Closing the Gap: A Needs Assessment of Medical Students and Handoff Training

Abstract

The Joint Commission cites communication errors between hospital personnel as a contributing cause of approximately two-thirds of sentinel events in hospitals.1The Joint Commission. Improving hand-off communications: meeting National Patient Safety Goal 2E. Joint Commission Perspectives on Patient Safety 2006;6:9–15.Google Scholar Communication failures are particularly common during handoffs of patient care.2Landrigan C. The handoff: a critical point of vulnerability. RMF Forum 2007;25:6–7.Google Scholar As a result of more stringent duty hour requirements and increasing clinical and educational demands on medical students and housestaff, handoffs are increasing in frequency in academic health centers. However, few residency programs and medical schools have standardized handoff training programs. This lack of training is particularly alarming for medical students because they assume patient care responsibilities and function as members of complex teams as soon as they begin their clinical rotations in medical school. A 2004 survey of internal medicine clerkship and subinternship directors found that only 8% of US medical schools provide formal handoff training, inferring that handoffs are part of the “hidden curriculum” in medical schools.3Solet D.J. Norvell J.M. Rutan G.H. Frankel R.M. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.Acad Med. 2005; 80: 1094-1099Crossref PubMed Scopus (373) Google Scholar, 4Solet D.J. Norvell J.M. Rutan G.H. Frankel R.M. Physician-to-physician communication: methods, practice and misgivings with patient handoffs.J Gen Intern Med. 2004; 19: 108Google Scholar A survey of 152 medical students from 2 medical schools in 2011 found that only 30% of students report training on creating a written handoff document and only 23% report training on performing verbal handoffs.5Eastment M, Bethea E, Friedman E, Franan J, Arora V. Medical student experience and confidence in patient handoffs. Abstract presented at the American of American Medical Colleges (AAMC) Annual Meeting. November 4-9, 2011. Denver, Colorado.Google Scholar Prior studies focusing on the development of handoff interventions for medical students most frequently involve a single primary intervention (eg, didactic training alone) with limited or nonexistent “bundling” of components (eg, handoff training plus introduction of written templates, mnemonics, faculty observations, and campaign efforts) to help reinforce and complement the training experience.6Chu E.S. Reid M. Burden M. Mancini D. Schulz T. Keniston A. et al.Effectiveness of a course designed to teach handoffs to medical students.J Hosp Med. 2010; 5: 344-348Crossref PubMed Scopus (22) Google Scholar, 7Farnan J.M. Paro J.A. Rodriguez R.M. Reddy S.T. Horwitz L.I. Johnson J.K. Arora V.M. Hand-off education and evaluation: piloting the Observed Simulated Hand-off Experience (OSHE).J Gen Intern Med. 2010; 25: 129-134Crossref PubMed Scopus (79) Google Scholar, 8Klamen D.L. Reynolds K.L. Yale B. Aiello M. Students learning handovers in a simulated in-patient unit.Med Educ. 2009; 43: 1097-1098Crossref PubMed Scopus (14) Google Scholar Only 1 study evaluated the use of computer-based training, consisting of an online module, to allow for flexible delivery.8Klamen D.L. Reynolds K.L. Yale B. Aiello M. Students learning handovers in a simulated in-patient unit.Med Educ. 2009; 43: 1097-1098Crossref PubMed Scopus (14) Google Scholar Outcome measures for prior studies are based primarily on subjective ratings of self-perceived knowledge, preparedness, and ability or on behavioral changes in simulated settings. To date, no studies have evaluated students in clinical settings conducting live handoffs of care or assessed the impact of training on key outcomes such as rates of miscommunications or medical errors. Furthermore, no prior studies have been carried out across multiple institutions; thus, the generalizability of previous findings is limited. There is increasing recognition of the importance of formal handoff training. The Council on Medical Student Education in Pediatrics and the Association of Pediatric Program Directors have recognized the knowledge and communication skills needed to perform a handoff as critical competencies that fourth-year students need to acquire.9APPD and COMSEP pediatric subinternship curriculum. http://www.comsep.org/curriculum/pdfs/COMSEP-APPDF.pdf. Accessed September 4, 2012.Google Scholar However, standardized multi-institutional efforts to develop and assess the quality of training curricula are lacking. With the launch of the Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Signouts (I-PASS) Study in 2010, a team of health services researchers and medical educators began developing and rigorously evaluating a multifaceted handoff program at 10 pediatric residency training programs across North America.10Sectish T.C. Starmer A.J. Landrigan C.P. Spector N.D. Establishing a multisite education and research project requires leadership, expertise, collaboration, and an important aim.Pediatrics. 