Formal Education Not Enough To Teach Effective Patient Handoffs Among Medical Residents Interview with:

Nicholas A. Rattray, Ph.D.Research Scientist/InvestigatorVA HSR&D Center for Health Information and CommunicationImplementation Core, Precision Monitoring to Transform Care (PRISM) QUERIRichard L. Roudebush Veterans Affairs Medical CenterIndiana University Center for Health Services & Outcomes ResearchRegenstrief Institute, Inc.Indianapolis, Indiana

Dr. Rattray

Nicholas A. Rattray, Ph.D.
Research Scientist/Investigator
VA HSR&D Center for Health Information and Communication
Implementation Core, Precision Monitoring to Transform Care (PRISM) QUERI
Richard L. Roudebush Veterans Affairs Medical Center
Indiana University Center for Health Services & Outcomes Research
Regenstrief Institute, Inc.
Indianapolis, Indiana

on behalf of study co-authors re:
Rattray NA, Flanagan ME, Militello LG, Barach P, Franks Z, Ebright P, Rehman SU,
Gordon HS, Frankel RM What is the background for this study? What are the main findings? 

Response: End-of-shift handoffs pose a substantial patient safety risk. The transition of care from one doctor to another has been associated with delays in diagnosis and treatment, duplication of tests or treatment and patient discomfort, inappropriate care, medication errors and longer hospital stays with more laboratory testing. Handoff education varies widely in medical schools and residency training programs. Although there have been efforts to improve transfers of care, they have not shown meaningful improvement.

Led for the last decade by Richard Frankel, Ph.D., a senior health scientist at Regenstrief Institute and Indiana University and professor at Indiana University School of Medicine, our team has studied how health practitioners communicate during end-of-shift handoffs. In this current study, funded by VA Health Services and Research Development, we conducted interviews with 35 internal medicine and surgery residents at three VA medical centers about a recent handoff and analyzed the responses. Our team also video-recorded and analyzed more than 150 handoffs.

Published in the Journal of General Internal Medicine, this study explains how the person receiving the handoff can affect the interaction. Medical residents said they changed their delivery based on the doctor or resident who was taking over (i.e., training level, preference for fewer details, day or night shift). We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as “recipient design”.

In another paper led by Laura Militello, we focus on how residents cognitively prepare for handoffs. In the paper published in The Joint Commission Journal of Quality and Patient Safety®, researchers detailed the tasks involved in cognitively preparing for handoffs. A third paper, published in BMC Medical Education, reports on the limited training that physicians receive during their residency. Residents said they were only partially prepared for enacting handoffs as interns, and clinical experience and enacting handoffs actually taught them the most. What should readers take away from your report?

Response: Based on these articles, discuss how formal education is not enough to teach effective handoffs. We offer recommendations to improve education, including:

  • Establishing collaborative learning meetings among medical students, interns and residents.
  • Providing point-of-care education programs connecting best practices with patient safety and efficacy goals.
  • Using stories to make handoff curricula salient for learners.
  • Enacting actual handoffs. What recommendations do you have for future research as a result of this work?

Response: In addition to our recommendations above, we suggest that interventions designed to improve patient handoffs should more explicitly account for the role of the handoff recipient and not overemphasize standardizing the procedure. Is there anything else you would like to add?

Response: Richard Frankel, Ph.D., was a senior scientist on the papers. He is a research scientist at Regenstrief Institute, Inc., a core investigator at the VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center and a professor at the Indiana University School of Medicine. Nick Rattray, Ph.D. is a research scientist at Regenstrief Institute, Inc. and the VA Health Services Research & Development Center for Health Information and Communication, Roudebush VA Medical Center. Other co-authors include Patricia Ebright, RN, Ph.D., from the Indiana University School of Nursing; Mindy E. Flanagan, Ph.D., and Zamal Franks from the HSR&D Center for Health Information and Communication, Roudebush VAMC; Laura G. Militello, M.A., from Applied Decision Science, LLC; Paul Barach, M.D., from Wayne State University School of Medicine; Shakaib U. Rehman, M.D., from Phoenix VA Health Systems and the University of Arizona College of Medicine-Phoenix; and Howard S. Gordon, M.D., from Jesse VAMC, VA HSR&D Center of Innovation for Complex Chronic Healthcare and the University of Illinois at Chicago.

Militello LG, Rattray NA, Flanagan ME, Franks Z, Rehman S, Gordon HS, Barach P, Frankel RM. “Workin’ on Our Night Moves”: How Residents Prepare for Shift Handoffs. Jt Comm J Qual Patient Saf. 2018 Aug;44(8):485-493. doi: 10.1016/j.jcjq.2018.02.005. Epub 2018 May 2.

Rattray NA, Ebright P, Flanagan ME, Militello LG, Barach P, Franks Z, Rehman SU, Gordon HS, Frankel RM. Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs. BMC Med Educ. 2018 Nov 3;18(1):249. doi: 10.1186/s12909-018-1350.


“Do You Know What I Know?”: How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.
J Gen Intern Med. 2019 Feb;34(2):264-271. doi: 10.1007/s11606-018-4755-5. Epub 2018 Dec 10.

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Last Updated on March 19, 2019 by Marie Benz MD FAAD