The standards begin with what seems like an obvious statement, but a necessary one for some hospital medicine groups: “A formally recognized hand-off plan should be instituted at the end of a shift or a change in service.” The standards also state that, “Effective hand-offs will require not only a program policy, but standards for verbal exchange and content exchange,” said Dr. Arora.
To guide hospital medicine groups through this exchange, the speakers offered three mnemonic devices: The 3 T’s, the 4 I’s and the 3 A’s.
The 3 T’s: Your program should have a policy in place that stipulates:
- Time set aside for hand-offs. Ensure that busy hospitalists have adequate time blocked out.
- Template or technology solution. “You need a structured template to help people do their work,” said Dr. Arora. “The program needs to decide what kind of template to adopt—and a move to standardization meets that Joint Commission goal.”
- Train new staff on hand-off expectations. Keep everyone in your practice, including appropriate hospital staff, in the loop.
The 4 I’s of verbal, or face-to-face, exchange include:
- Interruptions are limited. There will always be interruptions, but you can take steps to limit them during hand-offs by designating a time and/or place as “interruption free,” or having someone cover the pagers of the involved hospitalists during hand-offs.
- Interactive process is used. “There should be some interactive dialogue” between the physicians, insisted Dr. Arora.
- Ill patients are given priority. Make sure that you give your sickest patients top priority during hand-offs.
- Insight given to receiver on what to expect or do. What would you do if you were staying on for the next shift? Give the receiver a list of “to-do” items.
The 3 A’s of content exchange standards are:
- All data are up to date. This can be a real problem in healthcare. Make sure all information you turn over, both written and oral, reflects your latest knowledge.
- Anticipated events are emphasized. “What do you anticipate will be a problem?” asked Dr. Arora. Think this through and let the receiver know.
- Action items are highlighted. Again, include a to-do list with the information.
What’s Next?
The task force didn’t stop with these new basic standards. They put together a research agenda, a “wish list” of what’s needed in hospital medicine research to improve hand-offs.
“We need to use research to evaluate these standards rigorously,” said Dr. Arora. “And we must emphasize controlled interventions because only 10 of the articles we found were controlled interventions. We have to urge the research community to do more in this area.”
The group would also like to encourage the development of patient-based outcomes that are sensitive to hand-off quality. “This is talked about a lot, but few people are doing anything about it,” Dr. Arora pointed out.
And finally, they’d like to enable additional funding for further research on hand-offs.
Attendees at the session were polled on their hand-off practices. By a show of hands, approximately 40% indicated they had a standardized hand-off procedure. However, virtually no one thought their procedure was ideal.
The task force encouraged attendees and other hospitalists to share their thoughts and input on hand-off standards. If you have ideas for the task force, you can e-mail them at [email protected].
The task force plans to revise their recommendations, with attention to SHM member input. They’d also like to engage an expert panel for an external review of their work before they disseminate it. TH