2010; 126: 619-622Crossref PubMed Scopus (30) Google Scholar, 11I-PASS Handoff Study. http://www.ipasshandoffstudy.com. Accessed September 4, 2012.Google Scholar The I-PASS handoff program consists of an innovative resident handoff bundle that includes multimodal handoff training, a verbal mnemonic, a standardized template for written handoffs, faculty observations, and a campaign to enhance adoption of the I-PASS handoff method.12Starmer A.J. Spector N.D. Srivastava R. Allen A.D. Landrigan C.P. Sectish T.C. I-PASS, a mnemonic to standardize verbal handoffs.Pediatrics. 2012; 129: 201-204Crossref PubMed Scopus (138) Google Scholar As I-PASS was launched at participating sites, it became apparent that medical students and residents lack systematic training in this critical skill. To address this concern, several I-PASS study investigators drew upon the expertise of the ongoing multisite collaborative with the following objectives: (1) to conduct a literature review and a needs assessment to evaluate the current state of medical student handoff training; and (2) to develop recommendations for medical schools regarding handoff training for students. We performed a literature search in MEDLINE, using the medical subject headings of “medical students” and “handoffs,” which revealed the limited number of studies assessing medical student handoff training programs summarized earlier. Subsequently, in accordance with the framework for curriculum development by Kern et al, we conducted a needs assessment of participating sites.13Kern D.E. Thomas P.A. Hughes M.T. Curriculum development for medical education: A six-step approach.2nd ed. Johns Hopkins University Press, Baltimore, MD2009Google Scholar Using an expert, consensus-driven process, an interview script was developed to assess current practices, existent curricula, and training preferences for medical student handoffs. Research and education experts from the study group reviewed and edited the script for content validity. Senior investigators led 1-hour-long focus groups of medical students and educators at 6 I-PASS institutions. Results from the focus groups were analyzed quantitatively and qualitatively for themes. Thirty-nine individuals (15 students, 17 faculty, 7 residents/chief residents) from 6 I-PASS study sites participated in the focus groups. Responses revealed 5 key themes. First, a majority of medical students actively participate in the handoff process. Four of the 6 sites allow third-year students and all 6 sites allow fourth-year students to participate in handoffs of care (either verbally or in a written fashion) on inpatient rotations. Second, faculty are not consistently present to supervise handoffs at any of the sites, with only 2 of the 6 sites having faculty present on an intermittent basis. Third, senior resident oversight of the handoff process is also quite variable, with senior supervision (ranging from mere presence in the room to active, direct observation and feedback) occurring at 3 of 6 sites. Fourth, handoff training varies widely, ranging from a brief didactic on what details should be included in a handoff for fourth-year students at the start of a pediatric inpatient month (3/6 sites), to training on handoffs occurring during other specialty rotations (1/6 sites), to brief directions on where handoffs should take place and how the handoff document may be accessed (1/6 sites). Finally, despite the Council on Medical Student Education in Pediatrics and Association of Pediatric Program Directors' recommendations, only one of our needs assessment sites explicitly lists handoff skills as a graduation competency, and only one other site includes handoff skills in course objectives.9APPD and COMSEP pediatric subinternship curriculum. http://www.comsep.org/curriculum/pdfs/COMSEP-APPDF.pdf. Accessed September 4, 2012.Google Scholar When focus group participants were asked how