Journal of General Internal Medicine

, Volume 34, Issue 2, pp 264–271 | Cite as

“Do You Know What I Know?”: How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs

  • Nicholas A. RattrayEmail author
  • Mindy E. Flanagan
  • Laura G. Militello
  • Paul Barach
  • Zamal Franks
  • Patricia Ebright
  • Shakaib U. Rehman
  • Howard S. Gordon
  • Richard M. Frankel
Original Research



Poor 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.


We 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.


We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs).

Main Measures

We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews.

Key Results

The 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.


We 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.

Key Words

communication resident handoffs qualitative research sociolinguistics quality of care patient safety risk management 


Authors’ Contribution

All authors were involved in the design of this research, participated in manuscript development, and critically revised the manuscript for its intellectual content. RMF obtained study funding and directed the study. NAR, MEF, LGM, PB, ZF, PE, and RMF participated in data analysis. NAR, RMF, MEF, and LGM drafted the manuscript, and NAR, MEF, RMF, LGM, ZF, PE, PB, SUR, and HSG read, revised, and approved the final version.We appreciate the efforts of Paige DeChant in data collection and analysis, and Dr. Maddamsetti Rao, Christopher Kurtz, Ava Harms, Angela Kuramoto, Naomi Ashlely, and Natalia Skorohod for assistance in recruitment and logistics. We thank Rachel Gruber for excellent assistance with manuscript preparation and submission, and Julie DiIulio for her graphic design contribution. We would also like to thank the VA residents that volunteered to take time out of their regular duties to participate in the study.


The research was funded by the Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416), Project No. IIR 12-090.

Compliance with Ethical Standards

Ethics approval was obtained from the University Institutional Review Board and the VAMC R&D Human Subjects board.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4755_MOESM1_ESM.docx (28 kb)
ESM 1 (DOCX 27 kb)


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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply)( 2018

Authors and Affiliations

  • Nicholas A. Rattray
    • 1
    • 2
    • 3
    Email author
  • Mindy E. Flanagan
    • 1
  • Laura G. Militello
    • 4
  • Paul Barach
    • 5
  • Zamal Franks
    • 1
  • Patricia Ebright
    • 6
  • Shakaib U. Rehman
    • 7
  • Howard S. Gordon
    • 8
  • Richard M. Frankel
    • 1
    • 3
    • 9
  1. 1.VA HSR&D Center for Health Information and Communication Roudebush VAMCIndianapolisUSA
  2. 2.Department of AnthropologyIndiana University-Purdue University IndianapolisIndianapolisUSA
  3. 3.Regenstrief Institute, Inc.IndianapolisUSA
  4. 4.Applied Decision ScienceLLCDaytonUSA
  5. 5.Jefferson College of Population HealthWayne State University School of MedicineDetroitUSA
  6. 6.Indiana University School of NursingIndianapolisUSA
  7. 7.Phoenix VA Healthcare SystemsUniversity of Arizona College of Medicine-PhoenixPhoenixUSA
  8. 8.Jesse Brown VAMC, VA HSR&D Center of Innovation for Complex Chronic HealthcareUniversity of Illinois at ChicagoChicagoUSA
  9. 9.Indiana University School of MedicineIndianapolisUSA

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