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Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4764 (Published 05 December 2018) Cite this as: BMJ 2018;363:k4764

Linked opinion

Improving patient safety? Ask the patient

Linked opinion

Ensure that the family’s voice is heard first and last, and in their own words

  1. Alisa Khan, instructor in pediatrics, staff physician1 2,
  2. Nancy D Spector, professor of pediatrics, associate dean of faculty development, executive director of Executive Leadership in Academic Medicine3 4,
  3. Jennifer D Baird, director5,
  4. Michele Ashland, lead parent coordinator6,
  5. Amy J Starmer, assistant professor of pediatrics, director of primary care quality improvement1 2,
  6. Glenn Rosenbluth, clinical professor of pediatrics, pediatric hospitalist7 8,
  7. Briana M Garcia, medical student, Patient and Family Centered I-PASS study coordinator7 9,
  8. Katherine P Litterer, family partnerships coordinator10,
  9. Jayne E Rogers, nursing director11,
  10. Anuj K Dalal, assistant professor of medicine, researcher1 12,
  11. Stuart Lipsitz, professor of biostatistics, statistician1 12,
  12. Catherine S Yoon, statistical programmer12,
  13. Katherine R Zigmont, project manager12,
  14. Amy Guiot, associate professor of clinical pediatrics, pediatric hospitalist13 14,
  15. Jennifer K O’Toole, associate professor of clinical pediatrics and internal medicine, pediatric and adult hospitalist13 14,
  16. Aarti Patel, assistant professor of pediatrics, pediatric hospitalist15 16,
  17. Zia Bismilla, associate professor of paediatrics, staff pediatrician17 18,
  18. Maitreya Coffey, associate professor of paediatrics, staff pediatrician17 18,
  19. Kate Langrish, clinical director, adjunct faculty19 20,
  20. Rebecca L Blankenburg, clinical associate professor of pediatric hospital medicine21 22,
  21. Lauren A Destino, clinical associate professor, associate medical director21 22,
  22. Jennifer L Everhart, clinical assistant professor, pediatric hospitalist21 22,
  23. Brian P Good, associate professor of pediatrics, pediatric hospitalist23 24,
  24. Irene Kocolas, assistant professor of pediatrics, paediatric hospitalist23 24,
  25. Rajendu Srivastava, professor of pediatrics, pediatric hospitalist23 24,
  26. Sharon Calaman, professor of pediatrics, program director of the Pediatrics Residency Program3 4,
  27. Sharon Cray, family advisor25,
  28. Nicholas Kuzma, assistant professor of pediatrics, attending physician3 4,
  29. Kheyandra Lewis, assistant professor of pediatrics, attending physician3 4,
  30. E Douglas Thompson, interim pediatrician-in-chief and interim chair3 4,
  31. Jennifer H Hepps, assistant professor of pediatrics, associate program director of the pediatrics residency program26 27,
  32. Joseph O Lopreiato, associate dean for simulation education, professor of pediatrics, medicine and nursing26,
  33. Clifton E Yu, professor of pediatrics, chief of graduate medical education26 27,
  34. Helen Haskell, founder28,
  35. Elizabeth Kruvand, coordinator, family partner29 30,
  36. Dale A Micalizzi, founder31,
  37. Wilma Alvarado-Little, associate commissioner, director32 32,
  38. Benard P Dreyer, professor of pediatrics, director34 35,
  39. H Shonna Yin, associate professor of pediatrics and population health, general pediatrician34 36,
  40. Anupama Subramony, assistant professor of pediatrics, chief quality officer and vice president of quality and safety37 38,
  41. Shilpa J Patel, associate professor of pediatrics, physician liaison for quality/patient safety39 40,
  42. Theodore C Sectish, professor of pediatrics, vice chair for education and program director of the Boston Combined Residency Program1 2,
  43. Daniel C West, professor of pediatrics, director of the pediatrics residency program7 8,
  44. Christopher P Landrigan, professor of pediatrics, research director of the inpatient pediatrics service, director of the Sleep and Patient Safety Program, for the Patient and Family Centered I-PASS Study Group1 2 41
  1. 1Harvard Medical School, Boston, MA, USA
  2. 2Department of Medicine and Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
  3. 3Drexel University College of Medicine, Philadelphia, PA, USA
  4. 4Department of Pediatrics, St Christopher’s Hospital for Children, Philadelphia, PA, USA
  5. 5Institute for Nursing and Interprofessional Research, Children’s Hospital Los Angeles, Los Angeles, CA, USA
  6. 6Family-Centered Care Department, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA
  7. 7University of California San Francisco School of Medicine, San Francisco, CA, USA
  8. 8Department of Pediatrics, Benioff Children’s Hospital, San Francisco, CA, USA
  9. 9Department of Medicine and Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
  10. 10Office of Experience, Boston Children’s Hospital, Boston, MA, USA
  11. 11Inpatient Medicine, Boston Children’s Hospital, Boston, MA, USA
  12. 12Center for Patient Safety Research, Division of General Medicine, Department of Medicine at Brigham and Women’s Hospital, Boston, MA, USA
  13. 13University of Cincinnati College of Medicine, Cincinnati, OH, USA
  14. 14Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
  15. 15University of California San Diego School of Medicine, San Diego, CA, USA
  16. 16Division of Pediatric Hospital Medicine, Rady Children’s Hospital San Diego, San Diego, CA, USA
  17. 17Pediatrics, University of Toronto, Toronto, ON, Canada
  18. 18Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
  19. 19Faculty of Nursing, University of Toronto, Toronto, ON, Canada
  20. 20Division of Pediatric Hospital Medicine, Hospital for Sick Children, Toronto, ON, Canada
  21. 21Stanford School of Medicine, Palo Alto, CA, USA
  22. 22Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA
  23. 23University of Utah School of Medicine, Salt Lake City, UT, USA
  24. 24Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, UT, USA
  25. 25Family Advisory Council, St Christopher’s Hospital for Children, Philadelphia, PA, USA
  26. 26Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
  27. 27Walter Reed National Military Medical Center, Bethesda, MD, USA
  28. 28Mothers Against Medical Error, Columbia, SC, USA
  29. 29Family Partner Program, St Louis Children’s Hospital, St Louis, MO, USA
  30. 30St Louis Children’s Hospital, St Louis, MO, USA
  31. 31The Justin’s HOPE Project, Task Force for Global Health, Decatur, GA, USA
  32. 32New York State Department of Health, New York, NY, USA
  33. 33Office of Minority Health & Health Disparities Prevention, Corning Tower, Empire State Plaza, Albany, NY, USA
  34. 34New York University School of Medicine, New York, NY, USA
  35. 35Division of Developmental-Behavioral Pediatrics, New York University Langone Medical Center, New York, NY, USA
  36. 36Departments of Pediatrics and Population Health at New York University Langone Medical Center, New York, NY, USA
  37. 37Cohen Children’s Medical Center, New York, NY, USA
  38. 38Hofstra Northwell School of Medicine, Queens, NY, USA
  39. 39University of Hawaii John A Burns School of Medicine, Honolulu, HI, USA
  40. 40Hawai‘i Pacific Health, Honolulu, HI, USA
  41. 41Brigham and Women’s Hospital, Boston, MA, USA
  1. Correspondence to: A Khan 21 Autumn Street, Room 200.2, Boston, MA 02115, USA alisa.khan{at}childrens.harvard.edu
  • Accepted 31 October 2018

