Clinical Trial

. 2018 Dec 5:363:k4764.

doi: 10.1136/bmj.k4764.

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

Alisa Khan^{1

2}, Nancy D Spector^{3

4}, Jennifer D Baird⁵, Michele Ashland⁶, Amy J Starmer^{1

2}, Glenn Rosenbluth^{7

8}, Briana M Garcia^{7

2}, Katherine P Litterer⁹, Jayne E Rogers¹⁰, Anuj K Dalal^{1

11}, Stuart Lipsitz^{1

11}, Catherine S Yoon¹¹, Katherine R Zigmont¹¹, Amy Guiot^{12

13}, Jennifer K O'Toole^{12

13}, Aarti Patel^{14

15}, Zia Bismilla^{16

17}, Maitreya Coffey^{16

17}, Kate Langrish^{18

19}, Rebecca L Blankenburg^{20

21}, Lauren A Destino^{20

21}, Jennifer L Everhart^{20

21}, Brian P Good^{22

23}, Irene Kocolas^{22

23}, Rajendu Srivastava^{22

23}, Sharon Calaman^{3

4}, Sharon Cray²⁴, Nicholas Kuzma^{3

4}, Kheyandra Lewis^{3

4}, E Douglas Thompson^{3

4}, Jennifer H Hepps^{25

26}, Joseph O Lopreiato²⁵, Clifton E Yu^{25

26}, Helen Haskell²⁷, Elizabeth Kruvand^{28

29}, Dale A Micalizzi³⁰, Wilma Alvarado-Little^{31

31}, Benard P Dreyer^{32

33}, H Shonna Yin^{32

34}, Anupama Subramony^{35

36}, Shilpa J Patel^{37

38}, Theodore C Sectish^{1

2}, Daniel C West^{7

8}, Christopher P Landrigan^{1

2

39}

Affiliations

¹ Harvard Medical School, Boston, MA, USA.
² Department of Medicine and Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.
³ Drexel University College of Medicine, Philadelphia, PA, USA.
⁴ Department of Pediatrics, St Christopher's Hospital for Children, Philadelphia, PA, USA.
⁵ Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA, USA.
⁶ Family-Centered Care Department, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
⁷ University of California San Francisco School of Medicine, San Francisco, CA, USA.
⁸ Department of Pediatrics, Benioff Children's Hospital, San Francisco, CA, USA.
⁹ Office of Experience, Boston Children's Hospital, Boston, MA, USA.
¹⁰ Inpatient Medicine, Boston Children's Hospital, Boston, MA, USA.
¹¹ Center for Patient Safety Research, Division of General Medicine, Department of Medicine at Brigham and Women's Hospital, Boston, MA, USA.
¹² University of Cincinnati College of Medicine, Cincinnati, OH, USA.
¹³ Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
¹⁴ University of California San Diego School of Medicine, San Diego, CA, USA.
¹⁵ Division of Pediatric Hospital Medicine, Rady Children's Hospital San Diego, San Diego, CA, USA.
¹⁶ Pediatrics, University of Toronto, Toronto, ON, Canada.
¹⁷ Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.
¹⁸ Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
¹⁹ Division of Pediatric Hospital Medicine, Hospital for Sick Children, Toronto, ON, Canada.
²⁰ Stanford School of Medicine, Palo Alto, CA, USA.
²¹ Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
²² University of Utah School of Medicine, Salt Lake City, UT, USA.
²³ Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT, USA.
²⁴ Family Advisory Council, St Christopher's Hospital for Children, Philadelphia, PA, USA.
²⁵ Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
²⁶ Walter Reed National Military Medical Center, Bethesda, MD, USA.
²⁷ Mothers Against Medical Error, Columbia, SC, USA.
²⁸ Family Partner Program, St Louis Children's Hospital, St Louis, MO, USA.
²⁹ St Louis Children's Hospital, St Louis, MO, USA.
³⁰ The Justin's HOPE Project, Task Force for Global Health, Decatur, GA, USA.
³¹ New York State Department of Health, New York, NY, USA.
³² New York University School of Medicine, New York, NY, USA.
³³ Division of Developmental-Behavioral Pediatrics, New York University Langone Medical Center, New York, NY, USA.
³⁴ Departments of Pediatrics and Population Health at New York University Langone Medical Center, New York, NY, USA.
³⁵ Cohen Children's Medical Center, New York, NY, USA.
³⁶ Hofstra Northwell School of Medicine, Queens, NY, USA.
³⁷ University of Hawaii John A Burns School of Medicine, Honolulu, HI, USA.
³⁸ Hawai'i Pacific Health, Honolulu, HI, USA.
³⁹ Brigham and Women's Hospital, Boston, MA, USA.

PMID: 30518517
PMCID: PMC6278585
DOI: 10.1136/bmj.k4764

Clinical Trial

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

Alisa Khan et al. BMJ. 2018.

. 2018 Dec 5:363:k4764.

doi: 10.1136/bmj.k4764.

