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We have been working on the issue of resident signout through the Healthdesignby.us initiative, and as part of my academic service to explore how design thinking and emerging technologies can be applied to systems design in healthcare!
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Resident Sign-out Deserves
Great Design Joyce Lee, Doctor as Designer, Jennifer Zank,
Xiaoying He, Matt Kenyon Healthdesignby.us
Resident Sign-out
It’s the handoff that happens between residents in the hospital from day to night shift and night
shift to day shift
How might we improve the pain points around sign-out, instead of
accepting the status quo?
And since residents are creative hackers, why not have them
help with the redesign of the tools that they use everyday?
We held a design workshop with interns, senior residents,
chief residents, and Faculty from the Schools of Art, Architecture, Engineering, and Medicine at the
University of Michigan to redesign resident signout
We used Human-Centered Design Thinking
a form of User-Centered Problem Solving
But what is Design Thinking?
Empathy Prototype Define Ideate Test
It’s an iterative process that starts with the user
Empathy Understand a problem
before solving it
De!ne Patient-de!ned problem
Ideate Collaborative, creative
brainstorming
Prototype Sketch, draw, glue, code
,,
Test Iterative Feedback from User
,,
Empathy Prototype Define Ideate Test
Before the workshop, we started by understanding the user and
de!ning the problem
We performed user interviews with the interns and senior residents in the trenches
We mapped out the system: Users, Teams, and
Interactions
Intern
1st year resident
Senior
3rd year resident
We ran simulations to see if the duration of night shift
schedules impacted patient continuity
(Conclusion: not so much)
We observed resident signout in the hospital
Our Design Synthesis lead to these insights:
FACTORS IMPACTING SIGNOUT
TEAM COMPOSITION
SERVICE TYPE
CALL SCHEDULES(NIGHTS/WEEKENDS)
RESIDENT GUILT
SEASONALITY(NEW INTERNS!)
SIGNOUT QUALITY(VERBAL/WRITTEN)
Factors Impacting Signout
TEAM COMPOSITION
SERVICE TYPE
CALL SCHEDULES(NIGHTS/WEEKENDS)
RESIDENT GUILT
SEASONALITY(NEW INTERNS!)
SIGNOUT QUALITY(VERBAL/WRITTEN)
Factors Impacting Signout
A BOTTLENECK IN COMMUNICATION
“There are two different time issues. There is the time it takes to sign-out your own team and also the time that the other 2 teams are taking. So if you’re the third team to sign-out and you’re waiting an hour-and-a-half for the !rst two teams to sign-out, so that’s also a problem.”
Intern Resident
“The night team travelling was an ef!ciency issue too, as people would be waiting in line but we didn’t have a set-up such that people as they were waiting could kind of do work at the same time. They would just be standing around and waiting.”
“I signed out 3 teams a couple of days ago in 45 minutes. It was just me and my team people, me and the other intern and my senior talking to one team with however many patients of the three teams. There was no bottleneck and I was the last team so I was able to sign-out at 6 o’ clock.”
Senior Resident
Intern Resident
HOW MIGHT WE
IMPROVE THE OVERALL CALL STRUCTURE?
A BOTTLENECK IN COMMUNICATION
TEAM COMPOSITION
SERVICE TYPE
CALL SCHEDULES(NIGHTS/WEEKENDS)
RESIDENT GUILT
SEASONALITY(NEW INTERNS!)
SIGNOUT QUALITY(VERBAL/WRITTEN)
Factors Impacting Signout
NOT WANTING TO BURDEN OTHERS DELAYS SIGNOUT
“So if they’re admitting patients or a patient is sick or whatever things that can happen during our day, and they don’t feel like they’re ready to sign-out, then that can also delay the process.”
Intern Resident “I can fairly understand what that feeling is about wanting to stay because it’s best for continuity of care and handling an issue. So I think that’s a big problem.”
“The thing is that getting out at 4:00 never really means 4:00, like gets pushed back to 5:00 and that’s when people think it is 5:00 and it’s silly to sign-out my team to another team, only to be signed-out an hour later, so they might as well stay as they feel bad about it; or the team that would expect to sign-out is like why are you signing-out to me, you should just stay for an hour.”
Senior Resident
Senior Resident
HOW MIGHT WE
HELP RESIDENTS GO HOME WHEN THEY ARE SUPPOSED TO?
NOT WANTING TO BURDEN OTHERS DELAYS SIGNOUT
TEAM COMPOSITION
SERVICE TYPE
CALL SCHEDULES(NIGHTS/WEEKENDS)
RESIDENT GUILT
SEASONALITY(NEW INTERNS!)
SIGNOUT QUALITY(VERBAL/WRITTEN)
Factors Impacting Signout
THE SIGN-OUT PROCESS IS LONGEST IN JULY
“The worst time of the year was late summer, early fall. Not every night, but yeah, the sign-out takes three to four hours.”
Intern Resident “I think (the training) is the problem to a certain extent but I’ve seen people late in the year who I think should be better but they aren’t.”
“Some people are under the impression that seniors should give a separate conversation to the seniors because it’s less information traditionally and it can be quicker and that the interns should sign-out to the interns because, maybe because the concerns are different but also because just tends be a little longer.”
