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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20

Systematic Training in Internal Medicine-Pediatrics End of Residency Handoffs: Residency Director Attitudes and Perceived Barriers a

a

Michael J. Donnelly , Janelle M. Clauser & Rochelle E. Tractenberg

b

a

Department of Medicine and Pediatrics, Medstar Georgetown University Hospital , Washington , DC , USA b

Departments of Neurology, Georgetown University Medical Center , Washington , DC , USA Published online: 09 Jan 2014.

Click for updates To cite this article: Michael J. Donnelly , Janelle M. Clauser & Rochelle E. Tractenberg (2014) Systematic Training in Internal Medicine-Pediatrics End of Residency Handoffs: Residency Director Attitudes and Perceived Barriers, Teaching and Learning in Medicine: An International Journal, 26:1, 17-26, DOI: 10.1080/10401334.2013.857334 To link to this article: http://dx.doi.org/10.1080/10401334.2013.857334

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Teaching and Learning in Medicine, 26(1), 17–26 C 2014, Taylor & Francis Group, LLC Copyright  ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.857334

Systematic Training in Internal Medicine-Pediatrics End of Residency Handoffs: Residency Director Attitudes and Perceived Barriers Michael J. Donnelly and Janelle M. Clauser Department of Medicine and Pediatrics, Medstar Georgetown University Hospital, Washington, DC, USA

Rochelle E. Tractenberg

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Departments of Neurology, Georgetown University Medical Center, Washington, DC, USA

study found that residents were readily able to identify highrisk patients to hand off and that many patients fail to follow up with the correct provider or even at all.15 Our own prior multicenter trial of an e-mail intervention increased the number of formal signouts in an electronic medical record for high-risk patients in Internal Medicine, Family Medicine, and Combined Internal Medicine-Pediatrics (Med-Peds) clinics.16 No studies as of yet have shown patient outcomes to improve due to these formal systems, although adverse events associated with their absence have been previously documented.11 The Accreditation Council on Graduate Medical Education (ACGME) requires that residency curricula “must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety” and “must ensure that residents are competent in communicating with team members in the hand-over process.”17 This is important to training professionalism because end-of-residency handoffs teach physicians to perform handoffs when leaving a practice, changing sites, or retiring. However, in a prior study we found that less than half of Med-Peds residency programs have structured outpatient handoff protocols and estimated that they are present in even fewer categorical Internal Medicine and Pediatrics programs.18 Handoff systems are not ubiquitous, and little is known as to why. No studies have looked at what barriers exist to implementing structured handoff systems within residency programs.

Background: It is unclear why systematic training in end-ofresidency clinic handoffs is not universal. Purposes: We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors’ attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation. Methods: We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems. Results: Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04). Conclusions: Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes. Keywords

patient handoffs, physician communication, graduate medical education

BACKGROUND Ambulatory patient handoff communication is not well studied, despite a growing body of inpatient handoff research.1–6 These handoffs were first identified by Young as a safety concern, as thousands of residents graduate from continuity clinic and transition an estimated 1 million patients per year to new providers.7 The few studies of year-end continuity clinic handoffs from psychiatry and internal medicine departments have focused on identifying patient satisfaction indicators,8,9 balancing residents’ caseloads at the beginning of residency,10 and utilizing a standardized system to hand off patients.11–15 One

PURPOSES To identify factors for what seems to be a gap between the ACGME goals and what exists in residency training, we surveyed Med-Peds program directors’ attitudes toward outpatient handoffs and barriers impeding their performance, because program directors would be responsible for overseeing the implementation of these systems. Med-Peds programs are an excellent convenience sample of institutions throughout the country, due to their geographic and community/academic distribution, because of their focus on primary care, and due to the fact that 4 years allows for longer continuity clinic relationships.

