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LOT-986 exam Dumps Source : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques

Test Code : LOT-986
Test title : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques
Vendor title : IBM
: 164 real Questions

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IBM Creating IBM Lotus Notes

IBM's massive wager on synthetic Intelligence practising | killexams.com real Questions and Pass4sure dumps

The subsequent time you convoke an 800 number with a gripe about a product or service, regard this: notwithstanding it’s a honest are live adult who answers, she or he could not breathe the one determining how to deal with you. in its place, a posh collection of algorithms might furthermore step in, to gauge your temper and react therefore. One version of IBM’s interactive expertise Watson coadjutant instantly analyzes your tone of voice. Then, based on precisely how peeved you sound, the device suggests what the carrier rep should present as a repair for whatever your issue is—money back, as an example, or free transport in your next order—with the purpose of keeping on to your business.

wondering why a human CSR can’t simply tackle this dialog? “people interpret tones of voice in another way, so that they reply in a different passage to shoppers,” explains IBM advisor Aman Kochhar. against this, he provides, “A.I. isn't subjective. So it’s a noteworthy deal greater constant.”

Kochhar has been getting to know to supervene synthetic intelligence to enterprise problems on the grounds that final December, when he begun taking A.I. lessons as partake of the first partake of a huge modern training push inside IBM. referred to as AI talents Academy (AISA), the software is designed to enact two things. First, it teaches employees about integrating A.I. into their personal jobs within the company, from creating marketing apps to improving deliver chain efficiency. on the very time, AISA educates IBMers in consulting, income, operations, and in other places a passage to collaborate with shoppers to exhaust A.I. of their organizations, too. Divided into two tracks—one for techies (application developers, engineers, research scientists) and one for everybody else—the curriculum has four ranges, from basic to skilled.

greater than 2,200 IBM staffers fill started the practising due to the fact it launched remaining year, and IBM expects at the least 4,000 graduates of entire four degrees in 2019. however, says IBM vice president for competence Obed Louissant, that’s only for openers: “All of their employees will ultimately breathe knowledgeable in A.I.” additionally, AISA always adds modern content. within the works at this time: modern classes on making exhaust of A.I. in mission management and commonplace management roles.

in one experience, it’s simplest analytic that IBM is investing tall chunks of its $500 million annual training charge scope in AISA. after all, “we build these A.I. technologies,” notes Louissant. “So they now fill a accountability to drill individuals the passage to exhaust them, both internal and out of doors the company.”

ok, however AISA additionally obviously does whatever else — to wit, it makes IBM’s 350,000 employees global much more desirable to different employers. As more corporations depend extra heavily on statistics analytics, and extra jobs demand a working expertise of A.I., Gartner predicts 2.three million modern roles global that allows you to require these competencies by passage of the conclusion of next yr.

For IBM, AISA is a calculated chance. On the one hand, the enterprise has no precise option however to educate its staff in A.I. however even so, assisting personnel boost precisely the expertise most well-liked in the outside world at the jiffy looks dicey. “We did believe a noteworthy deal about this as they developed the software,” Louissant says, adding wryly, “We fill been involved from the outset about even if we’d breathe creating a public carrier.”

it might probably determine that approach, but for now, Louissant thinks most graduates of IBM’s program will want to stick round. He elements to the proven fact that, among the many roughly 800 americans who fill already completed AISA working towards—and who are for this intuition much more marketable than they were a 12 months in the past—attrition, thus far, is reduce than for IBM’s staff universal.

It’s early days yet, of route, but that tiny attrition cost may breathe a reflection of what employees pointed out, in designated surveys, about what motivates and engages them. much more than money, which of direction opponents can proffer too, IBMers notify they’re “most interested in keeping up with the innovative in technology and consistently gaining knowledge of modern competencies,” says Louissant. “So providing them modern practising is a retention method.” in this term of persistent (and, it seems, multiplying) skills gaps, that’s a notion value wondering.

