By Alisa Khan, MD, a pediatric hospitalist and health services research fellow at Boston Children’s Hospital and Christopher Landrigan, MD, MPH, director of Boston Children’s Inpatient Program, recently received the Community/Patient Empowerment Award at the National Pediatric Innovation Summit sponsored by the hospital.
Miscommunications are responsible for more than 70 percent of sentinel events in hospitals, according to The Joint Commission and the Department of Defense. A sentinel event happens when a patient has an injury related to medical care that wouldn't normally be expected when treating that illness.
Boston Children’s has launched several successful projects to improve these communications. Its focus thus far has been on improving clinician-to-clinician communication during patient “handoffs”: the time when one doctor's shift ends and another begins. These initiatives resulted in a 40 percent reduction in medical errors, and a 54 percent reduction in preventable adverse events (harmful, undesired events). Read more about it in this vector blog.
This successful intervention at Boston Children’s gave rise to I-PASS, a multi-faceted handoff improvement program that is being rolled out at 10 children’s hospitals across North America.
While I-PASS has greatly improved patient safety and communication between doctors, nurses and specialists, it wasn’t designed to involve the family. But families play an important role when it comes to patient safety, advocating for their children and helping them throughout their illnesses.
Families and health care providers communicate in many ways, but one of the most common connections occurs once a day through family-centered rounds—a time for all of the members of the health care team to get together to discuss the patient's care plan. During rounds families are invited to listen, add comments and ask any questions they may have. But these family-centered rounds usually occur in the mornings, a time when families may not be awake or present at the bedside. In some cases the family may not get a second chance to reconnect with the care team as the day progress, or may not hear about the latest recommendations and test results—usually available until in the afternoon—until the next morning.
Missed communication opportunities
Following in the footsteps of I-PASS, we undertook the “Nighttime Communication Study” to better understand and improve communication between families and hospital staff. We gave a survey to hundreds of resident physicians and parents and then had experts evaluate their responses. This is what we found:
- In 45 percent of hospitalizations, parents and the night resident physicians had significantly different understandings of either the reasons for the child’s hospitalization or her care plan while there.
- This difference in understanding was more likely for parents who had lower levels of education or whose children had more complex care plans.
- Neither the physicians’ nor the parents’ perceptions about whether parents understood the care plan predicted whether the parents’ actual understanding was correct.
We also surveyed almost 250 parents at discharge and asked them about their experience in the hospital. We found that despite the different understandings in 45 percent of cases, only 14 percent of parents reported experiencing a communication problem during their child’s hospitalization.
These results clearly show the importance of improving hospital communication with families. Because neither residents nor families are always good judges of whether families truly understand their children’s care plan—and because families may not always identify a communication problem—clinicians may incorrectly think the family fully understands things they do not. The more we can build a truly shared understanding between clinicians and families, the better care will be.
Aligning clinicians, patients and families
Working with residents, families, nurses and administrators at Boston Children’s, and incorporating lessons from I-PASS, we came up with an idea to empower families to play a more active, informed role. We are working to implement an easy-to-use electronic family “sign-out” tool to be used by families every night. This sign-out ensures that important details are shared:
We piloted this sign-out in paper form, and the results suggested families found it helpful. This fall, we were fortunate to receive a Taking on Tomorrow Innovation Award to develop the paper form into an electronic version that works with patients' electronic medical records. We next plan to study the effect of this signout, along with additional family-centered communication systems, including evening family-centered rounds on the sickest children. We hope to see a positive effect on family experience, communication and safety.
By providing better access to information, this nightly family sign-out has the potential to empower families to play a more active, informed role in managing their children’s health in the hospital. Improving communication with families may also improve patient safety by providing an extra safeguard against miscommunications and mistakes. Ultimately, we hope that our innovation will improve the quality and safety of care we and other hospitals provide to children and their families.