Jonathan Burlison, PhD, Patient Safety Project Manager in the Pharmaceutical Sciences department, contributed to this post.
Every year at St. Jude we see around 7,500 patients. Of those, around 3,500 are admitted as inpatients, and another 75,000 outpatient visits occur. Patients receive care from different specialists working as part of a multidisciplinary team, and treatment can last for months to years. St. Jude affiliate clinics account for 40% of the hospital’s new oncology patients, with patient care coordinated across eight affiliate sites and the main hospital. Our model of care involves many patient handoffs and transitions of care, which are vulnerable points where key information can be lost or misinterpreted.
Effective patient handoffs help maintain safe and efficient patient care. Ideally, handoffs should be concise to prepare the next clinician to care for that patient and to supplement other discussions of the patient’s history and care plan. Following a consistent structure helps make certain the clinicians address the relevant patient summaries, current patient needs, ongoing concerns and specific contingency plans for care in the coming hours.
Before our efforts, patient handoffs and transitions of care at St. Jude varied by area and by discipline. Communication failures are recognized as a root cause of serious patient safety events. Opportunities to improve handoff communication were evident at St. Jude, and no standard method was established across the hospital. To make improvements, teams led by the Office of Quality and Patient Care and the St. Jude Affiliate program engaged many St. Jude clinicians to standardize patient handoff practices.
For patient handoffs within the hospital, both from shift-to-shift and as patients travel throughout the hospital for procedures and imaging services, we adapted and implemented I-PASS. The acronym stands for illness severity (I), patient summary (P), action list (A), situational awareness and contingency plans (S) and synthesis by the receiver (S). SMART, which stands for summary (S), medications/road map (M), action plan (A), return visit setup (R) and transfer handoff complete (T) was developed and implemented to structure communication as patient care is transitioned from and to the St. Jude campus and affiliate clinics. Two publications outlining the I-PASS and SMART quality improvement efforts were recently published in Pediatric Quality and Safety.
Pediatric patient safety researchers established robust evidence for the ability of the I-PASS handoff model to reduce medical error and preventable adverse events. A paper on that process appeared in the New England Journal of Medicine. I-PASS helps to create a consistent pattern of communication among clinicians who need to share information for patient care.
I-PASS’ potential for reducing preventable patient harm is backed by rigorous evidence, but its use was largely limited to physicians in training. We saw potential for the model’s scope to be expanded, and we adapted I-PASS for handoff contexts throughout the hospital, across many disciplines and settings.
We partnered with clinicians to adapt handoff details to each context in which we implemented I-PASS. We wanted to be sensitive to not only what information is required for a safe handoff but also that the introduction of I-PASS was efficient. Also, we developed a direct observation and feedback model that provided information for continuous improvements and helped ensure the sustained use of I-PASS. To date, I-PASS project champions have observed and documented more than 2,000 patient handoffs, and their efforts have played a critical role.
Our team identified three elements that were essential for making I-PASS a success across St. Jude. These included broad institutional support, customized written handoff documents and peer observations with feedback. With these factors in place, clinicians reported improvements in handoff performance and reduced handoff-related medical errors.
While I-PASS is making a difference for in-person handoffs, researchers at St. Jude and its affiliate clinics developed and implemented a standardized communication tool to help patient handoffs between different health care facilities.
“There are important differences in how we communicate in person compared to remotely through mediums like email,” said Sara Helmig, MD, of the Oncology department and first author of the SMART study. “Working closely with our colleagues at our affiliate clinics, we designed and developed SMART to help remove barriers to communication.”
The users worked together to diagram the existing state of communication activity when patients transitioned between locations, and helped identify roadblocks to consistent, clear communication. SMART is a structured, secure communication tool—a modification of the I-PASS method adapted for email use. One important aspect of SMART is that the person who receives the email also replies to confirm an understanding of the contents.
Quality improvement initiatives like these are an essential part of what we do at St. Jude. We better serve our core mission of treating catastrophic pediatric diseases when we look critically at ourselves to see how we can do better. I-PASS and SMART help us communicate more smoothly and ensure that all necessary information flows between clinicians across disciplines and locations.