Anne Fisher is a career skilled and tips columnist who writes “Work It Out,” Fortune’s lead to working and live within the 21st century. each week, she’ll reply your most challenging profession questions. fill one? request her on Twitter or electronic mail her at workitout@fortune.com.


inner most fairness Acquires IBM advertising and marketing utility commerce | killexams.com real Questions and Pass4sure dumps

IBM sells its marketing and commerce utility systems to Centerbridge companions, a private equity company. IBM CEO Ginni Rometty continues to dump ageing assets.

IBM has sold its advertising and commerce application platforms to Centerbridge partners, a personal equity firm. The deal continues IBM CEO Ginni Rometty’s approach to sell off growing conventional commerce lines while making an attempt to pivot extra impulsively towards cloud, safety, cognitive computing and different enlarge markets. fiscal terms of the deal had been no longer disclosed.

The sale contains the following IBM advertising and marketing and commerce utility offerings:

  • crusade Automation
  • advertising and marketing Assistant
  • Media Optimizer
  • client event Analytics
  • content Hub
  • precise-Time Personalization
  • customized Search
  • customary conduct change
  • intelligent Bidder
  • rate & merchandising Optimization
  • payments Gateway
  • The deal, subject to regulatory approval, is expected to proximate in mid-2019. At that aspect, the assets might breathe equipped into a newly branded standalone enterprise led with the aid of current IBM VP stamp Simpson and different IBM veterans. 

    IBM has been selling off a lot of slow-growth or contracting assets in simultaneous quarters. Examples encompass:

    IBM is anticipated to promulgate its latest quarterly consequences on April sixteen, 2019. despite the fact the company has made some growth with cloud, AI and quantum computing, critics continue to request yourself if the commerce can in fact recur to a enlarge corporation. In its this plunge of 2018, salary fell three p.c to $21.eight billion.

    Return domestic

    as soon as king of enterprise application, Lotus Notes is dragging IBM down | killexams.com real Questions and Pass4sure dumps

    Lotus Notes is coming! Or, perhaps it's declining

    When IBM purchased Lotus for $3.5 billion in 1995, it appeared as even though the venerable computing significant was basically to lock up the software industry and coast to unstoppable earnings.

    Eighteen years later, Lotus looks extra fancy a millstone round IBM’s neck than a flywheel giving it added velocity.

    in keeping with a document within the Wall highway Journal, in strengthen of IBM’s this autumn profits liberate nowadays, Lotus changed into the weakest performer in IBM’s utility portfolio, shedding 6.4 % of its income quantity in the first 9 months of 2012.

    It likely accounts for about $1 billion in annual income, in response to estimates sourced via the WSJ, or one-sixth to one-fifth of IBM’s general software enterprise.

    ironically, Lotus once led the manner towards nowadays’s hottest enterprise technologies, the collaborative application that helps teams discourse and labor together on initiatives. probably the most success reports of that belt of interest is Yammer, which Microsoft received ultimate yr for $1.2 billion. So, why is IBM sitting at the back of the pack as a substitute of main from the entrance?

    Lotus, which made the first blockbuster “killer app” within the Nineteen Eighties (Lotus 1-2-three, a phenomenally a hit spreadsheet software), went on to create Lotus Notes, a powerful groupware suite that got here out within the early Nineteen Nineties earlier than anybody had any concept what “groupware” changed into.

    I used it noticeably at a number of agencies I worked with. originally, it was arcane and strong. fancy most conclusion-clients of Lotus Notes, I used it primarily as an e mail software. It had its quirks, nevertheless it worked. however there become one other dimension to Notes, an impressive, programmable backend that assist you to create databases and workspaces for collaborative work, contact management, suggestions sharing, and communique.

    nowadays, we’d title it a collaboration device or a company social-media device, and it could breathe internet-based and requisites-compliant, fancy Yammer, Jive, and Huddle. in the absence of necessities, Notes’ engineers had to invent every thing themselves, making it a smooth however proprietary solution.

    however lengthy before those net-based mostly startups got here alongside, Notes was already dropping its cool. The client software grew to breathe big and bloated. It was expensive to do into result and complicated to customise.

    because the internet received popularity in the late Nineteen Nineties, Lotus introduced necessities, fancy POP3 and IMAP email interfaces. They didn’t enact so neatly with the requirements department, besides the fact that children, using any one who needed to exhaust a web mail client with a Lotus Notes mail server fully insane.

