This hospital took on a system-wide change during a pandemic to reduce serious safety events.
by Elizabeth Burnett, Jenna Yarnell and Brian Wagers
It is no secret that poor communication contributes to errors in health care. According to the Child Health Patient Safety Organization (Child Health PSO) more than half of participating hospitals reported failures in communication (e.g., handoffs/handovers, diagnostic timeouts, escalation plans). Of those cases, the most serious harm, ranging from moderate permanent harm to death, occurred 57% of the time.
In early 2018, a quality and safety team at Riley Hospital for Children at Indiana University Health reviewed their previous year’s data and identified communication errors as one of the top three failure modes in safety events.
After further investigation, the team discovered communication errors were responsible for 72% of the serious safety events at the hospital from 2016 to 2019. This data served as a call to action for the team to do something to improve the efficiency and reliability of the hospital’s handoffs. Little did they know they would be further challenged by a worldwide pandemic.
Multidisciplinary approach to improving handoffs
The team formed a triad to lead the effort to move forward with instituting I-PASS as a universal language for responsibility transfer, which included a physician, nurse/quality improvement consultant, and child life specialist. They soon began to uncover and understand current practices for responsibility transfer across disciplines and determine the next steps to improve the handoff process throughout the hospital.
The team polled clinical and nonclinical health care staff across disciplines, which identified handoffs as a source of frustration and a risk point for patient safety. Specifically, colleagues voiced concerns about the consistency and quality of handoffs during shift changes and linked this with errors, the potential for patient harm, and reduced safety for team members.
The team recognized that 41% of errors that touched the patient occurred during two periods that corresponded with the most common shift change times.
In a time when burnout and moral injury among health care team members is increasing, addressing these concerns was a second goal for this work. As providers, the team knew that when patients are harmed, those who care for them also suffer. The team’s desire to decrease patient care errors and the resultant harm to both patient and staff became twin motivators to change the way responsibility was transferred at Riley Children’s Hospital.
The gold standard for transfers
The team soon realized that to truly create change in responsibility transfers, the entire health system needed to adopt change. Along with support from executive leadership, the team sought to implement standardization of handoffs for all team members, regardless of role.
Buy-in from colleagues would be key to the success of I-PASS. They presented data of current handoff errors and I-PASS success stories to multidisciplinary groups to generate support for the work. The message given to staff was that all transfers of responsibility in the organization would use the I-PASS framework to maintain a common language and increase the reliability of information transfer.
Team members initially were hesitant and resistant to change. But one nurse offered to trial I-PASS between the pre-post care unit and inpatient departments to determine its feasibility. And in the end, the pilot experience confirmed the evidence that I-PASS was the gold standard for handoffs, and although resistance still ensued, its implementation was approved.
The cycle of change
Implementation plans began with trial departments, grew to trial disciplines, and broadened to encompass an entire facility roll out. Each step of the way, PDSA cycles were completed to iteratively improve the process for the next group, culminating in the plan for the whole-house implementation.
The team held meetings with individuals from 20 departments to create examples of how they could utilize I-PASS in their daily workflows. Visual management demonstrated what a current state handoff in representative departments consisted of and how using I-PASS could transform their practice into an improved future state.
Working with education experts, the team developed an education plan, and the Quality and Safety Department offered to be the pilot department for education and implementation efforts. The team created a year-long implementation plan that would start with a house-wide informative flyer sharing the planned process.
They also developed a leader playbook that gave extensive instructions and defined activity dates to ensure all departments would follow the same process and plan. The pre-implementation education blitz launched in February 2020.
Navigating a hospital-wide change during a pandemic
The formal I-PASS launch was planned for National Patient Safety Awareness Week in March 2020. Because of the timing during the NCAA basketball tournament, Miscommunication Madness became the theme. The week was focused solely on standardizing responsibility transfer, educational endeavors regarding I-PASS, and leader rounding to help with departmental implementation activities.
