Journal of General Internal Medicine

, Volume 27, Issue 3, pp 287–291 | Cite as

Use of an Appreciative Inquiry Approach to Improve Resident Sign-Out in an Era of Multiple Shift Changes

  • Adam S. Helms
  • Thomas E. Perez
  • Joseph Baltz
  • Gerald Donowitz
  • George Hoke
  • Ellen J. Bass
  • Margaret L. Plews-Ogan
Original Research



Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents’ sign-out process.


To characterize resident sign-out process and identify effective strategies for quality improvement.


Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement.


Internal medicine residents (n = 89).


An appreciative inquiry process identified five exemplar residents and their peers’ effective sign-out strategies.


Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach.


The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication.


Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.


sign-out handoff of care continuity of patient care internship and residency communication patient transfer medical errors 



The project was supported in part by grant no. T15LM009462 from the National Library of Medicine (NLM), the University of Virginia’s Graduate Medical Education office, and the University of Virginia’s Institute of Quality and Patient Safety. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NLM, the National Institutes of Health, or the University of Virginia.

We would like to acknowledge Lindsay Friesen who assisted in the development of an educational curriculum for the residents based on the findings in this study. We would also like to acknowledge the five “exemplar” internal medicine residents who were critical to our appreciative inquiry approach: Peter Pollak, Luther Bartelt, Jonathon Bleeker, Jamie Kennedy, and Dave Winchester.

Conflict of Interest

Dr. Plews-Ogan is an investigator on a Bristol-Myers Squibb-sponsored research study on empowering African-American women in self care for diabetes.


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Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Adam S. Helms
    • 1
  • Thomas E. Perez
    • 2
  • Joseph Baltz
    • 1
  • Gerald Donowitz
    • 1
  • George Hoke
    • 1
  • Ellen J. Bass
    • 2
  • Margaret L. Plews-Ogan
    • 1
  1. 1.Department of Internal MedicineUniversity of Virginia HealthsystemCharlottesvilleUSA
  2. 2.Department of Systems and Information EngineeringUniversity of VirginiaCharlottesvilleUSA

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