Print this page Email this page Users Online: 185 | Click here to view old website
Home About us Editorial Board Search Current Issue Archives Submit Article Author Instructions Contact Us Login 

 Table of Contents  
Year : 2016  |  Volume : 29  |  Issue : 1  |  Page : 51-55

Addressing outpatient continuity for ambulatory training: A novel tool for longitudinal primary care sign out

1 Center of Excellence in Primary Care Education, West Haven; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
2 Center of Excellence in Primary Care Education, West Haven, CT, USA
3 Center of Excellence in Primary Care Education, West Haven; Department of Internal Medicine, Section of General Medicine, Yale School of Medicine, New Haven, CT, USA

Date of Web Publication18-Mar-2016

Correspondence Address:
Theodore Long
Robert Wood Johnson Clinical Scholars Program, 333 Cedar Street, SHM IE-61, P.O. Box. 208088, New Haven, CT 06520
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1357-6283.178923

Rights and Permissions

Background: We created a tool to improve communication among health professional trainees in the ambulatory setting. The tool was devised to both inform practice partner teams about high-risk patients and assign patient follow-up issues to team members. Team members were internal medicine residents and nurse practitioner fellows in the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE), an interprofessional training model in primary care. Methods: We used a combination of Likert scale response questions and open ended questions to evaluate trainee attitudes before and after the implementation of the tool, as well as solicited feedback to improve the tool. Results: After using the primary care sign out tool, trainees expressed greater confidence that they could identify high-risk patients that had been cared for by other trainees and that important patient care issues would be followed up by others when they were not in clinic. In terms of areas for improvement, respondents wanted to have the sign out tool posted online. Discussion: Our sign out tool offers a strategy that others can use to improve communication and knowledge of shared patients within teams comprised of interprofessional trainees.

Keywords: Interprofessional education, medical education, sign out, teamwork, transitions of care

How to cite this article:
Long T, Uradu A, Castillo R, Brienza R. Addressing outpatient continuity for ambulatory training: A novel tool for longitudinal primary care sign out. Educ Health 2016;29:51-5

How to cite this URL:
Long T, Uradu A, Castillo R, Brienza R. Addressing outpatient continuity for ambulatory training: A novel tool for longitudinal primary care sign out. Educ Health [serial online] 2016 [cited 2023 Jun 7];29:51-5. Available from:

  Background Top

Internal medicine residency programs, which are comprised of post-graduate physician trainees in the US, often have a conflict between the balance of time that residents spend in the outpatient setting versus in the hospital. A strategy has been introduced to improve this balance through having “blocks” which have a fixed ratio of time where residents are in the hospital versus in outpatient clinics. However, with this change, residents are often in outpatient primary care clinics more frequently but for shorter amounts of time, which has created an increasing need to ensure continuous communication and sign out between resident practice partners caring for the same group, or “panel,” of patients.[1],[2] “Sign out” refers to a process for communicating urgent patient concerns or follow up issues between a trainee that is finishing a rotation in an outpatient clinic and a trainee that is starting an outpatient rotation and assuming responsibility for patients managed by both of the trainees. In the outpatient setting, there is a paucity of data describing sign out strategies, with existing studies having focused on year-end transfer of care.[3],[4],[5],[6] To date a tool for longitudinal sign out between rotation blocks during the academic year (July 1 to June 30 in the US) has not been established.

The need for high-quality sign out among residents in the inpatient setting has been well established.[7],[8],[9],[10] However, it is unclear what comprises a high-quality sign out between residents on outpatient blocks. We at the Center of Excellence in Primary Care Education training site within the West Haven, Connecticut VA sought to identify the priorities of primary care trainees for longitudinal sign out during the year, and develop a tool as well as a structured sign-out process to address these needs. We created this tool with designated domains for follow-up issues and a list of high-risk patients with active medical problems. We report results from before and six months after implementation of the tool.

