Download Safe Transitions For Every Patient (STEP) Instructor Guide

SAFE TRANSITIONS FOR EVERY PATIENT
(STEP): IT’S PRIMARY
Workshop for Residents in Care Transition Communication
INSTRUCTOR GUIDE
AUTHORS
Michael Weisgerber MD, MS, Heather Toth MD, David Klehm MD, Geoffrey Lamb,
MD, Linda Meurer MD, MPH
Senior Editors
Deborah Simpson PhD, Karen Marcdante MD, Jeff Morzinski PhD
Contributors
Paul Koch MD, Kristin Guilonard MD, Nancy Havas MD, Emily Densmore MD,
Angie Zikos MD, Laura Currey MS, Staci, Young, PhD, Karen Nelson MD,
Michael Radzienda MD, Ankur Segon MD
Partially Funded by HRSA -Primary Care Faculty Development Grant #: 2 D55 HP 00093
1
STEP Instructor Guide : It’s PRIMARY for Residents
Abstract
This submission contains the materials and instructor’s guide for the highly rated Safe
Transitions for Every Patient (STEP) Resident Workshop. Care transitions are a key component
of good patient care and poor communication is known to be a major contributor to patient harm.
Few educational materials are available for use to train residents in this important skill. To
address this gap, the STEP Collaborative, composed of faculty from family medicine, medicine
and pediatrics, systematically designed a resident-focused workshop on care transitions using
the following steps:
 identified resident level objectives focused on transitions to/from the medical
home,
 created a mnemonic to facilitate care transitions,
 designed, delivered and evaluated an interactive workshop to provide training and
practice focused on care transitions.
This one hour workshop is composed of an introductory presentation, an interactive discussion
of critical incidents involving care transitions, and a spirited Jeopardy-like game to reinforce key
elements of the standardized care transition process. This workshop packet contains the
PRIMARY care transition mnemonic, a critical incident worksheet, a quiz for assessing learner
knowledge, and a workshop evaluation form. By using these materials, users can create a fun
and valuable interactive care transition training experience for their residents easily adaptable to
other audiences.
2|Page
STEP Instructor Guide : It’s PRIMARY for Residents
Table of Contents
Abstract
Table of Contents
Background/Overview- Safe Transitions For Every Patient
Learner Audience
Session Objectives
What this Packet contains:
Learner Assessment
Quality of the Workshop
The PRIMARY Care Transition Tool
Detailed Schedule of the Safe Transitions For Every Patient Resident Workshop
Facilitator and Present Qualifications and Responsibilities
Advanced Preparation: Materials, Resources, and Facilities, Checklist
Appendices: Worksheets and Handouts
Critical Incident Worksheet
Pre-Post Quiz
Pre-Post Quiz Instructor’s Copy with Answers
Session Evaluation Form
PRIMARY Tool
Jeopardy Game
References
2
3
4
4
5
5
6
6
8
9
10
11
12
13
14
16
18
20
21
22
3|Page
STEP Instructor Guide : It’s PRIMARY for Residents
Background/Overview- Safe Transitions for Every Patient (STEP)
Lack of quality communication at the time of transition of patient care from one health care
provider to another results in medical errors, patient dissatisfaction, and inefficiencies. The Joint
Commission (TJC) 1 has identified that 70% of errors leading to significant patient harm arise
from poor communication, often at the time of a transition in care. Despite this, there is little
formal education on the best methods of communicating necessary information at the time of a
care transition. A search of existing peer reviewed medical education repositories using the key
words of transitions, handoffs, care transitions, patient safety and quality revealed fewer than 5
available resources in the general topic area. Existing curricula have focused almost entirely on
handoffs within the hospital setting, or on discharge from the hospital from the hospitalists’
perspective.2-6 Transitions to and from the medical home including referrals to specialists,
admissions to hospitals, and alternative care settings have not been addressed. There is a
need for curricula that emphasize the effective transition of patients to and from the medical
home, including the communication of necessary information, incorporate a standardized
approach and encourage bidirectional dialogue between providers.
The STEP Collaborative is a group of Medical College of Wisconsin faculty in internal medicine,
pediatrics, and family medicine participating in a three year faculty development program
designed to train faculty to study and develop methods to effectively teach various learners to
conduct safer and more effective care transitions. This submission and Instructor’s Guide
includes elements adapted with permission from the SAFE TRANSITIONS FOR EVERY PATIENT
(STEP): IT’S PRIMARY Medical Student Workshop Instructor’s Guide.7 The methods of creation
and style of the student and resident care transition workshop are different and therefore have
been submitted as separate workshops. The resident subgroup of the STEP Collaborative has
developed a workshop for training residents to effectively define care transitions, recognize the
key elements of care transitions, and perform care transitions using a standardized tool. The
subject matter of the workshop came from a systematic process including 1) a review of the
care transition literature, 2) needs assessment using surveys and structured interviews, 3)
faculty development group synthesis of the results of #1 and #2 to develop a standardized tool
for care transitions (the PRIMARY tool) and 4) workshop creation and piloting during monthly
faculty development sessions. The workshop resulting from this process has been used
successfully with residents in medicine, pediatrics, and family medicine here at the Medical
College of Wisconsin. This Instructor’s Guide contains all the materials necessary for others to
use the methods we have developed to train residents at their institutions to engage in
systematic and safe care transitions.
