Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

Innovation
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Summary

Medical errors (all errors in medicine), harmful errors (medical errors that specifically lead to patient harm), and adverse events (harms due to medical care) are leading causes of death and harm in patients in the hospital setting.^1,2 Communication failures are a common root cause of sentinel events, which are the most serious harmful errors.³ Minimal research has investigated whether efforts to reduce communication failures across healthcare providers, patients, and families could improve patient safety.⁴ This intervention sought to determine whether patient safety and communication processes could be improved via a family-centered communication program. Harvard Medical School and Boston Children’s Hospital designed a prospective, multicenter before-and-after intervention study in which families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds in hospitals. This approach is also known as family-centered rounds.⁴

The intervention was conducted on seven pediatric units across the United States and Canada from December 2014 to January 2017. Before the intervention, most sites did not have a formal structure for rounds.⁴ This intervention, known as Patient and Family Centered I-PASS, was based off of the I-PASS Resident Handoff Study.5 It was adapted for the current study. A team of parents and healthcare professionals adapted the I-PASS framework⁵ to provide a formal structure for family-centered rounds. I-PASS stands for Illness severity (family reports if child was better, worse, or the same), Patient summary (brief summary of patient presentation, overnight events, plan), Action list (to-dos for the day), Situation awareness and contingency planning (what family and staff should look out for and what might happen), and Synthesis by receiver (family reads back key points of plan for the day, prompted by presenter and supported by nurse as needed).⁴ In addition to structuring communication on rounds around the I-PASS framework, the intervention sought to engage families in rounds by having them share their questions and concerns first and ensuring providers used simple language instead of medical jargon. The intervention engaged nurses to be present and speak early on rounds and support families. Finally, it involved a written summary of rounds filled out in real time, known as the Rounds Report.

The study team reviewed 3,106 patient admissions (1,574 preintervention and 1,532 postintervention), or a total of 13,171 patient days (6,326 preintervention and 6,845 postintervention) for medical errors, harmful errors, and nonpreventable adverse events.⁴ After the standardized family-centered rounds intervention was implemented, harmful errors decreased by 38% (20.7 per 1,000 patient days preintervention to 12.9 per 1,000 days postintervention; p=0.01).⁴ The overall rate of medical errors and nonharmful medical errors did not change.⁴

The study also had an unexpected decrease in nonpreventable adverse events. They decreased from 12.6 per 1,000 preintervention to 5.2 per 1,000 postintervention (p=0.003).⁴ This unexpected improvement may be due to improved engagement and communication with families, which prevented some adverse events from occurring in ways not apparent in the normal determination of adverse events.⁴ The reduction in harmful events occurred without significantly increasing the duration of rounds.⁴ Additionally, the intervention was found to improve key communication behaviors, like family and nurse engagement on rounds, and several measures of family experience.⁴

Per the innovator, Patient and Family Centered I-PASS is a novel approach in the patient safety movement. This innovation can be applied in many other settings of care, such as nursing homes and rehabilitation centers. Patient and Family Centered I-PASS has the potential to significantly reduce medical errors.

Innovation Patient Safety Focus

The Patient and Family Centered I-PASS innovation aimed to improve patient safety by improving health literacy, family engagement, and bidirectional structured communication between healthcare providers and patients’ families through the use of the modified I-PASS framework to standardize family-centered rounds.⁴

Resources Used and Skills Needed

Institutional support: Leadership support for the intervention
Buy-in from families and the patient’s team of healthcare providers
Unit physician and nursing champions who can help support implementation and training
Support from families in sustaining the innovation
Time and finances to properly train families and the patient’s healthcare team on the intervention. This includes a family orientation via brochures (for families, training on the content in the brochures is conducted by nurse staff), training modules (for healthcare providers), and the review of an implementation guide (for healthcare providers).⁴
The implementation of observational tools (including core items and modules on activating and engaging the family and interprofessional team, patient-centered conversation and written information, use of structured communication techniques, and teaching) to ensure intervention adherence and improvement through audit and feedback⁴
Disseminate campaign materials to encourage adoption of the intervention⁴
Conduct meetings and teleconferences across sites, if the intervention is implemented across multiple sites, to track innovation progress and to address any challenges discovered during implementation⁴
Conduct statistical analyses to assess changes in patient safety (medical errors and adverse events) and communication processes⁴
Interpretation and translation resources for those who speak languages other than English

Use By Other Organizations

Per the innovator, engaging families in rounds has traditionally been done in the pediatric setting. Understanding where family-centered rounds could fit into the adult care setting has the potential to make a major impact. This innovation has the potential to improve health equity by ensuring standardized, clear communication and a partnership with patients and families.

