Structured Handoffs Among Practitioners

on October 15, 2012 Conferences with 1 comment

Structured Handoffs Among Practitioners: A Regularized Ad-hoc IT Solution Created by a Resident, Enhanced by Enterprise IT, Embraced by All


ACGME Duty Hour requirements and widespread use of hospitalists has resulted in increasing shift work by practitioners, driving more handoffs between these practitioners. A computerized tool using “screen-scraped” information was developed by a house-officer, then adopted by numerous practitioners on staff. User feedback that was brought to the attention of the CMIO and enterprise HIT staff resulted in standardization of extracts and customization of the documentation facility, leading to adoption by more than 300 practitioners. Incidentally, reliable maintenance of patient problem lists, a Meaningful Use requirement, have improved. SBAR (Situation, Background, Assessment & Recommendations) structured handoffs, a patient safety intervention, have become more routine and reliable.


  • Steven Davidson, MD, MBA, FACEP, FACPE – Senior Vice President and Chief Medical Informatics Officer, Maimonides Medical Center
  • Guy Kulbak, MD – Senior Resident in Internal Medicine, Maimonides Medical Center
  • Diane Tonetti – Director of Clinical Systems Implementation, Maimonides Medical Center


We are set up and ready to go!

From left to right we have: Dr. Davidson, Dr. Kulbak, and Diane Tonetti from Maimonides Medical Center in Brooklyn, NY.

Dr. Davidson is up first.

Welcome to what is the “afternoon nap time”… after lunch meeting.

Telling a story.

Some of the lessons that enterprise and its leaders can gain from the story.

Showing picture of new building of Maimonides Medical Center. Maimonides is a large, non-profit teaching tertiary hospital in Brooklyn. Large teaching program — 450 residents and fellows and more than 1,100 medical staff.

Inpatient system used is Sunrise Clinical Manager v.5.5, feature pack 1, hosted at the TSC, still in hybrid environment. 6.0 is next year… got it on his mind.

Hybrid environment = CPOE, documentation is still hand-written on paper. Some procedures documented in the SCM system and other tools in the making that essentially serve as “electronic typewriters.”

Dr. Kulbak identified problem… more to come from that.

Diane Tonetti was key to success of this project. “through her we engaged our MIS department and HIT experts and garnered their support for a tool that delivers great value to our clinicians.”

Why is it important that we pay attention to handoffs and sign out?

Attention on issue of sign outs among clinicians because of a lot of “bad things happening to patients” around communication, which, unfortunately fails. And it has failed many times across the years and settings.

7% of the payouts are consequence of poor communication.

Communication among staff — a physician handing over a patient to another physician, or interdisclipinary departments, opens up opportunities for miscommunications. Can be distractions which divert attention at the moment of key information. Reliance on memory in the communication, rather than documentation.

In addition, driver for all of these handoffs, we have the limitation on resident duty hours and the requirement that residents turnover the care of their patients to others.

So having the means to have a proper way to do handoffs/sign outs has become a national patient safety goal. Information appears to be delivered, but folks may not hear it.

NPSG and JCAHO have proposed and approached handoffs by the short name “SBAR” — summary, background, assessment, and recommendations for a certain patient at the moment of handoff.

Maimonides has structured handoff tool that is used. Lots of room for interpretation in SBAR approach by problem or by patient. Or by all of the above. And everyone had a different way of doing it. It wasn’t meeting the needs.

Dr. Kulbak identified the problem.

Next up, Dr. Kulbak!

Talk about journey to create a sign out system and progress note generator.

Printed out sign out report, had some information — vitals, labs, medications. Didn’t have any info about patient — how did the pt present? Why is pt in hospital?

Solution was to handwrite in any space available. It was “inefficient, inaccurate and very time consuming.”

In regular day, day shift would sign out to short call, then short call sign outs to night float folks. Approximately 4 hrs of the day (50-60%) is spent giving sign out and getting sign out. On weekends, Friday AM, Friday NF, Sat AM, Sat NF, Sunday AM, Sunday NF.

Information is getting lost, getting distorted.

Another issue is progress notes — they are handwritten. Illegible at times. Unable to ensure compliance with hospital regs and JCAHO standards.