Abstract

Objective To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds.

Design Prospective, multicenter before and after intervention study.

Setting Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017.

Participants All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents.

Intervention Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds (“family centered rounds”), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement.

Main outcome measures Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting.

Results The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, “excellent”) ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly.

Conclusions Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds.

Trial registration ClinicalTrials.gov NCT02320175.

Footnotes

  • Group authorship

  • The Patient and Family Centered I-PASS Study Group includes all authors listed in the byline, as well as the following: Brenda K Allair, Claire Alminde, Marisa Atsatt, Megan E Aylor, James F Bale, Jr, Dorene Balmer, Kevin Barton, Carolyn E Beck, Debra Chandler, Amanda Choudhary, Eileen Christensen, Sally Coghlan-McDonald, F Sessions Cole, Sarah Collins, Elizabeth Corless, Roxi Da Silva, Amanda S Growdon, LeAnn Gubler, Roben Harris, Michele Lane, Christy JW Ledford, Christopher G Maloney, Peggy Markle, Fernando Mendoza, Alexandra N Mercer, Katherine A O’Donnell, Mary Ottolini, Rita Pickler, Matthew W Ramotar, Lee M Sanders, Kimberly Sauder, Samir S Shah, Meesha Sharma, Arabella Simpkin, Laura Trueman, Tanner Trujillo, Cindy Warnick, Chelsea Welch, Andrew J White, Matthew F Wien, Ariel S Winn, and Stephanie Wintch.

