The Otorhinolaryngology Hand-Off: Pursuing Excellence in Patient Care and Safety

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The Otorhinolaryngology Hand-OffPursuing
Excellence in Patient Care and Safety

• Mark A. Zacharek, MD, FACS, FAAOA
• Associate Professor
• Associate Residency Program Director
• Department of Otorhinolaryngology
• Michigan Sinus Center
• University of Michigan Health System

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ACGME Common Program Requirements

• Sponsoring institutions must ensure and monitor
  effective, structured hand-over processes to
  facilitate both continuity of care and patient
  safety. Programs must ensure that residents are
  competent in communicating with team members in
  the hand-over process.

ACGME 2011 CPR www.acgme.org
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Halstead on Surgical Residency

• It will be objected that this is too long an
  apprenticeship, that the young surgeon will be
  stale, his enthusiasm gone before he has
  completed his arduous term of service. These
  positions are not for those who soon weary of the
  study of their profession, and it is a fact that
  the zeal and industry of these young assistants
  seem to increase as they advance in years and as
  their knowledge and responsibilities become
  greater.

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The Otorhinolaryngology Hand-off

• ACGME standards promote teamwork.
• Residents must work effectively as a member or
  leader of a health care team or other
  professional group.
• Residents are expected to work in
  inter-professional teams to enhance patient
  safety and improve patient care quality.
• Residents should have representation on hospital
  quality improvement committees.

ACGME 2011 CPR www.acgme.org
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Residents have Duty Hour Restrictions

• With a focus on restricted duty hours, the
  importance of communication between teams and
  individuals is of the utmost importance.
• Bo Schembechler (1983)-
• The Team, The Team, The Team!
• The handoff (handover signout ) is part
  of the continuity of care when one resident is no
  longer in the hospital for a continuous period of
  time.

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Definition Transitions of Care
ACGME 2011 CPR www.acgme.org

• Programs must design clinical assignments to
  minimize the number of transitions in patient
  care.
• Responsibility for each patient may be
  transferred between 2 or more residents within a
  24 hour period.
• Sponsoring institutions and programs must ensure
  and monitor effective, structured handover
  processes to facilitate both continuity of care
  and patient safety. Programs must ensure that
  residents are competent in communicating with
  team members in the handover process.

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Can we standardize the otorhinolaryngology
handoff?

• Handoffs may occur asynchronously without person
  to person/face to face interaction.
• Reduction in errors due to fatigue should not be
  offset by an increase in errors due to poor
  communication/improper information transfer.

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Multiple types of Handoffs

• Post-op Ambulatory
• Inpatient consult
• Outpatient/clinic
• Primary Oto inpatient service
• Primary Oto SICU patient in closed ICU system
  (General Surgery Staff and Resident)
• Different Otolaryngology Services (Neurotology,
  Head and Neck, VA, Pediatric)
• Multiple Hospitals (Home Call vs In House)

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Program Director Strategies

• Supervision and provision of feedback
• Coaching (Senior resident and faculty observation
  of junior handoffs)
• Objective skills-based examinations
• Simulation of practice handoff skills
• Metrics in Portfolio for Interpersonal Skills
  and Communication
• Using a checklist?
• What do other professionals do?

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Causes of Error in Teaching Hospitals

• Between 1979-2001, closed malpractice claims data
• 240 errors in teaching settings
• - errors in judgement 72
• - problems with teamwork 70
• - lack of technical competence 58

Singh H et al. Medical errors involving trainees
a study of Closed malpractice claims for 5
insurers. Arch Intern Med. 2007167(19)2030-2036
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Transitions of Care in the Training Environment
ACGME Standards

• Dr. Bradley Marple, MD  Dr. Marple is Professor
  and Vice Chairman of the Department of
  Otorhinolaryngology-Head and Neck Surgery at the
  University of Texas Southwestern. Additionally,
  he is the Chair of the ACGME Otolaryngology
  Residency Review Committee.

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Patient Handoffs A Cognitive Systems Engineering
Perspective

• Emily Patterson, PhD  Dr. Patterson is an
  assistant professor at Ohio State University in
  the Health Information Management and Systems
  Division of the School of Allied Medical
  Professionals in the College of Medicine. She is
  an expert in the field of cognitive systems
  engineering with interests in health informatics
  and macro-cognitive communication.

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Patient Hand-offs A Medical Education
Perspective

• Ingrid Philibert, PhD MBA    Senior Vice
  President, Department of Field Activities at the
  ACGME. Dr. Philibert is responsible for the
  Council's 31 MD and PhD accreditation field
  representatives as well as the 2000 site visits
  conducted annually. She is one of the editors of
  the ACGME's recent monologue regarding Duty Hour
  Standards "The ACGME 2011 Duty Hour Standards
  Enhancing Quality of Care, Supervision, and
  Resident Professional Development".  
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