The Institute of Medicine’s 1999 report, “To Err is Human,” highlighted the number of patients who die in U.S. hospitals due to medical errors—98,000 per year. Since then, patient safety has become a focus for health care organizations and providers, patients and families, professional organizations, insurance payers and regulatory bodies. But despite this, hospitals continue to experience patient harm events.
In 2010, the Office of the Inspector General estimated adverse events accounted for almost 180,000 deaths per year. While studies like this circulated within the medical community, there was a parallel patient- and family-led movement putting focus on the faces and stories behind major safety events, like 15-year-old Lewis Blackman and 18-month-old Josie King.
Both patients died from a series of medical errors while hospitalized. Attaching faces and stories of patients who suffered injury or death from medical errors mobilized the patient safety movement. As the transparency of safety events has increased to consumers, so has the call to improve patient and family engagement.
Patient- and family-centered rounds
Patient and family-centered rounds (PFCRs) are a multidisciplinary approach to discussing medical care with patients and their families at the bedside. PFCRs have been espoused, particularly in pediatrics, as a way to improve communication by including hospitalized patients and their family members during rounds with other interprofessional team members. In the past decade, institutions have adopted varying models of PFCRs, though evidence about the effect of PFCRs on patient outcomes is limited.
Small studies have reported improved patient and family satisfaction and team member collaboration. However, the great variability in how providers conduct PFCRs potentially reduces their effectiveness. One commonly practiced version of PFCRs shifts the medical team’s “table rounds” from the conference room to the bedside. The medical team discusses clinical reasoning using medical jargon. The team fails to engage other team members, like the bedside nurse—a constant patient advocate—and most importantly, the patient and family.
In this situation, communication is often unidirectional, from the physician to patient/family members, resulting in a hierarchical transfer of information that may reduce the likelihood of a shared understanding between the patient, family members and other team members.
This often leaves the patient and family members at the mercy of their own health literacy level, and limited health literacy has been linked to poor patient outcomes. Therefore, emphasizing health literacy as a requirement for effective communication with patients and families may not only result in improved patient outcomes but also in improved patient experience.
The Joint Commission reviewed sentinel events between 1995 and 2006 and found communication errors are a leading cause of these serious safety events, prompting the development of a National Patient Safety Goal focused on handoff communication. The Controlled Risk Insurance Company (CRICO), a professional liability firm for over 400 diverse hospitals and 165,000 physicians, found miscommunication was a factor in 30% of patient harm malpractice cases. Of these cases, 55% involved provider-to-patient/family communication failures, with occurrences across all provider types and specialties.
According to the Child Health Patient Safety Organization®, data compiled from reported cases indicates failure to communicate is a contributor to the “most serious” and “serious moderate harm” categories. It remains one of the top causes for “severe moderate harm.” While the top cause of the most severe harm is “failure to recognize,” when it’s combined with factors like “failure to communicate,” there’s even more vulnerability.
Industries that suffer severe consequences when communication failures occur, such as aerospace, nuclear energy and aviation, have proven that behaviors, processes and tools promote high reliability and reduce communication errors. Using this concept, the I-PASS handoff study measured the effect of standardizing shift-to-shift handoff communication between pediatric residents in nine children’s hospitals across North America.
The results, published in 2014 in the New England Journal of Medicine, demonstrated a 23% reduction in overall medical errors and a 30% reduction in preventable adverse events following implementation of a resident handoff intervention.
Although promising for shift-to-shift communication between same provider types, like resident-physicians, the I-PASS handoff bundle did not address other areas vulnerable to communication failures, such as communication between providers and families or between interprofessional team members, like physicians and bedside nurses.
Building on the improvements in medical errors and adverse events achieved in the I-PASS handoff study, the Patient- and Family-Centered I-PASS study brought high reliability principles of standardized, structured communication to PFCRs. This created a collaborative environment with equal contributions from patients/families, nurses and physicians.
Patient- and Family-Centered I-PASS is an evidence-based intervention that standardizes communication and improves patient and family engagement using principles of patient- and family-centered care and health literacy.
The intervention includes guidelines for verbal and written exchanges of medical information during PFCRs, emphasizing health literacy principles, two-way communication and family engagement. Interprofessional training encourages communication among health professionals and defines their roles during PFCRs.
