Contact email

alisa.khan@childrens.harvard.edu

Overview

This program at a pediatric academic medical center utilized a standardized healthcare provider-family handoff communication protocol called I-PASS to optimize patient safety, family satisfaction, and provider-family communication. 

Collaborators

Nancy D Spector
Jennifer D Baird
Michele Ashland
Amy J Starmer
Glenn Rosenbluth
Briana M Garcia
Katherine P Litterer
Jayne E Rogers
Anuj K Dalal
Stuart Lipsitz
Catherine S Yoon
Katherine R Zigmont
Amy Guiot
Jennifer K O’Toole
Aarti Patel
Zia Bismilla
Maitreya Coffey
Kate Langrish
Rebecca L Blankenburg
Lauren A Destino
Jennifer L Everhart
Brian P Good
Irene Kocolas
Rajendu Srivastava
Sharon Calaman
Sharon Cray
Nicholas Kuzma
Kheyandra Lewis
E Douglas Thompson
Jennifer H Hepps
Joseph O Lopreiato
Clifton E Yu
Helen Haskell
Elizabeth Kruvand
Dale A Micalizzi
Wilma Alvarado-Little
Bernard P Dreyer
H Shonna Yin
Anupama Subramony
Shilpa J Patel
Theodore C Sectish
Daniel C West
Christopher P Landrigan
Patient and Family Centered I-Pass Study Group

Status/Stage of Development

Completed

Funding Sources

Funding for the program came from the Patient-Centered Outcomes Research Institute, United States Agency for Healthcare Research and Quality, and from other sources within the Agency for Healthcare Research and Quality.

Practice Setting

Academic Hospital

National/Policy Context

• A main contributor to patient harm or death worldwide is medical error, with communications failures being among the most common causes. 
  • Interventions reducing miscommunications while patient care responsibilities are being handed off between providers at the end of their shifts have led to substantial improvements in patient safety.
• In North American hospitals, the same phenomenon was observed to be occurring where medical errors, particularly from communication failures, were leading to patient harm or death. 

Patient Population Served and Payor Information

• The patient population in this program consisted of pediatric patients less than 18 years and their caregivers who were hospitalized in the inpatient setting.
• In this patient population, 68.3% had government insurance, 31.7% had non-government/private insurance.
• In this patient population, 5.4% were Asian, 19.6% were Black, 52.1% were White, and 22.9% were of another race.

Leadership

• 100 collaborating parents, nurses, and physicians (as well as health services researchers, medical educators, hospitalist physicians, health literacy experts, and communication experts) developed and oversaw the program.

Project Research + Planning

• Parents, nurses, physicians, health services researchers, communication experts, health literacy experts, medical educators, and hospitalists formed a team to implement an intervention focusing on standardizing rounds through structured and bidirectional communication, health literacy, and family engagement. 
• Based on feedback from family members, physicians, and nurses, inpatient healthcare provider working rounds were re-designed to make the process more family-focused, an important aspect of the intervention.

Tools or Products Developed

• Family Brochure: A brochure provided to program patients and their caregivers providing an orientation to the roles and responsibilities of healthcare team members as well as of family members during working rounds
• Nurse training module: An online training module consisting of a Powerpoint slide deck with voiceover covering information on nurse and family engagement strategies, the nursing role on working rounds, health literacy concepts, and the I-PASS methodology
• Medical Student/Resident Physician/Attending Physician training module: An online training module consisting of slide deck and role-play exercises with information on family engagement strategies, role, health literacy, and the I-PASS methodology
• Implementation Guide: 62 page “how-to” implementation guide for site leaders
• Observation Tools: Information on engaging the family and interprofessional team, centering communication on the patient, and using structured communication techniques
• Campaign materials: Logo and posters to promote the use of the I-PASS  intervention
• Computerized Real-Time Assessment Tool: This tool measures team members’ adherence to evidence-based communication processes while rounding on patients.

Training

• Nurse training was 15 minutes for each individual with a total of 42 sessions that were held to train 680 nurses, medical student training was for 1 hour for each individual over 63 sessions held to train 506 medical students, resident physician training was 2-3 hours for each individual over 34 sessions held to train 515 resident physicians, and attending physician training was 1 hour for each individual over 26 sessions held to train 182 faculty members.
• Implementation of the project required in-person training of healthcare professionals. Trainors provided reinforcement and feedback, and delivered the training during resident physician orientations, routine staff meetings, or one-on-one meetings.
• Training occurred between March 2015 and January 2017
• Some nurses finished their training independently online (via voiceover slide deck).

Tech Involved

• Desktop computer

Team Members Involved

• Clinical Trainee or Student
• NPs
• Physicians

Workflow Steps

• The patient/family comes in for orientation upon admission to the inpatient unit. They are given the family brochure. 
• During healthcare providers’ rounds, the verbal communication used by nurses and providers occurs in the order dictated by the I-PASS mnemonic. The family speaks first and engages in bidirectional communication. The nurses speak early during rounds. The healthcare providers use universal health literacy precautions.
• Then, medical providers and nurses report their experience with the program while rounding (done on paper at two of the sites and on whiteboard at the other five sites)
• In the middle of each nursing shift, the nurses and physicians “huddle” to address family concerns and issues with patient care.

Outcomes

• Medical error: 4.12% pre-intervention vs 3.58% post-intervention (not significant, p-value 0.21; percentage based on rate per 1000 patient days)
• Preventable adverse events: Decreased 37.9% (from 20.7% pre-intervention to 12.9% post-intervention). 
• Non-preventable adverse events: Decreased from 12.6% pre-intervention to 5.2% post-intervention
• Family experience: “Excellent” ratings improved for 6 of 25 components
• Family rounds: Increased in frequency from 72.2% pre-intervention to 82.8% post-intervention
• Family engagement: Increased from 55.6% pre-intervention to 66.7% post-intervention
• Nurse engagement: Increased from 20.4% pre-intervention to 35.5% post-intervention
• Families expressing concerns at the start of healthcare provider working rounds: Increased from 18.2% pre-intervention to 37.7% post-intervention
• Families reading back plans: Increased from 4.7% pre-intervention to 26.5% post-intervention
• Trainee teaching: Did not change significantly
• Duration of rounds: Did not change significantly

Future Outcomes

• A future metric will involve testing the intervention in adult patient populations. 
• Another future metric will be to measure improvement in families’ reported experience with nurses apart from physicians.

Benefits

• The major benefits of this intervention were improvement in family experience, and change in rates of preventable and non-preventable adverse event occurrence. 

Intervention-Specific Challenges

• There was the possibility of misclassification because medical error and adverse event classification was complex.
• Adherence to certain parts of the intervention varied in terms of nurse engagement, frequency of incorporation of plans by family members during rounds, and use of plain language.

Sources

Khan A, Spector ND, Baird JD, Ashland M, Starmer AJ, Rosenbluth G, Garcia BM, Litterer KP, Rogers JE, Dalal AK, Lipsitz S, Yoon CS, Zigmont KR, Guiot A, O’Toole JK, Patel A, Bismilla Z, Coffey M, Langrish K, Blankenburg RL, Destino LA, Everhart JL, Good BP, Kocolas I, Srivastava R, Calaman S, Cray S, Kuzma N, Lewis K, Thompson ED, Hepps JH, Lopreiato JO, Yu CE, Haskell H, Kruvand E, Micalizzi DA, Alvarado-Little W, Dreyer BP, Yin HS, Subramony A, Patel SJ, Sectish TC, West DC, Landrigan CP. Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ. 2018 Dec 5;363:k4764.