Stephanie L. Clark, MD, MPH

Acute illness requiring hospitalization can be overwhelming for children and their families who are coping with illness and the synthesis of information from a variety of healthcare providers.[1] Patient and family centeredness is endorsed by the Institute of Medicine and the American Academy of Pediatrics[2, 3] as central to quality healthcare. In academic institutions, the presence of medical students and residents adds to the number of providers families encounter. In July 2011, the Accreditation Council for Graduate Medical Education implemented new duty hour restrictions, limiting first year residents to a maximum of 16 hour shifts.[4] Consequently, caregivers and patients may be in contact with more healthcare providers; this fractured care may confuse patients and caregivers, and increase dissatisfaction with care.[5]

The primary objective of our study was to determine the effect of a face sheet tool on the percentage of medical team members correctly identified by caregivers. The secondary objective was to determine the effect of a face sheet tool on the evaluation and satisfaction rating of the medical team by caregivers. We hypothesized that caregivers who receive the face sheet tool will correctly identify a greater percentage of team members by name and role and have higher overall satisfaction with their hospital stay.

METHODS

We performed a prospective controlled study on 2 general pediatric units at Cincinnati Children's Hospital Medical Center (CCHMC). Patients on the intervention unit received the face sheet tool, whereas the concurrent control unit maintained usual procedures. Both units have 24 beds and care for general pediatric patients primarily covered by 4 resident teams and the hospital medicine faculty. Two paired resident teams composed of 2 senior residents, 3 to 4 interns, and 4 medical students primarily admit to each general pediatric unit. Team members rotate through day and night shifts. All employees and rotating students are required to wear the hospital issued identification badge that includes their names, photos, credentials, and role. The study was conducted from November 1, 2011 to November 30, 2011.

Included patients were admitted to the study units by the usual protocol at our hospital, in which nurse patient‐flow coordinators determine bed assignments. We excluded families whose children had an inpatient hospital stay of <12 hours and families who did not speak English. All patient families scheduled to be discharged later in the day on weekday mornings from the 2 study units were approached for study participation. Families were not compensated for their participation.

A face sheet tool, which is a sheet of paper with pictures and names of the intervention team attendings, senior residents, interns, and medical students as well as a description of team member roles, was distributed to patients and their caregivers. The face sheet tools were created using Microsoft Publisher (Microsoft Corp., Redmond, WA). Neither families nor providers were blinded to the intervention, and the residents assumed responsibility for introducing the face sheet tool to families.

For our primary outcome measure, the research coordinator asked participating caregivers to match provider photographs with names and roles by placing laminated pictures backed with Velcro tape in the appropriate position on a laminated poster sheet. Initially, we collected overall accuracy of identification by name and role. In the second week, we began collecting specific data on the attending physician.

The satisfaction survey consisted of the American Board of Internal Medicine (ABIM) patient satisfaction questionnaire, composed of 10, 5‐point Likert scale questions,[6, 7] and an overall rating of hospital question, On a scale from 1 to 10, with 1 being the worst possible hospital and 10 being the best possible hospital, what number would you rate this hospital? from the Hospital Consumer Assessment of Health Plans Survey.[8] Questions were asked aloud and families responded to the questions orally. A written list was also provided to families. We collected data on length of stay (LOS) at the time of outcome assessment as well as previous hospitalizations.

RESULTS

A total of 96 families were approached for enrollment (50 in the intervention and 46 in the control). Of these, 86 families agreed to participate. Three families in the intervention group did not receive the face sheet tool and were excluded from analysis, leaving an analytic cohort of 83 (41 in intervention and 42 in control). Attending recognition by role was collected from 54 families (28 in intervention group and 26 in control group) and by name from 34 families (15 in intervention group and 19 in control group). Table 1 displays characteristics of each group. Among the 83 study participants, LOS at time of outcome assessment ranged from 0.4 to 12.0 days, and the number of medical team members that cared for these patients ranged from 3 to 14.

Families in the intervention group had a higher percentage of correctly identified members of the medical team by name and role as compared to the control group (Table 2). These findings remained significant after adjusting for LOS and prior hospitalization. In addition, in a subset of families with attending data available, more families accurately identified attending name and attending role in the intervention as compared to control group.

