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Development and Validation of a Tool to Evaluate Hand-off Quality

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Transitions of patient care among providers occur frequently and require providers to transmit critical clinical information. If information is omitted or misunderstood during a hand-off, serious clinical consequences may result for patient care. In fact, studies have shown that hand-offs are often variable and represent a major gap in safe patient care. For patients cared for by resident physicians, dangers posed by poor communication may be amplified since the implementation of resident duty hour restrictions in July 2003 has increased transfer frequency. In addition, few trainees receive formal training on hand-offs. The Joint Commission currently requires hospitals to implement a standardized, interactive approach to hand-off communications. Unfortunately, due to a lack of valid, standardized tools to evaluate hand-off quality, hospitals and educators can not assess whether their hand-offs meet these criteria. More recently, the Institute of Medicine has recommended that all residents receive formal education on handoff strategies. Understanding best practices during hand-offs and valid assessment of hand-off quality are needed for several reasons: to improve clinical practice through evaluation and feedback, to illuminate areas of deficiency in current practices and to maximize patient safety in this era of duty hour restrictions. At the University of Chicago and Yale, investigators have extensive experience in describing hand-off quality, designing and implementing novel curricula to improve hand-off education amongst varying levels of trainees and have elucidated the relationship between patient care outcomes and poor hand-off quality. Therefore, drawing from our preliminary work in this area, and relevant practices in other industries, we aim to develop and test a generalizable tool to evaluate hand-offs in clinical settings. The aim of this application is to develop and validate a simple, flexible, reliable, real-time observation tool to evaluate hand-off practices. The Hand-off CEX is a paper-based instrument that can be used to evaluate either the sender or the receiver of hand-off communication. This tool is based on a previously-validated, widely-used, real-time educational evaluation tool (the Mini-CEX);published expert opinion;and our prior research. Our tool incorporates unique role-based anchors for both senders and receivers that refer to verbal communication, professionalism and environment, hand-off domains informed by preliminary work and expert opinion. The Hand-off CEX (Clinical Evaluation Exercise) will be used by academic hospitalists and house staff physicians to assess feasibility. We will also assess the construct validity and inter-rater reliability of the tool through the use of standardized, videotaped hand-off scenarios depicting various levels of performance of a hand-off scenario. The Hand-off CEX will arm educators with an innovative, necessary, valid and feasible method for training health professionals to conduct safe and effective hand-offs. Finally, the Hand-off CEX will be a useful tool to assist hospitals in improving patient safety.

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