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Background Rounds are a critical activity on any inpatient service, but there is little literature describing the purpose of rounds from the perspective of faculty and trainees in teaching hospitals. Objective To evaluate and compare the perceptions of pediatric and internal medicine attendings and medical students regarding the purpose of inpatient attending rounds. Methods The authors conducted 10 semistructured focus groups with attendings and medical students in the spring of 2014 at 4 teaching hospitals. The protocol was approved by the institutional review boards at all institutions. The authors employed a grounded theory approach to data collection and analysis, and data were analyzed by using the constant- comparative method. Two transcripts were read and coded independently by 2 authors to generate themes. Results Forty-eight attendings and 31 medical students participated in the focus groups. We categorized 218 comments into 4 themes comprised of 16 codes representing what attendings and medical students believed to be the purpose of rounds. These themes included communication, medical education, patient care, and assessment. Conclusions Our results highlight that rounds serve 4 purposes, including communication, medical education, patient care, and assessment. Importantly, both attendings and students agree on what they perceive to be the many purposes of rounds. Despite this, a disconnect appears to exist between what people believe are the purposes of rounds and what is happening during rounds.

BACKGROUND Despite increasing healthcare costs, training on cost-consciousness is lacking in graduate medical education (GME). Medical centers must consider how best to incorporate value-based training into their GME curricula. OBJECTIVE To incorporate low-value principles into an existing GME simulation exercise and assess incoming interns' recognition of low-value care. METHODS Choosing Wisely™ lists were reviewed to identify 4 low-value hazards to be embedded into a simulated hospital room in addition to the 8 patient safety hazards used previously. Interns were given 10 minutes to independently review a mock chart and list all hazards they identified in the simulation. Interns completed a short survey on their prior training in medical school and a follow-up survey one month into internship. 𝑡 tests used to compare identification of low-value vs safety hazards and to associate performance with prior training. RESULTS The mean percentage of hazards correctly identified was 50.4% (standard deviation [SD] 11.8%). Interns identified significantly fewer low-value hazards (mean 19.2%, SD 18.6%) than safety hazards (mean 66.0%, SD 16.0%; 𝑃 < .001). For example, while 96% of interns identified the hand hygiene hazard, only 6% identified the unnecessary blood transfusion and none identified the unnecessary stress ulcer prophylaxis. Interns who self-reported as confident in their ability to identify hazards were not any more likely to correctly identify hazards than those who were not confident. CONCLUSIONS The "Room of Horrors" simulation revealed poor awareness of low-value care among interns. The simulation highlights a promising model for the prioritization and inclusion of value-based experiential training in GME.

BACKGROUND Inpatient service handoffs occur when physicians who care for hospitalized patients end a period of clinical service and handover a panel of patients to an oncoming physician. Despite the large amount of research on handoffs, none has described the patient perspective when cared for by a hospitalist physician during a service handoff. OBJECTIVE To describe hospitalized patients' experiences regarding inpatient service changes, and develop a conceptual framework to inform future efforts to improve service-level handoffs. METHODS Interview-based qualitative analysis using in-depth, semistructured interviews of hospitalized patients on a nonteaching hospitalist service. Patients were interviewed between October 2014 and December 2014 at an academic medical center whose inpatient stay spanned a weekly service change. We utilized an inductive approach with no a priori hypotheses and used a constant comparative method to generate emerging themes to develop a conceptual model that captured the patient experience during the transition. RESULTS Of patients who agreed to participate (40/43), most (85%) were unaware that a transition had occurred between their hospitalists. Six major themes emerged related to patients' experiences with hospitalist service handoffs: (1) importance of physician-patient communication, (2) desire for transparency in transitions, (3) an indifference toward transitions, (4) importance of hospitalist-specialist communication, (5) formation of new opportunities from a transition, and (6) effects of bedside manner. CONCLUSIONS Hospitalized patients desire improved communication and a more formalized transition process between hospitalists during service handoffs. Hospitalists should recognize that this transition may represent an opportunity to improve the hospitalized patient's experience and satisfaction. Journal of Hospital Medicine 2016;11:675–681. © 2016 Society of Hospital Medicine