Handwritten progress notes have no structure. Showing pictures of extreme examples. Question marks? Not sure what that is, but it is something.

He has computer skills and training in medicine and he thought he could create something better.

ICU rotation… used Word document to document patient.

Sign out is even more important in ICU system because patients are so sick and you don’t want information to be lost.

Create Microsoft Access database solution. Benefits — more structure, multi-user environment, enhanced security, prog note writing feature.

Had great success — residents, colleagues and attendings really liked it and used it. Based on feedback, made tweaks.

Met with performance improvement specialists and showed the solution to her. She was very excited.

Root/cause analysis committees always talk about how errors occur in failed communication.

Pilot approved in January 2011. New challenges with pilot project. ICU system was geographic constrained. Easy to develop and maintain in small place and only handle about 20 pts. Now we are looking to scale. More areas in hospital, etc.

Hospital MIS department deployed SharePoint site — accessible through hospital intranet. Secure, behind hospital firewalls, and you can store patient information on those servers.

Within one week of implementation, 100% uptake of the new tool.

Missed some stuff there about Allscripts, will fill in later.

Challenges of SharePoint list: limited user interface, limited print capabilities, limited flexibility in adjusting the system per users requests; loss progress note generator. Continued to work more withMIS dept to make system much more synchronized.

Now Diane is up.

She’s going to talk about the SCM intergration.

Anyone who works with inpatient EHRs knows it takes a long time before you get to that value-add with all that data.

Heard about sign out and knew they could provide a quick value-add to the providers.

Used existing SBAR report as the stating point and modified to meet the needs for handoff. Developed two extracts — a header file (includes basic dem data) and a data file: includes some results, meds, vital signs, I & O, etc. Extracts are scheduled to run every hour.

Will continue to do even more when they continue to integrate the system even further.

SCM SQL Database > Crystal Report server runs jobs to execute procedures > Data extracted and saved as Excel files > Handoff app picks up files and processes.

Impacting real-time clinical system that was critical to our hospital. If the SCM was down, we were impacting our providers who are using the sign out system.

Dr. Kulbak is back up again — talking about future direction with the sign out application.

3rd generation of system: MS Access and SharePoint.

Combination of MS Access, SharePoint list, SCM data extracts, front-end/back-end. Yielded a solution the SharePoint list alone could not.

Progress note generator advantages: increase compliance with JCHAO requirements, users presented with mandatory fields, legibility, increased efficiency.

Screen shots of new application in MS Access. Can toggle between sign out and progress notes.

Great success in medicine, and peds wanted to use it as well.

Pediatrics – due to cross coverage of peds patients by other teams, multiple signout layers created.

Psych – special psyc exam template created.

Surgery – the final frontier..

New forms added

Dr. Kulbak created service-specific changes.

Challenges — “garbage-in” and “garbage-out” phenomenon and copy/pasting.

Future plans:

  • Create custom tab within Allscripts SCM
  • Adding nurses to the computerized sign out format
  • Synchronization of docs generated from the system
  • Bridge to robust EMR documentation in the next year


“We are lacking some things they have in their sign out, they are lacking some things we have in our sign out.” –on nurses, Dr. Kulbak


Overall on daily basis:

  • 400 progress, admission and transfer notes
  • 35 H&Ps
  • 25 consultation notes


By department:

  • Medicine: 100% (both house staff and PAs)
  • Peds: 50%
  • Psych: 85%
  • Surgery: 10%


Survery results of about 160 residents, fellows, PAs, attendings…

  • Increased pt safety: 83%
  • Improved comm among physicians: 84%
  • Answered a need that the current systems did not provide: 89%


Sign out time: prior to compu sign out:

  • More than an hr – 74%


After copu signout:

  • Less than hr – 88%
  • 1/2 hr or less: 57%


60-80 hours being saved a day, allowing caretakers to be at the bed side, to talk to patients, to actually do their jobs on a daily basis.

Help my colleagues and improve patient care and make it safe.

Applause from audience.

Dr. Davidson back on stage to summarize present. Giving kudos to senior vp of Maimonides, thank you for partnership.

Developed in the trenches trying to solve their own problem. Got brought to Dr. Davidson by fellow and nurse he knew from performance improvement.

“Believe me, when nurse and resident on the front lines bring a boss a project, you BETTER pay attention.”

Great value.

Look at the speed and complete uptake with minimal or no training. Very limited training. How much training did we get for our iPhones or iPads? And we love them and use them. This is a system that the clinicians adopted without any training.

Always remember the staff on the front lines. The willing workers will try to do their best. They will try to find the way. It’s the leaders job to create systems so that they can get the best results.

And that’s the end.

Time for Q&A!

First question — How is this going to affect the design of the EMR? What’s the impact going forward on documentation?

Dr. Davidson: Lets realize at the moment, what we’re doing with a fancy typewriter … what it does tell us and informs us on how the residents are working with these tools. That gives us some wisdom — have been participating in design build sessions for the EMR.

Dr. Kulbak: This is a fancy typewriter. Has a lot to offer, but not close to full-fledge EMR where you’re having info being pulled in. In terns of experience, example from last week. Few options to do H&P — free text box or ability to select Dx. Clinicians want free text. They want that box to type whatever they want/can and ignore the other clicks.

Handoff tool that you’re using — is that patient centric? Does each provider have to develop a handoff on that patient and then handoff?

Dr. Kulbak: sign out per patient, per team, for entire length of stay. Carries on. Patient-centric.

Progress note: hybrid system, relying on people using electronic note to print it out and put it on the chart?

Dr. K: Understanding from beginning that this note must be printed and placed in chart and that’s the only place it will exist. The progress note generator won’t stay and you won’t have it the next day — it will be gone by midnight.

Dr. D: No content preserved from session to session. Overwritten, have to print it. More than one occasion when someone did H&P in system and failed to print it, closed out the session and now wants to know “can they recover it for me?”

Audience: because it can be viewed electronically, we’re having issues printing it out.

Now that you’ve established this adds value and is saving time, what has been the driver behind the decision to keep developing in-house vs working with outside vendor that can build something that’s robust and will scale?

Dr. D: Real reason is that the vendor’s documentation product is integrated with other areas of the vendor’s offering, including clinical decision support and other aspects of care. Where Dr. Kulbak is in process to look to build both on temp basis, taking document and putting it back in record. But more importantly, moving off Access and SharePoint platform altogether. Allscript uses development tool set that Dr. Kulbak is using to build handoff functionality that may survive the implementation of full documentation.

They can annotate, comment upon, and help direct next clinician.

You had high degree of success in adoption from users — what techniques did you use to gain buy-in?

Dr. K: I was a resident and I knew what we needed. It was very inefficient. I spent majority of my time during short calls taking and giving sign out. 2-4 hours of doing this process was just unreasonable. All had same feeling. Just needed a simple solution that worked. Provided essential info that was missing that would get lost and distorted all the time. Also had few users/friends/colleagues that were able to implement it throughout the floors, but it’s the need that drove the process.

Dr. D: Residents learn from being with their patients and being with their faculty. Not from sitting at their desks writing notes. These are good people trying to do their job but their time was being eaten up writing notes and documenting. You want to be with your patients and with senior people that can teach you something.

Minimal budget …

Medical records department — did you involve them from get-go? Is sign out part of legal medical record?

Dr. D: We involved health info management at point that we were printing progress notes and H&Ps. We wanted them to accept the forms and incorporate that as part of med record. That created requirement to format printouts in expected fashion for HIM.

Handful of clinicians in the room…

Sign outs did not go on chart. Back in day it was 3×5 card with a few comments on it, and line between each patient. Then it became one 3×5 card per patient w/ stamper plate. Then it continued to evolve…

What is in-record clinical document requirement for sign outs?

Not clear that there is legal or regulatory requirement. At the moment, handoffs are private between the clinicians doing the handoff. Room agrees.

Session ended. Thanks to the speakers for your insight!

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Tiffany Tcheng

I am a co-founder of Smart Sign Out and an internet marketer at Cypress North. Previously, I worked in Public Relations at nonprofit Banner Health, and graduated from Arizona State University with a Master's in Healthcare Innovation.

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