Lee Ann Riesenberg

Residents' and attending physicians' handoffs: a systematic review of the literature.

Purpose Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians’ handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective. Method The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians’ handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors. Results Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1–16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness. Conclusions Despite the negative consequences of inadequate physicians’ handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Systematic Review of Handoff Mnemonics Literature

A systematic review of published English-language articles on handoffs is conducted (1987 to June 4, 2008). Forty-six articles describing 24 handoff mnemonics are identified by trained reviewers. The majority (82.6%) have been published in the last 3 years (2006-2008), and SBAR (Situation, Background, Assessment, Recommendation) is the most frequently cited mnemonic (69.6%). Of 7 handoff research articles, only 4 study mnemonics. All 4 of these studies have relatively small sample sizes (10-100) and lack validated instruments. Only 1 study has obtained IRB approval. Scientifically rigorous research studies are needed to assess the effectiveness of handoff mnemonics. These should be published in the peer-reviewed literature using the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

Nursing handoffs: a systematic review of the literature.

Objective:Handoffs of patient care from one nurse to another are an integral part of nursing practice; but there is abundant evidence that poor communication and variable procedures result in inadequate handoffs. We sought to conduct a systematic review of articles that focused on nursing handoffs, conduct a qualitative review of barriers to and strategies for effective handoffs, and identify features of structured handoffs that have been effective. Methods:We conducted a systematic review of English-language articles, published between January 1, 1987, and August 4, 2008, that focused on nursing handoffs in the United States. The search strategy yielded 2,649 articles. After title review, 460 of these were obtained for further review by trained abstractors. Results:Ninety-five articles met the inclusion criteria; of these, 55 (58%) were published between January 1, 2006 and August 4, 2008. Content analysis yielded identification of barriers to effective handoffs in eight major categories and strategies for effective handoffs in seven major categories. Twenty articles involved research on nursing handoffs. Quality assessment scores for the research studies ranged from 2 to 12 (possible range, 1 to 16). The majority of the research studies on nursing handoffs (17 studies; 85%) received quality scores at or below 8 and only three achieved scores above 10. Ten (50%) of the studies included measures of handoff effectiveness. Conclusion:Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices. There is remarkable consistency in the anecdotally suggested strategies; but there is a paucity of evidence to support them. We call for high-quality studies of handoff outcomes that focus on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Nonphysician medical educators: a literature review and job description resource.

Purpose Designing, implementing, and evaluating high-quality, relevant education for physicians is of great importance. The purpose of this study was to describe the historical development of nonphysician medical educators, including health care professionals working in this role, and to develop a job description resource. Method In 2007, the authors conducted a historical content analysis and literature review to identify resources relevant to the early historical development of nonphysician medical educators. Also in 2007, they carried out a thorough review of the English-language literature, 1950–2007, to describe nonphysician health care professionals working as medical educators. To investigate job descriptions, the authors studied job boards of associations and medical education listservs, July 2006 to November 2007. Results Nonphysician educators have participated effectively in physicians’ learning for more than 80 years. Their popularity has grown exponentially in the last 15 years, as have the numbers of master’s-in-medical-education degree programs. The nonphysician medical educator can provide essential help to the overtaxed physician educator in many facets of the educational process, such as educational theory; curriculum design, validation, and evaluation; clinical instruction; and medical education research. The study of job descriptions yielded 237 distinctly different duties in 17 categories. Conclusions The nonphysician medical educator will never replace the physician educator. However, as team training, interdisciplinary education, and the general competencies become the norm, the need for the nonphysician medical educator will increase. The authors believe the use of nonphysician medical educators offers a way to improve the quality of physician clinical education while controlling costs. They also recommend areas for future research.