Intern Resident
Senior Resident
HOW MIGHT WE
IMPROVE THE PRE-JOB TRAINING PROCESS?
THE SIGN-OUT PROCESS IS LONGEST IN JULY
TEAM COMPOSITION
SERVICE TYPE
CALL SCHEDULES(NIGHTS/WEEKENDS)
RESIDENT GUILT
SEASONALITY(NEW INTERNS!)
SIGNOUT QUALITY(VERBAL/WRITTEN)
Factors Impacting Signout
THE AMOUNT OF INFORMATION EXCHANGED DURING SIGN-OUTS FLUCTUATES AND IS PROBLEMATIC
“The senior sign out really just needs be a one liner and these are the overnight events and todos. But the intern sign out needs to be more because they need to understand how to process something if they’re at the bedside and the nurse is asking them a question.”
Senior Resident
“Another thing that was not done well, is that some people will try to get too much information to sort of include what are all the terrible things that could happen in the patient overnight, based on their major diagnosis, and then try to list them. And then it’s too much information or trying to give things that we as doctors know as protocols.”
“The "ipside of too much is not enough. If there is something big that happened that day and…they totally don’t tell you…”
Intern Resident
Intern Resident
HOW MIGHT WE
DEFINE THE RIGHT AMOUNT OF INFORMATION?
THE AMOUNT OF INFORMATION EXCHANGED DURING SIGN-OUTS FLUCTUATES AND IS PROBLEMATIC
THE WRITTEN FORM OF COMMUNICATION, SIGN OUT ROUNDING SHEET, IS NOT EFFICIENTLY DESIGNED
“Some of the information we don’t like read off every night, like for example, there is like the patient’s weight is on here. We usually don’t say like they weigh 9.2 kg.”
Intern Resident
“Sign out sheets can make things inef!cient like if you are a call team or post call team and a pre call team signs out to you at 4 and their sign-outs are built for you, and then things happen in the afternoons. It is then your responsibility to make a new sign-out sheet for the night team or some teams writes on the sign out sheet and then it’s like a mess.”
“One of the things that I liked to do was if you are going to print out all the sheets at night, the rounding sheets and write notes on them you should just be able to hand that to the senior in the morning because it’s going to be the same rounding sheet in the morning.”
Senior Resident
Intern Resident
Senior Resident
HOW MIGHT WE?
REDESIGN THE WRITTEN RESIDENT SIGNOUT?
THE WRITTEN FORM OF COMMUNICATION, SIGN OUT ROUNDING SHEET, IS NOT EFFICIENTLY DESIGNED
THE WRITTEN FORM OF COMMUNICATION, SIGN OUT ROUNDING SHEET, IS NOT EFFICIENTLY DESIGNED
“But I always wonder right, we all have smart phones, if you were at the patient’s bed side and you wrote, person had a low hemoglobin, got transfused, why can’t someone just look that up from home and get their whole sign out done before they even got in? Do you know what I mean, like you do like the Facebook. People do this all the time, right? You update people about technology before and they know in real time what’s going on.”
We love technology, but we were really struck by this statement from our colleague Joy Knoblauch from Art and Architecture,
who said:
“I have a lot of respect for paper”
“I have a lot of respect for paper”
“Yeah, we believe in the paperwork. It’s equitable, it’s not biased, you’re not trying to shirk your tasks because you’ve written it down, we can see it, we’re just going to move through each phase…Everybody kind of feels like we’re making progress because now we’re on box !ve…I think it reassures people.”
We elected to focus on the design of the resident paper sign-out for the
workshop
Current State of the Resident Paper Sign-out Form
Because of HIPAA, this is simulated data but the design
is modeled after the real signout
What could be the future of the cutting-edge
Resident Signout?
We provided some inspiration in the next slides
DESIGN FOR DEMOCRACY AIGA identified common design problems on the ballot and offered improvements
http://goo.gl/ALzA7G
REDESIGN OF THE REPORT CARD GOOD’s redesign the report card project creates a visually appealing report card that informs, inspires, and gives context to student achievement
http://goo.gl/Tt9C71
KNOW BEFORE YOU OWE CFPB (Consumer Financial Protection Bureau) redesigned the mortgage form to better inform consumers
http://goo.gl/jLpAoH
REDESIGN OF US INCOME TAX FORM
New York design studio FormNation has proposed a redesign for two US income tax forms to make them clearer and easier to use
http://goo.gl/GtKEfC
BEFORE
AFTER
Fellow Residents,
Do you still use a paper signout?
How is your signout designed?
How might the resident signout be improved?
STAY TUNED FOR WHAT HAPPENED NEXT! Follow us on Twitter: @healthbyus
Sign up for our mailing list: http://goo.gl/mEmaiO
Special thanks to Emily Hirschfeld, Dr. Castle,
Dr. Haftel, the residents, Camilla Kraft, Joy Knoblauch, Franc Nunoo-Quarcoo,
& Amy Cohn
Slide design mostly by Xiaoying He with a little help from Joyce Lee!