We created Sleep for Inpatients: Empowering Staff to Act (SIESTA), which combines electronic "nudges" to forgo nocturnal vitals and medications with interprofessional education on improving patient sleep. In one "SIESTAenhanced unit," nurses received coaching and integrated SIESTA into daily huddles; a standard unit did not. Six months pre- and post-SIESTA, sleep-friendly orders rose in both units (foregoing vital signs: SIESTA unit, 4% to 34%; standard, 3% to 22%, P < .001 both; sleeppromoting VTE prophylaxis: SIESTA, 15% to 42%; standard, 12% to 28%, P < .001 both). In the SIESTAenhanced unit, nighttime room entries dropped by 44% (-6.3 disruptions/room, P < .001), and patients were more likely to report no disruptions for nighttime vital signs (70% vs 41%, P = .05) or medications (84% vs 57%, P = .031) than those in the standard unit. The standard unit was not changed. Although sleep-friendly orders were adopted in both units, a unit-based nursing empowerment approach was associated with fewer nighttime room entries and improved patient experience.

BACKGROUND The most recent iteration of the Accreditation Council for Graduate Medical Education duty-hour regulations includes language mandating handoff education for trainees and assessments of handoff quality by residency training programs. However, there is a lack of validated tools for the assessment of handoff quality and for use in trainee education. METHODS Faculty at 2 sites (University of Chicago and Yale University) were recruited to participate in a workshop on handoff education. Video-based scenarios were developed to represent varying levels of performance in the domains of communication, professionalism, and setting. Videos were shown in a random order, and faculty were instructed to use the Handoff Mini-Clinical Examination Exercise (CEX), a paper-based instrument with qualitative anchors defining each level of performance, to rate the handoffs. RESULTS Forty-seven faculty members (14 at site 1; 33 at site 2) participated in the validation workshops, providing a total of 172 observations (of a possible 191 [96%]). Reliability testing revealed a Cronbach α of 0.81 and Kendall coefficient of concordance of 0.59 (>0.6 = high reliability). Faculty were able to reliably distinguish the different levels of performance in each domain in a statistically significant fashion (ie, unsatisfactory professionalism mean 2.42 vs satisfactory professionalism 4.81 vs superior professionalism 6.01, P

BACKGROUND Medical supervisors struggle to find meaningful ways to evaluate the preparedness of trainees to independently perform patient care tasks. The aim of this study was to describe the factors that influence how attending and resident physician perceptions of trust impact decision making. METHODS Internal medicine residents and attending physicians at a tertiary academic medical center were interviewed during a single academic year. Participants were asked to describe, using the critical incident technique, entrustment decisions made during their clinical rotations. A deductive qualitative analysis using the entrustable professional activities framework was used. The inter-rater reliability was calculated using a generalized kappa statistic. RESULTS Eighty-four percent (46/50) of residents and 88% (44/50) of attending physicians participated. The analysis yielded 535 discrete mentions of entrusting factors that were mapped to the following domains deductively, with inductively derived subthemes: trainee factors (eg, confidence, specialty plans), supervisor factors (eg, approachability), task factors (eg, situational characteristics) and systems factors (eg, workload). The inter-rater kappa between the 2 raters was 0.84. CONCLUSIONS Factors influencing trust in a trainee are related to the supervisor, trainee, their relationship, task, and the environment. Attending physicians note early interactions and language cues as markers of trustworthiness. Attending physicians reported using perceived confidence as a gauge of the trainee's true ability and comfort. Attendings noted trainee absences, even those that comply with regulation, negatively affected willingness to entrust. Future studies are needed to develop better assessment instruments to understand how entrustment decisions for independent practice are made. Journal of Hospital Medicine 2014;9:169–175. © 2014 Society of Hospital Medicine

Changes in the clinical learning environment under resident duty hours restrictions have introduced a number of challenges on today's wards. Additionally, the current group of medical trainees is largely represented by the Millennial Generation, a generation characterized by an affinity for technology, interaction, and group-based learning. Special attention must be paid to take into account the learning needs of a generation that has only ever known life with duty hours. A mnemonic for strategies to augment teaching rounds for hospitalists was created using an approach that considers time limitations due to duty hours as well as the preferences of Millennial learners. These strategies to enhance learning during teaching rounds are Flipping the Wards, Using Documentation to Teach, Technology-Enabled Teaching, Using Guerilla Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments into Rounds (FUTURE). Hospitalists serving as teaching attendings should consider these possible strategies as ways to enhance teaching in the post-duty hours era. These techniques appeal to the preferences of today's learners in an environment often limited by time constraints. Hospitalists are well positioned to champion innovative approaches to teaching in a dynamic and evolving clinical learning environment.

