Transitions of patient care among providers occur frequently and require providers to transmit critical clinical information. If information is omitted or misunderstood during a hand-off, serious clinical consequences may result for patient care. In fact, studies have shown that hand-offs are often variable and represent a major gap in safe patient care. For patients cared for by resident physicians, dangers posed by poor communication may be amplified since the implementation of resident duty hour restrictions in July 2003 has increased transfer frequency. In addition, few trainees receive formal training on hand-offs. The Joint Commission currently requires hospitals to implement a standardized, interactive approach to hand-off communications. Unfortunately, due to a lack of valid, standardized tools to evaluate hand-off quality, hospitals and educators can not assess whether their hand-offs meet these criteria. More recently, the Institute of Medicine has recommended that all residents receive formal education on handoff strategies. Understanding best practices during hand-offs and valid assessment of hand-off quality are needed for several reasons: to improve clinical practice through evaluation and feedback, to illuminate areas of deficiency in current practices and to maximize patient safety in this era of duty hour restrictions. At the University of Chicago and Yale, investigators have extensive experience in describing hand-off quality, designing and implementing novel curricula to improve hand-off education amongst varying levels of trainees and have elucidated the relationship between patient care outcomes and poor hand-off quality. Therefore, drawing from our preliminary work in this area, and relevant practices in other industries, we aim to develop and test a generalizable tool to evaluate hand-offs in clinical settings.
The aim of this application is to develop and validate a simple, flexible, reliable, real-time observation tool to evaluate hand-off practices. The Hand-off CEX is a paper-based instrument that can be used to evaluate either the sender or the receiver of hand-off communication. This tool is based on a previously-validated, widely-used, real-time educational evaluation tool (the Mini-CEX);published expert opinion;and our prior research. Our tool incorporates unique role-based anchors for both senders and receivers that refer to verbal communication, professionalism and environment, hand-off domains informed by preliminary work and expert opinion. The Hand-off CEX (Clinical Evaluation Exercise) will be used by academic hospitalists and house staff physicians to assess feasibility. We will also assess the construct validity and inter-rater reliability of the tool through the use of standardized, videotaped hand-off scenarios depicting various levels of performance of a hand-off scenario. The Hand-off CEX will arm educators with an innovative, necessary, valid and feasible method for training health professionals to conduct safe and effective hand-offs. Finally, the Hand-off CEX will be a useful tool to assist hospitals in improving patient safety.

Public Health Relevance

Although hand-offs of patient care among hospital providers are a frequent occurrence and require the transmission of important clinical information, studies demonstrate that hand-offs are characterized by communication failures which could threaten patient safety. Numerous organizations, including the Institute of Medicine, the Joint Commission, and the World Health Organization have called for formal education and systematic improvements in in-hospital handoffs. However, due to a lack of valid, standardized tools to evaluate the quality of hand-offs, hospitals and educators are unable to improve clinical practice through evaluation and feedback. Drawing from our preliminary work in assessing and improving hand-offs, and relevant practices in other industries, we aim to test and validate a tool to evaluate hand-off quality in the clinical setting.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Small Research Grants (R03)
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Health Care Quality and Effectiveness Research (HQER)
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Burgess, Denise
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University of Chicago
Internal Medicine/Medicine
Schools of Medicine
United States
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Arora, Vineet M; Berhie, Saba; Horwitz, Leora I et al. (2014) Using standardized videos to validate a measure of handoff quality: the handoff mini-clinical examination exercise. J Hosp Med 9:441-6
Arora, Vineet M; Reed, Darcy A; Fletcher, Kathlyn E (2014) Building continuity in handovers with shorter residency duty hours. BMC Med Educ 14 Suppl 1:S16
Arora, Vineet M; Greenstein, Elizabeth A; Woodruff, James N et al. (2013) Implementing peer evaluation of handoffs: associations with experience and workload. J Hosp Med 8:132-6
Horwitz, Leora I; Dombroski, Janet; Murphy, Terrence E et al. (2013) Validation of a handoff assessment tool: the Handoff CEX. J Clin Nurs 22:1477-86
Horwitz, Leora I; Rand, David; Staisiunas, Paul et al. (2013) Development of a handoff evaluation tool for shift-to-shift physician handoffs: the Handoff CEX. J Hosp Med 8:191-200
Greenstein, Elizabeth A; Arora, Vineet M; Staisiunas, Paul G et al. (2013) Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf 22:203-9
Farnan, Jeanne M; Arora, Vineet M (2012) A longitudinal approach to handoff training. Virtual Mentor 14:383-8
Wohlauer, Max V; Arora, Vineet M; Horwitz, Leora I et al. (2012) The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med 87:411-8
Williams, Joshua A; Meltzer, David; Arora, Vineet et al. (2011) Attention to inpatients' religious and spiritual concerns: predictors and association with patient satisfaction. J Gen Intern Med 26:1265-71
Press, Valerie G; Arora, Vineet M; Shah, Lisa M et al. (2011) Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med 26:635-42

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