Changes in Efficiency and Safety Culture After Integration of an I-PASS–Supported Handoff ProcessShreya Sheth, MD,a Elisa McCarthy, BA,b Alaina K. Kipps, MD,b Matthew Wood, PhD,c Stephen J. Roth, MD, MPH,b Paul J. Sharek, MD, MPH,c,d Andrew Y. Shin, MDb,c

aDivision of Pediatric Cardiology, Department of Pediatrics,

Cedars-Sinai Medical Center, Los Angeles, California;

Divisions of bPediatric Cardiology, and dPediatric

Hospitalist Medicine, Department of Pediatrics, Stanford

University School of Medicine, Palo Alto, California; and cCenter for Quality and Clinical Effectiveness, Lucile

Packard Children’s Hospital, Stanford University, Palo Alto,

California

Dr Sheth conceptualized and designed the study,

interpreted the data, and drafted the initial

manuscript; Drs Shin and Sharek designed

the study, carried out the initial analysis and

interpreted the data, and critically revised the

manuscript for important intellectual content; Ms

McCarthy and Drs Kipps, Wood, and Roth acquired

and analyzed the data and critically revised the

manuscript for important intellectual content;

and all authors approved the fi nal manuscript

as submitted and agree to be accountable for all

aspects of the work.

DOI: 10.1542/peds.2015-0166

Accepted for publication Jun 30, 2015

Address correspondence to Andrew Y. Shin, MD,

Lucile Packard Children’s Hospital, Stanford

University, 750 Welch Rd, Suite 305, Palo Alto, CA

94304. E-mail: drewshin@stanford.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2016 by the American Academy of

Pediatrics

FINANCIAL DISCLOSURE: The authors have

indicated they have no fi nancial relationships

relevant to this article to disclose.

FUNDING: No external funding.

Ineffective handoff communication

is a recognized patient safety risk

in health care. In response, quality

improvement experts have developed

methods for structuring and

standardizing transfer processes and

handoff communication. These have

included mnemonics for use during

handovers, scripts or worksheets for

the standardization of information

conveyed, and the minimization of

interruptions and distractions during

verbal handovers.1–4 Recent studies

have also reported successfully

leveraging multidisciplinary team

strategies and workflow adjustments,

such as reducing nighttime transfers

from the ICU.5 Most notably, the

implementation of the I-PASS (illness

severity, patient summary, action list,

situation awareness and contingency

plans, and synthesis by receiver)–

supported handoff bundle studied

with resident-to-resident handoffs has

abstractBACKGROUND AND OBJECTIVES: Recent publications have shown improved outcomes

associated with resident-to-resident handoff processes. However, the

implementation of similar handoff processes for patients moving between

units and teams with expansive responsibilities presents unique challenges.

We sought to determine the impact of a multidisciplinary standardized

handoff process on efficiency, safety culture, and satisfaction.

METHODS: A prospective improvement initiative to standardize handoffs

during patient transitions from the cardiovascular ICU to the acute care unit

was implemented in a university-affiliated children’s hospital.

RESULTS: Time between verbal handoff and patient transfer decreased from

baseline (397 ± 167 minutes) to the postintervention period (24 ± 21

minutes) (P < .01). Percentage positive scores for the handoff/transitions

domain of a national culture of safety survey improved (39.8% vs 15.2%

and 38.8% vs 19.6%; P = .005 and 0.03, respectively). Provider satisfaction

improved related to the information conveyed (34% to 41%; P = .03), time to

transfer (5% to 34%; P < .01), and overall experience (3% to 24%; P < .01).

Family satisfaction improved for several questions, including: "satisfaction

with the information conveyed” (42% to 70%; P = .02), “opportunities to ask

questions” (46% to 74%; P < .01), and “Acute Care team's knowledgeabout

my child’s issues” (50% to 73%; P = .04). No differences in rates of

readmission, rapid response team calls, or mortality were observed.

CONCLUSIONS: Implementation of a multidisciplinary I-PASS–supported handoff

process for patients transferring from the cardiovascular ICU to the acute

care unit resulted in improved transfer efficiency, safety culture scores, and

satisfaction of providers and families.