    The upshot is that, just as the internet became known, Lotus Notes grew to become worrying and obsolete.

    bound, it became quiet potent, but unlocking the vigour of Notes frequently required expert talents, giving climb to a sector of Notes consultants. No shock that these consultants are having a tough time getting taken critically nowadays. The WSJ quotes a Notes consultant who complains about his reception:

    “i'm going to a party, and i shortly net insulted,” says Eugen Tarnow, a director of the consultancy Avalon company methods, which sells the aging electronic mail application to businesses. “they are saying, ‘Lotus Notes, that’s nonetheless round?’ It’s no fun.”

    sadly, IBM’s engineers realized the value of necessities compliance too late and didn’t bake interoperability into Lotus Notes smartly adequate or early sufficient. So, as powerful as Notes could be, it was and is ill-organized to labor in nowadays’s API-prosperous cloud atmosphere.

    IBM has extra simultaneous social-media application, too, but most effectual makes about $fifty five million per yr from that phase of its business. So the challenge for IBM is to proceed milking as an needy lot salary as it can from Lotus, while progressively affecting the branding and the earnings to more recent, sexier traces of enterprise. One example: Renaming its annual Lotus convention, Lotusphere, as “Connect2013.” Yeah, that’ll assist.

    We’ll breathe looking at to study if the revenue document sheds to any extent further gentle on IBM’s efforts to exhibit Notes round. however as for me, I’m now not preserving my breath.

    photo credit score: Andrew Mason via photopin cc


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    Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature | killexams.com real questions and Pass4sure dumps

    Effective communication is central to patient safety and quality. Inadequate communication consistently appears as a factor contributing to medical errors, across settings and practitioners. These span from an incident with a unique patient1 to broader communication issues between physicians and nurses.2 In reviews of malpractice claims, communication problems were contributing factors in 26% to 31% of cases.3–5 The Joint Commission has reviewed data from 6,244 sentinel events occurring between 1995 and June 30, 2009.6 Communication problems fill long been preeminent as a major contributing factor to these sentinel events. Sutcliffe et al7 conducted semistructured interviews with residents, who recalled 70 recent medical mishaps, and indicated that 91% contained communication failures.

    Handoffs, the transfer of patient dependence from one health dependence provider to another, are known to breathe vulnerable to communication failures8 and fill been called “remarkably haphazard.”9 As defined by the Joint Commission, handoff communication refers to a standardized process “in which information about patient/client/resident dependence is communicated in a consistent manner.”10

    Retrospective reviews of malpractice claims in the ambulatory setting11 and emergency department12 showed that handoffs were a contributing factor in 20% and 24% of medical errors, respectively. When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs.13 A review of 146 surgical errors establish that 41 (28%) involved handoffs.14 Of residents and fellows who reported caring for a patient with an adverse event, 15% indicated the intuition for the mistake was a problem with handoffs.15

    Numerous surveys document health dependence staff concern. In an Agency for Healthcare Research and quality 2008 survey, just over half (51%) of the 160,176 hospital staff respondents reported that “important patient dependence information is often lost during shift changes.”16 When 93 fourth-year medical students and 228 residents responded to a survey about patient safety, (70%) agreed that improved handoffs would reduce medical mishaps.17

    Reduced resident duty hours were first introduced in modern York status in 1989 and were mandated for entire U.S. residency programs in 2003. Although reductions in duty hours may lead to less fatigue and improved well-being in residents, many fill expressed concern about the resultant requisite for increased handoffs and reduced continuity of patient care.18 As a result of reduced hours, patients can breathe seen by three different physicians in the first 24 hours of their care.19 Seventy-six percent of 29 surgical residents in a modern York study agreed that continuity of dependence had been negatively affected as a result of duty hours changes.20

    Discontinuity in patient care, which can occur with cross-coverage and night float systems, has been establish to lead to increased in-hospital complications,21 preventable adverse events,22 increased cost due to unnecessary tests being ordered by residents not familiar with the patient,19 and diagnostic test delays.21 In a study at one teaching hospital during a four-month period, the risk of a preventable adverse event was strongly associated (more than twice as likely) with coverage by a physician from another team.22