BACKGROUND Increasing frequency of shift-to-shift handoffs coupled with regulatory requirements to evaluate handoff quality make a handoff evaluation tool necessary. OBJECTIVE To develop a handoff evaluation tool. DESIGN Tool development. SETTING Two academic medical centers. SUBJECTS Nurse practitioners, medicine housestaff, and hospitalist attendings. INTERVENTION Concurrent peer and external evaluations of shift-to-shift handoffs. MEASUREMENTS The Handoff CEX (clinical evaluation exercise) consists of 6 subdomains and 1 overall assessment, each scored from 1 to 9, where 1 to 3 is unsatisfactory and 7 to 9 is superior. We assessed range of scores, performance among subgroups, internal consistency, and agreement among types of raters. RESULTS We conducted 675 evaluations of 97 unique individuals during 149 handoff sessions. Scores ranged from unsatisfactory to superior in each domain. The highest rated domain for handoff providers was professionalism (median: 8; interquartile range [IQR]: 7–9); the lowest was content (median: 7; IQR: 6–8). Scores at the 2 institutions were similar, and scores did not differ significantly by training level. Spearman correlation coefficients among the CEX subdomains for provider scores ranged from 0.71 to 0.86, except for setting (0.39–0.40). Third-party external evaluators consistently gave lower marks for the same handoff than peer evaluators did. Weighted kappa scores for provider evaluations comparing external evaluators to peers ranged from 0.28 (95% confidence interval [CI]: 0.01, 0.56) for setting to 0.59 (95% CI: 0.38, 0.80) for organization. CONCLUSIONS This handoff evaluation tool was easily used by trainees and attendings, had high internal consistency, and performed similarly across institutions. Because peers consistently provided higher scores than external evaluators, this tool may be most appropriate for external evaluation. Journal of Hospital Medicine 2013;8:191–200. © 2013 Society of Hospital Medicine

BACKGROUND: Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions. OBJECTIVE: To report older patients' experiences with problems after hospital discharge and investigate whether PCPs were aware of their hospitalization. DESIGN: Prospective mixed methods study. SETTING: Single academic medical center. PATIENTS: Hospitalized patients and PCPs. MEASUREMENTS: Telephone interviews of frail, older general medical patients conducted 2 weeks after discharge to elicit patient problems after discharge, such as: (1) obtaining medications, or follow-up appointments; and (2) perceptions of hospital physician communication with their PCP. For each patient interviewed, their PCP was faxed a survey 2 weeks after discharge to assess awareness of hospitalization. RESULTS: Forty-two percent (27) of patients reported 42 different post-discharge problems. The most frequently reported problems were difficulty with follow-up appointments or tests (12). Other reported problems included readmission and return to the Emergency Department (10), problems with medications (8), not-prepared for discharge (8), and hospital complications or questions (4). Thirty percent of PCPs were unaware of patient hospitalization. Patients were twice as likely to report a problem if their PCP was unaware of the hospitalization (31% PCP aware, vs. 67% PCP not aware; P < 0.05). CONCLUSION: This study suggests that many frail, older patients reported problems after discharge and were twice as likely to do so when the patient's PCP was not aware of the hospitalization. Systematic interventions to improve communication with PCPs during patient hospitalization are needed. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

BACKGROUND: Little data exist to inform hospitalist communication during service changes. OBJECTIVE: To characterize hospitalist handoffs during service changes. DESIGN: Serial survey study. SETTING: Single academic medical center. MEASUREMENTS: From May to December 2007, 60 service changes among 17 hospitalists on a nonteaching service were targeted for evaluation using an anonymous 18-item survey that was completed by hospitalists within 48 hours of assuming care for patients. Survey items assessed completeness of handoff communication, certainty of patient care plans, missed information, time spent recovering information, and near misses/adverse events due to incomplete handoffs. The association between completeness of communication and handoff outcomes was examined. Narrative comments were analyzed qualitatively. RESULTS: Ninety-three percent (56/60) of surveys were returned. All 17 hospitalists participated. Thirteen percent of respondents reported incomplete handoffs and 18% were uncertain of care plan on transition day. At least 1 near miss, attributable to incomplete communication was reported by 16%. Hospitalists who reported incomplete handoffs were more likely to report uncertainty about patient care plans on the transition day (71% incomplete vs. 10% complete, P < 0.01), discovery of missing information (71% incomplete vs. 24% complete, P = 0.01), near misses/adverse events (57% incomplete vs. 10% complete, P < 0.01), and more time resolving issues arising from missed information (71% incomplete vs. 22% complete, P < 0.01). Qualitative comments suggest the need for a more systematic, focused, team-based, and patient-centered handoff model. CONCLUSIONS: Incomplete handoffs during service changes are associated with uncertainty and potential patient harm. Suggestions to improve the completeness of hospitalist service change communications are offered. Journal of Hospital Medicine 2009;4:535–540. © 2009 Society of Hospital Medicine.