QUALITY REPORTPEDIATRICS Volume 137 , number 2 , February 2016 :e 20150166

To cite: Sheth S, McCarthy E, Kipps AK, et al.

Changes in Effi ciency and Safety Culture After

Integration of an I-PASS–Supported Handoff

Process. Pediatrics. 2016;137(2):e20150166

SHETH et al

shown reductions in medical errors

and preventable adverse events.1,6–8

Although previous reports have

shown important benefits in

standardizing handoffs, there is little

information available reflecting the

association of standardized handoff

process with efficiency and culture

of safety. One recent report found

that a standardized communication

process was not associated with

an increase in time for handoff

between the operating room and

the recovery room.9 In such cases in

which patients are transferred from

1 unit to another, efficient handoffs

between sending and receiving unit

teams are challenged by disparate

clinical agendas, contributing to

delays in the transfer process.10 The

impacts on efficiency and safety

culture from standardized handoff

processes are outcome measures

of interest to investigators and

clinicians alike to explore the value

and reliability of timely but safe care.

The goals of our quality improvement

efforts were as follows: (1) to

redesign the process for patient

transfer between the cardiovascular

ICU (CVICU) to the acute care unit

(ACU), including an integration of

the previously successful I-PASS1

tool; (2) to reduce delays in patient

transfer; (3) to improve the culture

of safety surrounding handoffs and

transitions in these 2 units; and (4)

to maintain patient/family and care

provider satisfaction surrounding the

transfer process.

METHODS

Setting

We conducted a prospective cohort

study using data from July 2012 to

January 2013 to assess the impact

of an I-PASS–supported handoff

process for patients transferring

from the CVICU to the ACU. The

quality improvement initiative was

conducted at the Children’s Heart

Center at Lucile Packard Children’s

Hospital, a nonprofit, freestanding

academic children’s hospital at

Stanford University. The center

has ∼800 admissions per year and

provides all of the hospital services

for cardiology and cardiovascular

surgery, treating both children

and adults with congenital heart

disease and children with acquired

heart disease. Patients admitted

to the CVICU commonly transition

their care to the ACU before being

discharged from the hospital. Cardiac

care is provided by teams of medical

students, residents, cardiology and

critical care fellows, hospitalists and

advanced practice providers and is

supervised by attending physicians.

The Institutional Review Board at

Stanford University Medical Center

approved the study and certified

that it met the criteria for a waiver

of informed consent. This article

was prepared in accordance with

the SQUIRE (Standards for Quality

Improvement Reporting Excellence)

guidelines.11

Planning the Quality Improvement Intervention

The Heart Center Handoff Taskforce

was formed in July 2011 in response

to a trending gap between our

institution’s performance and that

of other pediatric institutions with

handoff/transitions survey results

from the Agency for Healthcare

Research and Quality’s Hospital

Survey on Patient Safety Culture.12

The taskforce primarily consisted

of a cardiology-trained quality

improvement fellow working

with CVICU- and ACU-based local

improvement teams (Table 1).

The local improvement teams

at Lucile Packard Children’s

Hospital are modeled after

the Dartmouth and Institute

for Healthcare Improvement’s

clinical microsystems.13 The

teams’ responsibilities included

participation in all aspects of

development and implementation

of the intervention and subsequent

auditing and iterative improvement.

The Handoff Taskforce was formed

during a hospitalwide effort to

standardize communication to a

“one message, one time” handoff

process, where all teams involved

in a patient care transition were

brought together for a single face-

to-face communication supported

by information prepopulated in

the electronic medical record

in an I-PASS format, conscious

minimization of distractions, a formal

time for questions to be asked, and

a formal spoken acknowledgment

of acceptance of accountability for

the patient from the receiving team.9

The Handoff Taskforce reported to

an institutional handoff oversight

committee but had the ultimate

responsibility of tailoring the transfer

process to the CVICU and ACU

workflows.