We thank Michael Adams, MD; Amy Burke, MD; Patrick Donnelly, PhD; and Jason Umans, MD, for their assistance with this manuscript. Correspondence may be sent to Michael J. Donnelly, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA. E-mail: [email protected]

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METHODS Survey Design We created a survey (described in a previous publication)18 to assess program director attitudes towards the value of, and perceived barriers to, ambulatory handoff systems in MedPeds residencies throughout the country. The survey instrument design and the instrument itself have been described elsewhere.18 Briefly, we developed a 12-item instrument for Med-Peds program directors to assess end of academic year continuity clinic handoffs in U.S. Med-Peds residencies. Because we found no validated surveys on outpatient handoff systems, we created one based on Young’s discussion of important elements,11 our own previous research,13 and discussion with experts on handoffs (senior clinicians and program directors in our institution). Survey items were designed to capture information in several areas: the presence or absence of a formal handoff system in their residency, specific characteristics of the program, program director attitudes regarding the importance of handoffs, barriers to systemic implementation, and factors affecting whether such a system is or would be important for their program. A prior publication focuses specifically on the presence and characteristics of these systems,18 whereas this article focuses on program director attitudes toward the systems and the identification of potential barriers to their implementation. The Georgetown University Institutional Review Board approved this protocol. Setting and Administration As described previously,18 we identified all 79 residency programs through Freida Online (American Medical Association, Chicago, IL).19 Med-Peds program directors and associate program directors at the 2011 national Med-Peds Program Directors Association meeting were asked to complete a paper survey. The nonresponding programs (N = 48) were sent a link to the Internet-based survey via e-mail (SurveyMonkey.com, LLC, Palo Alto, CA), and we collected data from April to October of 2011. Attitudes were assessed using a 5-point Likert rating scale, but given the ordinal nature of the data, responses were analyzed by treating responses as dichotomous variables with somewhat important and very important being treated as positive, and neutral, somewhat unimportant, and very unimportant considered as negative responses to each item. We set out to determine whether the presence or absence of a handoff system was related to the perception of handoff importance and to possible barriers that may impede formalizing the outpatient handoff procedure for graduating residents. The full Likert rating response distributions (Figures 1–3) and the calculated median of the Likert ratings are presented in the complete data table in the appendix. To facilitate interpretability of the survey results, we analyzed responses using Fisher’s ex-

act testing with an internet tool (www.graphpad.com; GraphPad Software, La Jolla, CA). For each item in the survey (as shown in Table 1), we computed the chi-square statistic on the 2 × 2 contingency table for ratings of positive (important) versus negative (unimportant/neutral) in those programs with and without formal systems. All planned comparisons focused on differences between programs with and without formal systems, (maintaining the per-comparison error rate [alpha] at 0.05). Thus, we did not correct for multiple comparisons. RESULTS Response Rate Sixty-seven of the seventy-nine (84.8%) Med-Peds residency programs in the United States completed the survey. One program director answered the first question but failed to complete the rest of the survey. Formal handoff systems were reported to be present in 31 of the 67 combined Med-Peds programs that responded (46.3%). Attitudes, Perceptions, and Barriers to Handoff Systems Program directors tended to characterize formal outpatient handoffs as important, with 53 of 64 respondents (82.8%) stating that they were somewhat or very important (see Figure 1). Only 11 respondents (17.2%) characterized the formal performance of outpatient handoffs as neutral, very, or somewhat unimportant nationwide. Significantly more programs with (28/30, 93.5%) than without (25/34, 73.5%) formal systems characterized the process as important (p = .049; see Table 1). Notably, nine programs without handoff systems gave negative responses as to whether handoffs were important, but only one rated handoffs as “very unimportant,” and seven of nine negative responses were “neutral.” Conversely, only two programs with a handoff system did not characterize them as important and they both rated the process as “very unimportant.” We asked program directors to rate five factors for their contributions to the importance of such systems; this data can be found in Figure 2. There were significant differences between program directors’ perceptions of barriers in programs that do have formal handoff systems in place compared to those that do not, as shown in Table 1. The final question on the survey asked program directors to identify reasons why a formal handoff system would not be helpful; these are listed in Figure 3. Of the barriers listed in this item, significantly greater importance was ascribed to a lack of faculty interest (p = .011) and an inability to identify the resident as the primary provider (p = .024) by those programs that did not have a formal system. One item in the survey was open ended, asking for “other” reasons or factors for the presence or absence of a handoff system. Free text responses (given by 28 of the 67 respondents) touched upon many different handoff-related issues. Five program directors suggested that the timing of graduation and the

