TY - JOUR
T1 - Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care
T2 - Disseminating, Adapting, and Implementing the I-PASS Program
AU - for the I-PASS Study Group
AU - Starmer, Amy J.
AU - Spector, Nancy D.
AU - West, Daniel C.
AU - Srivastava, Rajendu
AU - Sectish, Theodore C.
AU - Landrigan, Christopher P.
AU - Landrigan, Christopher P.
AU - Spector, Nancy D.
AU - Starmer, Amy J.
AU - Sectish, Theodore C.
AU - West, Daniel C.
AU - Menon, Aravind Ajakumar
AU - Ali, Arshia
AU - Allair, Brenda K.
AU - Allen, April D.
AU - Almaddah, Nureddin
AU - Alminde, Claire
AU - Alvarado-Little, Wilma
AU - Anson, Elizabeth
AU - Ashland, Michele
AU - Atsatt, Marisa
AU - Aylor, Megan
AU - Baird, Jennifer D.
AU - Bale, James F.
AU - Balmer, Dorene
AU - Barber, Aisha
AU - Barton, Kevin
AU - Bates, Kimberly
AU - Beck, Carolyn
AU - Berchelmann, Kathleen
AU - Bhan, Renuka
AU - Bismilla, Zia
AU - Blankenburg, Rebecca L.
AU - Boa-Hocbo, Aileen
AU - Bordin-Wosk, Talya
AU - Brooks, Michelle
AU - Calaman, Sharon
AU - Campe, Julie
AU - Campos, Maria Lucia
AU - Chandler, Debra
AU - Cheung, Yvonne
AU - Choudhary, Amanda
AU - Christensen, Eileen
AU - Clark, Katherine
AU - Coffey, Maitreya
AU - Coghlan-McDonald, Sally
AU - Cohen, Ellen
AU - Cole, F. Sessions
AU - Corless, Elizabeth
AU - Vaniawala, Vishwas
N1 - Funding Information:
Communication problems have been long considered a leading cause of medical errors—which are in turn a leading cause of death and injury in the United States and beyond. Patient handoffs, which are vulnerable to communication failures, occur multiple times each day in all hospitals. I-PASS was designed to reduce handoff-related communication failures by training patient care providers to use a standardized, structured method to hand off patient responsibility and minimize the risk of communication failures. I-PASS is one of only a handful of patient safety interventions proven in large multicenter studies to be associated with significant reductions in preventable injuries due to medical care. In light of the substantial reductions in medical errors that followed implementation of I-PASS and its broad applicability across different types of transitions in care, disciplines, and health care settings, we believe that widespread adoption and implementation of I-PASS has the potential to transform patient safety. Funding. The work of the I-PASS Study Group has been supported by the following sources of grant funding: 1. Implementing a Comprehensive Handoff Program to Improve Patient Safety (2009–2010) U.S. Department of Defense (Principal Investigator [PI]: Landrigan) (Grant Number: BAA01 07005001 ) 2. Implementing a Pediatric Handoff Program to Improve Pediatric Patient Safety (2009–2010) Harvard Risk Management Foundation (HRMF) (PI: Landrigan) 3. Effects of a Comprehensive Handoff Program on Resident Workflow (2009–2010) Boston Children's Hospital Program for Patient Safety and Quality (PPSQ) (PI: Starmer) 4. Quantifying Nursing Workflow and Handoff Practices to Investigate the Impact of a Multidisciplinary Handoff Program on Communication and Patient Safety (2010–2013) Boston Children's Hospital PPSQ (PI: Starmer) 5. Bundling Effective Resident Hand Off Practices To Improve Patient Safety (2010–2013) U.S. Department of Health and Human Services (PI: Landrigan) (Grant Number: R18 AE000029 ) 6. Oregon Comparative Effectiveness Research K12 Program (2011–2013) Agency for Healthcare Research and Quality (AHRQ) (PI: Guise) (Grant Number: 1K12HS019456-01 ) 7. Patient Safety Culture and Quality of Patient Care: Relationship Between Measures of Patient Safety Culture and Physician Workflow Patterns, Communication, and Medical Error Rates (2011–2013) Medical Research Foundation of Oregon (PI: Starmer) 8. Improving Resident Handoff in Teaching Hospitals: Understanding Implementation and Effectiveness of a Handoff Bundle (2011–2013) Physicians Services Inc. Foundation (PI: Coffey) 9. Development of Self-Directed Computer Modules. Pfizer Grant (PI: Calaman) 10. Closing the Gap in Handoff Communications: Evaluating the Effects of an I-PASS Medical Student Handoff Bundle (2013–2014) Council on Medical Student Education in Pediatrics (PI: Guiot) 11. The I-PASS Electronic Family Signout: A Technological Innovation to Empower and Engage Families of Hospitalized Patients (2013–2017) Boston Children's Hospital Innovation Award (PI: Landrigan) 12. Bringing I-PASS to the Bedside: A Communication Bundle to Improve Patient Safety and Experience (2014–2017) Patient-Centered Outcomes Research Institute (PI: Landrigan) (Grant Number: CDR-1306-03556 ) 13. Disseminating Safe Handoffs: Mentored Implementation of the I-PASS Program (2014–2017) AHRQ (PI: Landrigan) 14. I-PASS: Improved Handoffs for Safer Care at CRICO Hospitals (2014–2017) HRMF (PI: Landrigan) 15. Ensuring High Reliability Communication Between Ambulatory Care Settings and the Emergency Department to Improve Patient Safety (2016–2017) PPSQ (PI: Starmer). Acknowledgments. The authors extend their deepest appreciation to the faculty, residents, nurses, patients, and families who participated in the I-PASS studies, as well as those who served as research assistants, study nurses, and coordinators. The I-PASS Study was supported with input from the Initiative for Innovation in Pediatric Education (IIPE) and TeamSTEPPS. The authors express special thanks to the Pediatric Research in Inpatient Settings Network (PRIS; supported by the Children's Hospital Association, the Academic Pediatric Association, the American Academy of Pediatrics, and the Society for Hospital Medicine), which has provided ongoing support for I-PASS research and dissemination efforts from the program's inception through the present. Dorene Balmer, PhD, RD; Carol L. Carraccio, MD, MA; and Alan Schwartz, PhD, supported the I-PASS Study Group as part of the IIPE. Karen M. Wilson, MD, MPH, and Sanjay Mahant, MD, MSc, provided guidance to the I-PASS Study Group from the PRIS Executive Council. John Webster served as a representative from TeamSTEPPS and provided early guidance to the I-PASS Study Group and Education Executive Committee. The authors also thank Cindy Brach, MPP, Agency for Healthcare Research and Quality, for her contributions to the Patient and Family Centered I-PASS Study; and the Society for Hospital Medicine (SHM), for contributions to the SHM-IPASS Mentored Implementation Project. Finally, the authors thank MD Anderson Cancer Center (Diane Bodurka, MD; Helene Phu; Carmen Escalante, MD; and Mohamed Ait Aiss), St. Jude Children's Research Hospital (James Hoffman, MD; Nan Henderson, BSN; Jonathan Burlison, PhD; Patricia Flynn, MD; and Joel Townsend), and Massachusetts General Hospital (David Shahian, MD; Laura Rossi, RN, PhD; Kayla McEachern; Elizabeth Mort, MD; and Roger Gino Chisari, RN, DNP) for their contributions to the advancement of our implementation model. Conflicts of Interest. Drs. Starmer, Spector, West, Srivastava, Sectish, and Landrigan cofounded, hold equity in, and serve as consultants for the I-PASS SM Patient Safety Institute, for which Drs. Starmer, Spector, Sectish, and Landrigan are also board members.
Publisher Copyright:
© 2017 The Joint Commission
PY - 2017/7
Y1 - 2017/7
N2 - Background In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. Methods To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program. Results As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASSSM Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. Conclusion Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.
AB - Background In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. Methods To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program. Results As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASSSM Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. Conclusion Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.
UR - http://www.scopus.com/inward/record.url?scp=85020083425&partnerID=8YFLogxK
U2 - 10.1016/j.jcjq.2017.04.001
DO - 10.1016/j.jcjq.2017.04.001
M3 - Article
C2 - 28648217
AN - SCOPUS:85020083425
SN - 1553-7250
VL - 43
SP - 319
EP - 329
JO - Joint Commission Journal on Quality and Patient Safety
JF - Joint Commission Journal on Quality and Patient Safety
IS - 7
ER -