Resident Signout Deserves Great Design

Resident Sign-out
Deserves
Great Design
Joyce Lee, Doctor as Designer, Jennifer Zank,
Xiaoying He, Matt Kenyon
Healthdesignby.us

Resident Sign-out
It’s the handoff that happens
between residents in the hospital
from day to night shift and night
shift to day shift
How might we improve the pain
points around sign-out, instead of
accepting the status quo?

And since residents are creative
hackers, why not have them
help with the redesign of the tools
that they use everyday?

We held a design workshop
with interns, senior residents,
chief residents, and Faculty from
the Schools of Art, Architecture,
Engineering, and Medicine at the
University of Michigan
to redesign resident signout

We used
Human-Centered Design Thinking
a form of
User-Centered Problem Solving

Empathy PrototypeDefine Ideate Test
It’s an iterative process that
starts with the user

Empathy
Understand a problem
before solving it

Define
Patient-defined problem

Ideate
Collaborative, creative
brainstorming

Prototype
Sketch, draw, glue, code
,,

Test
Iterative Feedback from User
,,

Empathy PrototypeDefine Ideate Test
Before the workshop, we started by
understanding the user and
defining the problem

We performed user
interviews with the interns and
senior residents in the trenches

We mapped out the system:
Users, Teams, and
Interactions

Intern
1st year resident
Senior
3rd year resident

We ran simulations to see
if the duration of night shift
schedules impacted
patient continuity
(Conclusion: not so much)

We observed resident
signout in the hospital

Our Design Synthesis lead
to these insights:

TEAM COMPOSITION
SERVICE TYPE
CALL SCHEDULES(NIGHTS/WEEKENDS)
RESIDENT GUILT
SEASONALITY(NEW INTERNS!)
SIGNOUT QUALITY(VERBAL/WRITTEN)
Factors Impacting Signout

A BOTTLENECK IN COMMUNICATION
“There are two different time issues. There is the time it takes to sign-out
your own team and also the time that the other 2 teams are taking. So if
you’re the third team to sign-out and you’re waiting an hour-and-a-half
for the first two teams to sign-out, so that’s also a problem.”
Intern Resident
“The night team travelling was an efficiency issue too, as
people would be waiting in line but we didn’t have a set-
up such that people as they were waiting could kind of
do work at the same time. They would just be standing
around and waiting.”
“I signed out 3 teams a couple of days ago in 45 minutes. It was just me
and my team people, me and the other intern and my senior talking to
one team with however many patients of the three teams. There was no
bottleneck and I was the last team so I was able to sign-out at 6 o’ clock.”
Senior Resident
Intern Resident

HOW MIGHT WE
IMPROVE THE OVERALL CALL
STRUCTURE?
A BOTTLENECK IN COMMUNICATION

NOT WANTING TO BURDEN OTHERS DELAYS SIGNOUT
“So if they’re admitting patients or a patient is sick or whatever
things that can happen during our day, and they don’t feel like
they’re ready to sign-out, then that can also delay the process.”
Intern Resident “I can fairly understand what that feeling is about
wanting to stay because it’s best for continuity of care
and handling an issue. So I think that’s a big
problem.”
“The thing is that getting out at 4:00 never really means 4:00, like
gets pushed back to 5:00 and that’s when people think it is 5:00
and it’s silly to sign-out my team to another team, only to be
signed-out an hour later, so they might as well stay as they feel
bad about it; or the team that would expect to sign-out is like why
are you signing-out to me, you should just stay for an hour.”
Senior Resident
Senior Resident

HOW MIGHT WE
HELP RESIDENTS GO HOME
WHEN THEY ARE SUPPOSED TO?
NOT WANTING TO BURDEN OTHERS DELAYS SIGNOUT

THE SIGN-OUT PROCESS IS LONGEST IN JULY
“The worst time of the year was late summer,
early fall. Not every night, but yeah, the sign-out
takes three to four hours.”
Intern Resident
“I think (the training) is the problem to a certain
extent but I’ve seen people late in the year who
I think should be better but they aren’t.”
“Some people are under the impression that seniors should give a
separate conversation to the seniors because it’s less information
traditionally and it can be quicker and that the interns should sign-
out to the interns because, maybe because the concerns are
different but also because just tends be a little longer.”
Intern Resident
Senior Resident