The Patient- and Family-Centered I-PASS handoff study demonstrated a 38% reduction in harmful medical errors, improvements in aspects of patient and family experience with hospital communication processes, with no change in duration of teaching on rounds.
Currently, the I-PASS study group, with funding from Patient-Centered Outcomes Research Institute, has partnered with the Society of Hospital Medicine to disseminate the program to 21 community and academic hospitals across the country.
Patient and family roles
In this model, patients and families are not only experts on the patient but also critical members of the health care team. Patient and family participation are fostered by including patients and families early and often in discussions. The model also uses well-established and evidence-based health literacy principals, such as the use of plain language and frequent checks for understanding.
In addition, the model highlights the bedside nurse’s critical role as a patient/family advocate. The I-PASS study group partnered with family representatives at each study site to develop the educational intervention, define roles and refine the scientific methods.
The nurse’s role
Nurses are present at the patient bedside around the clock and are familiar with the nuances of the patient’s care and the family’s priorities—they play a critical role on the care team. The patient information nurses bring to discussions guarantees decision-making on rounds will be more holistic, ensuring the care plan establishes realistic goals for the patient’s progress and is aligned with the patient’s and family’s priorities.
In the Patient- and Family-Centered I-PASS model, nurses introduce the concept of PFCRs to families, encourage and support the family to participate in the discussion, and they serve as a key point of contact for concerns and questions. Interprofessional communication is ensured during PFCRs and at other communication points throughout the day. Nurses are trained on this model at convenient times that fit into their workflow to ensure understanding of their role.
The physician’s role
Patients, families, nurses and other members of the interprofessional team often regard physicians as the leader of the treatment team. Facilitating effective team communication requires effective team leaders. The Patient- and Family-Centered I-PASS intervention was studied in academic centers where the medical team often consists of medical students and resident physicians, each with specific roles during PFCRs and throughout the day. It is the attending physician’s role to ensure each team member understands individual trainee and physician roles.
The attending physician must model ideal communication techniques and set the stage for collaborative decision-making. Aside from guiding treatment decisions, the faculty physician in PFCRs must oversee the team in eliciting patient and family preferences, ensuring nursing presence on rounds, and encouraging each team member to provide input to maintain shared understanding of care goals.
Therefore, the Patient- and Family-Centered I-PASS intervention included targeted training for attending physicians, resident physicians and medical students. Incorporation of daily physician-led debriefs after selected patient/family encounters allowed for attending physicians to give feedback to team members as needed to adjust and enhance future communication and interactions.
Personnel such as project managers, administrative support, and physician, nurse, patient/family team leads are key to driving the initiative and ensuring adoption. Also, support of hospital leaders, such as the CEO, COO, chief medical officer, chief nursing executive, unit managers and division heads helps prioritize and drive urgency for frontline providers to adapt behavior and work flows.
Engaging these leaders in planning and communicating successes and challenges is beneficial for maintaining continued support. Resources to perform data-driven improvement efforts require commitment to long-term goals to achieve sustainable change.
Family safety reporting
As health care providers increasingly view patients and families as experts in their own care and partners in care delivery—rather than solely recipients of care—patients and families can serve as partners in hospital safety surveillance. To engage families as safety partners, the study team developed a tool with direct family input and a family advisory council review to capture parent-reported errors and safety concerns.
The team included this family safety reporting tool into the standard systematic surveillance process used to measure errors and adverse events in the study. The family safety reporting tool asked about categories of errors such as medications, miscommunication, diagnosis, delays, complications and equipment, and provided examples.
Using the tool, family members on the study units were asked weekly and at discharge about harmful and non-harmful errors and other issues with care during their child’s hospital stay. Families identified several harmful errors not otherwise detected by other sources.
Families and clinicians reported errors at similar rates, but families reported five times the rate of errors and three times the rate of adverse events as hospital incident reporting systems. The value of engaging families as safety partners underscores the need to develop mechanisms for engaging families in error detection in systematic safety surveillance used in research and in the more common incident reporting systems most hospitals use.
Applying the high reliability principle of structured communication can improve communication with patients/families and other members of the interprofessional care team. By implementing the Patient- and Family-Centered I-PASS intervention, children’s hospitals have the potential to directly affect patient safety, the patient experience, patient engagement, interprofessional communication and the culture of safety at health care institutions.