Authors

Affiliations

¹ Harvard Medical School, Boston, MA, USA.
² Department of Medicine and Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.
³ Drexel University College of Medicine, Philadelphia, PA, USA.
⁴ Department of Pediatrics, St Christopher's Hospital for Children, Philadelphia, PA, USA.
⁵ Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA, USA.
⁶ Family-Centered Care Department, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
⁷ University of California San Francisco School of Medicine, San Francisco, CA, USA.
⁸ Department of Pediatrics, Benioff Children's Hospital, San Francisco, CA, USA.
⁹ Office of Experience, Boston Children's Hospital, Boston, MA, USA.
¹⁰ Inpatient Medicine, Boston Children's Hospital, Boston, MA, USA.
¹¹ Center for Patient Safety Research, Division of General Medicine, Department of Medicine at Brigham and Women's Hospital, Boston, MA, USA.
¹² University of Cincinnati College of Medicine, Cincinnati, OH, USA.
¹³ Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
¹⁴ University of California San Diego School of Medicine, San Diego, CA, USA.
¹⁵ Division of Pediatric Hospital Medicine, Rady Children's Hospital San Diego, San Diego, CA, USA.
¹⁶ Pediatrics, University of Toronto, Toronto, ON, Canada.
¹⁷ Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.
¹⁸ Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
¹⁹ Division of Pediatric Hospital Medicine, Hospital for Sick Children, Toronto, ON, Canada.
²⁰ Stanford School of Medicine, Palo Alto, CA, USA.
²¹ Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
²² University of Utah School of Medicine, Salt Lake City, UT, USA.
²³ Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT, USA.
²⁴ Family Advisory Council, St Christopher's Hospital for Children, Philadelphia, PA, USA.
²⁵ Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
²⁶ Walter Reed National Military Medical Center, Bethesda, MD, USA.
²⁷ Mothers Against Medical Error, Columbia, SC, USA.
²⁸ Family Partner Program, St Louis Children's Hospital, St Louis, MO, USA.
²⁹ St Louis Children's Hospital, St Louis, MO, USA.
³⁰ The Justin's HOPE Project, Task Force for Global Health, Decatur, GA, USA.
³¹ New York State Department of Health, New York, NY, USA.
³² New York University School of Medicine, New York, NY, USA.
³³ Division of Developmental-Behavioral Pediatrics, New York University Langone Medical Center, New York, NY, USA.
³⁴ Departments of Pediatrics and Population Health at New York University Langone Medical Center, New York, NY, USA.
³⁵ Cohen Children's Medical Center, New York, NY, USA.
³⁶ Hofstra Northwell School of Medicine, Queens, NY, USA.
³⁷ University of Hawaii John A Burns School of Medicine, Honolulu, HI, USA.
³⁸ Hawai'i Pacific Health, Honolulu, HI, USA.
³⁹ Brigham and Women's Hospital, Boston, MA, USA.

PMID: 30518517
PMCID: PMC6278585
DOI: 10.1136/bmj.k4764

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.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PubMed Disclaimer

Conflict of interest statement

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.

Figures

**Fig 1**
Family experience before and after implementation of Patient and Family Centered I-PASS. Measured through surveys administered before discharge, six of 25 elements of family experience improved significantly after implementation of the intervention. *P<0.05. †Top box=top most response on a scale (eg, “excellent”). Response options for scale=“Not at all”, “Slightly”, “Somewhat”, “Very”, “Extremely”, except when marked by § (“Never”, “Rarely”, “Sometimes”, “Usually”, “Always”) or ¶ (“Poor”, “Fair”, “Good”, “Very good”, “Excellent”)

**Fig 2**
Changes in rounds process data before and after implementation of Patient and Family Centered I-PASS based on: (top) real time structured direct observations of rounds and (bottom) post hoc analyses of audio recordings of a subset of rounds observations. After implementation of the intervention, frequency of family centered rounds, nurse and family engagement on rounds, and provision of written summaries to families significantly increased, as did families expressing concerns at the start of rounds and synthesizing (ie, reading back) key action items and contingency plans. Families reporting illness severity improved but not significantly. Effective use of plain language by providers on rounds was unchanged. †Top-box=5, “Nurse present and paying attention to rounds. Answers questions, asks questions, and speaks up to fill in missing details and correct misinformation without prompting”. ‡Top box=5, “Family completely engaged in rounds. Answered questions, asked questions, and spoke up to fill in missing details and correct misinformation without prompting”. §Top-box=3, “Yes, completely”. ¶Top-box=4, “To a great extent”

See this image and copyright information in PMC

References

1. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:i2139. 10.1136/bmj.i2139 - DOI - PubMed
1. Institute of Medicine . To Err is Human: Building a Safer Health System. The National Academies Press, 2000. - PubMed
1. World Health Organization Regional Office for Europe. Data and statistics. www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and... (accessed 24 Oct 2018).
1. World Health Organization Regional Office for Europe. A Brief Synopsis on Patient Safety. World Health Organization: Copenhagen, 2010. www.euro.who.int/en/health-topics/Health-systems/patient-safety/publicat....
1. The Joint Commission. Sentinel event statistics released for 2014. Jt Comm Online 2015. www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf (accessed 24 Oct 2018).

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Associated data

Grants and funding

LinkOut - more resources

Full Text Sources

Medical