No significant differences were noted between the groups when comparing all individual ABIM survey question scores or the overall hospital satisfaction rating (Table 2). Scores in both intervention and control groups were high in all categories.

DISCUSSION

Caregivers given the face sheet tool were better able to identify medical team members by name and role than caregivers in the control group. Previous studies have shown similar results.[9, 10] Families encountered a large number of providers (median of 8) during stays that were on average quite brief (median LOS of 23.6 hours). Despite the significant increase in caregivers' ability to identify providers, the effect was modest.

Our findings add to prior work on face sheet tools in pediatrics and internal medicine.[9, 10, 11] Our study occurred after the residency duty hour restrictions. We described the high number of providers that families encounter in this context. It is the first study to our knowledge to quantify the number of providers that families encounter after these changes and to report on how well families can identify these clinicians by name and role. Unlike other studies, satisfaction scores were not improved.[9] Potential reasons for this include: (1) caregiver knowledge of 2 to 4 key members of the team and not the whole team may be the primary driver of satisfaction, (2) caregiver activation or empowerment may be a more responsive measure than overall satisfaction, and (3) our satisfaction measures may have ceiling effects and/or be elevated in both groups by social desirability bias.

Our study highlights the need for further investigation of quality outcomes associated with residency work hour changes.[12, 13, 14] Specifically, exposure to large numbers of providers may hinder families from accurately identifying those entrusted with the care of their loved one. Of note, our research coordinator needed to present as many as 14 provider pictures to 1 family with a hospital stay of <24 hours. Large numbers of providers may create challenges in building rapport, ensuring effective communication and developing trust with families. We chose to evaluate identification of each team member by caregivers; our findings are suggestive of the need for alternative strategies. A more valuable intervention might target identification of key team members (eg, attending, primary intern, primary senior resident). A policy statement regarding transitions of care recommended the establishment of mechanisms to ensure patients and their families know who is responsible for their care.[15] Efforts toward achieving this goal are essential.

This study has several limitations. The study was completed at a single institution, and thus generalizability may be limited. Although the intervention and control units have similar characteristics, randomization did not occur at the patient level. The control group had significantly more patients who had greater than 1 admission compared to the intervention group. Patients enrolled in the study were from a weekday convenience sample; therefore, potential differences in results based on weekend admissions were unable to be assessed. The exclusion of nonEnglish‐speaking families could limit generalizability to this population. Social desirability bias may have elevated the scores in both groups. Providers tasked with the responsibility of introducing the face sheet tool to families did so in a nonstandardized way and may have interacted differently with families compared to the control team. Finally, our project's aim was focused on the effect of a face sheet tool on the identification and satisfaction rating of the medical team by caregivers. Truly family‐centered care would include efforts to improve families' knowledge of and satisfaction with all members of the healthcare team.

A photo‐based face sheet tool helped caregivers better identify their child's care providers by name and role in the hospital. Satisfaction scores were similar in both groups.

Acute illness requiring hospitalization can be overwhelming for children and their families who are coping with illness and the synthesis of information from a variety of healthcare providers.[1] Patient and family centeredness is endorsed by the Institute of Medicine and the American Academy of Pediatrics[2, 3] as central to quality healthcare. In academic institutions, the presence of medical students and residents adds to the number of providers families encounter. In July 2011, the Accreditation Council for Graduate Medical Education implemented new duty hour restrictions, limiting first year residents to a maximum of 16 hour shifts.[4] Consequently, caregivers and patients may be in contact with more healthcare providers; this fractured care may confuse patients and caregivers, and increase dissatisfaction with care.[5]

The primary objective of our study was to determine the effect of a face sheet tool on the percentage of medical team members correctly identified by caregivers. The secondary objective was to determine the effect of a face sheet tool on the evaluation and satisfaction rating of the medical team by caregivers. We hypothesized that caregivers who receive the face sheet tool will correctly identify a greater percentage of team members by name and role and have higher overall satisfaction with their hospital stay.

METHODS

We performed a prospective controlled study on 2 general pediatric units at Cincinnati Children's Hospital Medical Center (CCHMC). Patients on the intervention unit received the face sheet tool, whereas the concurrent control unit maintained usual procedures. Both units have 24 beds and care for general pediatric patients primarily covered by 4 resident teams and the hospital medicine faculty. Two paired resident teams composed of 2 senior residents, 3 to 4 interns, and 4 medical students primarily admit to each general pediatric unit. Team members rotate through day and night shifts. All employees and rotating students are required to wear the hospital issued identification badge that includes their names, photos, credentials, and role. The study was conducted from November 1, 2011 to November 30, 2011.

