Children's Hospitals Today - Spring 2022 - 5

INNOVATION / ROUNDS
Changing hands
A system-wide change reduced serious
safety events and improved efficiency
and reliability-despite the pandemic.
BY ELIZABETH BURNETT, BRIAN WAGERS
and JENNA YARNELL
I
n 2018, a quality and safety team at Riley Hospital for Children
at Indiana University Health reviewed the previous year's
data and identified communication errors as one of the top three
failure modes in safety events. After further investigation, the
team discovered communication errors were responsible for
72% of the serious safety events at the hospital from 2016 to 2019.
This data served as a call to action for the team to improve the
efficiency and reliability of handoffs. Little did they know their
efforts would be further challenged by a pandemic.
The team realized that to improve responsibility transfers,
the entire organization needed to adopt a change. Along with
support from executive leadership, the team sought to implement
I-PASS to standardize handoffs for all team members,
regardless of role. The I-PASS
launch was planned for National
Patient Safety Awareness Week
in March 2020. The week focused
on standardizing responsibility
transfer, education and leader
rounding. But within hours of day
one, the first cases of COVID-19
were confirmed in the state. Health
care teams began to shift to remote operations and plan for the
realities of carrying on daily hospital operations amid a pandemic.
The team faced a difficult decision: continue with I-PASS
implementation or halt the launch? With data reminding them
that handoffs were currently not optimal and recognizing the
need for proper handoffs in a time of crisis, the team continued
with the rollout. Within months, more than 2,900 health care
team members participated in the I-PASS training process.
After two months of staying the course, the team recognized
that communication was getting lost as the focus on COVID-19
took precedent. They relaunched the initiative in June 2020,
as the pace of change with COVID-19 information slowed and
staff settled into the new normal.
Initially, the team saw a decrease in handoff errors. Overall,
there was a 27% decrease in handoff errors from 2019 (preimplementation)
to 2020. Even with the decreased patient
encounters, the team sought ways to improve uptake and
sustainment of I-PASS use. Strategies focused on storytelling,
and daily management boards prompted conversations
around successes and barriers to using I-PASS. Secret shopper
observations and auditing were used to understand the state
of I-PASS use, and by December 2020, data showed that 80% of
handoffs were using the five components of I-PASS.
Overall, Riley Children's Hospital benefited from standardMore
than half of the
reporting children's hospitals
in the Child Health Patient
Safety Organization noted
communication as a top
contributor to diagnostic errors,
prompting the creation of a
toolkit to enhance diagnostic
safety. View the toolkit at
childrenshospitals.org/dxtoolkit.
izing transfers of responsibility throughout all roles in the
organization. Leaders were surveyed five months post implementation
to identify any barriers and elicit stories regarding
improved patient care or staff well-being.
Positive outcomes were attributable to having a common language
and process for transferring responsibility for patients,
projects and challenges. One story came from the social work
team, who said I-PASS increased the efficiency of their handoffs
in a way that allowed them to assess patients' social determinants
of health and unify the care provided between outpatient
and inpatient environments more sufficiently.
As Riley Children's Hospital continues this work, the team
meets regularly to determine next steps on the journey toward
reliability for handoff communication. Although the focus will
remain system-wide and include communication beyond the
diagnostic process, tools provided in CHA's diagnostic patient
safety toolkit will be leveraged in advancing the hospital's reach
related to handoff communication.
Elizabeth Burnett B.S.N., RN, CPN, CPPS, is a safety improvement
consultant; Brian Wagers, M.D., FAAP, is the associate
chief medical officer, physician director of Pediatric and
Maternal Quality and Safety; and Jenna Yarnell, M.S., CCLS, is
a child life supervisor at Riley Hospital for Children at Indiana
University Health in Indianapolis.
Tell your hospital's story. Email magazine@childrenshospitals.org.
CHILDREN'S HOSPITALS TODAY Spring 2022
5
http://www.childrenshospitals.org/dxtoolkit
Children's Hospitals Today - Spring 2022

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