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BARRIERS TO TRAINING RESIDENCY HANDOFFS

FIG. 1.

2011 Med-Peds program director attitudes about the importance of several factors related to outpatient handoffs.

busy orientation of the new PGY-1 residents are barriers to effective communication. Four programs cited lack of continuity as an issue because they have difficulty identifying the resident as the primary provider. In addition, four program directors stated that if the medical record is up to date, there is

no need to hand off patients. Four clinics utilized an attendingresident comanagement model; their program directors reasoned that because attending continuity already exists, the need for a resident handoff is minimal. Two noted that attendings in their institutions also do not hand off patients upon leaving the

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M. J. DONNELLY, J. M. CLAUSER, R. E. TRACTENBERG

FIG. 2.

Barriers to implementation of a handoff system at the Med-Peds program director’s institution, 2011.

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BARRIERS TO TRAINING RESIDENCY HANDOFFS

FIG. 3.

Med-Peds program director responses to the question of why a handoff system would NOT be helpful, 2011.

practice. Other barriers that were listed included the inability to monitor resident compliance with handoffs (two programs), the problem of having different systems at three clinic sites (one program), and the problem of having too many patients (one program).

DISCUSSION This is the first study to our knowledge that has assessed program director attitudes and identified perceived barriers toward end-of-academic-year outpatient handoff systems. Programs were more likely to have a system in place if responding

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TABLE 1 2011 Med-Peds program director dichotomized attitudes about the importance of several factors related to outpatient handoffs

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Please Assess How Important the Following Aspects of Outpatient Handoffs Are: Patient Safety Continuity of Care Patient Satisfaction Teaching Professional Responsibility to Residents Having Early Knowledge Of Patient Needs How Important Are The Following Barriers: Can’t Identify Which Resident Is Primary Provider Lack of Resident Interest Lack of Faculty Interest Not a Priority in a Busy Clinic Lack of Protected Time for Residents to Complete Handoffs Why a Handoff System Would NOT Be Helpful: Residents Won’t Participate Patients Not Complicated Enough to Warrant Handoff Patients Too Complicated Patients Seen Infrequently Attending Co-Management Attending Knows the Patient