  Methods Top


We developed an outpatient sign out tool to facilitate improved communication between members of our trainee practice-partner teams for use in the Veterans Administration Connecticut Healthcare System (VACHS) Center of Excellence in Primary Care Education (CoEPCE), which is an interprofessional practice partnership model for primary care education. In the US, the VA is a national healthcare system that provides both inpatient and outpatient care to veterans of all branches of the U.S. Military. The practice-partner teams are comprised of trainees who are internal medicine residents and nurse practitioner (NP) fellows. These trainees are assigned to teams and are supervised by the same MD/NP faculty dyads throughout the duration of their training. The NP fellows are part of a one year post-Master's Adult interprofessional fellowship focused on primary care training and are present in clinic every day. The internal medicine residents alternate between being present full time during primary care immersion blocks and one half day per week on other clinical rotations. Immersion block for internal medicine residents designates a continuous four week outpatient block when residents are in clinic every day and do not have inpatient responsibilities. The immersion blocks for residents were generally followed by two months of inpatient and other elective rotations. Approval from the VA Institutional Review Board was given for evaluation of educational outcomes of the Center of Excellence in Primary Care Education, which included this project.

Creating the sign out tool

We conducted pilot interviews to establish what trainees felt was important to include in a sign out tool. Based this feedback, we created the tool with two overarching goals, which are to alert covering team members about issues for follow up when the individual provider is not available, and to identify high-risk patients on shared panels. “High risk” was defined as patient that were either medically complex or had active issues necessitating close follow up. The final version of the tool was comprised of five sections [Appendix 1 [Additional file 1]]: Brief HPI/Active issues, Functional status, Long-term goals, To-Do list with anticipatory guidance, and Identification of the responsible party for follow up. Trainees rotating off of immersion block were expected to follow up on routine issues. Sign out was given for timely issues for complex patients as well as involved follow up for active medical evaluation. There was protected time for sign-out meetings involving all trainees and overseen by faculty twice per one-month immersion block. During these meetings, sign out of follow-up issues was provided to the covering team member as well as discussion about high-risk patients that may be seen by other members of the team.


We surveyed trainees using a combination of Likert scale and open ended questions that we analyzed qualitatively. Our study population was comprised of all Center of Excellence trainees: internal medicine residents (n = 10) and NP fellows (n = 4). Prior to creating the tool, we sent out 14 surveys to all Center of Excellence trainees, and received ten completed surveys back in December, 2012 (71% response rate). The questions on the surveys were based on former studies, as well as pilot individual interviews with trainees to determine their priorities for sign out between outpatient rotations [Table 1].[3],[4] This survey served as a needs assessment to determine baseline responses that were compared to survey responses after the tool was rolled out.
Table 1: Trainee responses before and after implementation of sign-out tool

Click here to view

After the tool had been actively used for six months, which included two sessions where the tool was utilized, we re-administered the initial survey and added a series of five open-ended questions focused on the perceived usefulness of the tool and areas for improvement. This survey was sent to the same 14 trainees, with nine surveys being returned in May, 2013 (64% response rate). We used a paired t-test to compare the Likert means in the study group. The P values had statistical significance calculated at the 0.05 alpha level.

For the open-ended questions, two investigators (T.L, R.C.) independently evaluated the responses and placed initial codes. The codes represented ideas put forth by the respondents. While the responses were usually brief, the investigators met to negotiate a consensus on the codes, and this code structure was then applied to all of the responses. Once the coding was complete, the codes were arranged into themes.

  Results Top

In the survey before the tool was used, trainees had low levels of confidence in having issues for their patients followed up, and 8/10 (80%) of trainees agreed or strongly agreed with the value in creating a longitudinal sign-out tool [Table 1].

For the survey sent after the sign-out tool had been in use for six months, there was a statistically significant difference in trainee confidence identifying high-risk patients in other trainee patient panels. In addition, 6/9 (67%) felt confident or very confident in having issues related to their patients being followed up by other team members when they were not in clinic.

The main themes identified in the open ended questions for the survey sent after the implementation of the tool were heightened awareness of high-risk patients, follow-up issues, and areas for improvement. Trainees felt that they were more familiar with high-risk patients on other panels, and that the sign-out tool helped facilitate the follow up of outstanding issues, but that there should be a way to update the tool electronically. Of note, all trainee responses were positive at the end of the six month period.

In identifying high-risk patients, one trainee noted that “though we go for continuity, there's still a chance we'll see patients from other teams/panels in urgent visits.” Another trainee commented that the tool “provide[d] a streamlined process that would decrease the amount of chart review necessary […] in the event of urgent visits.”

In terms of following up on outstanding issues, trainees described that “[using the tool] makes me much more comfortable leaving immersion knowing 'to do's' will be addressed” and “as one receiving the sign out, I've found it varies from resident to resident so far-I can think of some who have used it tremendously, and one who hasn't signed out.” Trainees finally described that the tool could be improved through “putting it online” and having “automated ways to import data into the sign out tool.”

