Document Type


Publication Date




Publication Title

BMJ Open






e015762 (1-9)


OBJECTIVES: Although JCAHO requires a standardised approach to handoffs, and while many standardised protocols have been tested, sign-out practices continue to vary. We believe this is due to the variability in workflow during inpatient duty cycle. We investigate the impact of such workflows on intern sign-out practices.

DESIGN: We employed a prospective, grounded theory mixed-method design.

SETTING: The study was conducted at a residency programme in the mid-Atlantic USA. Two observers randomly evaluated three types of daily sign-outs for 1 week every 3 months from September 2013 to March 2014. The compliance of each observed behaviour to JCAHO's Handoff Communication Checklist was recorded.

PARTICIPANTS: Thirty one interns conducting 134 patient sign-outs were observed randomly among the 52 in the programme.

RESULTS: In the 06:00 to 07:00 sign-back, the night-cover focused on providing information on overnight events to the day interns. In the 11:00 to 12:00 sign-out, the night-cover focused on transferring task accountability to a day-cover intern before departure. In the 20:00 to 21:00 sign-out, the day interns focused on transferring responsibility of their patients to a night-cover.

CONCLUSION: Different sign-out periods had different emphases regarding information exchange, personal responsibility and task accountability. Sign-outs are context-specific, implying that across-the-board standardised sign-out protocols are likely to have limited efficacy and compliance. Standardisation may need to be relative to the specific type and purpose of each sign-out to be supported by interns.

Original Publication Citation

Lee, S. H., Desai, S. V., & Phan, P. H. (2017). The impact of duty cycle workflow on sign-out practices: A qualitative study of an internal medicine residency program in Maryland, USA. BMJ Open, 7(5), e015762. doi:10.1136/bmjopen-2016-015762