I-PASS reaches major milestones

Handoff process marks five years of success

By Matt Phillion

Failures in communication frequently prompt medical errors, which make up one of the leading causes of death in the United States, behind heart disease and cancer. Patient handoffs present an especially high risk for communication errors. The Joint Commission has found that communication mistakes made during patient handoffs are a root cause for more than two-thirds of the most serious errors that befall patients. In addition, handoff communication errors can lead to financial costs and reputational harm.

To combat these risks, I-PASS has developed methods for improving communication during transitions—and the I-PASS Institute has just celebrated its fifth year using its process. Partnering with more than 100 U.S. hospitals, the I-PASS Institute and the I-PASS Study Group have seen significant successes over the past decade:

• 100 million handoffs using the I-PASS solution
• 3 million major and minor patient harm events prevented
• A 75% reduction in both major and minor patient harm events due to miscommunications

I-PASS co-founder Dr. Chris Landrigan, chief of general pediatrics at Boston Children’s Hospital, began looking into the issue of patient handoffs as a pediatric hospitalist.

“I trained in an era of no shift length limits,” he says, noting it wasn’t uncommon for physicians to be on for 36 hours or more at the time. “I started working on trying to understand the risks of long work hours early in my career. As we started implementing safer work schedules that eliminated these marathon shifts, handoffs between physicians working shorter shifts became more common. We realized we had to develop systems to solve handoff problems. It was pretty clear early on, the dangers there.”

The I-PASS team took lessons learned from other patient safety interventions that were having an impact in the industry, such as efforts to eliminate hospital-acquired infections (HAI). Specifically, the team observed that HAI prevention wasn’t going to happen with one silver-bullet intervention, but rather with bundles of smaller interventions to get more bang for the buck.

“They’d say, ‘Let’s not just do handwashing, but let’s also optimize the use of sterile precautions when putting in catheters, and let’s implement daily checklists to try to minimize the amount of time catheters are in place’ … a series of little things with some evidence behind each of them” to maximize the end results, Landrigan says. “Sure enough, when the whole bundle was put in place, the team working on HAIs found that rates for those kinds of infections fell 80%. We took a page from that book.”

The first issue Landrigan and his team discovered was a lack of training in how to conduct handoffs. They also thought about elements that would be conducive to a good handoff: the right people in the room, a sufficient level of quiet, and assistance from the electronic health record (which required some help from IT).

“Even building in a few little elements, we saw medical error rates plummet on our units,” says Landrigan. “It’s been an amazing thing to see. When we started out with this idea, people weren’t convinced it would make an impact. But we did careful measurement on its impact on patient safety, doctor workflows, and on the handoffs themselves, and in every one of those respects, things looked really positive.”

The single-center pilot study was published in the Journal of the American Medical Association, and this served as the preliminary data for a major grant funded by the U.S. Department of Health and Human Services. With the input of medical educators, hospitalists, health services researchers, and quality improvement experts, the pilot bundle was transformed into I-PASS. The nine-center study examining the effects of I-PASS across institutions was a huge success.

“Those results looked even better,” says Landrigan. “With that little bit of preliminary data people were more willing to engage, and with academic credentials behind it, it planted the seed for the I-PASS Institute. It really has taken off.”

Improving numbers through small changes

Returning to the parallels with successful changes to HAIs, Landrigan notes that earlier on, there was a belief that certain procedures had certain rates of infections, and HAIs were considered an inevitable downside. But over time, the field worked to demonstrate just how preventable those infections really were. Handoffs feel very similar, he says.

“If you do handoffs in a really structured, organized way, you may not get the risk to zero, but you can definitely see very substantial improvements,” says Landrigan.

As noted earlier, The Joint Commission’s sentinel event reports have found that miscommunication is the leading cause of medical errors. “It’s not isolated to one area,” says Landrigan. “It’s relevant to surgery, medicine, nursing. Everyone has handoff communication problems.”

Additionally, recent data surrounding malpractice claims indicates that as many as 30%–50% of those claims were attributable to miscommunication. Preventing even a fraction of these could have major implications for hospital risk management.

“Communication errors have an impact in every part of healthcare: medication errors, surgical errors, nursing errors,” says Landrigan. “One of the biggest issues is diagnostic errors, such as a delay when someone doesn’t pass along an abnormal lab value to the next caregiver.”

The more the I-PASS team explored ways to improve handoff communication, the more areas of relevancy they identified, Landrigan says. When they started out, their focus was on resident work hours and shift changes, but the process was also relevant to a patient changing locations, floors, or even facilities.

“A few years into this journey, our nurses approached us, saying they have similar problems to  the residents with communication. Can we adapt this for nurses?” he says. “We did, and we found that it was really effective. We then started thinking about use cases further afield.”

I-PASS would prove to be an effective tool when patients moved from an inpatient to an outpatient setting or transitioned between two care facilities, such as from acute care to rehab. “It’s effective in every single one of these settings,” says Landrigan.

The I-PASS team is currently looking at expanding I-PASS into long-term care facilities and intra-hospital transfers. It’s even hoping to include families and patients in the process with a program called Patient and Family Centered I-PASS. An initial seven-center study of that program found that even in a group of hospitals that were already using I-PASS for resident handoffs, implementing Patient and Family Centered I-PASS was associated with an additional 38% reduction in harmful medical errors. These findings were published in the British Medical Journal in 2018.