    Night float systems, often implemented to ensure that residents enact not exceed duty hours limits, fill been preeminent to result in inadequate information transfer to the covering residents.23 Nurses fill expressed concern over these changes. Fifty-one percent of the 67 nurses who responded to a survey about a modern resident night float system agreed that “residents don’t know the patients as well as in the conventional system.”24

    Other issues surrounding attending physicians’ and residents’ handoffs fill been documented. Gandhi25 notes that inadequate handoffs can lead to diffused responsibility, which can breathe a major contributor to medical errors. In addition, Coiera26 establish that health dependence communications are supine to interruptions, with a third of communication events (30.6%) interrupted.27 Many of these interruptions result in inefficiencies,28 and interruptions during handoffs are likely to lead to failures of working memory,29 which result in decreased recall accuracy.

    In 2006, the medium length of wait for entire hospitalized patients was 4.8 days.30 Assuming that patient dependence transfers between covering residents and/or attending physicians occur 1 to 2 times per day, the medium patient will breathe handed off 5 to 10 times per admission. Each of these handoffs represents a risk for inadequate communication, which could result in reduced patient safety and increased medical errors.

    In response to concerns about inadequate health dependence handoffs, a number of national patient safety organizations fill highlighted the consequence of communication, including the Institute for Healthcare Communication31 and the National quality Forum. In 2006, the Joint Commission created a modern National Patient Safety Goal on handoffs.32 In 2009, the goal remains virtually unchanged, requiring the organization to implement “a standardized approach to hand-off communications, including an occasion to request and respond to questions.”33

    As the preceding paragraphs suggest, there is abundant evidence of the negative consequences of needy communication and inadequate handoffs in health care. The purpose of the current study was to identify entire English-language articles on resident and/or attending physicians’ handoffs in the United States, conduct a systematic review of research studies, achieve a qualitative review of barriers and strategies mentioned across entire articles, and identify features of structured handoffs that fill been shown to breathe effective. This review was conducted in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient dependence Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and quality through projects coordinated at a national level.

    Method National initiative labor group

    A labor group of the National Initiative developed resources and wrote systematic reviews of the literature in champion of the National Initiative's goals. They performed this study as one of a progression of literature reviews initiated by that group. The methodology that they employed included regular, substantive discussions about manuscript concept and design, such as key questions, inclusion and exclusion criteria, and search strategies. There were faultfinding interchanges among us about entire primary aspects of each systematic review written by this group, including those for this report, and they reached consensus on how to treat each systematic review. The specific subject, commandeer technique, and final presentation of this systematic review are the product of a progressive, iterative, and qualitative process of refinement.

    Literature search

    We conducted a thorough and systematic literature search of English-language articles published on handoffs from 1987 to June 4, 2008 using Ovid Medline, Medline In-Process & Other Non-Indexed Citations, CINAHL, HealthSTAR, and Christiana dependence plenary Text Journals@Ovid, followed by reference section review. The search terms used were hand-off$, handoff$, signout$, token out$, sign-out$, handover$, hand-over$, signover$, and sign-over$. A total of 2,590 articles were identified. entire titles were reviewed for viable inclusion, and 401 articles were obtained for further review (Figure 1). Reference sections of entire 401 articles were reviewed for additional articles.

    Inclusion criteria

    Articles meeting the following criteria were eligible for review of barriers and strategies: English language, indexed in PubMed, published between 1987 and June 4, 2008, focused on health dependence handoffs in the United States, and including information about either resident or attending physicians’ handoffs. Articles included in the systematic review had one of the following study designs: randomized controlled trial; nonrandomized trial, with control or comparison group; single-group pre- and posttest, cohort study; single-group cross-sectional research; single-group posttest only, or qualitative research.

    Trained reviewers (J.L. and L.R.) deemed that 46 articles met inclusion criteria for the initial review of barriers and strategies. Using an iterative process, an abstraction profile was developed to authenticate eligibility for plenary review, assess article characteristics, and extract data apposite to the study questions. This iterative process started with an initial form, which was used by two reviewers (J.L. and L.R.) to independently abstract data from four articles. The reviewers then met to dispute the abstraction profile for inclusion of entire apposite data. A second, more minute profile was then created for abstraction. Reviewers (J.L. and J.M.) independently absorbed entire data. Most abstraction disagreements were minor, and entire disagreements were quickly resolved during discussion, when a consensus was reached on the absorbed data.