All Programs Responding Very/Somewhat Important

Programs With Handoff Systems

Programs Without Handoff Systems

p for Chi-Square Analysis

53/6681.1% 53/6581.5% 48/6672.7% 54/6583.1%

27/3187.0% 28/3190.3% 26/3183.9% 27/30 90%

26/3574.3% 25/3473.5% 22/3562.9% 27/3577.1%

.22 .11 .10 .20

48/6672.7%

25/3180.6%

23/3565.7%

.26

27/6442.2%

8/3026.7%

19/3455.9%

.02

21/6532.3% 24/6536.9% 29/6445.3% 39/65 60%

8/3026.7% 6/3020.0% 11/3036.7% 14/3046.7%

13/3537.1% 18/3551.4% 18/3452.9% 25/3571.4%

.44 .01 .21 .08

24/6636.4% 16/6524.7%

12/3138.7% 8/3125.8%

12/3534.3% 8/3423.5%

.79 1.0

11/6516.9% 22/6334.9% 27/6640.9%

4/3112.9% 10/2934.4% 9/3129.0%

6/3417.6% 12/3441.2% 18/3551.5%

.73 1.0 .08

program directors stated that outpatient handoff systems are somewhat or very important (p = .049). Although more than half of Med-Peds programs lack a formal handoff system, more than 70% of those without a system regard them as somewhat or very important. This inconsistency can be attributed to the fact that although most program directors likely recognize the professional and educational value of such handoffs, there are substantial barriers to starting handoff systems. Most programs endorsed barriers on the survey at similar rates, regardless of whether they had a formal system or not, with the exception of three. Those programs that cited a lack of faculty interest (p = .011) or an inability to identify the resident as the primary provider (p = .024) were significantly less likely to have a handoff system, and more programs without formal systems also tended to cite a lack of protected time to perform them (p = .075) as an important barrier. The lack of protected time and faculty interest are barriers that may be less challenging to overcome, especially because more than 70% of program directors responded that such a system would be important for patient safety, continuity of care,

teaching professionalism to the residents, and patient satisfaction. Of interest, in programs without handoff systems, we found that program directors endorsed a lack of faculty interest more frequently than a lack resident interest. As Young pointed out in outpatient psychiatry11,12 and Pincavage in Internal Medicine,15 changing the culture of the program can have a large effect. Prioritizing this change from the top down could help, as our prior research showed that residents who do not receive education in outpatient handoffs are unlikely to perform them.13 Because informing the patient of the upcoming change is the best predictor of patient satisfaction with the process,8,9 it is likely necessary to introduce the handoff process at least several months prior to graduation to identify the patients in need of a handoff, introduce the residents to how the process works, express the institutional commitment to formally handing off high-risk patients, and getting the residents to begin addressing the upcoming handoff directly with the patients. Added to the fact that outgoing residents identified an average of 6.5 to 10 patients apiece as high risk in two internal medicine studies,15,20 programs should consider setting an expectation for residents to

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perform the handoffs, and then provide residents some protected time to actually perform them. Part of the difficulty is the residency structure itself. That is, although the ACGME mandates that “residents’ longitudinal continuity experience must include the resident serving as the primary physician for a panel of patients,”21 about 40% of the programs in our survey reported having difficulty identifying the resident as the primary provider for patients. High-risk patients (those with the greatest need for a formal end-of-residency handoff) tend to both be medically complex and have a high likelihood of not following up at all (20–50% in several studies).14–16,20 In fact, even in programs where the end-of-residency transition has been scrutinized, the overall likelihood of the patient following up with the assigned provider is low, about 10% to 44%.14–16 Within the current residency structure, maintaining continuity with patients when residents are rotating through other rotations remains a significant hurdle. To accommodate such patients, close attention to scheduling around the time of the transition may be the most important variable given the low rates of follow-up and the lower rates of seeing the assigned provider. These problems are likely shared by categorical pediatrics and internal medicine programs given their structure; this potential merits further research in this area. To further support achievement of more universal structured handoff processes, we suggest assigning a primary provider to each patient, encouraging residents to maintain an updated patient panel list, and encouraging incoming residents to take ownership of the new patients even before the patient’s next visit, as have been suggested previously.12,14,15 There are several limitations to this study. It is possible that we missed significant barriers to implementing formal handoff systems by not including them in the survey list. Our list might not have been diverse enough, which might have biased what barriers program directors thought about during the survey; thus, other barriers may exist that were neither identified by us in the survey nor articulated by respondents in the free-response area of the questions. Thus, it is very possible that other barriers to the implementation of more formal outpatient handoff training systems were not captured in our survey. Another, less significant limitation, could be nonresponse bias, for example, program directors who felt that outpatient handoffs were important were more likely to answer the survey, whereas those who see little value in the process were less likely to respond (or vice versa). However, because nearly 85% of programs nationwide did provide responses, and because 17% of survey respondents stated that they did not feel outpatient handoffs were important, the nonresponse bias may be minimal. Last, as we have stated previously,13 our failure to define what a “formal” handoff “system” is may have led to underreporting bias as well, as some program directors may have protocols that they do not consider to be “formal” or “formalized” yet accomplish the same effect and satisfy the ACGME requirement. Most program directors we surveyed believe that end-ofresidency outpatient handoffs are good for patients and resi-