In an effort to effect rapid process

improvement, the team met weekly,

set goals, developed and implemented

an education plan and process flow

map (Fig 1), and used the Institute

2

TABLE 1 Heart Center Handoff Taskforce

Team Role Role Within the Organization

Executive sponsors Chief Patient Safety Offi cer

Medical Director, CVICU

Medical Director, Cardiac ACU

Team leader Heart Center Quality Improvement fellow

Core team Cardiology administrative support

CVICU Local Improvement Team

Cardiac ACU Local Improvement Team

Ad hoc members Representative, transfer center

Representative, patient placement services

Administrative Director, Heart Center

Charge nurse

PEDIATRICS Volume 137 , number 2 , February 2016

of Healthcare Improvement’s Plan,

Do, Study, Act (PDSA) methodology14

to modify the handoff bundle with

subsequent iterative improvements.

Efficiency and compliance data

were analyzed on a monthly basis

throughout the study period, and

this information was used to plan

any changes to the process or to

further education. The taskforce’s

work, along with the hospitalwide

handoff efforts, was influenced by

participation in the concurrent

Child Health Corporation of America

23-children’s hospital handoff–

focused collaborative Improving Patient Handoffs.15 This participation

allowed both access to webinars and

presentations that identified potential

or perceived barriers to success from

other institutions’ experiences and

venues to solicit direct feedback on

the work of the taskforce.

Intervention

The handoff bundle consisted of 4

major elements. First, the taskforce

defined the handoff intent to ensure

that a common understanding of the

patient is achieved. The common

understanding was confirmed

by the receiving team’s use of a

“read-back” technique. Second,

the taskforce standardized the

handoff content, aided by a standard

template using the I-PASS structure

with prepopulated patient-specific

information pulled from the

electronic medical record. Third, the

handoff process was standardized

to require sending and receiving

team disciplines to participate in

face-to-face communication in a

“one-message, one-time” format with

time allocated for receiver synthesis

of information and questions. Fourth,

the handoff concluded with a formal

acknowledgment of responsibility

and accountability to ensure clear

transition of care.

Patient Population

Demographic features (age, gender)

and surgical complexity (as defined

by the Risk Adjusted Congenital

Heart Surgery Score [RACHS-1]16)

were collected. Case-mix index, based

on the US Centers for Medicare and

Medicaid Services cost weights,

was assessed for each patient who

spent at least 1 day in the CVICU

and transferred to the ACU during

the baseline or postintervention

time frame. Patients in the baseline

and postintervention periods were

compared to determine if significant

differences in demographic

characteristics or severity of illness

existed.17

3

FIGURE 1Process fl ow map that shows the 5 phases of the handoff sequence, including standardization of the preidentifi cation process, the transfer trigger event by ACU bed availability, and the handoff bundle. APP, Advanced Practice Provider; CV, CVICU.

SHETH et al

Primary Outcome

Transfer Latency

Transfer latency was defined as

the interval between the initiation

of the verbal patient handoff in

the CVICU and the time of patient

arrival to his or her room in the

ACU. Because the baseline and

postintervention workflows included

an electronic transfer order entry

into the electronic medical record at

the time of verbal handoff, we were

able to measure transfer latency

directly as the time between transfer

order entry and time of patient

arrival to the ACU. Transfer latency

was determined to be the most

important outcome metric in this

initiative because the period of time

between the verbal handoff and the

patient’s transfer at our institution

was a period of risk associated with

confusion in provider accountability

and/or decreased clinical monitoring

Secondary Outcome

Culture of Safety

We evaluated the impact of the

intervention on the handoffs and

transitions domain of the Agency

for Healthcare Research and

Quality’s Culture of Safety survey

tool. Specifically, the 2 items “things

‘fall between the cracks’ when

transferring patients from one unit

to another” and “problems often

occur in the exchange of information

across hospital units” were evaluated

for the CVICU and the ACU from the

hospitalwide survey completed in

2012 (preintervention) and 2014

(postintervention).

Compliance to Handoff Process

The compliance to the handoff

process was measured by auditors

using a convenience sampling

method. Compliance was defined as

meeting all elements of the handoff

bundle.

Balancing Measures

Provider Satisfaction

We evaluated the impact of

provider satisfaction using a

12-question survey tool for the

providers involved in patients

transferred in the postintervention

period. Preintervention provider

satisfaction was determined by

surveying providers for a 2-month

period before the intervention.