HOW MIGHT WE
IMPROVE THE PRE-JOB TRAINING
PROCESS?
THE SIGN-OUT PROCESS IS LONGEST IN JULY

THE AMOUNT OF INFORMATION EXCHANGED DURING SIGN-OUTS
FLUCTUATES AND IS PROBLEMATIC
“The senior sign out really just needs be a one liner and these are the
overnight events and todos. But the intern sign out needs to be more
because they need to understand how to process something if they’re
at the bedside and the nurse is asking them a question.”
Senior Resident
“Another thing that was not done well, is that some people will try to get too
much information to sort of include what are all the terrible things that could
happen in the patient overnight, based on their major diagnosis, and then try
to list them. And then it’s too much information or trying to give things that
we as doctors know as protocols.”
“The flipside of too much is not enough. If there is
something big that happened that day and…they totally
don’t tell you…”
Intern Resident
Intern Resident

HOW MIGHT WE
DEFINE THE RIGHT AMOUNT OF
INFORMATION?
THE AMOUNT OF INFORMATION EXCHANGED DURING SIGN-OUTS
FLUCTUATES AND IS PROBLEMATIC

THE WRITTEN FORM OF COMMUNICATION, SIGN OUT ROUNDING
SHEET, IS NOT EFFICIENTLY DESIGNED
“Some of the information we don’t like read off every night, like
for example, there is like the patient’s weight is on here. We
usually don’t say like they weigh 9.2 kg.”
Intern Resident
“Sign out sheets can make things inefficient like if you are a call team or post
call team and a pre call team signs out to you at 4 and their sign-outs are
built for you, and then things happen in the afternoons. It is then your
responsibility to make a new sign-out sheet for the night team or some
teams writes on the sign out sheet and then it’s like a mess.”
“One of the things that I liked to do was if you are going to print out all the
sheets at night, the rounding sheets and write notes on them you should
just be able to hand that to the senior in the morning because it’s going to
be the same rounding sheet in the morning.”
Senior Resident
Intern Resident

HOW MIGHT WE?
REDESIGN THE WRITTEN
RESIDENT SIGNOUT?

“But I always wonder right, we all have smart phones, if you were at the
patient’s bed side and you wrote, person had a low hemoglobin, got
transfused, why can’t someone just look that up from home and get their
whole sign out done before they even got in? Do you know what I mean, like
you do like the Facebook. People do this all the time, right? You update
people about technology before and they know in real time what’s going on.”
We love technology, but we were really
struck by this statement from our colleague
Joy Knoblauch from Art and Architecture,
who said:
“I have a lot of respect for paper”

“I have a lot of respect for paper”
“Yeah, we believe in the paperwork. It’s equitable, it’s
not biased, you’re not trying to shirk your tasks because
you’ve written it down, we can see it, we’re just going to
move through each phase…Everybody kind of feels like
we’re making progress because now we’re on box five…I
think it reassures people.”
We elected to focus on the design of
the resident paper sign-out for the
workshop

Current State of the
Resident Paper Sign-out Form
Because of HIPAA,
this is simulated data but the design
is modeled after the real signout

What could be the
future of the cutting-edge
Resident Signout?

We provided some
inspiration in the next slides

DESIGN FOR DEMOCRACY
AIGA identified common design problems on the ballot and offered improvements
http://goo.gl/ALzA7G

REDESIGN OF THE REPORT CARD
GOOD’s redesign the report card project creates a visually appealing report
card that informs, inspires, and gives context to student achievement
http://goo.gl/Tt9C71

KNOW BEFORE YOU OWE
CFPB (Consumer Financial Protection Bureau) redesigned the mortgage
form to better inform consumers
http://goo.gl/jLpAoH

REDESIGN OF US INCOME TAX
FORM
New York design studio FormNation has proposed a redesign for two US
income tax forms to make them clearer and easier to use
http://goo.gl/GtKEfC

INFOGRAPHIC DESIGNS
http://goo.gl/BC5zxk

A MEDICAL RECORD REDESIGN
http://goo.gl/vdTPTF

Fellow Residents,
Do you still use a paper signout?
How is your signout designed?
How might the resident signout
be improved?

STAY TUNED FOR
WHAT HAPPENED NEXT!
Follow us on Twitter: @healthbyus
Sign up for our mailing list:
http://goo.gl/mEmaiO
Special thanks to Emily Hirschfeld, Dr. Castle,
Dr. Haftel, the residents, Camilla Kraft,
Joy Knoblauch, Franc Nunoo-Quarcoo,
& Amy Cohn
Slide design mostly by Xiaoying He with a little help
from Joyce Lee!

Resident Signout Deserves Great Design

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