ABSTRACT
BACKGROUND
Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents’ sign-out process.
OBJECTIVE
To characterize resident sign-out process and identify effective strategies for quality improvement.
DESIGN
Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement.
PARTICIPANTS
Internal medicine residents (n = 89).
INTERVENTIONS
An appreciative inquiry process identified five exemplar residents and their peers’ effective sign-out strategies.
MAIN MEASURES
Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach.
KEY RESULTS
The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication.
CONCLUSIONS
Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.
Similar content being viewed by others
REFERENCES
Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care. 2008;17(1):6–10.
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
Haizlip JAMC, Williams A, Angle JF, Keefe-Jankowski C, May NB, Schorling JB, Whitney D, Plews-Ogan M. Successful adaptation of appreciative inquiry for academic medicine. J AI Practitioner. 2010;12(3):44–48.
Plews-Ogan MMN, Schorling J, Becker D, Frankel R, Graham E, Haizlip J, Hostler S, Pollart S, Howell RE. Feeding the good wolf: appreciative inquiry and graduate medical education. ACGME eBulletin. 2007:5–8.
Shendell-Falik NFM, Mohr BJ. Enhancing patient safety: improving the patient handoff process through appreciative inquiry. J Nurs Adm. 2007;37(2):95–104.
Guerlain S, Adams RBT, Shin T, Guo H, Collins S, Calland F. Assessing team performance in the operating room: Development and use of a “black-box” recorder and other tools for the intraoperative environment. 2005;200(1):29–37.
Sledd R, Bass EJ, Waggoner-Fountain L, Borowitz S. Supporting the characterization of sign-out in acute care wards. Paper presented at: IEEE International Conference on Systems, Man, and Cybernetics; October 8–11, 2006; Taipei, Taiwan.
Fleiss JL. Measuring nominal scale agreement among many raters. Psychol Bull. 1971;76(5):378–382.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174.
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248–255.
Perez T, Bass, EJ, Helms, A, and Plews-Ogan, M. Comparison of Patient Data in Parallel Records: The Sign-Out Sheet and the Electronic Medical Record. 2010 IEEE International Conference on Systems, Man, and Cybernetics. Istanbul, Turkey; 2010:1884–1888
Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med. 2007;22(12):1751–1755.
Gakhar B, Spencer AL. Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Acad Med. 85(7):1182–1188
Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4):257–266.
Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22(10):1470–1474.
Acknowledgments
The project was supported in part by grant no. T15LM009462 from the National Library of Medicine (NLM), the University of Virginia’s Graduate Medical Education office, and the University of Virginia’s Institute of Quality and Patient Safety. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NLM, the National Institutes of Health, or the University of Virginia.
We would like to acknowledge Lindsay Friesen who assisted in the development of an educational curriculum for the residents based on the findings in this study. We would also like to acknowledge the five “exemplar” internal medicine residents who were critical to our appreciative inquiry approach: Peter Pollak, Luther Bartelt, Jonathon Bleeker, Jamie Kennedy, and Dave Winchester.
Conflict of Interest
Dr. Plews-Ogan is an investigator on a Bristol-Myers Squibb-sponsored research study on empowering African-American women in self care for diabetes.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Helms, A.S., Perez, T.E., Baltz, J. et al. Use of an Appreciative Inquiry Approach to Improve Resident Sign-Out in an Era of Multiple Shift Changes. J GEN INTERN MED 27, 287–291 (2012). https://doi.org/10.1007/s11606-011-1885-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-011-1885-4