  • Affiliations of Patient and Family Centered I-PASS Study Group: Benioff Children’s Hospital, San Francisco, CA, USA (Coghlan-McDonald); Boston Children’s Hospital, Boston, MA, USA (Allair, Mercer, Ramotar, Sharma); Boston Children’s Hospital/Harvard Medical School, Boston, MA, USA (Growdon, O’Donnell, Winn); Brigham and Women’s Hospital, Boston, MA, USA (Wien); Children’s Hospital of Philadelphia/Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA (Balmer); Children’s National Health System/George Washington University School of Medi\cine and Health Sciences, Washington, DC, USA (Ottolini); Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA (Chandler, Trueman); Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, OH, USA (Shah); Columbia University, New York, NY, USA (Collins); Doernbecher Children's Hospital/Oregon Health and Science University, Portland, OR, USA (Aylor); Hospital for Sick Children/University of Toronto, Toronto, ON, Canada (Beck); Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA (Atsatt, Wintch); Lucile Packard Children’s Hospital Stanford/Stanford School of Medicine, Stanford, CA, USA (Mendoza, Sanders); Massachusetts General Hospital/Harvard Medical School, Cambridge, MA, USA (Simpkin); Ohio State University College of Nursing, Colombus, OH, USA (Pickler); Primary Children’s Hospital, Salt Lake City, UT, USA (Choudhary, Christensen, Corless, Gubler, Trujillo, Warnick, Welch); Primary Children’s Hospital/University of Utah School of Medicine, Salt Lake City, UT, USA (Bale, Maloney); St Christopher’s Hospital for Children, Philadelphia, PA, USA (Alminde); St Louis Children’s Hospital, St Louis, MO, USA (Harris, Lane, Sauder); St Louis Children’s Hospital/Washington University School of Medicine in St Louis, St Louis, MO, USA (Barton, Cole, White); Uniformed Services University of the Health Sciences, Bethesda, MD, USA (Ledford); and Walter Reed National Military Medical Center, Bethesda, MD, USA (DaSilva, Markle).

  • Contributors: All authors conceived and designed the study; contributed to the acquisition, analysis, or interpretation of data; content; and critically revised the report and agreed to submit the report for publication. CPL supervised the study. AK and CPL obtained funding and drafted the initial manuscript. BMG provided administrative support. SL and CSY had full access to the data and take responsibility for the integrity of the data and the accuracy of the statistical analysis. AK is responsible for the overall content as guarantor and accepts full responsibility for the work and conduct of the study. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This project was supported by grant CDR-1306-03556 from the Patient-Centered Outcomes Research Institute (principal investigator: CPL). AK was supported by grant K12HS022986 from the Agency for Healthcare Research and Quality (principal investigator: Jonathan Finkelstein; Boston Children’s Hospital, Boston, MA). JDB was supported by grant 5T32HS00063-21 from the Agency for Healthcare Research and Quality (principal investigator: Jonathan Finkelstein). The funders had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication. Researchers were independent from funders and all authors had full access to the data and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no associations with commercial entities that provided support for the work reported in the submitted manuscript. JFB, AKD, CPL, SJP, TCS, SSS, NDS, AJS, and DCW hold equity in the I-PASS Patient Safety Institute. RS works for Intermountain Healthcare, which holds equity in the I-PASS Patient Safety Institute. SC, JKO’T, and SJP hold stock options in the I-PASS Patient Safety Institute. SC, CPL, JKO’T, SJP, GR, TCS, NDS, AJS, and DCW have consulted with the I-PASS Patient Safety Institute. The I-PASS Patient Safety Institute is a company that seeks to train institutions in best handoff practices and aid in their implementation. The current study was designed before the I-PASS Patient Safety Institute was conceived of as an entity and the I-PASS Patient Safety Institute is not involved in bedside rounds or family-centered care and was in no way involved in this study. Moreover, to ensure objectivity, all data were sent directly from the sites to the statistical team at the Data Coordinating Center, who do not have any involvement with the I-PASS Patient Safety Institute. All analyses were conducted by this statistical team. TCS, NDS, AJS, and DCW have received monetary awards, honorariums, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on physician performance and handoffs. CPL and RS are supported in part by the Children’s Hospital Association for their work as executive council members of the Pediatric Research in Inpatient Settings (PRIS) network. RS has received monetary awards, honorariums, and travel reimbursement from multiple academic and professional organizations for talks about pediatric hospitalist research networks and quality of care. CPL has also served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. In addition, CPL has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and has served as an expert witness in cases regarding patient safety and sleep deprivation. All other authors have no conflicts of interest to disclose at this time.

  • Ethical approval: This study was approved by Boston Children’s Hospital (BCH) institutional review board (IRB-P00012045) and participating institutions’ institutional review boards, either through individual site approval or reliance agreements with BCH. Participants gave informed consent before taking part. We obtained waivers of consent to review patient charts.

  • Data sharing: Individual participant data collected during the trial, after deidentification, can be made available to interested parties who follow the process outlined in the supplementary data sharing plan. No other documents are available.

  • Transparency: The lead author (AK) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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