Date First Implemented

2014

Problem Addressed

Communication failures across patients, families, and the healthcare provider team are a leading root cause in sentinel events, the most serious harmful errors.³ This intervention aimed to improve rates of medical errors, family experience scores, and communication processes via a standardized family-centered rounds approach organized around the I-PASS framework in seven pediatric inpatient hospitals. Prior to this intervention, there was no standardized rounding process in many pediatric inpatient hospitals. This innovation standardized family-centered rounds and increased family and healthcare provider team engagement, which led to a reduction in harmful medical errors by 38% (20.7 per 1,000 patient days preintervention versus 12.9 per 1,000 days postintervention; p=0.01).⁴

Description of the Innovative Activity

The standardized family-centered rounds innovation consisted of a communication framework focused on health literacy, family engagement, and bidirectional communication principles organized around the adapted I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver) framework.⁴ A Rounds Report, which is a daily summary of rounds on paper or whiteboard using the I-PASS structure, was written for families in real time during rounds.⁴ Training was conducted for families and healthcare providers using tools like brochures, training modules, and an implementation guide.⁴ Additionally, process changes were included in the intervention, such as healthcare team huddles to discuss patient issues and family concerns, observations of rounds to ensure proper implementation of the intervention through audit and feedback, and sustainability campaigns to support continued staff, family, and leadership buy-in.⁴

Context of the Innovation

Communication failures are a common root cause of sentinel events, which are the most serious harmful errors.³ Other types of errors, such as medical errors (all errors in medicine), harmful errors (medical errors that specifically lead to patient harm), as well as adverse events (harms due to medical care), are significant contributors to death and harm in the hospital setting for patients.^1,2 Interventions that reduce one type of communication failure, like miscommunications during handoff, have demonstrated substantial improvements in patient safety.^5,6,7,8 However, little was known about whether efforts to reduce miscommunication among healthcare providers, patients, and families could improve patient safety. The team at Harvard Medical School and Boston Children’s Hospital identified rounds (also known as ward rounds) as an important daily communication process in which healthcare providers could more effectively engage with patients and families.⁴ This innovation sought to demonstrate that implementing a standard process for family-centered rounds would improve patient safety outcomes.⁴ This was done with an innovation that focused on improving health literacy, family engagement, and bidirectional communication between healthcare providers and patients’ families, organized around the modified I-PASS framework.⁴

Results

This innovation led to a decrease in harmful errors by 38% (20.7 per 1,000 patient days preintervention to 12.9 per 1,000 days postintervention; p=0.01). Nonpreventable adverse events decreased from 12.6 per 1,000 preintervention to 5.2 per 1,000 postintervention (p=0.003).⁴ There was no significant increase in duration of the rounds.⁴ Family-centered rounds increased from 72.2% preintervention to 82.8% postintervention (p=0.02).⁴ Family engagement on rounds increased from 55.6% preintervention to 66.7% postintervention (p=0.04).⁴ Nurse engagement increased from 20.4% preintervention to 35.5% postintervention (p=0.03).⁴ Adherence to key communication behaviors, including families expressing concerns at the start of rounds, increased from 18.2% preintervention to 37.7% postintervention (p=0.03).⁴ Parent reporting of illness severity on rounds increased from 28.8% preintervention to 43.5% postintervention (p=0.08).⁴ The rates of overall medical errors remained unchanged, but this could have been secondary to a lack of change in nonharmful errors. The result suggests that the intervention might have affected harmful and nonharmful errors differently.⁴

Planning and Development Process

Per the innovator, it is important to obtain buy-in from key partners, like physicians, nurses, families, frontline staff, and senior and unit leaders. Additionally, it is important to properly set the stage for the value proposition for this innovation by highlighting how this innovation improves patient safety and the experience of the patients, families, and staff. It is important to emphasize the involvement of families in the planning and development process of the innovation. Parents engaged in the creation of the intervention, were involved in the intervention itself, and received training via a family and patient orientation and a rounds brochure. Recruitment of family advisors can be done via patient and family advisory boards, national patient advocacy networks, and local organizations. The innovators found that inclusion of families in the planning and development process was instrumental in obtaining staff and hospital leadership buy-in for the intervention.

Resources Used and Skills Needed

Institutional support: Leadership support for the intervention
Buy-in from families and the patient’s team of healthcare providers
Unit physician and nursing champions who can help support implementation and training
Support from families in sustaining the innovation
Time and finances to properly train families and the patient’s healthcare team on the intervention. This includes a family orientation via brochures (for families, training on the content in the brochures is conducted by nurse staff), training modules (for healthcare providers), and the review of an implementation guide (for healthcare providers).⁴
The implementation of observational tools (including core items and modules on activating and engaging the family and interprofessional team, patient-centered conversation and written information, use of structured communication techniques, and teaching) to ensure intervention adherence and improvement through audit and feedback⁴
Disseminate campaign materials to encourage adoption of the intervention⁴
Conduct meetings and teleconferences across sites, if the intervention is implemented across multiple sites, to track innovation progress and to address any challenges discovered during implementation⁴
Conduct statistical analyses to assess changes in patient safety (medical errors and adverse events) and communication processes⁴
Interpretation and translation resources for those who speak languages other than English