Learner Audience
The session was designed for residents of all levels in General Internal Medicine, Family
Medicine and Pediatrics.
The session would also be appropriate for residents in all specialties, and medical students
involved in transitioning patients. It could also be used for CME purposes to improve skills in
transitions/handoffs for attending physicians. All health care professionals (e.g. midlevel
providers) who accept or receive patients from other providers may benefit from this workshop
4|Page
STEP Instructor Guide : It’s PRIMARY for Residents
Session Objectives
By the end of this session, each resident will learn a systematic approach to providing safe
transitions for his/her patients through accomplishment of the following:
1) Define transitions in care and the roles patients and providers play in safe transitions.
2) Recognize the key elements of safe transitions
3) Describe the crucial role that effective transitions have on safe and high quality patient
care as well as the effects of unsafe transitions.
4) Use a standardized communication tool (the PRIMARY mnemonic) to systematically
prepare and convey a patient transition to a colleague.
What this Packet contains:
This 1-hour educational program was developed as an intervention to teach primary care
residents how to effectively transition their patients to and from the medical home using a
standardized tool for communication.
The materials for this program are listed in the table below.
Item
 Instructors’ guide
 Introduction
Powerpoint
Presentation
 Critical Incident
Worksheet
 PRIMARY Mnemonic
Tool Summary
 Jeopardy-like Game
 Pre- and Post-Quiz
 Workshop evaluation
form
Brief Description
An all-inclusive guide to administer the session
An introductory presentation, lasting approximately 10
minutes, that covers the significance of care transitions in
the quality of care and the use of an original mnemonic
“PRIMARY” to facilitate the communication of handoffs
A worksheet that is used for the interactive discussion of
participants’ personal experiences with care transitions
A one-page summary of the PRIMARY mnemonic
describes and explains key communication components
essential to safe transitions to/from the medical home.
A “Jeopardy” type game, in PowerPoint format, to reinforce
the concepts learned through the introduction, critical
incident and PRIMARY mnemonic tool summary
A brief (7 item) pre and post-quiz to reinforce concepts
learned
An evaluation form to assess the session’s outcomes on
residents’ reaction and learning
5|Page
STEP Instructor Guide : It’s PRIMARY for Residents
Learner Assessment
The 7-item multiple choice quiz was developed to align with session objectives and written using
case- based vignettes per NBME item format8. The items were reviewed first by two senior
medical students, and then piloted by a group of 6 senior students unfamiliar with the
curriculum. Based on the results and feedback, the items were revised to enhance examination
quality.
Items were used as part of the curriculum with 35 family medicine residents immediately
following instruction on care transitions. Quiz statistics and item analyses were performed and
overall the quiz had good psychometric results: Item standard quiz reliability (.79), mean item
difficulty 0.81 and mean item discrimination 0 .35. After a detailed review of item analysis data
selected item distracters were revised to enhance examination quality.
The quiz was re-administered to 20 medicine and pediatrics residents and yielded a standard
reliability of 0.93 and with a mean item difficulty of 0.66 and mean item discrimination of 0.47.
Score range was 2-7.
Quality of the Workshop: Using Results for Continuous Improvement
Workshop #1: Family Practice Session
We first presented the workshop to 37 family practice residents of all levels of training.
This residency has a standard evaluation form used for educational sessions. This group gave
the session an overall mean rating of 5.16 (SD 1.14) [possible range 1-7 with 7 being the
highest rating]. The content was given a mean rating of 5.32 (SD 1.23) and presenter rating
was 5.32 (SD 1.25). Open ended comments revealed that some residents liked the jeopardy
game, describing it as fun and interactive. Others gave feedback that the game needed
improvements: noting it could have been run more effectively by explaining the rules clearly
before the session, ensuring everyone could participate, and fixing the buzzer system. We
learned that without a short time limit for giving an answer the game changed into a contest
dependent on buzzer speed. Teams began to buzz in before they even knew the question and
then took their time figuring out the answer. This frustrated other players. It was also noted
some of the jeopardy questions were “poorly written” and “needed to get to the point.” The initial
didactic lecture portion was criticized as “boring.”
Workshop Revisions
We then addressed these areas. The resident feedback confirmed the authors’
evaluation of areas needing improvements.
Jeopardy Game Improvements – The questions were revised or eliminated thereby
decreasing the total number of questions resulting in a more concise and focused game with
higher quality questions. Rules were clarified on the introductory slide for the game and
highlighted by the facilitator prior to the beginning the jeopardy game. The timer was re-set on
the buzzer for 5 seconds so that once a team buzzed in they needed to give their answer within
5 seconds or be marked as incorrect. To add more “competition” to the game, incorrect
answers led to a loss of points similar to the game show rules.
