The Portfolio Effect

    • November 29, 2012

When health care providers end their shifts at hospitals, they walk through “handoffs” with the providers taking over their patients. The goal is to transmit the essential or pressing information the oncoming providers need to take care of patients from the moment they walk on the floor.

But in an environment in which time is a scarce resource, crucial communication during these handoffs often is not as effective as it should be to ensure patient safety and high quality care, says Michael D. Cohen, PhD, recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

A study led by Cohen, published online in the Archives of Internal Medicine, finds that physicians spend an average of 50 percent more time on the first-discussed patients in their handoffs than on those patients who are discussed last. And because patients are usually considered in random order—alphabetically or by bed numbers—the sickest patients or those with the most complex cases often do not get the attention they need.

Prioritizing Patients During Handoffs

Hospitals are required by the Joint Commission to standardize the way they do handoffs, but there is little research into best practices or even an accepted definition of what a handoff is, says Cohen, the William D. Hamilton Professor of Complex Systems, Information and Public Policy at the University of Michigan School of Information. Cohen has been studying handoffs since he received his Investigator Award in 2006.

“Handoffs are a key problematic process in patient safety,” he says, and they can cause communication breakdowns that contribute to preventable errors. In addition, much of the existing research looks at handoffs focusing on a single patient. During shift changes, multiple patients are transferred in a single handoff session and the potential for error is even greater.

Cohen and his research team used videotaped shift change handoffs between experienced attending physicians in a 21-bed ICU to track how much time they spent discussing each patient, relative to the order in which the patients were discussed. In this particular ICU, at Kingston General Hospital in Ontario, patients were discussed in order of their bed numbers.

Physicians turned over between six and 23 patients in each of the nearly two dozen sessions they observed, and spent an average of 2.5 minutes discussing each patient. But as they went through the cases, the physicians spent substantially more time discussing the first patients than the last, despite the randomization of the severity or complexity of the patient’s illness.

Cohen and his team dubbed this the “portfolio effect,” or how time is allocated as a result of handing off patients in sets instead of individually.

An Easy Fix

The solution is a pretty easy procedural change that doesn’t take any extra time, Cohen says. “Health care providers need to identify the cases that need the most discussion at the start of the handoff. They might be the sickest, they might have the most complex family decision-making, they might be new to the unit, or they might have a lot of complicated side conditions. There are many reasons why a patient needs more discussion time. If you identify those patients when you start the session, you’re more aware that you need to talk about them first, reserve time for them or just manage your time better.”

“When we tell people about our findings, they often react that it’s the sort of thing that should have been obvious,” Cohen adds, “but nobody had gone out and measured it before, and it tends to be masked by the natural variability of individual patient discussions.”

In addition to further research on handoffs, Cohen hopes to continue his work on the portfolio problem by creating web-based resources that allow hospitals to replicate his study with their own staffs and identify their own solutions.

Read the study.
Read a post by Cohen on the RWJF Human Capital Blog.
Learn more about the RWJF Investigator Awards in Health Policy Research.
For an overview of RWJF scholar and fellow opportunities, visit