Overcoming past training

Part of the initial challenge of improving handoffs was a lack of a unified way to teach handoffs. People performed handoffs the way they were taught by their supervisor, which often did not adhere to any industry standard.

“There was no standardization in how [providers] approached it,” says Landrigan. “Each of our ideas about what should be transmitted was completely different. Some doctors were coming into handoff not appreciating the need to share any information at all, while others would give you a two-page essay on the patient, providing too much information.” What the team tried to do was find a simple, streamlined structure that was in line with the patient safety literature.

“The cornerstone of the intervention is that you’re taking the patient summary and surrounding it with high-risk elements that people forget to mention,” says Landrigan. This involves clinical nuggets of information about the patient’s illness severity, an action list regarding what needs to be done right away, and contingency planning about what might go wrong and how to react if it does. Finally, there is a short synthesis or read-back to ensure that the information is transmitted to the new provider.

“The whole notion is that you have a simple structure that is adaptable across different areas. What’s appropriate in a summary for two nurses in the ICU, for example, is different from another unit,” says Landrigan. “But we keep the structure, which can be accordioned up or down while remaining intact.”

The I-PASS team frequently hears from junior staff that just having something like this in place increases their comfort level. “It helps them do the right thing and when they themselves go off duty, they enable the next person to do a good job,” says Landrigan.

Time benefits

Concerns that I-PASS slows things down between shifts have been quantifiably allayed. Though I-PASS may seem to add steps to the handoff process, it doesn’t make the process take longer.

“In study after study, it’s been time neutral, and seems to actually make things more efficient in some settings,” says Landrigan. “One organization had been looking at nurse overtime, and found that frequently, nurses were staying on for an extra half an hour or more for their handoff process. They didn’t have a good system in place at the time. When they introduced I-PASS, that overtime cost disappeared.”

I-PASS took something the staff were doing anyway and made it better, standardizing it to save time. Plus, there’s a downstream effect, Landrigan notes, as the staff are better oriented coming onto a shift.

Training for I-PASS has evolved significantly with each stage of its development. Originally, all training was done through hands-on workshops with 50–100 people at a time. Since then, the process has been scaled up using digital tools, 3D environments, and online interactive training.

“What [Landrigan] and his team have done is gone from 100% manual to 80% today through three software programs,” says Bill Floyd, CEO of the I-PASS Institute. “When we started out we worked with smaller departments and units, but now we’ve completed a 3,000-person hospital group and are looking at a 10,000-person hospital system. The ability to scale up could not have been done with that manual process.”

“The training was a blast to develop,” adds Landrigan. “Our biggest worry shifting from manual to online was that we’d end up like one of those routine online, PowerPoint® learning programs where you click through slides as fast as you can, get your certification, and you’re done without actually learning anything. We wanted to develop something much more engaging and interactive, so we developed an immersive training platform, with 3D environments and gamification elements. In the final section, you record a verbal I-PASS handoff into the computer, and then the recording is played back to you while you look at a gold-standard list of what should have been included in that verbal handoff. It is an amazing way of giving a learner instant formative feedback, and gets them up to speed much faster than our original approach to teaching I-PASS.”

The future of I-PASS

The goal, Landrigan says, is for I-PASS to become the standard across hospitals and systems for patient handoffs.

“If everyone is using the same language, it becomes synergistic,” he says. “But we recognize there is a need to tailor handoffs for each setting. We’re really trying to strike a balance; we are sensitive that clinical workflows and needs are different across areas, at the same time we are encouraging use of a common format for handoffs. We have coaches who work closely to make sure we’re adhering to the core principles, but allow for flexibility to make it work.”

As they look to expand, the team is also aware of the financial toll of communication errors. “The cost savings by standardizing handoffs is enormous,” says Floyd. “We’re starting to have malpractice carriers pay for this because they see the savings” that come from getting handoffs right.

“Adverse events and errors just from an operations standpoint are incredibly expensive,” adds Landrigan. “Smaller adverse events are extremely common in hospitals, and their costs add up fast.”

There is also evidence that malpractice claims tend to be more expensive if miscommunication is involved. “If a pediatrician and a surgeon don’t talk to each other and something goes wrong, it’s indefensible,” says Landrigan. “Those sorts of claims are much more likely … than most medical malpractice claims to lead to an expensive settlement or trial, and the costs incurred are greater.”

“The major motivator for most hospital leaders is to do the right thing,” he says. “They want their hospitals to provide the best, safest care possible. But often it’s hard to overcome the question of how to pay for an intervention when there are a million competing priorities and finances are tight. We have developed ROI models that demonstrate that the saving from implementing I-PASS recuperate the cost of implementing the program in very short order.”

In the end, the goal is still to improve handoffs across the industry. “Our next big step is to have more and more health systems wanting to do this, to start having a meaningful impact, and to get nursing homes, families, and patients into the mix as well,” says Landrigan. “The only way to truly make a dent in the national rates of errors and adverse events is to take successful interventions like I-PASS and figure out how to scale and spread them.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com. This story first ran on PSQH.