6|Page
STEP Instructor Guide : It’s PRIMARY for Residents
Didactic lecture improvements – The lecture was reviewed and adapted to be more
concise with added clinical examples and a better explanation of the PRIMARY mnemonic tool.
Subsequent Workshops: Internal Medicine and Pediatric Sessions
Nineteen first year internal medicine and eight pediatric residents completed the session.
Evaluations were performed using the Session Evaluation Form (appendix). Results for the
three sections of the evaluation are presented below.
SECTION I RESULTS: BASELINE RESIDENT BEHAVIOR- MEAN
Scale: 1=strongly disagree, 2= disagree, 3=agree, 4= strongly agree)
ROUTINELY INITIATE
COMMUNICATION WITH A
PHYSICIAN I REFER TO
Med
2.9
ROUTINELY INITIATE
COMMUNICATION WHEN PT
REFERRED TO ME
Peds
3.1
Med
2.9
Peds
2.8
FAILED TO COMMUNICATE
USE STANDARD PROCESS
IMPORTANT INFO DURING
HANDOFF
FOR HANDOFFS
Med
2.4
Peds
2.6
Med
2.8
Peds
1.9
SECTION II RESULTS: REACTION TO THE W ORKSHOP - MEAN
Scale:1= poor, 4= average, 7= excellent
PRESENTERS KNOWLEDGE
CONTENT WAS HIGHLY
ABOUT THE TOPIC
RELEVANT
Med
Peds
Med
Peds
6.5
5.3
6.0
5.6
MATERIAL CLEAR AND EASY TO
FOLLOW
Med
6.1
Peds
3.4
PROGRAM ENHANCED
LEARNING
Med
Peds
5.9
4.5
SECTION III RESULTS: POST SESSION RESIDENT ATTITUDES/INTENDED BEHAVIOR CHANGE - MEAN
Scale: 1=strongly disagree, 2= disagree, 3=agree, 4= strongly agree
NOW FEEL MORE
NOW INTEND TO
NOW INTEND TO USE
CAN DESCRIBE
EQUIPPED TO ELICIT
INFO DURING
HANDOFF
Med
3.1
REQUEST INPUT FROM
PRIMARY PHYSICIAN
Peds
3.1
Med
3.0
CAN LIST CONSEQUENCES OF
POOR HANDOFFS
Med
3.2
Peds
3.3
Peds
3.1
STANDARD PROCESS
FOR HANDOFF
Med
3.0
COMMUNICATION BETWEEN
PHYSICIANS AT THE TIME OF A
HANDOFF/CARE TRANSITION IS
ESSENTIAL TO PT CARE
Med
3.3
Peds
3.8
ELEMENTS OF A
HANDOFF TOOL
CAN APPLY THE HANDOFF
MNEMONIC TOOL TO
TRANSITION
Peds
Med
Peds
3.3
3.1
3.4
IDENTIFY ONE OR MORE THING
Med
Peds
3.1
3.3
CRITICAL INCIDENT
THAT YOU CAN DO TO ENHANCE
EFFECTIVE CARE TRANSITIONS
ENHANCED LEARNING
Med
3.2
Peds
2.7
Med
3.2
Peds
3.3
OVERALL GRADE FOR THIS CURRICULUM
High pass
Pass
87%
13%
What did you like the most?
o The game/jeopardy
o Interactive
o Real examples
What did you like the least?
o Lack of a final jeopardy question
o Buzzer malfunction/sound effects
o Double jeopardy role play
7|Page
STEP Instructor Guide : It’s PRIMARY for Residents
The PRIMARY Care Transition Tool
This tool was developed by consensus methods of the STEP Collaborative using the most valuable elements found in other transition
tools combined with two elements to reinforce the importance of two-way communication and receiver input. Primary was chosen as
a mnemonic that contained these essential care transition elements, was memorable and reinforced the importance of the Primary
Medical Home as a focus in the care transition. The Table below describes the elements included in the tool.
SAFE TRANSITIONS FOR EVERY PATIENT (STEP): PRIMARY CARE TRANSITION MNEMONIC
PRIMARY
P=People
Explanation
You/Patient/Person on phone
R=Reason
What’s occurring with the
patient and why the transition
is proposed
Verify receiver knows and cares
for patient
I=Input/Inquire
M=Medical Course
Pertinent chronology
A=Assessment
Patient’s current status
R=Recommendations &
Responsibilities
Y=Your turn
Explicit expectations of who will
do what/when
Receiver’s further input and
agreement with plan
How
Identify caller, receiving provider and all
patient ID info
Maximum of 1-2 sentence reason for
transition and relevant information
Pearls
Establishes WHO is calling
receiver
Gives CONTEXT for
understanding
Ask how well receiver knows patient and
what can add to understanding of
patient’s condition
Include pertinent specifics of
presentation, Dx & Tx. Answer questions
ENGAGES receiver and
recognizes his/her EXPERTISE
Summarize active and resolved problems,
immediate treatment plan, family and
patient understanding/expectations
Explain next steps, what needs to be
done in follow-up/ who will accept tasks
Ensure shared understanding,
agreement, and determine best means of
further communication.
