Using Direct Observation, Formal Evaluation, and an Interactive Curriculum to Improve the Sign-Out Practices of Internal Medicine Interns

The safe transfer (handoff) of responsibility for patient care from one physician to another requires that health care facilities have rigorous sign-out systems and that physicians develop effective communication skills. In 2007 and 2008, to improve the spoken and written sign-out practices of the 25 interns at Allegheny General Hospital (Pittsburgh, Pennsylvania), the authors designed and administered Likert scale surveys about training in and satisfaction with current sign-out practices; directly observed and evaluated interns performing spoken sign-outs; assessed and graded interns' sign-out sheets; and compared sign-out sheets with patient records to evaluate their accuracy. On the basis of their findings, the authors developed a new curriculum with didactic and interactive components to target intern-level and system-level problems. The curriculum emphasized the importance of complete and accurate sign-outs, provided examples of good and poor sign-outs, and assigned interns to work in small groups to practice sign-out skills and receive feedback from peers and program leaders. Reevaluation of interns two months after curriculum implementation revealed not only better performance on each of the seven items evaluated for spoken sign-out but also substantial improvement in the completeness of sign-out sheets and the accuracy of reporting of identification data, code status, and medications data. The curriculum was well received by interns, and it helped them develop skills required by the Accreditation Council for Graduate Medical Education, including competencies in communication, practice-based learning, and systems-based practice.