Medical education is moving toward assessment of educational outcomes rather than educational processes. The American Board of Internal Medicine and American Board of Pediatrics milestones and the concept of entrustable professional activities (EPA)--skills essential to the practice of medicine that educators progressively entrust learners to perform--provide new approaches to assessing outcomes. Although some defined EPAs exist for internal medicine and pediatrics, the continued development and implementation of EPAs remains challenging. As residency programs are expected to begin reporting milestone-based performance, however, they will need examples of how to overcome these challenges. The authors describe a model for the development and implementation of an EPA using the resident handoff as an example. The model includes nine steps: selecting the EPA, determining where skills are practiced and assessed, addressing barriers to assessment, determining components of the EPA, determining needed assessment tools, developing new assessments if needed, determining criteria for advancement through entrustment levels, mapping milestones to the EPA, and faculty development. Following implementation, 78% of interns at the University of Minnesota Medical School were observed giving handoffs and provided feedback. The authors suggest that this model of EPA development--which includes engaging stakeholders, an iterative process to describing the behavioral characteristics of each domain at each level of entrustment, and the development of specific assessment tools that support both formative feedback and summative decisions about entrustment--can serve as a model for EPA development for other clinical skills and specialty areas.

Background Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described. Objective To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes. Research design We analyzed inpatient data from the Health Care Utilization Project’s State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital’s ability to identify super-utilizers. Subjects Adult patients with 4 or more inpatient stays in 1 year. Measures Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer. Results Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer. Conclusions Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers.

Introduction Patient handoffs are common during residency and are often performed with little or no training. We devised a simple intervention to improve the readiness of interns to perform handoffs. Methods We administered a 90-minute interactive workshop during intern orientation in 2009 and 2010. It consisted of a discussion, a case presentation, and a trigger video, followed by debriefing and a role-play exercise. The workshop required minimal technology and materials. Interns were surveyed on their readiness to perform handoffs before and after the workshop as well as 3 to 6 months after the workshop. Results Eighty-nine interns participated in the workshop during a 2-year period. Seventy-four survey responses were collected. Self-reported readiness to perform a handoff increased by 26%. A total of 91% and 81% of respondents in 2010 and 2009, respectively, reported using aspects of the workshop up to 6 months later. Conclusion A brief workshop can improve interns' readiness to perform handoffs.

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