THOROUGH yet CONCISE
summary of patient’s recent
care
Establishes CARE PRIORITIES
“TAG, You’re It”; establishes
accountability
ACTIVE LISTENING used
8|Page
Detailed Schedule of the Safe Transitions for Every Patient
Resident Workshop
The table below is a suggested timeline for pre-workshop preparation and the workshop itself.
Time
Prior to
session
-10 min
5 min
10 min
20 min
20 min
5 min
Topic
Prepare copies of handouts for each participant
including:
 Pre and post quizzes
 Primary Mnemonic handout
 Critical Incident worksheets
 Evaluation forms
Obtain “prizes” for Jeopardy winners (Candy, books,
etc)
Arrange for signaling system for Jeopardy game
(buzzer system, noisemakers, etc)
Preparation: Immediately prior to session
 Set up AV equipment for powerpoint
presentation and Jeopardy game
 If using a buzzer system for jeopardy quiz set
that up as well
 Arrange room in format friendly to the number
of teams (suggested 3-5 teams with a buzzer
[or equivalent] at each table)
Welcome and Pre-quiz
 Handout 7-item pre-quiz
 Collect after completion
Powerpoint presentation – Safe Transitions for Every
patient (STEP)
 Hand out PRIMARY mnemonic
Critical Incident
 Handout Critical Incident Worksheet: Individual
work (5 minutes)
 Facilitate small group discussion of individual’s
recording of a critical incident that could have
been improved by utilizing PRIMARY
Jeopardy Game
 Jeopardy Host describes format and rules
 Teams are set
 Game begins
 Score is kept by designated scorer
 One facilitator in charge of buzzer system or
determining which team was first to express
desire to answer the question (can use buzzer,
holding up signing, banging table, etc.)
Closing remarks
 Handout post-quiz and evaluation form
Method/Who
Administrative assistant
Lecturer
Jeopardy moderator
All
Lecturer
Lecturer
Other facilitators
Critical Incident Facilitator
Jeopardy host
Jeopardy scorer
Jeopardy buzzer facilitator
Lecturer
9|Page
Facilitator and Presenter Qualifications and Responsibilities
o All facilitators and presenters (minimum of 3) must have an adequate background in
clinical health care and be familiar with the literature on medical errors attributable to
poor care transitions. Furthermore, all must be aware of the care transition concerns
likely to face medical residents. Finally, all must be able to explain the reasons for the
STEP curriculum and the elements of the PRIMARY mnemonic. At least one presenter
should be an effective, experienced speaker with moderate to large-sized audiences of
resident physicians.
o Facilitator(s) (one per six-to-eight learners) for the critical incidents component: should
have clinical health care experience in transitions to or from the medical home (e.g.,
physician, nurse practitioner, etc). Facilitators should also have skills to engage a group
of residents in discussion about their critical incidents. This includes skills to ask openended questions, seek input from the majority of the group, stay on time and on topic.
o Energetic game facilitator (one person): should have the ability to keep the audience
engaged and participating in the Jeopardy style game.
o Scorer (one person): should have the ability to add and subtract Jeopardy game
scores.
o Buzzer controller or observer of raised hands if no buzzer available (one person):
should have the ability to watch which team has pressed the buzzer or raised their
hand first, signaling the first team able to answer the Jeopardy game question.
10 | P a g e
Advanced Preparation: Materials, Resources, and Facilities,
Checklist
o
The checklist table below describes the required resources, facilities, materials in a checklist
format to use as you prepare for the workshop.
o
If you have administrative support, many of the tasks below can be delegated.
PRIOR TO
EVENT
- 8 weeks
- 4-8 wks
depending on
clinical
schedules
-3-4 days
- 1-2 days
-1-2 days
-1 day
- 45 min
TASKS

COMPLETE
Reserve room/ facilities:
o Room with tables set up for small groups of 8, PowerPoint
projector and screen, flip chart or white board for scoring, and
Internet access for computer if possible.
