Background: End of shift sign out is a major part of inpatient care and occurs multiple times for each patient on a Hospital Medicine service. Sign out guidelines recommend specific elements of the written sign out process to ensure patient safety. Use of these standardized written sign outs has been shown to improve care when combined with training. Hospitalist Physicians and Physician Assistants at our hospital work on different types of Hospitalist teams (Oncology, Transplant, Liver, General Medicine and Cardiology). However end of shift standardized written sign outs among Hospital Medicine providers was an inconsistent process which made the overall sign out process time consuming and created concerns for miscommunication of pertinent information.
Purpose: To implement and maintain standardized written sign outs among hospitalists using a modified I-PASS format
Description: The IPASS system was used to model a written sign out template specifically tailored for Hospital Medicine providers to be incorporated as a smart phrase in our electronic medical record system-EPIC. Educational sessions were held to explain the need for standardized sign outs and electronic mail reminders were sent to all providers to adopt the template upon its launch. The project proposal was approved by the Hospital’s Quality Improvement Determination Committee. Starting December 2017, the project was implemented through 8 PDSA cycles: PDSA 1- Single user template and workflow, PDSA 2- Updated template and workflow, PDSA 3- Second user template, PDSA 4- Multi-user template and workflow, PDSA 5- Multi-user active engagement, PDSA 6- Added use rate to quality board, PDSA 7- Updated template based on feedback and PDSA 8 – Expand template to additional workflows. Feedback from all providers was obtained on three domains: 1) ease of using template, 2) satisfaction with overall sign out after using template and 3) suggestions for improvement. Changes to the template and implementation process were made in real time based on feedback. Data on use of standardized sign outs on patients was collected at 90 time points over 8 months (December 2017 to August 2018) since launch of intervention. Evaluation of implementation was held at 3 months after launch through electronic surveys and shared at Hospital Medicine section meetings to improve and sustain multi-stakeholder engagement. Adoption of standardized written sign outs for patients on Hospitalist teams increased to 85% at the end of the first month of intervention. After the first month, on average 80% (n= 79/99) of patients admitted on Hospitalist teams had standardized written sign outs. Provider type but not service type was associated with delayed adoption in standardized written sign outs. Decrease in standardized written sign outs was noted on weekends or when providers changed teams.
Conclusions: We were able to implement and sustain a standardized written sign out among hospitalists by using a modified I-PASS format through multiple PDSA cycles, continuous feedback and engagement of all stakeholders.
