Policies,Administrative,UWHC,Department Specific,Graduate Medical Education (GME)

Transitions of Care / Handoff Policy (43.22)

Transitions of Care / Handoff Policy (43.22) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)


Graduate Medical Education Department Policy

Policy Title: Transitions of Care / Handoff Policy
Policy Number: 43.22
Effective Date: November 18, 2015
Version: New


To establish protocol and standards within UW Hospitals and Clinics Authority sponsored residency and
fellowship programs to ensure consistent, accurate, timely and unambiguous communication between
health care personnel that leads to high quality and safety of patient care when transfer of responsibility
occurs during duty hour shift changes and other scheduled or unexpected circumstances.


This policy applies to all Graduate Medical Education (GME) programs sponsored by the University of
Wisconsin Hospitals and Clinics Authority (UWHCA).


A. The term “resident” refers to residents and fellows of accredited training programs.
B. Program(s) will refer to ACGME-accredited program(s).
C. UW Health: For the purpose of this policy, the term “UW Health” shall mean University of
Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the ACGME-
accredited training programs. “UW Health” is the trade name of University of Wisconsin
Hospitals and Clinics Authority and its affiliates.
D. A handoff is defined as a transfer and acceptance of patient care responsibility from one caregiver
(sender) to another caregiver (receiver). The sender is responsible for sending or transmitting the
patient data and releasing the care of the patient to the receiver, who receives the patient data and
accepts care of the patient. The transition/hand-off process is an interactive communication
process of passing specific, essential patient information from one caregiver to another.
Transition of care occurs regularly under the following conditions:
ξ Change in level of patient care, e.g., inpatient admission from an outpatient procedure or
diagnostic area or ER and transfer to or from a critical care unit,
ξ Temporary transfer of care to other healthcare professionals, e.g., to and from procedure or
diagnostic areas,
ξ Discharge, including discharge to home or another facility such as skilled nursing care
ξ Change in caregiver or service change, e.g., change of shift, on call, and rotation changes for


Individual programs must design schedules and clinical assignments to maximize the learning experience
for residents as well as to ensure quality care and patient safety and adhere to general institutional policies
concerning transitions of patient care. Each GME program must establish and maintain an
intradepartmental policy and procedures associated with transitions of patient care. GME programs are
responsible for educating their trainees on UW HEALTH and program policies and procedures related to
transitions of patient care.


A. The transition/hand-off process must involve communication between the person handing over
patient care (sender) and the person assuming patient care responsibilities (receiver). When
feasible, synchronous communication, e.g., face-to-face interaction with both verbal and
written/computerized communication should be done, especially for patients that are critically ill
or have rapidly changing status. Asynchronous communication is permissible. Hand-offs can be
conducted over the phone as long as both parties have access to an electronic or hard copy
version of the sign-out sheet. All attempts to preserve patient confidentiality will be observed.
The receiver must have the opportunity to ask questions or clarify specific issues. The transition
process should include, at a minimum, the following IDEAL information in a standardized
ξ I = Identify patient and physician name or service,
ξ D = Diagnosis and current condition,
ξ E = (Recent) Events / changes in condition or treatment,
ξ A = Anticipated changes in condition or treatment, what to watch for in next interval of care,
contingency plans,
ξ L = Leave time for the opportunity to ask questions and clarify information

B. Each residency program must develop components ancillary to the institutional transition of care
policy that integrate specifics from their specialty field. Programs are required to develop
scheduling and transition/hand-off procedures to ensure that:
ξ Hand-off communications are be part of the resident work expectations and designed to fit
into the workflow of sending and receiving caregivers.
ξ Residents comply with specialty specific/institutional duty hour requirements
ξ Faculty are scheduled and available for appropriate supervision levels according to the
requirements for the scheduled residents.
ξ All parties (including nursing) involved in a particular program and/or transition process have
access to one another’s schedules and contact information. All call schedules should be
available on department-specific password-protected websites and also with the hospital
ξ Patients are not inconvenienced or endangered in any way by frequent transitions in their
ξ All parties directly involved in the patient’s care before, during, and after the transition have
opportunity for communication, consultation, and clarification of information.
ξ Safeguards exist for coverage when unexpected changes in patient care may occur due to
circumstances such as resident illness, fatigue, or emergency.
ξ Programs should provide an opportunity for residents to both give and receive feedback from
each other or faculty physicians about their handoff skills.

C. Each program must include the transition of care process in its curriculum.

D. Residents must demonstrate competency in performance of this task. There are numerous
mechanisms through which a program might elect to determine the competency of trainees in
handoff skills and communication. These include:
ξ Direct observation of a handoff session by a licensed independent practitioner (LIP)-level
ξ Direct observation of a handoff session by a peer or by a more senior trainee
ξ Evaluation of written handoff materials by an LIP-level clinician
ξ Evaluation of written handoff by a peer or by a more senior trainee
ξ Didactic sessions on communication skills including in-person lectures, web-based training,
review of curricular materials and/or knowledge assessment
ξ Assessment of handoff quality in terms of ability to predict overnight events
ξ Assessment of adverse events and relationship to sign-out quality through:
o Survey
o Reporting hotline
o Trigger tool
o Chart review

E. Programs must develop and utilize a method of monitoring the transition of care process and
update as necessary. Monitoring of handoffs by the program to ensure:
ξ There is a standardized process in place that is routinely followed
o The standardized process should include:
 The routine situations that handoff communications should occur in and when
and where the handoff is expected to occur. For example, “handoff at the end of a
daily work shift should occur between 4-5pm to the overnight call person in the
residents office,” or “handoff of patient after an OR case should occur between
the anesthesia resident and the PACU nurse immediately upon arrival to the
 The minimum content of the communication should include all details of IDEAL
above. Any additional requirements should be specified.
 Expectations for how the handoffs should occur, i.e., face-to-face with written
information also provided.
 Expectations for documentation of the handoff in the medical record, if any
ξ There is consistent opportunity for questions between the sender and receiver
ξ The necessary materials are available to support the handoff (including, for instance, written
sign-out materials, access to electronic clinical information)
ξ A quiet setting free of interruptions is consistently available, for handoff processes that
include face-to-face communication
ξ Sufficient time is scheduled into the resident work schedule to allow for complete hand-off
preparations and communications.
ξ Barriers to high-quality handoffs are addressed.
ξ Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines


Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee 11-18-15


Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education

Revision Details:

Previous Revision Date: 8/31/2013
Next Revision Due: 11/18/2018 (3 years after effective date)