o Borrow (or purchase) Jeopardy like buzzers/game lights
Recruit facilitators and presenters
o Send instructor guide
o Advise of room location, time
Practice Jeopardy
o Set up computer with jeopardy game loaded/buzzer/timer
system/ quiz to make sure it works
Duplicate
o Evaluation forms
o Pre-post quiz
o Handouts of PRIMARY mnemonic
o Critical incident forms
Purchase and Bring Prizes (e.g. candy, books, bragging rights, cash)
Meet/Review Facilitator instruction
o Review Objectives
o Assign roles
o Answer questions
Set Up and Test
o Jeopardy quiz hardware/software
o Projector & laptop
Verify Handouts
o Evaluation forms
o Pre-post quiz
o Handouts of PRIMARY pneumonic
o Critical incident forms
11 | P a g e
APPENDICES:
WORKSHEETS & HANDOUTS
SAFE TRANSITIONS FOR EVERY PATIENT
(STEP): IT’S PRIMARY
RESIDENT TRAINING MODULE
1. CRITICAL INCIDENT WORKSHEET
2. PRE-POST QUIZ
3. EVALUATION FORM
4. PRIMARY TOOL
12 | P a g e
SAFE TRANSITIONS FOR EVERY PATIENT [STEP]
CRITICAL INCIDENT
DIRECTIONS: Identify a recent patient for whom a care transition occurred -- when a patient’s care was
shifted from one provider to another. This could be any of an array of situations including:
 the patient “moved” from one setting of care to another (e.g., primary care clinic to a hospital,
rehab unit, home care, hospice)
 the patient “stayed” and the providers changed (e.g.,. shift change)
If possible, please select a patient/care transition which evoked in you a strong emotional reaction (e.g.,
sense of accomplishment for a job well done, anger, frustration, annoyance, exasperation).
1. Briefly describe: (A) the patient (do not provide actual names or other identifying information); (B)
the context/setting in which the care transition occurred; and (C) the process(es) and types of
information exchanged during transition.
2. Describe the emotion(s) and what and why this situation evoked your emotional response.
3. How do you think the processes and types of information exchanged during the transition impacted
the patient?
Turn Over and Use Back Side as Needed
13 | P a g e
STEP: PRIMARY QUIZ
Please choose the single best answer:
1. Resident X is the outgoing resident on a general internal medicine team. He is signing out to resident
Y who is the incoming resident. The patient is Andy Urisis, a 75 y/o male with past medical history of
prosthetic (metallic) valve, atrial fibrillation and localized prostate cancer. Medications prior to
admission include coumadin. Reason for this hospitalization is bilateral hydronephrosis secondary to
obstruction from prostate cancer. Coumadin is held and bilateral nephrostomy tubes are placed
with significant post-obstructive diuresis. Resident X communicates all the above information to
resident Y as he addresses the patient's medical course.
To assure a safe hand off, what additional information must resident X convey to resident Y?
A. The levels of sarcosine (marker of aggressive prostatic cancer)
B. The patient’s next of kin who would serve as power of attorney if needed.
C. The reason the patient is not on digoxin
D. The plan for managing the patient's anticoagulation
E. The patient's family history of heart disease.
2. A 9 yo boy is referred by his PCP to the pediatric surgery clinic. The mother misplaced the referral
slip that was given to her by the PCP. Mother states reason for visit is to follow-up after an ED visit
for a “fender bender” where her son was found to have a grade I splenic laceration. You examine
the patient and find mild left upper quadrant tenderness. You discharge the patient home with
activity restrictions after staffing the patient with your surgery attending. You call the referring
doctor and reiterate the plan. She states, “I know how to manage a grade I splenic laceration, but
what about the incidental CT finding of the adrenal mass?
What action would have best prevented this disconnect in this patient’s care?
A. Entering the diagnosis of adrenal mass into the problem list in the electronic medical record.
B. Reinforcing to the mother how important the referral slip is and to make sure she had it.
C. Direct contact between the PCP and surgeon to determine the reason for the referral
D. Sending the CT scan report to the surgeon’s office, with “adrenal mass” highlighted.
E. Completion of a referral slip.
3. A student on your service calls a PCP regarding a discharge. The student begins, “Hi Dr. Jones, I am
the M4 student and would like to notify you that your patient, Suzy Smart, will be discharged from
the hospital today. Suzy Smart is a 4yo with moderate persistent asthma who was admitted to the
PICU 3 days ago. Her asthma exacerbation was triggered by cigarette smoke exposure. She was
initially intubated, given IV steroids, and continuous nebulizer treatments. She was extubated
yesterday…”
As the supervising resident, what additional information would you encourage next in the medical
history to concisely communicate a summary of the patient’s care?
A. Review of Systems
B. Current Medications
C. History of prior intubations.
D. Home treatment regimen.
E. Chest radiograph results.
14 | P a g e
4. Dan, a PGY1 resident, calls the PCP for an inpatient, a 70 year old male w/p AMI and CABG, being
released to cardiac rehab today. The rehab facility has the full chart and a clear plan for rehab, with
scheduled release to home and to his PCP’s care, in 2 weeks. Dan tells the PCP about the patient’s
past medical history, social history, immunizations, habits, full physical exam on admission and
discharge, current diet, all meds and complete hospital course, commenting on daily events
throughout, nurses notes, daily labs, and full diagnostic reports. He completes the call by
mentioning that the family was grateful for their loved one’s care, and by commenting that this was
the first AMI patient he had managed and how exciting it was.