Included patients were admitted to the study units by the usual protocol at our hospital, in which nurse patient‐flow coordinators determine bed assignments. We excluded families whose children had an inpatient hospital stay of <12 hours and families who did not speak English. All patient families scheduled to be discharged later in the day on weekday mornings from the 2 study units were approached for study participation. Families were not compensated for their participation.

A face sheet tool, which is a sheet of paper with pictures and names of the intervention team attendings, senior residents, interns, and medical students as well as a description of team member roles, was distributed to patients and their caregivers. The face sheet tools were created using Microsoft Publisher (Microsoft Corp., Redmond, WA). Neither families nor providers were blinded to the intervention, and the residents assumed responsibility for introducing the face sheet tool to families.

For our primary outcome measure, the research coordinator asked participating caregivers to match provider photographs with names and roles by placing laminated pictures backed with Velcro tape in the appropriate position on a laminated poster sheet. Initially, we collected overall accuracy of identification by name and role. In the second week, we began collecting specific data on the attending physician.

The satisfaction survey consisted of the American Board of Internal Medicine (ABIM) patient satisfaction questionnaire, composed of 10, 5‐point Likert scale questions,[6, 7] and an overall rating of hospital question, On a scale from 1 to 10, with 1 being the worst possible hospital and 10 being the best possible hospital, what number would you rate this hospital? from the Hospital Consumer Assessment of Health Plans Survey.[8] Questions were asked aloud and families responded to the questions orally. A written list was also provided to families. We collected data on length of stay (LOS) at the time of outcome assessment as well as previous hospitalizations.

RESULTS

A total of 96 families were approached for enrollment (50 in the intervention and 46 in the control). Of these, 86 families agreed to participate. Three families in the intervention group did not receive the face sheet tool and were excluded from analysis, leaving an analytic cohort of 83 (41 in intervention and 42 in control). Attending recognition by role was collected from 54 families (28 in intervention group and 26 in control group) and by name from 34 families (15 in intervention group and 19 in control group). Table 1 displays characteristics of each group. Among the 83 study participants, LOS at time of outcome assessment ranged from 0.4 to 12.0 days, and the number of medical team members that cared for these patients ranged from 3 to 14.

Families in the intervention group had a higher percentage of correctly identified members of the medical team by name and role as compared to the control group (Table 2). These findings remained significant after adjusting for LOS and prior hospitalization. In addition, in a subset of families with attending data available, more families accurately identified attending name and attending role in the intervention as compared to control group.

No significant differences were noted between the groups when comparing all individual ABIM survey question scores or the overall hospital satisfaction rating (Table 2). Scores in both intervention and control groups were high in all categories.

DISCUSSION

Caregivers given the face sheet tool were better able to identify medical team members by name and role than caregivers in the control group. Previous studies have shown similar results.[9, 10] Families encountered a large number of providers (median of 8) during stays that were on average quite brief (median LOS of 23.6 hours). Despite the significant increase in caregivers' ability to identify providers, the effect was modest.

Our findings add to prior work on face sheet tools in pediatrics and internal medicine.[9, 10, 11] Our study occurred after the residency duty hour restrictions. We described the high number of providers that families encounter in this context. It is the first study to our knowledge to quantify the number of providers that families encounter after these changes and to report on how well families can identify these clinicians by name and role. Unlike other studies, satisfaction scores were not improved.[9] Potential reasons for this include: (1) caregiver knowledge of 2 to 4 key members of the team and not the whole team may be the primary driver of satisfaction, (2) caregiver activation or empowerment may be a more responsive measure than overall satisfaction, and (3) our satisfaction measures may have ceiling effects and/or be elevated in both groups by social desirability bias.

