Sustainability and Effectiveness of a Quality Improvement Project to Improve Handoffs to Night Float Residents in an Internal Medicine Residency Program

Abstract

Handoff is the process in which patient care is transitioned from one provider to another. In teaching hospitals, handoffs are frequent, and resident duty hour restrictions have increased the use of night float staff. To date, few studies have focused on long-term sustainability and effectiveness of a handoff quality improvement project. The objective of our resident-driven quality improvement project was to evaluate the effectiveness and sustainability of a standardized template for handoff quality in a community hospital internal medicine program. We used a multistep continuous quality improvement approach. Problems in the handoff process were identified through process mapping and anonymous needs assessment of the residents. A group of residents and faculty identified problems during biweekly discussions, created a standardized template, and adopted a new handoff process. We audited handoffs and surveyed residents at 3 and 9months after implementation to assess effectiveness and sustainability. Before the intervention, only 40% of residents reported regular morning handoff. Using the standardized template, statistically significant, sustained improvements were seen in morning handoff frequency (59% preintervention, 90% at 3months, 89% at 9months), along with decreases in unreported overnight events (84% preintervention, 58% at 3months, 50% at 9months) and uncertainty about decisions because of poor handoffs (72% preintervention, 49% at 3months, 37% at 9months). Statistically significant decreases in missed content (69%-46%) and copy-and-paste behavior (78%-38%) at 3months were not sustained. We demonstrated sustained improvements in unreported events and uncertainty caused by poor handoffs. Initial improvements in missed content and copy-and-paste behavior that were not sustained suggest a need for ongoing reinforcement and monitoring of handoff quality.