An Institutional Handoff Effort: Guiding Future Communication Milestones and Accreditation Requirements

Background: “Handoffs” occur when the care of a patient is transitioned from one provider to another. Safe and effective handoffs are integral to patient safety and are included in multiple specialties’ ICS milestone assessments. Unfortunately, poor handoffs continue to be a major cause of medical error. Purpose: As part of an institution-wide initiative to improve transitions of care, we explored experiences related to handoffs by housestaff across multiple specialties. This data will not only help inform future ICS milestones, but also serve as a targeted needs-assessment for the development of effective institution-wide handoff curricula. Underlying cultural and/or systems-level issues that impact handoffs may be identified that are outside individual trainees’ control. Findings may indicate the need for additional resources for both training programs and institutions, and in turn guide new accreditation requirements. Methods: A survey instrument was developed and administered to housestaff at a large, university-affiliated medical center with a wide range of ACGME specialties. We explored multiple handoff elements including content, process, and potential barriers to safe and effective handoffs. A mix of question types was used: demographics, Likert-style rankings, and open-ended responses. Data analysis included quantitative and thematic qualitative methods. Results: 687/1138 (60.4%) residents and fellows responded to the survey, representing 46 training programs. Our findings suggest wide variability in handoff content and process, notably code status not being reliably mentioned 34.7% of the time for patients who were not full code. Supervision of handoffs by attendings or senior residents commonly occurred only 39.4% of the time. 60% of respondents asked for a standardized patient hand-off tool or mnemonic. Our thematic analysis identified 5 important aspects of handoffs described by subjects: 1) handoff structure, 2) impact, 3) systems-level factors, 4) agency, and 5) blame/shame. Conclusions: Individual and systems-issues affect handoff communication. Our findings indicate a need for institution-wide training of providers that emphasizes the process and impact of handoff communications. Culture and systems-issues must be addressed, as an undercurrent of blame and shame permeates the work environment. Further study and increased programmatic and institutional -level support and resources are necessary to address this ongoing threat to patient safety and source of medical errors.