Our study highlights the need for further investigation of quality outcomes associated with residency work hour changes.[12, 13, 14] Specifically, exposure to large numbers of providers may hinder families from accurately identifying those entrusted with the care of their loved one. Of note, our research coordinator needed to present as many as 14 provider pictures to 1 family with a hospital stay of <24 hours. Large numbers of providers may create challenges in building rapport, ensuring effective communication and developing trust with families. We chose to evaluate identification of each team member by caregivers; our findings are suggestive of the need for alternative strategies. A more valuable intervention might target identification of key team members (eg, attending, primary intern, primary senior resident). A policy statement regarding transitions of care recommended the establishment of mechanisms to ensure patients and their families know who is responsible for their care.[15] Efforts toward achieving this goal are essential.

This study has several limitations. The study was completed at a single institution, and thus generalizability may be limited. Although the intervention and control units have similar characteristics, randomization did not occur at the patient level. The control group had significantly more patients who had greater than 1 admission compared to the intervention group. Patients enrolled in the study were from a weekday convenience sample; therefore, potential differences in results based on weekend admissions were unable to be assessed. The exclusion of nonEnglish‐speaking families could limit generalizability to this population. Social desirability bias may have elevated the scores in both groups. Providers tasked with the responsibility of introducing the face sheet tool to families did so in a nonstandardized way and may have interacted differently with families compared to the control team. Finally, our project's aim was focused on the effect of a face sheet tool on the identification and satisfaction rating of the medical team by caregivers. Truly family‐centered care would include efforts to improve families' knowledge of and satisfaction with all members of the healthcare team.

A photo‐based face sheet tool helped caregivers better identify their child's care providers by name and role in the hospital. Satisfaction scores were similar in both groups.

Acute illness requiring hospitalization can be overwhelming for children and their families who are coping with illness and the synthesis of information from a variety of healthcare providers.[1] Patient and family centeredness is endorsed by the Institute of Medicine and the American Academy of Pediatrics[2, 3] as central to quality healthcare. In academic institutions, the presence of medical students and residents adds to the number of providers families encounter. In July 2011, the Accreditation Council for Graduate Medical Education implemented new duty hour restrictions, limiting first year residents to a maximum of 16 hour shifts.[4] Consequently, caregivers and patients may be in contact with more healthcare providers; this fractured care may confuse patients and caregivers, and increase dissatisfaction with care.[5]

The primary objective of our study was to determine the effect of a face sheet tool on the percentage of medical team members correctly identified by caregivers. The secondary objective was to determine the effect of a face sheet tool on the evaluation and satisfaction rating of the medical team by caregivers. We hypothesized that caregivers who receive the face sheet tool will correctly identify a greater percentage of team members by name and role and have higher overall satisfaction with their hospital stay.

METHODS

We performed a prospective controlled study on 2 general pediatric units at Cincinnati Children's Hospital Medical Center (CCHMC). Patients on the intervention unit received the face sheet tool, whereas the concurrent control unit maintained usual procedures. Both units have 24 beds and care for general pediatric patients primarily covered by 4 resident teams and the hospital medicine faculty. Two paired resident teams composed of 2 senior residents, 3 to 4 interns, and 4 medical students primarily admit to each general pediatric unit. Team members rotate through day and night shifts. All employees and rotating students are required to wear the hospital issued identification badge that includes their names, photos, credentials, and role. The study was conducted from November 1, 2011 to November 30, 2011.

Included patients were admitted to the study units by the usual protocol at our hospital, in which nurse patient‐flow coordinators determine bed assignments. We excluded families whose children had an inpatient hospital stay of <12 hours and families who did not speak English. All patient families scheduled to be discharged later in the day on weekday mornings from the 2 study units were approached for study participation. Families were not compensated for their participation.

A face sheet tool, which is a sheet of paper with pictures and names of the intervention team attendings, senior residents, interns, and medical students as well as a description of team member roles, was distributed to patients and their caregivers. The face sheet tools were created using Microsoft Publisher (Microsoft Corp., Redmond, WA). Neither families nor providers were blinded to the intervention, and the residents assumed responsibility for introducing the face sheet tool to families.

For our primary outcome measure, the research coordinator asked participating caregivers to match provider photographs with names and roles by placing laminated pictures backed with Velcro tape in the appropriate position on a laminated poster sheet. Initially, we collected overall accuracy of identification by name and role. In the second week, we began collecting specific data on the attending physician.