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dents, and assert the same barriers toward their implementation. Programs looking to start or improve a formal handoff system may consider encouraging maintenance of patient lists, clearly assigning primary providers, and including handoffs in an EMR to help streamline the handoff process. Further study of the impacts of outpatient handoffs on patient outcomes is necessary to measure the effects that improving and/or formalizing training in outpatient handoffs might have on patient safety. Our results suggest that overcoming the barriers cited here, and adopting recommendations for modifying end of residency handoff training systems that have been identified,12–15 may help Med-Peds residency programs more uniformly implement structured handoff systems.

REFERENCES 1. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Annals of Internal Medicine 1994;121:866–72. 2. Volpp KGM, Grande D. Residents’ suggestions for reducing errors in teaching hospitals. New England Journal of Medicine 2003;348:851–5. 3. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Quality and Safety in Health Care 2005;14:401–7. 4. Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, et al. Residents’ and attending physicians’ handoffs: A systematic review of the literature. Academic Medicine 2009;84;12:1775–87. 5. Chu ES, Reid M, Schulz T, Burden M, Mancini D, Ambardekar AV, et al. A structured handoff program for interns. Academic Medicine 2009;843:347–52. 6. Salerno SM, Arnett MV, Domanski JP. Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Teaching and Learning in Medicine 2009;212:121–6. 7. Young JQ, Wachter RM. Academic year-end transfers of outpatients from outgoing to incoming residents: An unaddressed patient safety issue. Journal of the American Medical Association 2009:30212:1327–9. 8. Roy MJ, Herbers JE, Seidman A, Kroenke K. Improving patient satisfaction with the transfer of care. Journal of General Internal Medicine 2003;18:364–9. 9. Roy MJ, Kroenke K, Herbers JE. When the physician leaves the patient: Predictors of satisfaction with the transfer of care in a primary care clinic. Journal of General Internal Medicine 1995;10:206–10. 10. Young JQ, Niehaus B, Lieu SC, O’Sullivan PS. Improving resident education and patient safety: A method to balance initial caseloads at academic year-end transfer. Academic Medicine 2010;85:1418–24. 11. Young JQ, Eisendrath SJ. Enhancing patient safety and resident education during the academic year-end transfer of outpatients: Lessons from the suicide of a psychiatric patient. Academic Psychiatry 2011;351:54–7. 12. Young JQ, Pringle Z, Wachter RM. Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer. Joint Commission Journal on Quality and Patient Safety 2011;37:300–8. 13. Donnelly MJ, Clauser JM, Weissman NJ. An intervention to improve ambulatory care handoffs at the end of residency. Journal of Graduate Medical Education 2012;43:381–4. 14. Garment AR, Lee WW, Harris C, Phillips-Caesar E. Development of a structured year-end sign-out program in an outpatient continuity practice. Journal of General Internal Medicine 2013;281:114–20. 15. Pincavage AT, Ratner S, Prochaska ML, Prochaska M, Oyler J, Davis AM, et al. Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs. Journal of General Internal Medicine 2012;27:1438–44.

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16. Donnelly MJ, Clauser JM, Thakur N, Topol D, Weisman D, Tractenberg RE, et al. A multicenter intervention to improve ambulatory care handoffs at the end of residency. Manuscript under submission. 17. Accreditation Council on Graduate Medical Education. Common Program Requirements: VI.B. Transitions of Care. Available at: http://www.acgme. org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Accessed March 19, 2012. 18. Donnelly MJ, Clauser, JM, Tractenberg RE. Current Practices in Handoffs at the End of Residency: A Survey of Med-Peds Program Directors. Journal of Graduate Medical Education 2013;5;1:39– 47.

