Shift-change handoff program recognized for improving patient safety through standardization of provider-to-provider communication

The I-PASS Study Group, of which The Hospital for Sick Children (SickKids) is a member, has been recognized for excellence and leadership in patient safety with the John M. Eisenberg Patient Safety and Quality Award. The group was awarded in the category of “Innovation in Patient Safety and Quality at the National Level” and is being recognized for the international impact of this transformational communication program that brings standardized provider communication to handoffs of care. This award is the highest level of recognition from the National Quality Forum (NQF) and the Joint Commission in the United States and was presented at the NQF’s 2017 Annual Conference on April 4, 2017.

I-PASS is a mnemonic (Illness severity, patient summary, action list, situational awareness and synthesis by receiver) which is one part of a bundled intervention to promote reliable handover of a patient’s care from one health-care provider to another. SickKids was one of nine health care organizations who participated in the original study, which found harmful medical errors fell 30 per cent after implementation of the I-PASS handoff program. Since that study, I-PASS has been adapted and implemented in most units at SickKids, including surgical units, and at over 50 hospitals across the United States and Canada.

I-PASS handoff is one example of how clear, structured communication can significantly improve patient safety. While medical errors can occur as a result of several root causes, miscommunication is a common theme in patient harm events in both at SickKids and in other hospitals. The expectation that all staff communicate in a clear and structured way is a core aspect of Caring Safely, which represents SickKids’ commitment to eliminating preventable harm to patients and staff through all-staff education and a focus on improving our safety culture. Over 4,500 SickKids staff have been trained in safety behaviours, such as “everyone communicates clearly,” and error prevention strategies, of which I-PASS is one. The goal is to train all 8,000 staff at SickKids by the end of March 2018.

A number of SickKids staff are closely involved with the ongoing work of the I-PASS Study Group. Dr. Maitreya (Trey) Coffey, Medical Officer for Patient Safety and Medical Lead for Caring Safely, and Dr. Zia Bismilla, Staff Paediatrician, assist other hospitals with the implementation of I-PASS as mentors through the Society of Hospital Medicine Mentored Implementation Program. Kate Langrish, Clinical Director, Paediatric Medicine, Dr. Sanjay Mahant, Staff Physician, Paediatric Medicine, and Dr. Carolyn Beck, inpatient Medical Director, Paediatric Medicine, have also held formal roles in the I-PASS group. Many other SickKids staff have led or assisted in the adaptation and implementation of I-PASS within and beyond SickKids. In addition, families are provided the opportunity to engage in discussions around safety and their child’s care, through an I-PASS-based nursing handoff which is conducted at the bedside on many units, allowing parents or caregivers the opportunity to listen and ask questions.

The I-PASS handoff bundle is available for download, free of charge, and has been accessed by over 3,500 individuals, representing over 500 institutions in 58 countries.