    Quality scoring system

    Downs and Black34 created a convincing and reliable checklist designed to assess both experimental and observational studies. Two systematic reviews35,36 of published systems (scales and checklists) designed to assess study quality fill ranked the scale developed by Downs and Black as one of the best. Both of these systematic reviews went on to suggest that some modifications might breathe useful, depending on the specific topic and study designs. Therefore, five of us (L.R., J.L., J.M., J.J., J.S.P.) developed a quality scoring profile based on this approach, using four of the original items and eight modified items, which yielded scores ranging from 1 to 16, with 16 being the highest viable score (see Chart 1). This quality scoring profile contained two items related to study sort and sample size, five items related to reporting, and five items related to internal validity.

    If a study included multiple assessment formats, such as interviews and a questionnaire, that resulted in different sample sizes, the largest sample was used as the sample size in the quality scoring form. There was no passage to determine the number of independent study participants for each assessment method. Thus, to avoid counting the very study participant multiple times, they credited the study with the largest reported sample only.

    Quality scores were independently obtained from reviewer pairs (L.R. and J.L. or J.J.) for each study. The interrater reliability was assessed for entire identified research studies (n = 18). Overall agreement was 97.7%, and Cohen's kappa for agreement between the two reviewers was r = 0.96, P < .001. entire differences were resolved through discussion to defer a final quality score for each study.

    Qualitative analysis of barriers and strategies

    Conventional content analysis is a sort of qualitative research used when there is limited or no existing theory on the phenomenon of interest.37 This analysis involves an iterative process that allows themes to arise from data. Researchers immerse themselves in the content and allow categories to emerge.37

    All barriers and strategies mentioned in the reviewed articles were identified and listed in phrase format in two continuous lists, one for strategies and another for barriers. Reviewers (J.L. and L.R.) met to compare lists and, through discussion, agreed on final comprehensive lists. Through an inductive iterative process, category labels were created and entire phrases were moved to a category or subcategory. The final lists were reviewed by J.M. for coherence and consistency.

    Results

    Forty-six articles describing resident and/or attending physicians’ handoffs were identified. Thirty-three (71.7%) were published between 2005 and 2008 (Figure 2). Content analysis yielded 91 barriers in eight major categories and 140 strategies in seven major categories (Table 1).

    Figure 2

    Figure 2

    Table 1

    Table 1

    Twenty-two articles presented anecdotal data,38–58 one of which had a physician handoffs case sample and nursing handoffs research59; three provided circumscribed reviews,60–62 and three were editorials.63–65 The remaining 18 articles reported research on handoffs and were analyzed in depth (see the Appendix).66–83 Only one80 research study did not involve residents or fill a graduate medical education focus. quality assessment scores for the research studies ranged from 1 to 13 (possible scope 1–16). Six studies obtained scores of 8 or less, eight had scores between 8.5 and 11.5, and four achieved quality scores of 12 to 13.

    Only 6 of 18 (33.3%) research studies identified effectual handoff features.66,67,69,71,77,78 In studies comparing computerized handoff systems with other methods, such as personal handwritten notes, the computerized or electronic system performed better. Residents were more likely to fill entire patients on their list,67 to report that they received entire primary information,78 to fill increased satisfaction with the handoff system,67 to disburse less time in prerounding and rounding activities,67 and to self-report decreased adverse events related to handoffs.77 Others fill preeminent that resident-maintained lists in a database, such as a Microsoft Word file or excel database, accommodate content and medication errors.69,71 However, interns using standardized, self-maintained sign-out cards reported fewer needy sign-outs and were more likely to record code status, patient age, and allergies.66

    Discussion

    As stated earlier, they identified 46 articles describing residents’ and attending physicians’ handoffs in the United States. Eighteen were research studies (39.1%), only two of which were randomized controlled trials. The majority (71.7%) of articles were published in recent years, which is not surprising, given the Joint Commission's National Patient Safety Goal on handoffs issued in 2006. However, as demonstrated by their quality assessment scores (see the Appendix), there is a remarkable want of high-quality outcomes studies. It is notable that one third of the reviewed research studies obtained quality scores at or below 8 (out of a viable 16), and only one study achieved a score of 13.

