By Alisa Khan
Alisa Khan, MD, is a pediatric hospitalist and health services research fellow at Boston Children’s Hospital. She and Christopher Landrigan, MD, MPH, research director of the Boston Children’s Hospital Inpatient Pediatrics Service, recently received a Community/Patient Empowerment Award at the National Pediatric Innovation Summit sponsored by the hospital.
Miscommunications are a root cause of more than 70 percent of sentinel events, the most serious preventable adverse events in hospitals, according to data from the Joint Commission and the Department of Defense. As Vector reported yesterday, a bundle of interventions focused on improving patient "handoffs" during clinician shift changes, piloted at Boston Children’s Hospital, resulted in a 46 percent reduction in medical errors and a 54 percent reduction in preventable adverse events. What’s now known as I-PASS is now being implemented at 10 children’s hospitals across the U.S.
While I-PASS has greatly improved patient safety and communication between medical providers, it does not currently involve the family. Yet families play a pivotal safety role, advocating for their children and monitoring their progress through acute illness.
While about half of U.S. pediatric hospitals (including ours) have now adopted family-centered rounds, provider communication with families happens in varied ways and frequently occurs only once a day, often during these rounds. Family-centered rounds usually occur in the mornings, a time when families may not be awake or present at the bedside. As the day progresses, families often are not consistently updated, a troubling fact given that most relevant clinical updates, consultant recommendations and diagnostic test results generally aren’t available until later in the afternoon, well after morning rounds.
Following in the footsteps of I-PASS, we undertook the Nighttime Communication Study to better understand and improve provider-family communications. We compared written survey results from hundreds of resident-physicians and parents and had two physician reviewers rate their responses as concordant or discordant. This is what we found:
- In 45 percent of hospitalizations, parents and night residents had significantly different understandings of the reasons for hospitalization or the care plan.
- The discordance was more likely for parents who had lower levels of education or whose children had more complex care plans.
- Neither the residents’ nor the parents’ perceptions about whether parents understood the care plan predicted whether the parents’ actual understanding was correct.
We also surveyed almost 250 parents at discharge about their experience in the hospital and found that despite the different understandings in 45 percent of cases, only 14 percent of parents reported experiencing a communication problem during their child’s hospitalization.
These data underscore the importance of improving communication with families. Because neither residents nor families themselves can judge whether families objectively understand their children’s plan of care, and because families may not always identify a communication problem, clinicians can be lulled into a false sense of reassurance. The more we can build a truly shared understanding between providers and families, the better care will be.
Aligning clinicians, patients and families
Working with residents, families, nurses and administrators at Boston Children’s Hospital, and incorporating lessons from I-PASS, we came up with an idea to empower families of hospitalized children to play a more active, informed role: an interactive, structured electronic family "signout" tool. Distributed to families nightly and mirroring the I-PASS system for physician-to-physician patient handoff, the signout uses a family-friendly version of the I-PASS mnemonic to communicate pertinent clinical details:
• How sick the child is compared to the previous day (Illness Severity)
• Updates about the child from the day (Patient Summary)
• The care plan for the next 12 hours (Action Items)
• What to watch out for (Situational Awareness)
• A space for families to write down questions for providers (Synthesis).
We piloted this signout in paper form, and the results suggested that families found this signout helpful.
This fall, we were fortunate to receive a Taking on Tomorrow Innovation Award to develop the paper form into a scalable application that integrates into patients’ electronic medical records. We next plan to study the effect of this signout – along with a bundle of additional family-centered communication interventions, including focused evening family-centered rounds in I-PASS format on the sickest patients in a unit – on family experience, miscommunications and safety.
By increasing transparency and providing better access to information, this signout has the potential to empower families to play a more active, informed role in the management of their children’s health while in the hospital. Improving communication with families may not only improve family engagement, but may also improve patient safety, providing an extra safeguard against miscommunications and mistakes. Ultimately, we hope that our innovation will improve the quality and safety of care we and other hospitals provide.