ward) Need for HIPAA-compliant, secure system Understanding what is handoff eligible Understanding what is not handoff eligible Information overloadIT solutions for accessibility/organization;IT interface to be user-drivenAnticipatory management Understanding patient's condition/severitySickest patients first Clinical judgment: anticipate issuesInclude “why” information No training in handoffsCreate formal curricula to teach handoff processMutual trust Inherent ownership No supervision for trainees' skillsInclude different levels of expertise No agreement on professional behavior (serial handoff) Sign back in, closing the loopFeedback as part of formation process to improve the skill No exchange back and forthMake handoffs interdisciplinary Who is covering whomGeographic coverage, streamline assignmentsIT=information technology; RN=registered nurse; MD=medical doctor; ICU=Intensive Care Unit; HIPAA=Health Insurance Portability and Accountability Act. Open table in a new tab The “perfect” handoff process does not yet exist. It might be a combination of written or electronic documents and verbal discussions in the context of well-connected teams. In addition to the mechanics of creating optimal handoffs, deliberate partnerships between the givers and receivers of information will be required with efforts to improve the relationship between them. Promoting and fostering connections built on trust and confidence will improve handoffs. These personal bonds can subsequently take into account the various levels of provider competence and mastery and reinforce the reliability of the information.19Lanham H.J. McDaniel R.R. Crabtree B.F. et al.How improving practice relationship among clinicians and nonclinicians can improve quality in primary care.Jt Comm J Qual Patient Saf. 2009; 35: 457-466PubMed Google Scholar Information technology tools and mnemonics can certainly help with the necessary components of a handoff; however, we believe that the focus should be on the relational process and the shared responsibility required for safe patient care rather than the tool itself.20Jeffcott S.A. Evans S.M. Cameron P.A. et al.Improving measurement in clinical handover.Qual Saf Health Care. 2009; 18: 272-276Crossref PubMed Scopus (103) Google Scholar Much like a relay race, the handoff process will need to be practiced, deconstructed, and reconstructed to ensure high reliability and coordination.ConclusionsFinding a way to coordinate patient care means building teams and strong relationships between the team members. Starting at the student level, physicians and nurses should learn teamwork and collaboration. Team-based learning and novel applications using simulation offer rich tools to teach and evaluate such skills. Inter-professional relationships, such as those between nurses and physicians, need to be studied and nurtured. Having residents understand the importance of working as a team with other disciplines will help handoffs become part of the daily culture. Team members should reflect on and “debrief” previous suboptimal handoffs in an effort to improve the handoff process for future patients.Because health care professionals inherently exercise empathy and personal connections with patients, it should be an easy transition to shift these relational skills toward each other, but the culture also must shift to support it. This new culture must support collaboration and should work to minimize the lines of distinction and “silos” embedded in tradition. Curricular efforts and quality improvement projects on the handoff process should focus on TEAM. The key is to master the teamwork process, not the team-specific process. Whether through appreciative inquiry, learning huddles, staff development through simulation, or interdisciplinary handoff rounds, providers need to embrace teamwork and collegiality, and hospital systems need to work on building community and connection as part of safety improvement efforts. In July 2003, the Accreditation Council on Graduate Medical Education implemented duty hour regulations in all residency training programs. A direct result of these restrictions has been an increase in the discontinuity of care to inpatients in US teaching hospitals. This new model underscored the importance of transfers of care, or handoffs, from physician to physician. In 2007, the Joint Commission placed an additional emphasis on handoffs when it required a standardized handoff process for hospital accreditation. In December 2008, the Institute of Medicine report called for more stringent limits to resident duty hours that may further fragment patient care if implemented.1Ulmer C. Wolman D.M. John M.M. Institute of Medicine: Resident Duty Hours—Enhancing Sleep, Supervision and Safety. National Academies Press, Washington, DC2009Google Scholar This article aims to provide a framework to understand the critical issues embedded within the handoff process in teaching hospitals, highlight what has been learned to date, and make recommendations about where medical educators need to go from here. To provide a frame for content, we use the frequently cited SBAR method (Situation, Background, Assessment, Recommendation) for demonstration.2Haig K.M. Sutton S. Whittington J. SBAR: a shared mental model for improving communication between clinicians.Jt Comm J Qual Patient Saf. 2006; 32: 167-175PubMed Scopus (527) Google Scholar •Duty hours regulation has resulted in increased discontinuity of care among inpatients in US teaching hospitals.•Joint Commission regulations require a standardized handoff process for hospital accreditation.•Maintaining continuity of care in the face of regulatory action requires increased relationship building among caretakers, and continuous review and improvement of the systems established for handoffs. •Duty hours regulation has resulted in increased discontinuity of care among inpatients in US teaching hospitals.•Joint Commission regulations require a standardized handoff process for hospital accreditation.