Boston Medical Center is standardizing handoffs, and patients are safer for it
One sure way to reduce risky patient handoffs in a hospital, where the potential exists for miscommunication and medical errors, is to increase the length of shifts that physicians and nurses work. But a bleary-eyed doctor in the waning hours of a 30-hour shift presents its own patient safety challenges.
"Why are we putting people at risk when really we just need to improve these handoffs?" said William Floyd, president and CEO of the I-PASS Patient Safety Institute.
It's been estimated that 80 percent of the most dangerous medical errors occur because of communication failures during handoffs, when docs and nurses change shifts, or patients are moved to new locations in the hospital.
Several years ago, a group of physicians and researchers devised a tool to bring some standardization to the hand-off process. I-PASS – Illness severity, Patient summary, Action list, Situation awareness and contingency plans and Synthesis by receiver – is meant to be a checklist that summarizes a patient's care plan and uses "closed loop communication" to ensure clinicians get the right information.
The program was tested at nine pediatrics programs, and proved its mettle with some impressive safety gains. As noted in the New England Journal of Medicine, "medical errors decreased by 23 percent, preventable adverse events decreased by 30 percent, and critical information was included more frequently in written and verbal handoffs. And, importantly, handoffs weren't any more time-consuming than before." The program is now at use in about 50 hospitals nationwide.
In 2016, the I-PASS Patient Safety Institute was launched as a company to help scale up those strategies, and bring the program's mentors, immersive online simulation training, benchmarking tools and EHR customizations to more locations.
One of its newest clients is 496-bed Boston Medical Center, the biggest safety-net hospital in New England.
"We needed to expand this to other hospitals because it's such a significant improvement to medical errors," said Floyd.
Games, EHRs and the cloud
At BMC, which has been using I-PASS processes since 2015, working with the Patient Safety Institute will help it better train incoming medical professionals, standardize hand-off processes more widely and initiate metrics and benchmarking, he said.
"The training is an avatar-based gamification system," Floyd said. "It's immersive and drops you into an environment where you get rewards for achievement. It will allow a frontline provider to learn how to do an I-PASS handoff, and will then allow them to give an I-PASS handoff that then gets translated back to them, so they listen to their handoff. They do a scoring system and then that shows how well they've done compare with an exemplary handoff."
There are many different handoff scenarios – nursing, pediatrics, surgery and more – with specific I-PASS techniques. The web-based training allows the ability to scale the approach across departments a fast and effective way.
Electronic health record customizations are another important component, said Floyd.
"Epic, Cerner, Allscripts all have the standardized I-PASS mnemonic in their system. And so what occurs is we help the hospitals customize that for each of the different care areas. We work with either the hospital's IT group, or we have third-party companies we work with who will then make sure the I-PASS mnemonic is done (in the EHR) and is consistent with the standardized verbal hand-off."
Cloud-based benchmarking software, available on smartphones, tablets and desktop offers a way to assess the success of how the program is being implemented.
Hospital staff can simply tap on the elements of a particular handoff, "and it will then summarize how effectively it has been done and then do benchmarking across the hospital," said Floyd.
"So, in the ICU it's being done at 70 percent, versus in surgery it's being done at 90 percent. You can benchmark across the hospital. And then you can also benchmark between hospitals: Mass General and Boston Medical Center can see how they are doing by comparison, and by care area."
"The value of the I-PASS program is unquestionable in terms of improved patient care through reduction in medical errors," said James Moses MD, vice president of quality and safety and chief quality officer at Boston Medical Center, in a statement. "With the I-PASS Patient Safety Institute, we can continue to implement and sustain this important program in a fraction of the time we would spend doing it ourselves and with far fewer resources."
"Effective and consistent training on an effective handoff process is a requirement by the Accreditation Council for Graduate Medical Education to prevent medical errors," added Jeff Schneider, MD, designated institutional official in graduate medical education at BMC. "We feel that the I-PASS Patient Safety Institute will provide the most efficient and effective way for Boston Medical Center to meet those requirements."
As useful as the technology and tools are in helping train clinicians, there's no question that the I-PASS techniques require a substantial changes in process, workflow – even culture. And "that is by far the most difficult part of this," said Floyd.
At a large institution such as Boston Medical Center, the company will deploy three to five certified mentors, who will develop a full program showing how to integrate it "into the departments, into the culture," he said.
"These are very large, typically three-year programs," he said. "Because it is a cultural change, and that's exactly the most difficult part of this. Web-based measurement tools are important. But most important are our professional services, getting this detailed, what's the cadence of rollout, how do you customize this by different hospitals for their particular needs."