The satisfaction survey consisted of the American Board of Internal Medicine (ABIM) patient satisfaction questionnaire, composed of 10, 5‐point Likert scale questions,[6, 7] and an overall rating of hospital question, On a scale from 1 to 10, with 1 being the worst possible hospital and 10 being the best possible hospital, what number would you rate this hospital? from the Hospital Consumer Assessment of Health Plans Survey.[8] Questions were asked aloud and families responded to the questions orally. A written list was also provided to families. We collected data on length of stay (LOS) at the time of outcome assessment as well as previous hospitalizations.

RESULTS

A total of 96 families were approached for enrollment (50 in the intervention and 46 in the control). Of these, 86 families agreed to participate. Three families in the intervention group did not receive the face sheet tool and were excluded from analysis, leaving an analytic cohort of 83 (41 in intervention and 42 in control). Attending recognition by role was collected from 54 families (28 in intervention group and 26 in control group) and by name from 34 families (15 in intervention group and 19 in control group). Table 1 displays characteristics of each group. Among the 83 study participants, LOS at time of outcome assessment ranged from 0.4 to 12.0 days, and the number of medical team members that cared for these patients ranged from 3 to 14.

Families in the intervention group had a higher percentage of correctly identified members of the medical team by name and role as compared to the control group (Table 2). These findings remained significant after adjusting for LOS and prior hospitalization. In addition, in a subset of families with attending data available, more families accurately identified attending name and attending role in the intervention as compared to control group.

No significant differences were noted between the groups when comparing all individual ABIM survey question scores or the overall hospital satisfaction rating (Table 2). Scores in both intervention and control groups were high in all categories.

DISCUSSION

Caregivers given the face sheet tool were better able to identify medical team members by name and role than caregivers in the control group. Previous studies have shown similar results.[9, 10] Families encountered a large number of providers (median of 8) during stays that were on average quite brief (median LOS of 23.6 hours). Despite the significant increase in caregivers' ability to identify providers, the effect was modest.

Our findings add to prior work on face sheet tools in pediatrics and internal medicine.[9, 10, 11] Our study occurred after the residency duty hour restrictions. We described the high number of providers that families encounter in this context. It is the first study to our knowledge to quantify the number of providers that families encounter after these changes and to report on how well families can identify these clinicians by name and role. Unlike other studies, satisfaction scores were not improved.[9] Potential reasons for this include: (1) caregiver knowledge of 2 to 4 key members of the team and not the whole team may be the primary driver of satisfaction, (2) caregiver activation or empowerment may be a more responsive measure than overall satisfaction, and (3) our satisfaction measures may have ceiling effects and/or be elevated in both groups by social desirability bias.

Our study highlights the need for further investigation of quality outcomes associated with residency work hour changes.[12, 13, 14] Specifically, exposure to large numbers of providers may hinder families from accurately identifying those entrusted with the care of their loved one. Of note, our research coordinator needed to present as many as 14 provider pictures to 1 family with a hospital stay of <24 hours. Large numbers of providers may create challenges in building rapport, ensuring effective communication and developing trust with families. We chose to evaluate identification of each team member by caregivers; our findings are suggestive of the need for alternative strategies. A more valuable intervention might target identification of key team members (eg, attending, primary intern, primary senior resident). A policy statement regarding transitions of care recommended the establishment of mechanisms to ensure patients and their families know who is responsible for their care.[15] Efforts toward achieving this goal are essential.

This study has several limitations. The study was completed at a single institution, and thus generalizability may be limited. Although the intervention and control units have similar characteristics, randomization did not occur at the patient level. The control group had significantly more patients who had greater than 1 admission compared to the intervention group. Patients enrolled in the study were from a weekday convenience sample; therefore, potential differences in results based on weekend admissions were unable to be assessed. The exclusion of nonEnglish‐speaking families could limit generalizability to this population. Social desirability bias may have elevated the scores in both groups. Providers tasked with the responsibility of introducing the face sheet tool to families did so in a nonstandardized way and may have interacted differently with families compared to the control team. Finally, our project's aim was focused on the effect of a face sheet tool on the identification and satisfaction rating of the medical team by caregivers. Truly family‐centered care would include efforts to improve families' knowledge of and satisfaction with all members of the healthcare team.

A photo‐based face sheet tool helped caregivers better identify their child's care providers by name and role in the hospital. Satisfaction scores were similar in both groups.