Medical supervisors struggle to find meaningful ways to evaluate the preparedness of trainees to independently perform patient care tasks. The aim of this study was to describe the factors that influence how attending and resident physician perceptions of trust impact decision making.Internal medicine residents and attending physicians at a tertiary academic medical center were interviewed during a single academic year. Participants were asked to describe, using the critical incident technique, entrustment decisions made during their clinical rotations. A deductive qualitative analysis using the entrustable professional activities framework was used. The inter-rater reliability was calculated using a generalized kappa statistic.Eighty-four percent (46/50) of residents and 88% (44/50) of attending physicians participated. The analysis yielded 535 discrete mentions of entrusting factors that were mapped to the following domains deductively, with inductively derived subthemes: trainee factors (eg, confidence, specialty plans), supervisor factors (eg, approachability), task factors (eg, situational characteristics) and systems factors (eg, workload). The inter-rater kappa between the 2 raters was 0.84.Factors influencing trust in a trainee are related to the supervisor, trainee, their relationship, task, and the environment. Attending physicians note early interactions and language cues as markers of trustworthiness. Attending physicians reported using perceived confidence as a gauge of the trainee's true ability and comfort. Attendings noted trainee absences, even those that comply with regulation, negatively affected willingness to entrust. Future studies are needed to develop better assessment instruments to understand how entrustment decisions for independent practice are made.

BACKGROUND Unprofessional behavior can compromise care and detract from the hospital learning environment. Discrepancy between professional behaviors formally taught and what is witnessed has become increasingly evident. METHODS With funding from the American Board of Internal Medicine Foundation, a workshop was developed to address unprofessional behaviors related to inpatient care previously identified in a multi-institution survey. The aims were to utilize video-based education to illustrate unprofessional behaviors, how faculty play a role in promoting such behaviors, and facilitate reflection regarding motivation for and prevention of these behaviors. Hospitalists and housestaff at 3 Chicago-area academic hospitals and 1 community teaching affiliate participated. Videos were debriefed, identifying barriers to professional behavior and improvement strategies. A postworkshop survey assessed beliefs on behaviors and intent to change practice. RESULTS Forty-four (53%) faculty and 244 (68%) residents (postgraduate year 1 and greater) participated. The workshop was well received, with 89% reporting it “useful and effective.” Two-thirds expressed intent to change behavior. Most (86%) believed videos were realistic and effective. Those who perceived videos as “very realistic” were more likely to report intent to change behavior (93% vs 53%, P = 0.01). CONCLUSIONS Video-based education is a feasible way to promote reflection and address unprofessional behaviors among providers and may positively impact the learning environment. Journal of Hospital Medicine 2013;8:386–389. © 2013 Society of Hospital Medicine

BACKGROUND Graduated supervision is necessary for residents to progress to independence, but it is unclear what factors influence attendings' perception of housestaff autonomy. OBJECTIVE To determine if attending characteristics and secular trends are associated with variation in attendings' perception of housestaff autonomy. DESIGN Secondary data analysis of monthly survey data collected from 2001 to 2008. SETTING/PARTICIPANTS Attending hospitalists and nonhospitalists on teaching internal medicine services at an academic tertiary care center. MEASUREMENTS Attendings' perception of intern decision making and resident autonomy. RESULTS Response rate was 70% (514/738). Compared with early-career attendings, experienced attendings perceived more intern involvement in decision making (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.17-3.97, P=0.013). Hospitalists perceived less intern involvement in decision making (OR: 0.19, 95% CI: 0.06-0.58, P=0.004) and resident autonomy (OR: 0.27, 95% CI: 0.11-0.66, P=0.004) compared with nonhospitalists. A significant interaction existed between hospitalists and experience; experienced hospitalists perceived more intern decision making (OR: 7.36, 95% CI: 1.86-29.1, P=0.004) and resident autonomy (OR: 5.85, 95% CI: 1.75-19.6, P=0.004) compared with early-career hospitalists. With respect to secular trends, spring season of the academic year was associated with greater perception of intern decision making compared with other seasons (OR: 1.94, 95% CI: 1.18-3.19, P=0.009). The 2003 resident duty-hours restrictions were associated with decreased perception of intern decision making (OR: 0.51, 95% CI: 0.29-0.87, P=0.014) and resident autonomy (OR: 0.49, 95% CI: 0.28-0.86, P=0.012). CONCLUSIONS Perception of housestaff autonomy varies with attending characteristics and time trends. Hospitalists perceive autonomy and clinical decision making differently, depending on their attending experience. Journal of Hospital Medicine 2013;8:292–297. © 2013 Society of Hospital Medicine