What basic principle was ignored in relaying the medical course?
A. Reason for transition
B. Thoroughness including pertinent labs and imaging
C. Having a clear diagnosis
D. Having a clear treatment plan
E. Providing a concise summary of the patient’s care
5. Between 1995-2006, the leading cause of “Sentinel Events,” (per JCAHO, unexpected occurrences
involving death or serious injury in medical/hospital care) was:
A. Medication errors
B. Poor handoffs
C. Patient falls
D. Wrong site surgery
E. Equipment failure
6. According to medical literature, a discharge summary was available by the first post-discharge visit:
A. Less than 20% of the time
B. 25% of the time
C. About half of the time
D. 75% of the time
E. 90% of the time
7. A PGY3 resident Lucy, chief resident and most talented of all the residents in her program, calls the
Family Physician upon discharge of inpatient Mickey, a 2 y/o male admitted for an asthma
exacerbation. The patient’s condition became quite critical, requiring intubation and transfer to
PICU. The resident explained the hospital course with great precision and actually did a fabulous job
in managing the patient, doing all procedures and returning the patient to good health by discharge.
Resident Lucy was concise in her summary, but tended to talk over the Family doc, preempting his
questions and continuing with the oral report. She hung up from the call feeling quite proud of
herself because she gave a seamless report that required no interruptions or questions from the
primary care doc on the phone. His only comment was “thank you, have a good day” before he
hung up.
What principle was forgotten in Lucy’s discussion with the PMD?
A. Reason for transition
B. Medical course
C. Input from receiver
D. Assessment
E. Follow-up plan
15 | P a g e
STEP: PRIMARY QUIZ INSTRUCTOR COPY WITH ANSWERS
Correct Answers are bolded below: 1. D, 2. C, 3. B, 4. E, 5. B, 6. A, 7. C
Please choose the single best answer:
1. Resident X is the outgoing resident on a general internal medicine team. He is signing out to resident
Y who is the incoming resident. The patient is Andy Urisis, a 75 y/o male with past medical history of
prosthetic (metallic) valve, atrial fibrillation and localized prostate cancer. Medications prior to
admission include coumadin. Reason for this hospitalization is bilateral hydronephrosis secondary to
obstruction from prostate cancer. Coumadin is held and bilateral nephrostomy tubes are placed
with significant post-obstructive diuresis. Resident X communicates all the above information to
resident Y as he addresses the patient's medical course.
To assure a safe hand off, what additional information must resident X convey to resident Y?
A. The levels of sarcosine (marker of aggressive prostatic cancer)
B. The patient’s next of kin who would serve as power of attorney if needed.
C. The reason the patient is not on digoxin
D. The plan for managing the patient's anticoagulation
E. The patient's family history of heart disease.
2. A 9 yo boy is referred by his PCP to the pediatric surgery clinic. The mother misplaced the referral
slip that was given to her by the PCP. Mother states reason for visit is to follow-up after an ED visit
for a “fender bender” where her son was found to have a grade I splenic laceration. You examine
the patient and find mild left upper quadrant tenderness. You discharge the patient home with
activity restrictions after staffing the patient with your surgery attending. You call the referring
doctor and reiterate the plan. She states, “I know how to manage a grade I splenic laceration, but
what about the incidental CT finding of the adrenal mass?
What action would have best prevented this disconnect in this patient’s care?
A. Entering the diagnosis of adrenal mass into the problem list in the electronic medical record.
B. Reinforcing to the mother how important the referral slip is and to make sure she had it.
C. Direct contact between the PCP and surgeon to determine the reason for the referral
D. Sending the CT scan report to the surgeon’s office, with “adrenal mass” highlighted.
E. Completion of a referral slip.
3. A student on your service calls a PCP regarding a discharge. The student begins, “Hi Dr. Jones, I am
the M4 student and would like to notify you that your patient, Suzy Smart, will be discharged from
the hospital today. Suzy Smart is a 4yo with moderate persistent asthma who was admitted to the
PICU 3 days ago. Her asthma exacerbation was triggered by cigarette smoke exposure. She was
initially intubated, given IV steroids, and continuous nebulizer treatments. She was extubated
yesterday…”
As the supervising resident, what additional information would you encourage next in the medical
history to concisely communicate a summary of the patient’s care?
A. Review of Systems
B. Current Medications
C. History of prior intubations.
D. Home treatment regimen.
E. Chest radiograph results.
16 | P a g e
4. Dan, a PGY1 resident, calls the PCP for an inpatient, a 70 year old male w/p AMI and CABG, being
released to cardiac rehab today. The rehab facility has the full chart and a clear plan for rehab, with
scheduled release to home and to his PCP’s care, in 2 weeks. Dan tells the PCP about the patient’s
past medical history, social history, immunizations, habits, full physical exam on admission and
discharge, current diet, all meds and complete hospital course, commenting on daily events
throughout, nurses notes, daily labs, and full diagnostic reports. He completes the call by
mentioning that the family was grateful for their loved one’s care, and by commenting that this was
the first AMI patient he had managed and how exciting it was.