  Discussion Top

We created a tool for longitudinal sign out to both address the lack of a formal process to follow up tasks and facilitate trainees being aware of high-risk patients on other panels in the outpatient primary care setting. Our evaluation has shown that trainees value being aware of high-risk patients on their practice partner teams and using the tool for the follow up of tasks when they rotate out of ambulatory rotations. The results from this initial study demonstrate that our sign-out tool was useful and feasible within a busy ambulatory training program.

Our findings related to value of ambulatory sign out to trainees have been reflected in other studies.[3],[4] Garment et al. similarly found that the majority of residents felt that standardizing sign out would be important for the outpatient setting.[3] Consequently, they built an end of the year sign-out tool. Our tool has this function, but also operates as a strategy for continuous follow up for our residents when they rotate off immersion block as we have since posted the tool online on a shared space on a secure intranet server where it can be updated in real time during the year. The creation of this space allows all members within the interprofessional patient care team to have real-time access to this information.

Our evaluation has several limitations. First, our study group in the CoEPCE is a small group comprised of 14 trainees, making it difficult to assess for statistical significance in the pre and post-implementation surveys. Second, we did not assess patient level outcomes to determine whether the tool may improve quality of care.

Moving forward, the sign-out tool continues to serve the dual purpose of following up on patient issues and facilitating discussion of high-risk patients shared by practice partner teams. We believe that there is an educational value in having sign-out discussions about high-risk patients as it allows for each member of the team to learn about strategies for managing complicated patients. We have built the sign-out tool into our interprofessional curriculum, through allocating two sessions in each monthly immersion block to accomplish these goals. These educational sessions have an interprofessional focus, as they afford the opportunity for internal medicine residents and nurse practitioner fellows to collaborate on treatment strategies for high-risk patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Stevens DP, Wagner EH. Transform residency training in chronic illness care – Now. Acad Med 2006;81:685-7.  Back to cited text no. 1
Caines LC, Brockmeyer DM, Tess AV, Kim H, Kriegel G, Bates CK. The revolving door of resident continuity practice: Identifying gaps in transitions of care. J Gen Intern Med 2011;26:995-8.  Back to cited text no. 2
Garment AR, Lee WW, Harris C, Phillips-Caesar E. Development of a structured year-end sign-out program in an outpatient continuity practice. J Gen Intern Med 2013;28:114-20.  Back to cited text no. 3
Lerner CF, Hamilton LJ, Klitzner TS. Improving year-end transfers of care in academic ambulatory clinics: A survey of pediatric resident physician perceptions. Med Educ Online 2012;17.  Back to cited text no. 4
Pincavage AT, Ratner S, Prochaska ML, Prochaska M, Oyler J, Davis AM, et al. Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs. J Gen Intern Med 2012;27:1438-44.  Back to cited text no. 5
Donnelly MJ, Clauser JM, Weissman NJ. An intervention to improve ambulatory care handoffs at the end of residency. J Grad Med Educ 2012;4:381-4.  Back to cited text no. 6
Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: A national survey. Arch Intern Med 2006;166:1173-7.  Back to cited text no. 7
Wheat D, Co C, Manochakian R, Rich E. An assessment of patient sign-outs conducted by University at Buffalo internal medicine residents. Am J Med Qual 2012;27:39-47.  Back to cited text no. 8
Bump GM, Jovin F, Destefano L, Kirlin A, Moul A, Murray K, et al. Resident sign-out and patient hand-offs: Opportunities for improvement. Teach Learn Med 2011;23:105-11.  Back to cited text no. 9
Raduma-Tomàs MA, Flin R, Yule S, Williams D. Doctors' handovers in hospitals: A literature review. BMJ Qual Saf 2011;20:128-33.  Back to cited text no. 10


  [Table 1]

This article has been cited by
1 Successful Increase of Outpatient Clinic Continuity in a Fellowship Quality Improvement Project
Ranjini Srinivasan,Peter Sambatakos,Mariellen Lane,Usha Krishnan,Rachel Weller,Jonathan N. Flyer,Keith Robinson,Julie Glickstein
Pediatric Quality and Safety. 2020; 5(3): e306
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Tables

 Article Access Statistics
    PDF Downloaded420    
    Comments [Add]    
    Cited by others 1    

Recommend this journal