they would integrate handoff training into the education of medical students, all participants unanimously agreed that handoff training should be incorporated into the pediatric clerkship or subinternship. However, challenges for doing so were identified. Multiple sites commented on the difficulty of finding adequate time and resources for clerkship and subinternship course directors to weave handoff training into an already full schedule of clinical and educational requirements. The results of our multisite needs assessment and our literature review reveal there is an urgent need to provide medical students with handoff training. Just as we teach students how to conduct a history and physical, or document a daily progress note during the preclinical years, there is a similar critical need to teach handoff skills. Furthermore, educators need access to standardized, evidence-based, and rigorously evaluated training materials for learners and faculty. To accommodate increasing educational and clinical demands, handoff training needs to be flexible. Multimodal delivery options need to be offered to reach trainees in a variety of settings. In addition, faculty time should be protected to prioritize opportunities to role model handoff skills and for direct observations of live medical student handoffs. Based on our work thus far, we recommend the following for medical student education: (1) design a handoff training session that is brief and easy to integrate into existing curricula; (2) offer and reinforce handoff training throughout preclinical, as well as clinical years; (3) incorporate modeling of handoff skills by residents and faculty; (4) include simulation training, while also allowing for in vivo experience with live handoffs; (5) reinforce learned handoff skills through faculty and/or resident observations with targeted feedback; (6) provide computer-based training as a supplement to didactic lessons, allowing for a multimodal curricular approach; and (7) target the problem with a bundle of complementary interventions to address the complex, multifaceted nature of handoffs. Although development of one's skills surrounding the entrustable professional activity of handoffs must start at the beginning of the continuum of medical education, there is a need to reinforce and cultivate these skills throughout the course of one's medical training and career. The development of comprehensive handoff training programs for all health care professionals along the continuum of care and medical training is critical to the safety of hospitalized patients. Members of the I-PASS Study Group who participated in the needs assessment include faculty and co-investigators from the following institutions: University of California San Francisco School of Medicine/Benioff Children's Hospital: Glenn Rosenbluth, MD, Sara Buckelew, MD, Carrie Chen, MD, Tim Kelly, MD; University of Utah School of Medicine/Primary Children's Medical Center: Brian Good, MB, BCh, BAO, Adam Stevenson, MD, Rajendu Srivastava, MD, MPH; University of Toronto Faculty of Medicine/Hospital for Sick Children: Stacey Bernstein, MD, Zia Bismilla, MD, Angela Punnett, MD; University of Cincinnati College of Medicine/Cincinnati Children's Hospital Medical Center: Amy Guiot, MD, Corinne Lehman, MD, MEd, Jennifer O'Toole, MD, MEd, Lauren Solan, MD; Drexel University College of Medicine/St. Christopher's Hospital for Children: Sharon Calaman, MD, Leonard Levine, MD, Nancy Spector, MD; Oregon Health Sciences University/Doernbecher Children's Hospital: Carrie Phillipi, MD, PhD, Amy Starmer, MD, MPH; Harvard Medical School/Boston Children's Hospital: Christopher Landrigan, MD, MPH, Theodore Sectish, MD. Supported by the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation ( 1R18AE000029-01 ). Developed with input from the Initiative for Innovation in Pediatric Education and the Pediatric Research in Inpatient Settings Network (PRIS; supported by the Children's Hospital Association , the Academic Pediatric Association , the American Academy of Pediatrics , and the Society of Hospital Medicine ). A.S. is supported by the Agency for Healthcare Research and Quality ( 1K12HS019456-01 ). R.S. and C.L. are supported by the Children's Hospital Association for their work as Executive Council members of the PRIS Network. C.L. has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for delivering lectures on sleep deprivation, physician performance, handoffs, and safety. The other authors declare no conflicts of interest.