507330
research-article2013
AJMXXX10.1177/1062860613507330American Journal of Medical QualityAboumatar et al
Article
Focus on Transitions of Care: Description and Evaluation of an Educational Intervention for Internal Medicine Residents
American Journal of Medical Quality 2014, Vol. 29(6) 522–529 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613507330 ajmq.sagepub.com
Hanan Aboumatar, MD, MPH,1 Robert D. Allison, MD, MPH,1 Leonard Feldman, MD,1 Kevin Woods, MD,1 Patricia Thomas, MD,1 and Charles Wiener, MD1
Abstract Transitions of care between physicians and from inpatient to outpatient settings leave patients vulnerable to medical errors and adverse events. A transitions of care workshop consisting of 2 sessions, Sign-Out Success (SOS) and Transition To Home (TTH), taught sign-out and discharge skills to incoming internal medicine interns during orientation. The workshop used role-playing exercises, didactics, demonstrations, and peer and self-evaluations. Interns completed a survey at 3 months post workshop. Using pre–post workshop measures, SOS increased the quality of intern-rated sign-outs (P = .004). Interns reported more confidence in their ability to effectively sign out (P = .016) and a greater understanding of problems that might arise while on call (P = .012). TTH increased intern-reported confidence in their ability to communicate discharge instructions (P < .001) and to verify patient understanding of instructions (P < .001). A majority reported using SOS and TTH skills 3 months post workshop. This workshop may be replicable at other institutions. Keywords sign-outs, handoffs, discharges, transitions of care, physician–patient communication, sign-out success, transition to home Miscommunication among health team members and between health team members and patients during transitions of care increases the risk of patient harm.1,2 Transitions of care occur frequently during a patient’s stay at the hospital; for example, when nurses or physicians “hand off” or “sign out” responsibility for patient care to other colleagues who are covering the next shift, and on discharge when the inpatient team “hands off” the patient to an outpatient provider. Inadequate handoffs are an important contributor to medical errors and malpractice claims.3 The 2011 Accreditation Council for Graduate Medical Education requirements for limiting residents’ duty hours result in an increased number of handoffs among interns and other physician trainees, and as a result, patients are more likely to receive care from multiple physicians.4,5 There are often discrepancies in information transfer during transitions of care that have the potential to cause significant harm.6 A particularly complex and risky transition is that from hospital to ambulatory care setting. Approximately 19% of patients discharged from the hospital suffer from
adverse events within 3 weeks of discharge, and 66% of those events are medication related.7 Studies have shown an increased risk of rehospitalization when patients are inadequately prepared for discharge.8 Interventional studies providing patients with additional support services during such transitions have resulted in reduction of rehospitalization rates in the intervention groups.9-14 Recent changes in health care delivery, with trends toward shorter lengths of stay in the hospital, make addressing care transitions even more important. In many circumstances, an earlier discharge may necessitate a more complex discharge plan. Patients need to be educated on their diagnosis, treatment plan, medications, medication side effects, potential warning signs for deterioration of clinical conditions, and contingency plans. 1
Johns Hopkins University, Baltimore, MD
Corresponding Author: Hanan Aboumatar, MD, MPH, 601 N Caroline St, Suite 2080, Baltimore, MD 21287. Email: [email protected]
Downloaded from ajm.sagepub.com at The University of Iowa Libraries on June 9, 2015
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Aboumatar et al Table 1. Description of the Content and Organization of the Transitions Workshop and Its Components. Component
Time (min)
Sign-Out Success 1. Interns role-play, sign out in pairs; peer partner evaluation of sign-out qualitya 2. Didactic session 3. Sign-out video: examples of high- and low-quality sign-outs 4. Training on use of computer-based sign-out tool 5. Interns role-play again, applying what they’ve learned; peer partner reevaluation of sign-out quality Transition to Home 1. Interns role-play in pairs as patient and discharging physician; give their partner feedback 2. Didactic session 3. American Medical Association video “Health Literacy and Patient Safety: Help Patients Understand” 4. Training on use of computer-based discharge instructions tool 5. Interns role-play again, applying what they’ve learned; give their partner feedback Self-evaluationb
20 20 10 20 20 20 30 20 15 20 10
a
Table 2 presents the peer sign-out evaluation questions. Table 3 presents self-evaluation questions and results.
b
Though physicians in training play an important role in transitions of care, they receive formal education on this topic infrequently. To address this, the study team developed a workshop to prepare interns for their role in transitioning care to other physicians and preparing patients for self-management on discharge. The workshop teaches structured communication approaches for both sign-outs and discharge preparation and highlights the need to consider patients’ health literacy in patient– physician communications. Educational strategies included simulations of physician–physician and physician–patient communications at the start and end of the workshop and provision of peer feedback. The study team evaluated whether internal medicine interns who participated in an interactive workshop on transitions of care during orientation experienced increased self-efficacy and applied the skills taught during their intern year.
Methods This study was approved by the institutional review board at Johns Hopkins School of Medicine.
