This report describes the work of St. Luke's Hospital and Health Network to integrate graduate medical education and quality improvement as part of the Alliance of Independent Academic Medical Centers National Initiative, Improving Patient Care Through Graduate Medical Education.

John Pamula, MD, Internal Medicine Resident
Gloria Fioravanti, DO, Internal Medicine Residency Director
Joel C. Rosenfeld, MD, MEd, Chief Academic Officer

• Communication of patients’ critical events, critical labs, and code status
• Resident satisfaction with effective handoffs 
• Increased standardization of handoffs in terms of time, place,  and presentation

• Reviewed existing guidelines concerning patient handoffs from Joint Commission and other resources for implementation
• Obtained input from faculty, residents, and research director
• Adapted a “severity index “ to prioritize patient rounds 
• Developed a clear plan for anticipated problems
• Trained senior residents to be mentors of PGY-1 residents
• Incorporated effective handoff seminar during PGY-1 orientation
• Ensured handoffs occurred in a quiet private area with opportunity to ask questions
• Monitored periodically the PGY-1 residents’ handoffs
• Performed real-time audit of the handoff process
  • Stage 1: Observed the existing handoff process to recognize lapses
  • Stage 2: Developed, distributed, and analyzed a survey questionnaire analyzing residents’ perception and input for an effective handoff
  • Stage 3: Provided a seminar on improvement of handoffs based on Joint Commission 2007 Patient Safety Goals
  • Stage 4: Developed, distributed, and analyzed an assessment of residents’ verbal and written handoff before and after the seminar
• Fulfilled the Joint Commission guidelines for handoffs in the Internal Medicine residency

Results:

• Communication of patients’ critical events, critical labs, and code status
  • Pre-educational seminar: 68 percent
  • Post-educational seminar: 82 percent
• Resident satisfaction with effective handoffs 
  • Pre-educational seminar: 65 percent
  • Post-educational seminar: 90 percent

Lessons Learned:

• Need to involve residents at all levels. Junior residents need to be oriented to what constitutes an accurate handoff. Senior residents need to monitor process. New PGY-1 residents initially were overwhelmed in first two weeks, but with orientation and with senior resident guidance they developed confidence and competence in terms of the handoff process.
• Need to prioritize critical patient data. Residents may have difficulty in disseminating pertinent patient data when patient census is high.
• Involve Information Services Department early in the process.
• Need to tailor handoffs to the specific specialty.

Barriers:

• Incompatibility of software in importing patient data to written handoffs.

Next Steps:

• Continued monitoring of handoffs by faculty
• Development of electronic handoff form for use by all specialties
• Extension of handoffs training to other residencies
• Implementation of handoffs system to the Hospitalist service