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Background Increasing frequency of shift-to-shift handoffs coupled with regulatory requirements to evaluate handoff quality make a handoff evaluation tool necessary. Objective To develop a handoff evaluation tool Design Tool development Setting Two academic medical centers Subjects Nurse practitioners, medicine house staff and hospitalist attendings Intervention Concurrent peer and external evaluations of shift-to-shift handoffs. Measurements The Handoff CEX consists of 6 subdomains and one overall assessment, each scored from 1–9, where 1–3 is unsatisfactory and 7–9 is superior. We assessed range of scores, performance among subgroups, internal consistency, and agreement among types of raters. Results We conducted 675 evaluations of 97 unique individuals during 149 handoff sessions. Scores ranged from unsatisfactory to superior in each domain. The highest rated domain for handoff providers was professionalism (median 8, interquartile range [IQR] 7–9); the lowest was content (median 7, IQR 6–8). Scores at the two institutions were similar, and scores did not differ significantly by training level. Spearman correlation coefficients among the CEX sub-domains for provider scores ranged from 0.71–0.86, except for setting (0.39–0.40). Third-party external evaluators consistently gave lower marks for the same handoff than peer evaluators did. Weighted kappa scores for provider evaluations comparing external evaluators to peers ranged from 0.28 (95% CI, 0.01–0.56) for setting to 0.59 (0.38–0.80) for organization. Conclusions This handoff evaluation tool was easily used by trainees and attendings, had high internal consistency and performed similarly across institutions. Because peers consistently provided higher scores than external evaluators, this tool may be most appropriate for external evaluation.

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Background The increasing fragmentation of healthcare has resulted in more patient handoffs. Many professional groups, including the Accreditation Council on Graduate Medical Education and the Society of Hospital Medicine, have made recommendations for safe and effective handoffs. Despite the two-way nature of handoff communication, the focus of these efforts has largely been on the person giving information. Objective To observe and characterize the listening behaviors of handoff receivers during hospitalist handoffs. Design Prospective observational study of shift change and service change handoffs on a non-teaching hospitalist service at a single academic tertiary care institution. Measurements The “HEAR Checklist”, a novel tool created based on review of effective listening behaviors, was used by third party observers to characterize active and passive listening behaviors and interruptions during handoffs. Results In 48 handoffs (25 shift change, 23 service change), active listening behaviors (e.g. read-back (17%), note-taking (23%), and reading own copy of the written signout (27%)) occurred less frequently than passive listening behaviors (e.g. affirmatory statements (56%) nodding (50%) and eye contact (58%)) (p<0.01). Read-back occurred only 8 times (17%). In 11 handoffs (23%) receivers took notes. Almost all (98%) handoffs were interrupted at least once, most often by side conversations, pagers going off, or clinicians arriving. Handoffs with more patients, such as service change, were associated with more interruptions (r= 0.46, p<0.01). Conclusions Using the “HEAR Checklist”, we can characterize hospitalist handoff listening behaviors. While passive listening behaviors are common, active listening behaviors that promote memory retention are rare. Handoffs are often interrupted, most commonly by side conversations. Future handoff improvement efforts should focus on augmenting listening and minimizing interruptions.

Background The most recent iteration of the Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations includes language mandating handoff education for trainees and assessments of handoff quality by residency training programs. However, there are a lack of validated tools for the assessment of handoff quality and to utilize for trainee education. Methods Faculty at two sites (University of Chicago and Yale) were recruited to participate in a workshop on handoff education. Video-based scenarios were developed to represent varying levels of performance in the domains of communication, professionalism and setting. Videos were shown in a random order and faculty were instructed to use the Handoff mini-CEX, a paper-based instrument with qualitative anchors defining each level of performance, to rate the handoffs. Results Forty-seven faculty members (14=site 1; 33=site 2) participated in the validation workshops providing a total of 172 observations (of a possible 191 (96%)). Reliability testing revealed a Cronbach’s alpha of 0.81 and Kendall’s coefficient of concordance of 0.59 (>0.6=high reliability). Faculty were able to reliably distinguish the different levels of performance in each domain in a statistically significant fashion (i.e. unsatisfactory professionalism mean 2.42 vs. satisfactory professionalism 4.81 vs. superior professionalism 6.01, p<0.001 trend test). Two-way ANOVA revealed no evidence of rater bias. Conclusions Using standardized video-based scenarios highlighting differing levels of performance, we were able to demonstrate evidence that the Handoff mini-CEX can draw reliable and valid conclusions regarding handoff performance. Future work to validate the tool in clinical settings is warranted.