Educational Intervention Development The educational intervention consisted of a 4-hour workshop taught by 2 faculty members and 3 senior residents and was completed on 1 day during the residency program orientation for incoming internal medicine interns at The Johns Hopkins Hospital. The workshop included two 2-hour sessions: Sign-Out Success (SOS) and Transition To Home (TTH). Earlier versions of the SOS and TTH sessions were pilot tested separately. The sessions were then integrated and implemented as a combined workshop beginning in July 2010.
Sign-Out Success The first of the 2 sessions, SOS, focused on improving the transition of patient care between interns during signouts. Interns were taught to use a combination of verbal and written communication methods to optimize signouts. SOS also included training on the use of a computerized tool on the computerized physician order entry (CPOE) system to standardize the sign-out process. Five components were designed and implemented for the SOS session (Table 1). 1. Interns were randomly paired. Each was assigned 1 of 2 standardized cases; the interns then alternated giving and receiving verbal signout. The 2 cases, which were based on real patient scenarios, dealt with the common internal medicine service diagnoses of congestive heart failure and chronic obstructive pulmonary disease. Interns then evaluated each other’s sign-out (see Table 2 for sign-out evaluation questions). 2. Workshop faculty including senior residents led a brief didactic presentation on sign-out communication principles. The session focused on human factors and the delivery of clear, complete, and timely sign-outs. Based on literature from health care and other high-risk industries, the following aspects of effective handoffs were highlighted: (a) conducting face-to-face handoffs; (b) including both verbal and written components; (c) using a standardized, computerized template; (d) limiting interruptions; (e) verifying information received using techniques including read-back15; and (f) ensuring unambiguous transfer of
Downloaded from ajm.sagepub.com at The University of Iowa Libraries on June 9, 2015
524
American Journal of Medical Quality 29(6)
Table 2. Intern Pre–Post Evaluation of Received Sign-Out (N = 39). Strongly Agree,a n (%) Statement
Before
After
P Valueb
1. I felt confident that I knew the plan of care for each patient. 2. I knew what patients or tasks I needed to attend to first. 3. I received information about potential problems that might arise during my call period. 4. I received guidance on what to do if particular problems arise during my call period. 5. I was told (either verbally or in writing) what has or has not worked in the past for certain problems. 6. I got full information on things that I need to follow up on (eg, important pending information on labs or consultant recommendations). 7. In general, the overall quality of the sign-out was excellent.
28 (72) 21 (54) 23 (59)
33 (85) 32 (82) 32 (82)
.180 .007 .012
18 (46)
31 (79)
research-article2013
AJMXXX10.1177/1062860613507330American Journal of Medical QualityAboumatar et al
Article
Focus on Transitions of Care: Description and Evaluation of an Educational Intervention for Internal Medicine Residents
American Journal of Medical Quality 2014, Vol. 29(6) 522–529 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613507330 ajmq.sagepub.com
Hanan Aboumatar, MD, MPH,1 Robert D. Allison, MD, MPH,1 Leonard Feldman, MD,1 Kevin Woods, MD,1 Patricia Thomas, MD,1 and Charles Wiener, MD1
Abstract Transitions of care between physicians and from inpatient to outpatient settings leave patients vulnerable to medical errors and adverse events. A transitions of care workshop consisting of 2 sessions, Sign-Out Success (SOS) and Transition To Home (TTH), taught sign-out and discharge skills to incoming internal medicine interns during orientation. The workshop used role-playing exercises, didactics, demonstrations, and peer and self-evaluations. Interns completed a survey at 3 months post workshop. Using pre–post workshop measures, SOS increased the quality of intern-rated sign-outs (P = .004). Interns reported more confidence in their ability to effectively sign out (P = .016) and a greater understanding of problems that might arise while on call (P = .012). TTH increased intern-reported confidence in their ability to communicate discharge instructions (P < .001) and to verify patient understanding of instructions (P < .001). A majority reported using SOS and TTH skills 3 months post workshop. This workshop may be replicable at other institutions. Keywords sign-outs, handoffs, discharges, transitions of care, physician–patient communication, sign-out success, transition to home Miscommunication among health team members and between health team members and patients during transitions of care increases the risk of patient harm.1,2 Transitions of care occur frequently during a patient’s stay at the hospital; for example, when nurses or physicians “hand off” or “sign out” responsibility for patient care to other colleagues who are covering the next shift, and on discharge when the inpatient team “hands off” the patient to an outpatient provider. Inadequate handoffs are an important contributor to medical errors and malpractice claims.3 The 2011 Accreditation Council for Graduate Medical Education requirements for limiting residents’ duty hours result in an increased number of handoffs among interns and other physician trainees, and as a result, patients are more likely to receive care from multiple physicians.4,5 There are often discrepancies in information transfer during transitions of care that have the potential to cause significant harm.6 A particularly complex and risky transition is that from hospital to ambulatory care setting. Approximately 19% of patients discharged from the hospital suffer from
