By Jennifer J. Salopek
Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, so patients will inevitably be cared for by many different providers during hospitalization… [M]ultiple physicians may be responsible for a patient’s care at different times of the day. This discontinuity creates opportunities for error when clinical information is not accurately transferred between providers… The problems posed by handoffs of care have gained more attention since the 2003 implementation of regulations limiting housestaff duty hours, which has led to greater discontinuity among resident physicians.
This reality, and the many innovations designed to ameliorate it, is focused on inpatient handoffs. But in a prescient move, staff in the University of Chicago’s Pritzker School of Medicine recognized that transitions of care take place in a clinic, i.e. outpatient, environment as well. Their re-engineered handoff process, which places patients squarely at the center of their care, has been named a winner in the AAMC’s 2012 Readiness for Reform Innovation Challenge.
This winning entry was submitted by a team led by Amber T. Pincavage, MD, former ambulatory chief resident and current clerkship director, and Vineet M. Arora, MD, MAPP, associate program director. In their case submission, they wrote:
Every July, approximately 1 million patients experience a transition of primary care when residents graduate from training. Several studies, including our own, highlight the increased harm patients face after resident clinic handoffs, such as care delays, loss to follow-up, missed test results, and acute care visits.
“I had received handoffs as a year 2 resident, and found taking over very difficult,” explains Pincavage. “These patients are often quite sick, and had been seeing their previous doctor for up to three years. They often didn’t come back to the clinic, resulting in delays of care, or presented in the emergency department not knowing who their doctor was.”
The clinic staff conducted research to find out the nexus and nature of the issue, and determined that as many as 20 percent of patients were lost to follow-up after handoff. They also surveyed residents, asking, “When is a patient yours?” and found that most residents assumed responsibility for patients at the first visit, not at the handoff stage.
In redesigning the handoff process, the team had several goals:
- to improve resident knowledge about the patient risks of clinic handoffs
- to educate departing residents abut effective handoff and sign-out techniques in the clinic
- to educate junior residents about effective methods to assume care for patients during the transition
- to improve resident professional responsibility during clinic handoffs
- to improve patient safety during resident clinic handoffs
- to improve patient-centered care during resident clinic handoffs and increase patient satisfaction.
The team focused its efforts on 100 high-risk patients for the redesigned handoff process, which includes several key elements:
- standardized sign-out templates for pending tests and patient information
- training for departing residents in executing verbal handoffs
- coordination with clinic schedulers to prioritize scheduling and rescheduling of the patients in the cohort
- a transition orientation packet for patients
- “telephone visits” by new residents.
The redesigned process was aided by establishing earlier, longer-term relationships between departing residents and junior residents. In the winter of 2011, departing residents each selected a junior resident to assume their patient panel the following July. The departing residents received training on how to select high-risk patients and complete sign-outs; the importance of these steps was underscored by a teaching video, “Falling Through the Cracks,” and a small group exercise. The team created a job aid: laminated pocket cards called “Clinic Safe” that include ten handoff tips to help residents remember areas to focus on during the handoff.
Junior residents were trained on how to conduct the “telephone visits” and provided with a script, as well as protected time during clinic hours to make the calls. “We had dedicated handoff time in lieu of lectures,” says Pincavage. “We thought it was really important to make the space for this to happen.”
In 2012, patients became part of the solution. Pincavage, Arora, and their team interviewed more than 100 patients about their experiences after the clinic handoff, with a focus on barriers faced and adverse events. They also examined patient-identified solutions and developed a patient transition packet that includes several tools, and refined them after input from focus groups. These tools, plus the educational video and the pocket card, are available on the AAMC iCollaborative.
The intervention improved the number of high-risk patients seen by the correct resident in a timely manner and may have reduced acute visits in the emergency room and hospital. Improvement in adherence to handoff and sign-out practices, as well as professional responsibility for patients, was observed. However, the program has yet to result in significant improvement in the number of patients lost to follow-up six months after the handoff.
The redesigned process earned high marks from the distinguished panel of judges who reviewed this year’s Innovation Challenge submissions. They cited it particularly for its positive impact on processes that are important to patient care, and for its easy replicability by other institutions.
The number of patients lost to follow-up continues to nag. “Patient factors may be responsible and warrant further investigation regarding missed visits and other barriers,” Pincavage and Arora wrote in their submission. Plans to surmount these barriers include a patient-empowerment comic book and a patient-centered teaching video.
–Jennifer J. Salopek is managing editor of Wing of Zock. She can be reached at firstname.lastname@example.org.