I think it’s time for family medicine to rock the boat. Family physicians, and especially family medicine residents, are uniquely qualified to promote quality improvement by standardizing patient care processes.
As a family medicine intern at an urban academic institution, these past 6 months have been a blur of rotations. Every 4 weeks, we start a new service and drink from a fire-hose of learning the intricacies of “how-to-be-a resident.” Our intern training is the most diverse; we rotate through inpatient services in OBGYN, pediatrics, family medicine, internal medicine, general surgery, intensive care, and the emergency department.
For inpatient services, there are common tasks that all residents perform. We answer pages, place admission orders, write progress notes, discharge patients, sign-out the patient lists, etc. We have access to the same electronic medical record, the same resources, and are unified by an academic institution.
What dawned on me is that every service seems to coordinate patient care completely differently. Every 4 weeks, I would re-learn how to do the same types of tasks but with different methodology. The most glaring disparities I noticed were in how different services handle transitions of care, especially patient sign-out.
Why does every service have different methods of achieving the same goal when we have nearly the same resources? Why isn’t there a standardized approach to sign-outs? The best answer I’ve received is, “Oh, that’s just how it’s done.”
Because family medicine trainees experience the full variability of sign-out among services, we are uniquely poised to help standardize the process. For example, resident sign-out varies widely. Some services are completely dependent on the EMR to generate information, others have a completely separate Excel spreadsheet, and the rest seem to use a combination of the two.
The tools that are used for sign-out directly influence the amount of information passed between the day/night teams and when services transition at the time of rotation change. Patient care is directly impacted by the quality of sign-outs. Several prospective and retrospective studies have demonstrated that poor quality sign-outs resulted in higher numbers of medical errors. Taking a step further, the notable I-PASS multi-center study established the correlation between a standardized oral and written sign-out with a 23% relative reduction in the incidence of preventable adverse events.1 The difficulty lies in designing a standard that is useable across different services because most residents are not required to immerse themselves in an area outside of their practice.
Family medicine residents are an untapped resource for truly understanding gaps and idiosyncrasies between services and improving the sign-out process across services in their respective institutions. Time and again, I’ve shared information I learned from a prior rotation to improve patient care processes on a subsequent rotation. By virtue of our training, family medicine physicians can effectively communicate between services to unify them and create a cultural shift.
- Starmer, A. J. (2015). Changes in Medical Errors with a Handoff Program. New England Journal of Medicine,372(5), 490-491. doi:10.1056/nejmc1414788