Supervision and Feedback
Supervised evaluation of performance and feedback are key aspects of training for transfer of care.
“Training residents means supervising them,” says Dr. Horwitz. “Are they getting the concepts? Are they incorporating the key points into everyday communication and actions?” Having more senior and experienced doctors present during sign out or at the very least prepare people for sign out is crucial, she says, because an issue such as anticipatory guidance/contingency planning is difficult for less-experienced residents.
“As a chief resident I made a point of periodically going around and observing sign outs,” she says. “Nobody ever watches sign out because it happens at the odd hours of the day; nobody gets feedback or evaluation. Ideally an attending should, at least now and again, be involved.”
Questions to ask include:
- Do the residents meet face to face in a dedicated time and place?
- Do they fill out a standardized template and updating it appropriately, especially with regard to medications?
- Do residents measure aspects of hand-offs to ensure they are being done?
Just as the DHMC team recognized that communication for hand-offs is a two-way street, the same is true for performing a discharge communication exchange. Are primary care providers considering best practices to train themselves in this integral aspect of patient care and safety?5, 6
“I don’t think the primary care community has gotten together and come up with a consensus of what they want to know and how much interaction they want,” Dr. Horwitz says. “There should be a standard for that.”
That is a first step to encourage greater training all around. She urges collaboration between SHM and a national organization, such as the American Academy on Family Practice, and hopes SHM will open that dialogue.
In that regard, some steps have been taken.7 Dr. Kripalani is a member of the SHM Hand-off and Communication Standards Task Force, which is developing national standards (The Hospitalist, August 2007, p. 17). There is a working list of nine best practices for hand-offs at shift changes or rotation ends, and the group plans to publish a final list in the upcoming year. The list is designed primarily for practicing hospitalists but will also be suitable for residents. The task force hopes other groups, such as internal medicine program directors and chief residents, will disseminate the best practices to trainees. National best practices are also likely to affect providers in the community.
“My suspicion is that a lot of community-based programs are interested in improving hand-offs, but each program may develop a different set of procedures,” says Dr. Kripalani. “One of the main reasons for developing national standards is so that both academic and community groups can refer to a list of evidence-based best practices.”
Evolution of Training
“Training for transfer of care and transfer of care are very different things, says Dr. Chu, “but they’re interrelated.” He and his colleague Gregory Misky, MD, a hospitalist and instructor with the University of Colorado Health Sciences Center (UCHSC), have been disseminating that training program throughout the UCHSC internal medicine residency program for the past three years.
In order to develop a structured, standard method for patient hand-offs, they took on teaching and supervising interns during their internal medicine ward rotations. Although much of the literature advocates the SBAR (situation, background, assessment, and recommendation) communication technique, the UCHSC team has developed a verbal structure specifically for hand-offs that differs from the SBAR model.8