    One purpose of the current study was to identify features of physicians’ handoffs that fill been shown to breathe effective. Unfortunately, only 6 of the 18 (33.3%) research studies included measures of effectiveness. Of the three studies using computerized handoff systems, one was a stand-alone system,78 and the other two had some linkage with the hospital computer system.67,77 While these entire provided a structured template, they furthermore relied to varying degrees on residents to enter information, which introduces an occasion for errors to occur.69,71 Most of the studies assessing effectiveness used self-reported data, with a few exceptions. Van Eaton and colleagues67 looked at the number of patients missed on resident rounds and showed a lessen from 5 to 2.5 patients/team/month (P = .0001) when using a computerized handoff system. Two other studies assessed errors on resident-maintained handoff forms when compared with the medical record69,71 (a surrogate for actual medical errors) and, not surprisingly, establish errors on the resident lists.

    Of note, two survey studies documented a want of formal handoffs instruction during residency, with 60% to 74.4% (internal medicine72 and emergency medicine,73 respectively) reporting that they fill no lectures or workshops on the topic. Although 72.3% of the 185 emergency medicine residency/fellowship program directors studied agreed that standardized handoffs would reduce medical errors,73 the majority did not fill a uniform policy or procedure regarding handoffs. Only one of the studies reviewed here included the development, implementation, and assessment of a formal, structured handoffs curriculum.75 Horwitz and colleagues75 provide a comprehensive curricular template for others to use; however, they relied on postsession evaluations of perceived solace and consequence of handoffs. They commend their scheme to conduct observation of handoff skills and study forward to their future publications.

    Almost entire of the research articles (17 of 18; 94%) were conducted within a residency program. Graduate medical education has taken the lead in conducting handoffs research, which is one demonstration of the value added to health dependence by medical education.

    Handoff barriers

    We identified 91 barriers to effectual handoffs that could breathe organized into eight major categories. Of barrier categories, communication issues were reported most frequently (30.8%), with general communication barriers ranging from not listening to inadequate communication. Because effectual communication is an essential component of handoffs, this was an expected finding. However, hierarchy and sociable barriers constituted a less intuitive group. Here, they establish things such as relational communication barriers and residents not being likely to hand off labor to more senior residents, because of a rigid reliance on hierarchical norms that prohibit such behavior. Thus, adequately addressing handoff issues will require more than protocols, structure, and training. Understanding the complex sociable structures and hierarchies in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, will breathe required.

    Handoff strategies

    We identified 140 strategies that could breathe organized into seven major categories. Strategies for standardization were preeminent most frequently (44.3%), with technological solutions (16.4%), such as computerized handoff systems, next. Interestingly, whereas communication issues constituted approximately one third of barriers, improving communication skills was preeminent much less frequently (11.4%) as a strategy. Standardization would address some communication issues, but not all, such as language differences. Providing training or education (10%), evaluating the process (7.1%), and addressing environmental issues (5.7%), such as lighting and limiting interruptions and noise, construct intuitive sense. However, a less obvious strategy was insuring the recognition that a transfer of responsibility/accountability (5.0%) had occurred.

    Limitations and strengths

    Handoffs in a variety of environments were studied, which makes it difficult to exhaust their findings to formulate barriers and strategies for exhaust in every handoff situation. For example, some techniques may breathe better applied to inpatient medicine as opposed to the emergency department. In addition, they absorbed barriers and strategies from entire sections of the articles studied, including the introduction. This may fill resulted in overemphasis of some barriers or strategies, depending on the author's views and on repetition. However, they only counted the very barrier or strategy multiple times if the wording was significantly different in subsequent exhaust and if the two instances could stand alone as different aspects of the very category.

    Another potential limitation is that the barriers and strategies they identified (Table 1) delineate the opinions of the authors of the reviewed studies. Further, they identified the barriers and strategies through a qualitative process. Although they seem intuitively relevant, they were not derived from research studies designed to identify handoff barriers and strategies.