What basic principle was ignored in relaying the medical course?
A. Reason for transition
B. Thoroughness including pertinent labs and imaging
C. Having a clear diagnosis
D. Having a clear treatment plan
E. Providing a concise summary of the patient’s care
5. Between 1995-2006, the leading cause of “Sentinel Events,” (per JCAHO, unexpected occurrences
involving death or serious injury in medical/hospital care) was:
A. Medication errors
B. Poor handoffs
C. Patient falls
D. Wrong site surgery
E. Equipment failure
6. According to medical literature, a discharge summary was available by the first post-discharge visit:
A. Less than 20% of the time
B. 25% of the time
C. About half of the time
D. 75% of the time
E. 90% of the time
7. A PGY3 resident Lucy, chief resident and most talented of all the residents in her program, calls the
Family Physician upon discharge of inpatient Mickey, a 2 y/o male admitted for an asthma
exacerbation. The patient’s condition became quite critical, requiring intubation and transfer to
PICU. The resident explained the hospital course with great precision and actually did a fabulous job
in managing the patient, doing all procedures and returning the patient to good health by discharge.
Resident Lucy was concise in her summary, but tended to talk over the Family doc, preempting his
questions and continuing with the oral report. She hung up from the call feeling quite proud of
herself because she gave a seamless report that required no interruptions or questions from the
primary care doc on the phone. His only comment was “thank you, have a good day” before he
hung up.
What principle was forgotten in Lucy’s discussion with the PMD?
A. Reason for transition
B. Medical course
C. Input from receiver
D. Assessment
E. Follow-up plan
17 | P a g e
STEP CORE OBJECTIVE EVALUATION FORM
Please check your position:
Faculty
Student
Resident – PGY 1 2 3 (circle) – Program: ____________________
Section I:
Consider your patient care prior to today’s program & indicate your level of agreement:
Statements
Strongly
Disagree
Disagree
Agree
Strongly
Agree
I routinely initiate communication with a physician I
refer a patient to.
I routinely initiate communication when a physician
refers a patient to me
I have failed to communicate important information
at a time of patient handoff.
I use a standardized process for communicating all
patient transitions/ handoffs to/from the medical
home with the clinician accountable for follow-up.
Section II: Reaction 9
Use this scale to answer questions about the Care Transitions & Jeopardy Game session
1
Poor
2
3
4
Average
5
6
7
Excellent
1 . Were presenters knowledgeable about the topic?............................ 1 2 3 4 5 6 7
2. Content was highly relevant to my [M3/resident] curriculum………1 2 3 4 5 6 7
3. Material presented in a clear and easy to follow manner……………1 2 3 4 5 6 7
4. The amount of information was just about right……………………1 2 3 4 5 6 7
5. The game (program component) enhanced learning………………. 1 2 3 4 5 6 7
What did you like most?
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________
What did you like least?
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________
18 | P a g e
What did you learn?
_________________________________________________________________________________
Was there something you hoped to learn but did not?
Section III
Now, after today’s Care Transitions and Jeopardy Game session, check the box that corresponds to
your agreement with the following statements.
Statements
Strongly
Disagree
Disagree
Agree
Low Pass
Pass
High Pass
Strongly
Agree
I feel more equipped to elicit information at the time
of handoff or transition of care
I intend to routinely request input from a patient’s
Primary Care Practitioner related to a care transition.
I intend to use a standardized process for
communicating all patient transitions/ handoffs
to/from the medical home with the clinician
accountable for follow-up.
I can describe the elements of a handoff tool
I can apply the handoff mnemonic tool to transition
a patient
I can list consequences of poor handoffs on patient
care, health care teams and public health.
Communication between physicians at the time of a
handoff/ care transition is essential to patient care
Identify ≥1 thing that you can do to enhance
effective care transitions.
Critical Incident enhanced learning (helped to
personalize the care transition)
Overall Grade for this
Curriculum: (circle one)
Fail
Honors
Other comments:
Thank you!
19 | P a g e
The PRIMARY Care Transition Tool
SAFE TRANSITIONS FOR EVERY PATIENT (STEP): PRIMARY CARE TRANSITION MNEMONIC
PRIMARY
P=People
Explanation
You/Patient/Person on phone
R=Reason
What’s occurring with the
patient and why the transition
is proposed
Verify receiver knows and cares
for patient
I=Input/Inquire
M=Medical Course
Pertinent chronology
A=Assessment
Patient’s current status
R=Recommendations &
Responsibilities
Y=Your turn
Explicit expectations of who will
do what/when
Receiver’s further input and
agreement with plan
How
Identify caller, receiving provider and all
patient ID info
Maximum of 1-2 sentence reason for
transition and relevant information
Pearls
Establishes WHO is calling
receiver
Gives CONTEXT for
understanding
Ask how well receiver knows patient and
what can add to understanding of
patient’s condition
Include pertinent specifics of
presentation, Dx & Tx. Answer questions
ENGAGES receiver and
recognizes his/her EXPERTISE
Summarize active and resolved problems,
immediate treatment plan, family and
patient understanding/expectations
Explain next steps, what needs to be
done in follow-up/ who will accept tasks
Ensure shared understanding,
agreement, and determine best means of
further communication.
