• Nicholas A Rattray, Mindy E Flanagan, Laura G Militello, Paul Barach, Zamal Franks, Patricia Ebright, Shakaib U Rehman, Howard S Gordon, and Richard M Frankel.
• VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA. nrattray@iupui.edu.
• J Gen Intern Med. 2019 Feb 1; 34 (2): 264-271.

BackgroundPoor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks.ObjectivesWe investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients.Methods/ParticipantsWe interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs).Main MeasuresWe conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews.Key ResultsThe effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed.ConclusionsWe found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

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