“Workin’ on Our Night Moves”: How Residents Prepare for Shift Handoffs Laura G. Militello, MA; Nicholas A. Rattray, PhD; Mindy E. Flanagan, PhD; Zamal Franks, BA; Shakaib Rehman, MD; Howard S. Gordon, MD; Paul Barach, MD, MPH; Richard M. Frankel, PhD Background: Poor-quality handofs have been associated with serious patient consequences. Researchers and educators have answered the call with eforts to increase system safety and resilience by supporting handofs using increased commu- nication standardization. The focus on strategies for formalizing the content and delivery of patient handofs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement efective measures of handof quality. Methods: Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Afairs medical centers. Thirty-five residents participated in semi-structured interviews using a recent handof as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed inter- view data were analyzed using thematic analysis. Results: Six cognitive tasks emerged during handof preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation. Conclusion: Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand of patients from day shift to night shift. Cognitive preparation for the handof includes activities critical to efec- tive coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training. P oor-quality handofs have been associated with serious consequences, including increased hospital readmis- sions, complications, adverse events, unnecessary tests, and diagnostic delays. 1–3 The Joint Commission estimated that 80% of serious medical errors involve miscommunication between caregivers during patient handofs. 4 The Accredi- tation Council for Graduate Medical Education mandated, in response to this concern, common program require- ments to “ensure and monitor efective, structured hand- over processes to facilitate both continuity of care and patient safety.” 5(p. 13) Researchers and educators have answered the call with eforts to increase system safety by supporting handofs using increased standardization. 6 Generally, these attempts incor- porate some form of a mnemonic (for example, I-PASS, SBAR), checklist, or decision aid representing the classes of information that should be included in the handof and com- munication strategies. Indeed, a 2009 literature review uncovered 46 articles ofering 24 diferent mnemonics, with the majority unvalidated. 7 The I-PASS Handof Curricu- lum is perhaps the most well-known and most comprehensive such program, incorporating organizational planning and support, as well as a culture change campaign. 8,9 The I-PASS program has shown promise, 8,9 but many have failed to make an impact on the efectiveness of handofs. In fact, a con- temporaneous literature review concluded that little evidence indicates that standardization of handofs leads to sustain- able patient improvements. 10 A more recent meta-analysis suggests that introducing a standardized handof protocol may increase the information passed and improve out- comes but also tends to increase the rates of omission errors and time required to complete handofs. 11 The focus on strat- egies for formalizing the content and delivery of patient handofs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop efective measures of handof quality. 12 In this study, we focused on preparation for the end-of- shift transition from the primary team (day shift) to the cross- cover resident (night shift) (Figure 1). Residents on the day shift are actively engaged in planning, making treatment de- cisions, monitoring, and adjusting care plans for each patient on their panel. Night shift residents (cross cover), on the other hand, are usually responsible for a larger number of pa- tients and are generally charged with carrying out existing care plans and addressing emergencies such as patient de- terioration. Night shift residents are less actively engaged in choosing new treatment options and creating care plans and are not likely to have a deep familiarity with the patients under their care. 13 This fundamental diference in roles and responsibilities shapes the way that the outgoing day shift 1553-7250/$-see front matter © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjq.2018.02.005 ARTICLE IN PRESS The Joint Commission Journal on Quality and Patient Safety 2018; ■■:■■–■■ Q1 Q2 Q3 Q4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80