•Maintaining continuity of care in the face of regulatory action requires increased relationship building among caretakers, and continuous review and improvement of the systems established for handoffs. SituationA handoff is defined herein as the interaction, communication, and planning required to achieve seamless transition of care from one clinician to another. A handoff transfers information as well as responsibility for the care of the patient from one provider to another. It can occur between nurses, between physicians, or among different health care providers. For teaching hospitals, handoffs overwhelmingly occur within the inpatient hospital setting.The complex work environment in US teaching hospitals includes 5 main competing factors that contribute to the challenges to delivering consistent, reliable, effective handoffs, including duty hours regulation, increased documentation requirements for billing, the hospitalist movement, high bed utilization in hospitals, and the nursing shortage. Each of these issues has a direct influence on the learning environment of teaching hospitals and potentially erodes the team dynamics and relationship component required for best practice care. Lack of teamwork and sense of community in these settings is an important but under-recognized component of the handoff process. A handoff is defined herein as the interaction, communication, and planning required to achieve seamless transition of care from one clinician to another. A handoff transfers information as well as responsibility for the care of the patient from one provider to another. It can occur between nurses, between physicians, or among different health care providers. For teaching hospitals, handoffs overwhelmingly occur within the inpatient hospital setting. The complex work environment in US teaching hospitals includes 5 main competing factors that contribute to the challenges to delivering consistent, reliable, effective handoffs, including duty hours regulation, increased documentation requirements for billing, the hospitalist movement, high bed utilization in hospitals, and the nursing shortage. Each of these issues has a direct influence on the learning environment of teaching hospitals and potentially erodes the team dynamics and relationship component required for best practice care. Lack of teamwork and sense of community in these settings is an important but under-recognized component of the handoff process. BackgroundIn 2003, when the Accreditation Council on Graduate Medical Education mandated duty hours regulation for all postgraduate residency training programs, training programs responded by creating more shift work assignments, including day-float or night-float rotations.3Accreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education website.www.acgme.orgGoogle Scholar As a result, the number of handoffs and the associated risks of poor transitions in care have increased.4Arora V. Johnson J. Lovinger D. et al.Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.Qual Saf Health Care. 2005; 14: 401-407Crossref PubMed Scopus (428) Google Scholar, 5Horwitz L.I. Meredith T. Schuur J.D. et al.Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.Ann Emerg Med. 2009; 53: 701-710Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar The “handoff movement” seems to be a direct result of duty hours regulation, with more literature on the subject in the past 5 years than in the prior 25 years. Studies examining the duty hour effects on patient outcomes have demonstrated mixed results, while less data are available about the regulatory effects on resident learning, ownership and responsibility for patients, and medical professionalism.6Volpp K.G. Rosen A.K. Rosenbaum P.R. et al.Mortality among hospitalized beneficiaries in the first 2 years following ACGME resident duty hour reform.JAMA. 2007; 298: 975-983Crossref PubMed Scopus (261) Google Scholar, 7Volpp K.G. Rosen A.K. Rosenbaum P.R. et al.Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.JAMA. 2007; 298: 984-992Crossref PubMed Scopus (219) Google ScholarAn additional regulatory change occurred in the mid-1990s when the Center for Medicare Services launched administrative standards for billing and coding, with several high-profile fraud cases against prominent teaching hospitals. Strict regulations in documentation for teaching physicians were required to reimburse the hospital for services. Unfortunately, the net effect is more paperwork and charting for teaching physicians to document for billing and coding purposes versus providing the care and the appropriate level of supervision for physicians-in-training. Teaching of residents has suffered with a shift in team dynamics.8Farnan J.N. Johnson J.K. Meltzer D.O. et al.On-call supervision and resident autonomy: from micromanager to absentee attending.Am J Med. 2009; 122: 784-788Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The focus on documentation shifted the teaching attending's time to note-writing instead of bedside teaching. For early adopters of electronic medical records, computerized notes added to the time burden.In 1996, the hospitalist movement gained momentum. The business model of health care requires efficiency, so hospitals hired physicians to streamline throughput with early evidence of success.9Rifkin W.D. Holmboe E. Scherer H. Sierra H. Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics.J Gen Intern Med. 2004; 19: 1127-1132Crossref PubMed Scopus (37) Google Scholar, 10Everett G.D. Anton M.P. Jackson B.K. et al.Comparison of hospital costs and length of stay associated with general internists and hospitalist physicians at a community hospital.Am J Manag Care. 2004; 10: 626-630PubMed Google Scholar Since then, the number of hospitalists has skyrocketed, including nighttime positions in teaching hospitals to provide supervision for learners and to capture the lost billings of nighttime procedures.11Wachter R.M. Reflections: the hospitalist movement a decade later.J Hosp Med. 2006; 1: 248-252Crossref PubMed Scopus (36) Google Scholar, 12Freed D.H. Hospitalists: evolution, evidence, and eventualities.Health Care Manag (Frederick). 2004; 23: 238-256PubMed Google Scholar The hospitalist's high-pace, high-demand job has led to a high rate of turnover and burnout.13Hoff T. Whitcomb W.F. Nelson J.R. Thriving and surviving in a new medical career: the case of hospitalist physicians.J Health Soc Behav. 2002; 43: 72-91Crossref PubMed Scopus (40) Google Scholar To stabilize this work force and improve job satisfaction, hospitalist programs have adopted intermittent schedules (eg, 7 days on/7 days off or 14 days on/14 days off). With shorter shifts and assignments of work, hospitalists have less time to be engaged in hospital improvement processes. In teaching hospitals, they are often enlisted to cover for housestaff absences (eg, postcall days, days off, resident clinic). The frequent hospitalist handoffs generally do not coincide with the residency schedules, so a complex system of multiple handoffs without consistent standardization has emerged as the norm.Hospitals have consolidated beds and nursing units to save money, leading to higher bed utilization (sometimes running at over 90% bed occupancy). Without flexible capacity, assigning patients to geographic units is difficult and requires physicians to manage patients on multiple wards, on multiple floors of the hospital, and with a different care team for each