Funding Sources

Funding to evaluate the effectiveness of the Patient and Family Centered I-PASS innovation, as well as to disseminate and implement it, came from the Patient-Centered Outcomes Research Institute (PCORI). AHRQ provided critical funding for earlier phases of this work. Funding began 15 years ago, when the innovator developed the I-PASS Resident Handoff intervention via funding from the Health and Human Services division. AHRQ subsequently funded a project to disseminate and implement the I-PASS Resident Handoff intervention.

Getting Started with This Innovation

Gathering support is valuable when starting this innovation. A useful first step in developing this innovation is to identify champions, like families and organization leaders, who can advocate for the innovation with key stakeholders. For example, a champion could assemble a board of family representatives, nurses, and physicians to begin implementing this innovation.

Funding is helpful in getting started with this innovation. Time and personnel costs associated with garnering buy-in, implementing the intervention, and coaching and feedback are the real costs of the intervention. There may also be costs around printing brochures and creating templated whiteboards. The innovator recommended looking to institutional sources of support, as well as funding sources like AHRQ or PCORI if additional study of this intervention is intended.

Sustaining This Innovation

To sustain this innovation, thoughtful early development is necessary, per the innovator. It is particularly important to be thoughtful about workflows, like nursing. Additionally, institutional support must be maintained, such as staffing support and process support. For instance, team assistants who help with scheduling rounds or calling interpreters may be a helpful investment. Additionally, the innovator noted that the use of interpretation services is necessary to ensure the innovation is equitable for families who speak languages other than English. Institutional support is needed to fund interpretation.

References/Related Articles

Khan A, Spector ND, Baird JD, et al. Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ. 2018;363:k4764.

Rosenbluth G, Good BP, Litterer KP, et al. Communicating effectively with hospitalized patients and families during the COVID-19 pandemic. J Hosp Med. 2020;15(7):440-442.

Knighton AJ, Bass EJ, McLaurin EJ, et al. Intervention, individual, and contextual determinants to high adherence to structured family-centered rounds: a national multi-site mixed methods study. Implement Sci Commun. 2022;3(1):74.

Lewis KD, Destino L, Everhart J, et al. Patient and family-centered I-PASS SCORE program: resident and advanced care provider training materials. MedEdPORTAL. 2022;18:11267.

Patel SJ, Khan A, Bass EJ, et al. Family, nurse, and physician beliefs on family-centered rounds: a 21-site study. J Hosp Med. 2022;17(12):945-955.

Khan A, Patel SJ, Anderson M, et al. Implementing a family-centered rounds intervention using novel mentor-trios. Pediatrics. 2024;153(2):e2023062666.

O’Toole JK, Calaman S, Anderson M, et al. Utilizing co-production to improve patient-centeredness and engagement in healthcare delivery: lessons from the patient and family-centered I-PASS studies. J Hosp Med. 2023;18(9):848-852.

Kuzma N, Khan A, Rickey L, et al. Effect of patient and family centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. J Hosp Med. 2023;18(4):316-320.

Abu-Rish Blakeney E, Baird J, Beaird G, et al. How and why might interprofessional patient- and family-centered rounds improve outcomes among healthcare teams and hospitalized patients? A conceptual framework informed by scoping and narrative literature review methods. Front Med. 2023;10:1275480.

Khan A. Ensure that the family’s voice is heard first and last, and in their own words [editorial]. The BMJ Opinion. Cambridge; 2018 Dec 6. Accessed January 16, 2024. https://blogs.bmj.com/bmj/2018/12/06/in-clinical-practice-i-ensure-that-the-familys-voice-is-heard-first-and-last-and-in-their-own-words/

Everhart JL, Haskell H, Khan A. Patient- and family-centered care: leveraging best practices to improve the care of hospitalized children [editorial]. Pediatr Clin North Am. 2019;66(4):775-789.

Footnotes

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
Institute of Medicine Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000.
The Joint Commission. Sentinel event statistics released for 2014. Jt Comm Online. 2015. Accessed October 24, 2018. https://info.jcrinc.com/rs/494-MTZ-066/images/Sentinel39.pdf
Khan A., Haskell H. Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ. 2018;363:k4764.
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371:1803-1812.
Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310:2262-2270.
Graham KL, Marcantonio ER, Huang GC, Yang J, Davis RB, Smith CC. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Intern Med. 2013;28:986-993.
Sand-Jecklin K, Sherman J. A quantitative assessment of patient and nurse outcomes of bedside nursing report implementation. J Clin Nurs. 2014;23:2854-2863.

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