Unfortunately, within hours of day one, the first cases of COVID-19 were confirmed in the state of Indiana, and along with other in-person events, Safety Awareness Week was canceled.
Soon after, health care teams began to shift to remote operations, redirect, and plan for the new realities of carrying on daily hospital operations amid a global pandemic. Then concerns of minimal staffing emerged. The team was faced with a difficult decision: continue with implementation or halt the launch.
With clear data reminding them that handoffs were currently not optimal and recognizing the need for proper handoffs in a time of crisis, the team decided to continue with the education rollout.
In the initial months of the rollout, more than 2,900 health care team members participated in the I-PASS training process. Department leaders continued with workshops to develop and refine the processes surrounding I-PASS implementation. The team quickly shifted to providing virtual opportunities for leaders that helped support the implementation.
After launching I-PASS, the team hit a few bumps along the way. They received new information about I-PASS, while at the same time they were inundated with process and policy changes and navigating the unknown related to the pandemic.
Although the implementation was not ideal, and many departments struggled to prioritize, the message that I-PASS was moving forward cemented to staff that communication standardization was a priority and gave further credibility to the initiative.
After two months of staying the course, the team recognized that communication was getting lost as the focus on COVID-19 took precedent. A relaunch of the initiative occurred in June 2020, as the pace of change with COVID-19 information slowed and staff settled into the new normal.
Success despite the pandemic
Initially, the team saw a decrease in handoff errors after highlighting and bringing awareness to the problem. Eventually, however, there was an increase in errors, as patient days declined due to the pandemic and implementation efforts paused.
Overall, there was a 27% decrease in handoff errors from 2019 (pre-implementation) to 2020. Even with the decreased patient encounters, the team sought ways to improve uptake and sustainment of I-PASS utilization. Strategies focused on storytelling and daily management boards prompted conversations around successes and barriers to using I-PASS.
Secret shopper observations and auditing were used to gain a clearer understanding of the true state of I-PASS use, and by December 2020, data showed that 80% of handoffs were utilizing all five components of I-PASS.
Overall, Riley Children’s Hospital benefited from standardizing transfers of responsibility throughout all roles in the organization. Leaders were queried five months post implementation via survey to ascertain novel tactics for promotion and sustainment of the initiative, identify any continued barriers, and elicit positive stories regarding improved patient care or staff well-being attributable to the standardization of responsibility transfers.
Leaders’ responses were overwhelming, with positive outcomes attributable to having a common language and process by which responsibility for patients, projects, and problems are transferred.
One story came from the social work team, who said I-PASS increased the efficiency of their handoffs in a way that allowed them to assess patients’ social determinants of health and unify the care provided between outpatient and inpatient environments more sufficiently.
More efficient shifts in responsibility from clinical to nonclinical areas and between clinical teams, a standardized language that everyone used, decreased rework, confidence in voicing concerns, synthesis to end meetings, creation of handoffs missing prior to this work, and a decrease in the need for patients and families to repeat information were all highlighted as additional benefits of the project.
The future of I-PASS
As Riley Children’s Hospital continues this work, barriers still exist and not all teams have fully adopted I-PASS. In addition, communication failures continue to show that incomplete handoffs have led to incorrect assumptions and misinterpretations. The team continues to meet regularly to determine next steps on the journey toward reliability for handoff communication.
Although the focus will remain global and include communication beyond the diagnostic process, tools provided in CHA’s diagnostic patient safety toolkit will be considered for use in furthering the hospital’s reach related to handoff communication.
Elizabeth Burnett B.S.N., RN, CPN, CPPS, is a safety improvement consultant, Brian Wagers, M.D., FAAP, is the associate chief medical officer, physician director of Pediatric and Maternal Quality and Safety; and Jenna Yarnell, M.S., CCLS, is a child life supervisor at Riley Hospital for Children at Indiana University Health in Indianapolis. Send questions or comments.