    The current study is limited by the Ovid search strategy used. Specifically, the selected search terms may not fill included entire apposite terms. They strengthened the possibility of identifying entire articles that met inclusion criteria by reviewing the reference sections of entire obtained articles. Although this strategy minimizes the risk of missing germane studies, it does not liquidate the possibility.

    Publication warp refers to the possibility that high-quality studies with negative results may not fill been published. Others fill preeminent that many quality improvement (QI) projects are not published.84 In addition, it has been their observation that some QI projects are published in newsletters, with the authors never submitting them to peer-reviewed journals. Thus, there may breathe outcomes studies of handoffs that are not in the peer-reviewed literature. However, the definite search strategy, limpid inclusion criteria, and systematic process used to identify and evaluate articles strengthen the quality of this review.

    Although their quality scoring system was based on a validated methodology developed to assess experimental and observational studies together, their system has not been validated across multiple settings and investigators. The relative weightings may require refinement, and there may prove to breathe additional apposite categories. The system did fill a high internal reliability, and reviewers of various educational backgrounds and undergo establish it straightforward and effortless to use. Further, the quality scoring system provides a reproducible template for the assessment of handoffs articles.

    Recommendations

    Numerous authors fill preeminent the dearth of research focused on handoffs.45,57,70,83,85,86 In addition, there are risks involved in implementing interventions without evidence supporting their effectiveness.87 Winters and colleagues87(p1,647) preeminent that “[n]ational efforts to ameliorate patient safety should breathe supported by sufficiently tenacious evidence to warrant such a commitment of resources.”

    Evidence-based practice is informed by high-quality research. Recent publication guidelines for patient safety and quality initiatives fill established a framework for standardized reporting.88,89 They recommend that future handoffs studies exhaust the Standards for quality Improvement Reporting Excellence (SQUIRE) guidelines.89 Many of the studies reviewed here would fill been improved by doing so.

    Others fill preeminent that it may breathe unreasonable to anticipate patient safety and quality studies to supervene the design rigors of randomized controlled trials.87 However, the RAND/UCLA Appropriateness mode provides a structured, rigorous mode to synthesize data from other clinical study types with expert belief to provide the best available guidelines.90 Unfortunately, the literature on handoffs identified here is not of sufficient quality and quantity to synthesize into evidence-based recommendations.

    Although the Joint Commission is calling for structured handoffs, they identified very puny evidence to champion the exhaust of any specific structure, protocol, or method. However, direct observation of handoffs in other settings (i.e., NASA mission control, nuclear power, railroad, and ambulance dispatch) with high consequences for error, yielded 21 common strategies,91 which could proffer a starting point in the evolution of health dependence handoffs research. Their review of the U.S. physicians’ handoffs literature has led us to develop a list of research questions, organized by the content domains of knowledge, attitudes, skills, process outcomes, and clinical outcomes (see List 1).

    Across the United States, hospitals are implementing structured handoff protocols in an effort to comply with Joint Commission requirements. High-quality outcomes studies that focus on systems factors, human performance, and the effectiveness of protocols and interventions are urgently needed. These studies should address the barriers and strategies identified here. In addition, handoffs in different disciplines are likely to fill different requirements and issues. For instance, an emergency department handoff will requisite to fill different content than one for inpatient medicine or pediatrics. Therefore, researchers should conduct discipline-specific handoff studies.

    We convoke for rigorous outcomes studies designed to (1) assess the effectiveness of handoffs, (2) determine the elements of handoffs that lead to improved patient outcomes, and (3) identify the best implementation strategies. Finally, these studies should breathe reported using the SQUIRE guidelines. Without these studies, hospitals across the United States are destined to waste time, resources, and effort on flawed handoff practices.

    Acknowledgments

    Special thanks to Ellen M. Justice, MLIS, AHIP, medical librarian of the Lewis B. Flinn Medical Library, Christiana dependence Health System, for conducting literature searches; Dolores Ann Moran, medical library coadjutant II, and Janice Evans, medical library coadjutant II, for their assistance in locating articles; and Donald Riesenberg, MD, for feedback on the manuscript.

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    Academic Medicine84(12):1775-1787, December 2009.

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