THOROUGH yet CONCISE
summary of patient’s recent
care
Establishes CARE PRIORITIES
“TAG, You’re It”; establishes
accountability
ACTIVE LISTENING used
20 | P a g e
Jeopardy Game
We downloaded a PowerPoint jeopardy game template and added questions pertinent
to the PRIMARY mnemonic and care transitions. We obtained permission to use the
template and disseminate our version for care transitions from Elaine Fitzgerald
(Teacher/Facilitator of Technology, St. Charles Parish Schools, Luling, LA,).
The actual PowerPoint slideshow is contained in the submission materials. Simply load
the file on the computer you will using and run in the usual manner for a PowerPoint
slideshow.
Rules of the game
1. There are 3 categories with 5 questions in each category. The questions are
viewable in the attached PowerPoint file. The correct answers are listed in the Table
below.
CATEGORY 1
FACTS AND FIGURES
100
What is a handoff?
CATEGORY 2
WHAT AM I
100
What is person?
200
What is notification of
discharge?
200
What is input (I) or your
turn (Y)?
300
What are sentinel events?
300
What is medical course
(M)?
400
What is assessment (A)?
400
What are primary car
providers?
500
daily double
Role play 83 year old with
uti and confusion
500
What is responsible party
(R)?
CATEGORY 3
WHAT WENT WRONG
100
What is no input (I) or your
turn (Y) part of handoff?
200
daily double
Role play Joe with
recurrent bacterial
infections and pending
immunodeficiency workup
300
What is no responsible
party (R)?
400
What is incomplete patient
identification (P)?
500
What is no reason for
transition (R) explained?
2. The facilitator (be sure to have a dedicated facilitator running the game) chooses a
team to begin the game. The team then picks a category and dollar amount for the
first question.
3. When a team chooses a category and point value click on the dollar amount and the
question appears.
21 | P a g e
4. Begin reading the question and stop reading when a team buzzes in to guess the
answer. (Be sure to have a dedicated buzzer operator managing the buzzer.) If
you don’t have a buzzer consider having the teams hit the table or raise a flag to be
recognized and have the dedicated buzzer operator decide who was first)
5. Once the team buzzes in we recommend having a 5 second time limit for giving the
answer (Longer timeframes may lead to teams buzzing in and taking their time
reading the question after signaling. This leads to everyone buzzing in immediately
without reading the question.)
6. If the team does not answer correctly within 5 seconds they lose the dollar amount
from their score. (Have a dedicated scorer keeping track)
7. If they answer correctly add the dollar amount to their score. The team that answers
correctly has control of the board and chooses the next category and dollar amount
until another team answers correctly. If a team buzzes in and answers incorrectly
another team has a chance to buzz in and answer.
8. In the daily double question the team has to perform a role play of a care transition.
They get to wager an amount up to $500 and to earn it their role play must
successfully include all the correct elements of PRIMARY.
9. After all questions are completed the team with the highest amount wins. If you
want to make up a final jeopardy scenario that is another option for ending the
game. We did not do this because of time constraints but it could be fun.
References
1. Joint Commission Perspectives on Patient Safety 2007: 27(7)1-13
2. Vidyarthi AR, Baron RB. The Role of Graduate Medical Education (GME) in
Improving Patient Safety (Agency for Healthcare Research and Quality – web M&M)
3. Project Red – Jack BW, Chetty VK. A Re-engineered Hospital Discharge Program to
Decrease Re-hospitalization, Annals of Internal Medicine, Feb 3,2009, Vol. 150 no.3,
178-187.
4. Project Boost (University of Colorado): Seek to Improve Care Transitions, Medical
Ethics Advisor, July 1,2009.
5. Monson SP. Physician Transitions Within the Medical Home: Applied Strategies to
Safeguard Continuous Care, Family Medicine Digital Resources Library (FMDRL),
modified 5/12/2009.
6. Atallah H. Interprofessional Team Training Scenario, Emory University School of
Medicine, MedEdPORTAL ID# 1713.
7. SAFE TRANSITIONS FOR EVERY PATIENT (STEP): IT’S PRIMARY Medical Student
Workshop
8. Case SM, Swanson DB. Constructing Written Quiz Questions for the Basic and
Clinical Sciences. 3rd Edition. National Board of Medical Examiners. January 1998.
http://www.nbme.org/publications/item-writing-manual.html
9. Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels (3rd
Ed). San Francisco: Berrett Koehler. 2006
22 | P a g e