19. American Medical Association- FREIDA Online. Available at: https:// freida.ama-assn.org/Freida/user/viewProgramSearch.do. Accessed October 20, 2011. 20. Caines LC, Brockmeyer DM, Tess AV, Kim H, Kriegel G, Bates CK. The revolving door of resident continuity practice: Identifying gaps in transitions of care. Journal of General Internal Medicine 2011;269:995–8. 21. Accreditation Council on Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Internal. IV.A.2.c).(1).(g) Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013PR-FAQ-PIF/140 internal medicine 07012013.pdf. Accessed March 19, 2012.

APPENDIX

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TABLE A1 2011 Med-Peds program director attitudes about the importance of several factors related to outpatient handoffs Please Assess How Important The Following Aspects Of Outpatient Handoffs Are: In General

Patient Safety

Continuity of Care

Patient Satisfaction

Teaching Professional Responsibility to Residents

All Programs Responding VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median

4.7% (3) 1.6% (1) 10.9% (7) 54.7% (35) 28.1% (18) 4.0 4.5% (3) 1.5% (1) 13.6% (9) 48.5% (32) 31.8% (21) 4.0 4.6% (3) 3.1% (2) 10.8% (7) 36.9% (24) 44.6% (29) 4.0 4.5% (3) 4.5% (3) 18.2% (12) 39.4% (26) 33.3% (22) 4.0 4.6% (3) 1.5% (1) 10.8% (7) 43.1% (28) 40.0% (26) 4.0

Programs With Handoff Systems VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median

6.7% (2) 0.0% (0) 0.0% (0) 46.7% (14) 46.7% (14) 4.0 6.5% (2) 0.0% (0) 6.5% (2) 41.9% (13) 45.2% (14) 4.0 6.5% (2) 0.0% (0) 3.2% (1) 29.0% (9) 61.3% (19) 4.0 6.5% (2) 0.0% (0) 9.7% (3) 38.7% (12) 45.2% (14) 4.0 6.7% (2) 0.0% (0) 3.3% (1) 40.0% (12) 50.0% (15) 4.0

Programs Without Handoff Systems VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median

2.9% (1) 2.9% (1) 20.6% (7) 61.8% (21) 11.8% (4) 4.0 2.9% (1) 2.9% (1) 20.0% (7) 54.3% (19) 20.0% (7) 4.0 2.9% (1) 5.9% (2) 17.6% (6) 44.1% (15) 29.4% (10) 5.0 2.9% (1) 8.6% (3) 25.7% (9) 40.0% (14) 22.9% (8) 4.0 2.9% (1) 2.9% (1) 17.1% (6) 45.7% (16) 31.4% (11) 4.5

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BARRIERS TO TRAINING RESIDENCY HANDOFFS

Having Early Knowledge of Patient Needs

VU SU Neutral SI VI Median

4.5% (3) 4.5% (3) 18.2% (12) 43.1% (28) 36.4% (24) 4.0

VU SU Neutral SI VI Median

6.5% (2) 3.2% (1) 9.7% (3) 25.8% (8) 54.8% (17) 4.0

VU SU Neutral SI VI Median

2.9% (1) 5.7% (2) 25.7% (9) 45.7% (16) 20.0% (7) 5.0

Barriers to implementation of a handoff system at the Med-Peds program directors institution, 2011

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All Programs Responding Can’t Identify Which Resident Is Primary Provider

Lack of Resident Interest

Lack of Faculty Interest

Not a Priority in a Busy Clinic

Lack of Protected Time for Residents to Complete Handoffs

Programs With Handoff Systems

Programs Without Handoff Systems

VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU

34.4% (22) 12.5% (8) 10.9% (7) 32.8% (21) 9.4% (6) 3.0 13.8% (9) 21.5% (14) 32.3% (21) 27.7% (18) 4.6% (3) 3.0 18.5% (12) 12.3% (8) 32.3% (21) 33.8% (22) 3.1% (2) 3.0 12.5% (8)

VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU

33.3% (10) 20.0% (6) 20.0% (6) 20.0% (6) 6.7% (2) 4.0 20.0% (6) 33.3% (10) 20.0% (6) 23.3% (7) 3.3% (1) 3.0 36.7% (11) 16.7% (5) 26.7% (8) 20.0% (6) 0.0% (0) 4.0 26.7% (8)

VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU

35.3% (12) 5.9% (2) 2.9% (1) 44.1% (15) 11.8% (4) 2.0 8.6% (3) 11.4% (4) 42.9% (15) 31.4% (11) 5.7% (2) 2.0 2.9% (1) 8.6% (3) 37.1% (13) 45.7% (16) 5.7% (2) 2.0 0.0% (0)

SU Neutral SI VI Median VU SU Neutral SI VI Median

15.6% (10) 26.6% (17) 42.2% (27) 3.1% (2) 3.0 7.7% (5) 4.6% (3) 27.7% (18) 40.0% (26) 20.0% (13) 4.0

SU Neutral SI VI Median VU SU Neutral SI VI Median

20.0% (6) 16.7% (5) 36.7% (11) 0.0% (0) 4.0 16.7% (5) 6.7% (2) 30.0% (9) 30.0% (9) 16.7% (5) 4.0

SU Neutral SI VI Median

11.8% (4) 35.3% (12) 47.1% (16) 5.9% (2) 3.0

VU 0.0% (0) SU 2.9% (1) Neutral 25.7% (9) SI 48.6% (17) VI 22.9% (8) (Continued on next page)

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Med-Peds Program Director responses to the question of why a handoff system would NOT be helpful, 2011 All Programs Residents Won’t Participate

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Patients Are Not Complicated Enough to Warrant a Handoff

Patients Are Too Complicated

Patients Are Seen Infrequently

Attending Co-Management Model Means That the Attending Knows the Patient Anyway

VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median

16.7% (11) 24.2% (16) 33.8% (22) 28.8% (19) 7.6% (5) 3.0 24.6% (16) 16.9% (11) 33.8% (22) 18.5% (12) 6.2% (4) 3.0 40.0% (26) 26.2% (17) 20.0% (13) 25.4% (16) 9.5% (6) 2.0 15.9% (10) 23.8% (15) 25.4% (16) 25.4% (16) 9.5% (6) 3.0 20.0% (13) 10.8% (7) 29.2% (19) 23.1% (15) 18.5% (12) 3.0

Programs With Handoff Systems

Programs Without Systems

VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median

VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median VU SU Neutral SI VI Median

12.9% (4) 29.0% (9) 19.4% (6) 29.0% (9) 9.7% (3) 3.0 25.8% (8) 12.9% (4) 35.5% (11) 16.1% (5) 9.7% (3) 3.0 45.5% (15) 24.2% (8) 15.2% (5) 3.0% (1) 12.1% (4) 2.0 10.3% (3) 27.6% (8) 27.6% (8) 17.2% (5) 17.2% (5) 3.0 22.6% (7) 16.1% (5) 32.3% (10) 16.1% (5) 12.9% (4) 4.0

Note. VU = very unimportant; SU = somewhat unimportant; SI = somewhat important; VI = very important.

20.0% (7) 20.0% (7) 25.7% (9) 28.6% (10) 5.7% (2) 3.0 23.5% (8) 20.6% (7) 32.4% (11) 20.6% (7) 2.9% (1) 3.0 32.4% (11) 26.5% (9) 23.5% (8) 14.7% (5) 2.9% (1) 2.0 20.6% (7) 20.6% (7) 23.5% (8) 32.4% (11) 2.9% (1) 3.0 17.1% (6) 5.7% (2) 25.7% (9) 28.6% (10) 22.9% (8) 3.0

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers.

It is unclear why systematic training in end-of-residency clinic handoffs is not universal...
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