Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs.

BACKGROUND: Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions. METHODS: Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses. RESULTS: 687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame. CONCLUSIONS: Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

The Birth of a Return to work Policy for New Resident Parents in Emergency Medicine.

OBJECTIVE: With the rising number of female physicians, there will be more children than ever born in residency, and the current system is inadequate to handle this increase in new resident parents. Residency is stressful and rigorous in isolation, let alone when pregnant or with a new child. Policies that ease these stressful transitions are generally either insufficient or do not exist. Therefore, we created a comprehensive return-to-work policy for resident parents and piloted its implementation. Our policy aims to: 1) establish a clear, shared understanding of the regulatory and training requirements as they pertain to parental leave; 2) facilitate a smooth transition for new parents returning to work; and 3) summarize the local and institutional resources available for both males and females during residency training. METHOD: In Fall 2017, a task force was convened to draft a return-to-work policy for new resident parents. The task force included nine key stakeholders (i.e., residents, faculty, and administration) at our institution and was made up of three graduate medical education (GME) program directors, a vice chair of education, a designated institutional official (DIO), a chief resident, and three members of our academic department's faculty affairs committee. The task force was selected because of individual expertise in gender equity issues, mentorship of resident parents, GME, and departmental administration. RESULTS: After development, the policy was piloted from November 2017 to June 2018. Our pilot implementation period included seven new resident parents. All of these residents received schedules that met the return-to-work scheduling terms of our return-to-work policy including no overnight shifts, no sick call, and no more than three shifts in a row. Of equal importance, throughout our pilot, the emergency department schedules at all of our clinical sites remained fully staffed and our sick call pool was unaffected. CONCLUSION: Our return-to-work policy for new resident parents provides a comprehensive guide to training requirements and family leave policies, an overview of available resources, and a scheduling framework that makes for a smooth transition back to clinical duties.