BACKGROUND Although peer evaluation can be used to evaluate in-hospital handoffs, few studies have described using this strategy. OBJECTIVE Our objective was to assess feasibility of an online peer handoff evaluation and characterize performance over time among medical interns. DESIGN The design was a prospective cohort study. PATIENTS Subjects were medical interns from residency program rotating at 2 teaching hospitals. MEASUREMENTS Measurements were performance on an end-of-rotation evaluation of giving and receiving handoffs. RESULTS From July 2009 to March 2010, 31 interns completed 60% (172/288) of peer evaluations. Ratings were high across domains (mean, 8.3–8.6). In multivariate regression controlling for evaluator and evaluatee, statistically significant improvements over time were observed for 4 items compared to the first 3 months of the year: 1) communication skills (season 2, +0.34 [95% confidence interval (CI), 0.08-0.60], P = 0.009); 2) listening behavior (season 2, +0.29 [95% CI, 0.04-0.55], P = 0.025); 3) accepting professional responsibility (season 3, +0.37 [95% CI, 0.08-0.65], P = 0.012); and 4) accessing the system (season 2, +0.21 [95% CI, 0.03-0.39], P = 0.023). Ratings were also significantly lower when interns were postcall in written sign-out quality (8.21 vs 8.39, P = 0.008) and accepting feedback (8.25 vs 8.42, P = 0.006). Ratings from a community hospital rotation, with a lower census than the teaching hospital, were significantly higher for overall performance and 7 of 12 domains (P < 0.05 for all). Significant evaluator effects were observed. CONCLUSIONS Although there is evidence of leniency, peer evaluation of handoffs demonstrate increases over time and associations with workload such as postcall status. This suggests the importance of examining how workload impacts handoffs in the future. Journal of Hospital Medicine 2013;8:132–136. © 2012 Society of Hospital Medicine

In 2003, Accreditation Council for Graduate Medical Education (ACGME) announced the first in a series of guidelines related to the residency training. The most recent recommendations include explicit recommendations regarding the provision of on-site clinical supervision for trainees of internal medicine. To meet these standards, many internal medicine residency programs turned to hospitalist programs to fill that need. However, much is unknown about the current relationships between hospitalist and residency programs, specifically with regard to supervisory roles and supervision policies. We aimed to describe how academic hospitalists currently supervise housestaff during the on-call, or overnight, period and hospitalist program leader their perceptions of how these new policies would impact trainee-hospitalist interactions.

BACKGROUND: New supervisory regulations highlight the challenge of balancing housestaff supervision and autonomy. To better understand the impact of increased supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision-making before and after implementation of an in-hospital, overnight attending physician (nocturnist). METHODS: We established a nocturnist program in July 2010 at our academic, tertiary care medical center. We administered pre-surveys and post-surveys of internal medicine residents on night float rotation during the 2010–2011 academic year. We surveyed residents before and after experiencing the nocturnist program. RESULTS: Housestaff reported an increase in the clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) and the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001) without a change in decision-making autonomy (4.35 vs 4.45, P = 0.44). Trainees agreed that nocturnist supervision positively impacted patient outcomes (3.79 vs 4.30, P = 0.002). Housestaff contacted attendings more frequently for transfers from outside facilities (2.00 vs 3.20, P = 0.006), during adverse events (2.51 vs 3.25, P = 0.04), prior to ordering invasive diagnostics (1.75 vs 2.76, P = 0.004), and prior to vasopressor use (1.52 vs 2.40, P = 0.004). Residents' fear of revealing knowledge gaps and desire to make decisions independently did not change. CONCLUSIONS: Increased overnight supervision enhanced the clinical value of the night float rotation, increased rates of attending contact during critical clinical decision-making, and improved perception of patient care. These changes occurred without a decrease in housestaff's perceived decision-making autonomy. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine