Background: National guidelines recommend hospitals implement standardized approaches to handoffs, and recent quantitative research has indicated that standardized approaches such as the I-PASS tool can lead to sustained improvements in patient safety and provider communication in a diverse array of settings.1 Our hospital medicine group piloted a formal written handoffs process based on the I-PASS protocol with limited success. When surveyed, 79% of direct-care hospitalists reported satisfaction with shift handoffs. However, the piloted tool was only used 45% of the time during the evaluated period, and upon completion of the formal QI project, use of the tool ceased, despite integration into the electronic medical record (EMR). We used qualitative methods to elucidate the discrepancy. We evaluated hospitalists’ attitudes toward/knowledge of the handoff QI project and sought to understand barriers to use of the I-PASS tool in a large urban safety-net hospital.
Methods: Eleven physicians and 2 APPs covering both day and night shifts participated in interviews and homogeneous focus groups in February and March 2022. Recordings were transcribed and coded inductively with codebook revision until interrater agreement was high (κ=0.82). Specific concerns that were raised repeatedly in the interviews and focus groups were used as codes to organize textual data analysis. These included perceived sufficiency of existing handoff mechanisms (chart notes and Epic Chat), particularly within the specific hospital context; the importance of handoffs vis-à-vis patient safety; specific positive and negative aspects of both the I-PASS tool and use of Epic Chat/chart notes; frustration at time-consuming documentation in cases where it had little perceived utility; and concerns about “buy in” by night cover providers.
Results: Participants agreed that handoff processes are needed for patient safety, particularly given the high patient volume of the safety-net institution. Many attributed greater awareness of standardizing handoffs to our QI project. Participants noted that the piloted tool, which necessitated extra steps, consolidation of information from multiple sources, and written sign out for all patients regardless of condition were ultimately impractical and unlikely to be used. Most participants felt existing mechanisms (i.e., EMR notes/Epic interactive chat features) were either already sufficient or could become sufficient with standardized processes and clear expectations. Participants felt it was most important that handoff processes be useful for cross-cover/night providers for patient safety, and that taking extra time to document information that was not used by nighttime providers was frustrating.
Conclusions: The handoff QI pilot raised awareness and use of handoff processes among providers overall, though they perceived the I-PASS–based tool itself to be suboptimal in several respects. Aspects of an effective process include standardized process and format; buy-in/use by all parties engaged in patient care; education for how to use the tool effectively; and formal expectation that providers complete handoffs. For real-world use, handoff processes must provide necessary information quickly for cross-cover providers—“heads up” on patients’ conditions or context, on “watchers,” or anticipatory guidance—with no requirement for similar details for patients who were stable.