Resident Sign-Out: A Precarious
Exchange of Critical Information
in a Fast Paced World
Stephen M. Borowitz, M.D.
Linda A. Waggoner-Fountain, M.D., M.Ed.
Ellen J. Bass, Ph.D.
Justin DeVoge, M.S.
University of Virginia
Rick Sledd
Ted Perez
Kim Brantley
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Tammy Schlag
Peggy Plews-Ogan
George Hoke
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Mangwi Atia
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Matthew Bolton
Leigh Baumgart
McKinsey Bond
Adam Helms
Luther Bartelt
Sign-Out
a mechanism of transferring information,
responsibility and/or authority from one
set of care-givers to another
 primary objective is the accurate transfer
of information about patient’s state and
plan of care
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Sign-Out is a Lifelong Skill
In Academic Health Centers, resident
physicians sign-out to one another from
the very beginning of residency
 Few residency training programs formally
teach residents how to sign-out
 Few residency training programs assess
how well residents’ sign-out to one
another
 Sign-out is a life-long skill
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There are Multiple Resident
Hand-Offs Every Day
Patient Care Handoffs Can Lead to
Omissions and Misunderstandings
 Frequent
patient care hand-offs have
been associated with:
» longer hospital stays
» more laboratory tests being ordered
» more self-reported preventable adverse
events
A Changing Environment
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Hospitalized patients are sicker and sicker
Hospital stays are shorter and shorter
The “medical record” has been marginalized as
a source of communication between clinicians
There has been an explosion in scientific and
medical knowledge
There is an increasing reliance on electronic
health records/electronic data sources
In 2003, the ACGME instituted duty hour
restrictions for all residency programs
Sign-Out
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There is scant research on how sign-out
is actually conducted, and even less is
known about how sign-out should be
conducted, or how interventions
improve the quality of sign-out
» most of the available information comes
from other domains, particularly aviation
and the military
How often did something happen
you weren’t prepared for?
no unexpected event
109 (69%)
missing info
40 (82%)
unexpected event
49 (31%)
no missing info
9 (18%)
In 33 of the 40 (79%) cases where information was
missing, the problem/issue should have been
anticipated during sign-out
Residents Often Miss Key
Points During Sign-Out
Next Steps
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Process
Tool(s)
Education
Process
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We conducted facilitated sessions with
residents, and pediatric and systems
engineering faculty during which we:
» defined the goals of sign-out
» identified barriers to and opportunities for
improving sign-out
» characterized a desired process and the
information that should be exchanged during
sign-out
Tool
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We designed an electronic sign-out tool
using an iterative, human centered
systems design process
Education and Training
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Initially, we focused on
» the type(s) of patient information that should
be exchanged
» a training process that emphasized the
“giver” of information more than the
“receiver” of information
Who Gives Good Sign-Out and Why?
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We surveyed our residents and three
residents of varying levels of experience
and medical knowledge were identified
as sign-out exemplars
» “after signing out with them, I feel well
prepared for the next call shift”
» “they help me anticipate what might go
wrong during my call shift”
» “they give me a chance to ask questions”
Who Gives Good Sign-Out and Why?
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We met with our three “sign-out
exemplars” and conducted qualitative
research about their sign-out techniques
and the following themes emerged:
» they always achieve “co-orientation”
regardless of whether they are giving or
receiving sign-out
» they all have high emotional intelligence
Education and Training
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Over time, we have realized the cognitive
tasks of sign-out need to be reframed
» much less emphasis on the exchange of
information
» much more emphasis on the
development of a shared understanding
and meaning of the situation at hand
–situational awareness and coorientation
The Cognitive Tasks of Sign-Out
For a successful sign-out, physicians
handing off care and physicians assuming
care must assemble a shared mental
model of patients they are caring for
 This co-orientation is necessary to
recognize and analyze problems, to make
sense of the situation, and to plan
 Co-orientation also provides an
opportunity for rescue and recovery
(collaborative cross-checking)
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The Cognitive Tasks of Sign-Out
Clinicians need more than data to
understand a patient’s story and to try and
predict future trajectories
 During handovers, most high-reliability
organizations
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» exchange few data elements
» adhere to the “most important first” heuristic
» standardize the handover process
» do NOT standardize handover content
“Music is not just about the
notes. Rather it is created by the
spaces between the notes”
Claude Debussy
Sign–out vs Sign Over
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Culture change
» from “I’m just the cross-cover” to “This is my
patient right now”
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Care of patients must no longer be viewed
as a marathon run by a single runner, but
as a relay race run by many runners
» each person must run a leg of the race
» you must “hand off the baton” when your leg
is done
» if we drop the baton, the race is lost
Resident Sign-Out: A Precarious
Exchange of Critical Information
in a Fast Paced World
Stephen M. Borowitz, M.D.
Linda A. Waggoner-Fountain, M.D., M.Ed.
Ellen J. Bass, Ph.D.
Justin DeVoge, M.S.
University of Virginia