adverse events within 3 weeks of discharge, and 66% of those events are medication related.7 Studies have shown an increased risk of rehospitalization when patients are inadequately prepared for discharge.8 Interventional studies providing patients with additional support services during such transitions have resulted in reduction of rehospitalization rates in the intervention groups.9-14 Recent changes in health care delivery, with trends toward shorter lengths of stay in the hospital, make addressing care transitions even more important. In many circumstances, an earlier discharge may necessitate a more complex discharge plan. Patients need to be educated on their diagnosis, treatment plan, medications, medication side effects, potential warning signs for deterioration of clinical conditions, and contingency plans. 1
Johns Hopkins University, Baltimore, MD
Corresponding Author: Hanan Aboumatar, MD, MPH, 601 N Caroline St, Suite 2080, Baltimore, MD 21287. Email: [email protected]
Downloaded from ajm.sagepub.com at The University of Iowa Libraries on June 9, 2015
523
Aboumatar et al Table 1. Description of the Content and Organization of the Transitions Workshop and Its Components. Component
Time (min)
Sign-Out Success 1. Interns role-play, sign out in pairs; peer partner evaluation of sign-out qualitya 2. Didactic session 3. Sign-out video: examples of high- and low-quality sign-outs 4. Training on use of computer-based sign-out tool 5. Interns role-play again, applying what they’ve learned; peer partner reevaluation of sign-out quality Transition to Home 1. Interns role-play in pairs as patient and discharging physician; give their partner feedback 2. Didactic session 3. American Medical Association video “Health Literacy and Patient Safety: Help Patients Understand” 4. Training on use of computer-based discharge instructions tool 5. Interns role-play again, applying what they’ve learned; give their partner feedback Self-evaluationb
20 20 10 20 20 20 30 20 15 20 10
a
Table 2 presents the peer sign-out evaluation questions. Table 3 presents self-evaluation questions and results.
b
Though physicians in training play an important role in transitions of care, they receive formal education on this topic infrequently. To address this, the study team developed a workshop to prepare interns for their role in transitioning care to other physicians and preparing patients for self-management on discharge. The workshop teaches structured communication approaches for both sign-outs and discharge preparation and highlights the need to consider patients’ health literacy in patient– physician communications. Educational strategies included simulations of physician–physician and physician–patient communications at the start and end of the workshop and provision of peer feedback. The study team evaluated whether internal medicine interns who participated in an interactive workshop on transitions of care during orientation experienced increased self-efficacy and applied the skills taught during their intern year.
Methods This study was approved by the institutional review board at Johns Hopkins School of Medicine.
Educational Intervention Development The educational intervention consisted of a 4-hour workshop taught by 2 faculty members and 3 senior residents and was completed on 1 day during the residency program orientation for incoming internal medicine interns at The Johns Hopkins Hospital. The workshop included two 2-hour sessions: Sign-Out Success (SOS) and Transition To Home (TTH). Earlier versions of the SOS and TTH sessions were pilot tested separately. The sessions were then integrated and implemented as a combined workshop beginning in July 2010.
Sign-Out Success The first of the 2 sessions, SOS, focused on improving the transition of patient care between interns during signouts. Interns were taught to use a combination of verbal and written communication methods to optimize signouts. SOS also included training on the use of a computerized tool on the computerized physician order entry (CPOE) system to standardize the sign-out process. Five components were designed and implemented for the SOS session (Table 1). 1. Interns were randomly paired. Each was assigned 1 of 2 standardized cases; the interns then alternated giving and receiving verbal signout. The 2 cases, which were based on real patient scenarios, dealt with the common internal medicine service diagnoses of congestive heart failure and chronic obstructive pulmonary disease. Interns then evaluated each other’s sign-out (see Table 2 for sign-out evaluation questions). 2. Workshop faculty including senior residents led a brief didactic presentation on sign-out communication principles. The session focused on human factors and the delivery of clear, complete, and timely sign-outs. Based on literature from health care and other high-risk industries, the following aspects of effective handoffs were highlighted: (a) conducting face-to-face handoffs; (b) including both verbal and written components; (c) using a standardized, computerized template; (d) limiting interruptions; (e) verifying information received using techniques including read-back15; and (f) ensuring unambiguous transfer of
Downloaded from ajm.sagepub.com at The University of Iowa Libraries on June 9, 2015
524
American Journal of Medical Quality 29(6)
Table 2. Intern Pre–Post Evaluation of Received Sign-Out (N = 39). Strongly Agree,a n (%) Statement
Before
After
P Valueb
1. I felt confident that I knew the plan of care for each patient. 2. I knew what patients or tasks I needed to attend to first. 3. I received information about potential problems that might arise during my call period. 4. I received guidance on what to do if particular problems arise during my call period. 5. I was told (either verbally or in writing) what has or has not worked in the past for certain problems. 6. I got full information on things that I need to follow up on (eg, important pending information on labs or consultant recommendations). 7. In general, the overall quality of the sign-out was excellent.
28 (72) 21 (54) 23 (59)
33 (85) 32 (82) 32 (82)
.180 .007 .012
18 (46)
31 (79)