Systemic Barriers to Diabetes Management in Primary Care: A Qualitative Analysis of Delaware Physicians

Primary care providers deliver the majority of care for patients with diabetes. This article presents a qualitative analysis of systemic barriers to primary care diabetes management in the small office setting in Delaware. Grounded theory was used to identify key themes of focus group discussions with 25 Delaware physicians. A total of 6 systemic barriers were identified: (1) a persistent orientation toward acute care; (2) an inability to provide proactive, population-based patient management; (3) an inability to provide adequate self-management education; (4) poor integration of payer-driven disease management activities; (5) lack of universally available clinical information; and (6) lack of public health support. The results suggest that significant systemic barriers limit the ability of primary care providers, particularly those in small practices, to effectively manage diabetes in current practice. Future primary care reform should consider how to support providers, particularly those in small practices, to overcome these barriers.

Summary of Proceedings From the Association of American Medical Colleges 2011 Integrating Quality Meeting

As Editor-in-Chief of the American Journal of Medical Quality (AJMQ), and as a member of the Association of American Medical Colleges (AAMC) Integrating Quality (IQ) Steering Committee, I am particularly pleased to bring this special supplement to fruition. The supplement highlights proceedings from the AAMC 2011 IQ Meeting, which was held in Chicago, Illinois, on June 9 and 10, 2011. Having delivered the keynote address at the 2010 version of the IQ meeting, I have seen firsthand how far this important initiative has come. Let us examine the full title more closely, that is, “Integrating Quality: Linking Clinical and Educational Excellence.” How exactly can we link clinical improvement and educational excellence? I believe the genesis of this linkage can be traced directly to October 26, 2009, when the Lucien Leape Institute at the National Patient Safety Foundation published Unmet Needs: Teaching Physicians to Provide Safe Care. The recommendations contained in this report came from an expert roundtable comprising Lucien Leape Institute board members and invited experts (including this author) from medical education and related fields. The report described the existing system of medical education as greatly lacking in the arena of quality and safety and called for sweeping reform of both undergraduate and graduate medical education curricula. My colleagues and I used the unmet needs report as a jumping-off point. Indeed, Academic Medicine received scores of papers from a national solicitation, and those that were published in this journal laid out multiple worthy plans for integrating clinical improvement and educational excellence in such a way that the die was cast by late in the fourth quarter of 2009. In the editorial accompanying the Academic Medicine special issue, I noted that there were “growing choruses of voices from across all of organized medicine, which have collectively spoken out about the crucial need for better care.” Astute observers noted that “unless everyone in health care recognizes that they have 2 jobs when they come to work every day—that is, doing the work and improving it—we will have difficulty maintaining and nurturing our true professionalism . . . continuously moving toward new and better levels of performance.” At this point, the AAMC launched its IQ initiative. Lending their national authority to this important topic, the AAMC has come a long way in providing leadership for this crucial linkage. They have gone beyond the Lucien Leape unmet needs report and eclipsed all previous work in this arena. The June 2011 meeting is further evidence of their success, luring hundreds of individuals to Chicago to ponder issues that only 3 or 4 years ago seemed like the distant future. This is all well and good, but the AAMC cannot rest on its laurels. What will success look like when we finally link clinical improvement and educational excellence? I envision the development of a national core curriculum on quality and safety, applicable to both undergraduate and graduate medical education settings. I envision a world where quality and safety are not simply add-ons or electives to be slotted somewhere in the second semester of the fourth year of medical school. I also envision growth in the number of endowed chairs in quality and safety and a great expansion in the number of master’s programs in our field. Furthermore, with the implementation of the highly anticipated Accreditation Council for Graduate Medical Education institutional visit program, we finally will quantify institutional responses to the quality and safety agenda at the residency training level. We will no longer be able to check a box regarding our capabilities in systems-based learning and practice-based improvement. We will have to prove, once and for all, that house officers get it—that they are intimately involved in self-evaluation, measurement, and improvement. House officers will embrace the 2 jobs that all practitioners must have. 445460 AJMXXX10.1177/106286061244 5460American Journal of Medical Quality