Postintervention provider

satisfaction was determined by

surveying providers ∼6 months after

completion of the postintervention

period. Each of the 12 questions

had the following 5 answer options:

(1) strongly agree, (2) agree, (3)

neutral, (4) disagree, and (5) strongly

disagree. A positive response was

considered as answers of either

“strongly agree” and “agree,” and

the percentage of positive responses

was defined as the total number of

positive responses over the total

number of responses.

Family Satisfaction

We evaluated the impact of patient

satisfaction using a 12-question

survey tool for families present at

the time of transfer for all patients

transferred during the baseline and

postintervention periods. Patients

and families were surveyed with a

face-to-face structured interview ∼30

to 60 minutes after handoff by using

a convenience sampling approach.

Each question had the following 5

options for answering: (1) strongly

agree, (2) agree, (3) neutral, (4)

disagree, and (5) strongly disagree.

A positive response was considered

as answers of either “strongly agree”

and “agree,” and the percentage of

positive responses was defined as the

total number of positive responses

over the total number of responses.

Data Analysis

Descriptive statistics were used to

compare patient characteristics in

the time periods before and after

the intervention with variables

expressed as means with SDs or

medians with interquartile ranges

according to their parametric

distribution. A process control chart

was used to follow transfer latency

time over the study period. Unless

otherwise specified, χ2 analysis,

Fisher’s exact test, rank-sum test,

and Mann-Whitney U test were used

to compare the transfer latency

periods, patient characteristics, and

survey response before and after

the intervention. Statistical analyses

were performed with the use of

PRISM, version 5.0a (2007).

RESULTS

Patient Characteristics

A total of 278 patient transfers from

the CVICU to the ACU occurred

during the study period. A total of

122 (47%) transfers were audited for

bundle compliance by convenience

sampling and included for analyses.

Full compliance to the elements

of the handoff bundle occurred

for 114 (93.4%) of these 122

audited transfers. Characteristics of

inpatients included during the study

protocol are displayed in Table 2.

Transfer Latency

There was a significant reduction

in transfer latency time after the

intervention. During the baseline

period, the mean latency time

was 378 ± 167 minutes; during

the intervention period, this time

was reduced to 24 ± 21 minutes,

representing an 84% reduction (Fig

2). Figure 3 shows that the decrease

in latency time occurred immediately

after implementation of the

handoff process and was sustained

throughout the postintervention

period.

Culture of Safety

Response rates to the Hospital

Survey on Patient Safety Culture

from health care providers in the

CVICU and ACU increased over time,

with 46 respondents in 2012 and 83

4

PEDIATRICS Volume 137 , number 2 , February 2016

respondents in 2014. During that

time period, there was an increase in

the mean percentage of respondents

who gave a positive response to

the 2 questions in the handoffs and

transitions domain of the survey

relevant to the between-unit handoff

process (Table 3).

Balancing Metrics

Patient and family satisfaction

in their CVICU-to-ACU transition

increased in the postintervention

period. Families reported strong

satisfaction with the information

conveyed (from 41% to 70%; P =

.02), opportunity to ask questions

(from 46% to 74%; P < .01), and

satisfaction regarding the receiving

team’s knowledge with the medical

issues (from 50% to 73%; P = .04)

after handover (Fig 4). Providers

also reported strong satisfaction in

the amount of information conveyed

(from 34% to 41%; P = .03), transfer

time after handoff (from 5% to

34%; P < .01), and overall transfer

process (from 3% to 24%; P < .01)

(Fig 5). There were no differences

in CVICU 24-hour readmission

rates, in-hospital mortality, and

rapid-response team calls between

the baseline and postintervention

periods.

DISCUSSION

We report improvements in transfer

efficiency and handoff safety

culture after the implementation of

a standardized I-PASS–supported

handoff process for patients

transferring from the CVICU to the

ACU. Although previous studies

using the I-PASS tool for between-

shifts handoffs between residents

have been associated with improved

patient safety outcomes, this is the

first report that we are aware of that

demonstrates an I-PASS–supported

handoff process associated with

improved transfer efficiency

and handoff safety culture. The

intervention, despite the inherent

challenges associated with the

coordination from both sending and

receiving teams, was not associated

with decreased satisfaction related

to the handoff process. In fact, the

new process was associated with

improved satisfaction with the

transfer experience among families

and providers involved in the patient

care transition.

Our findings are aligned with

previous studies that have shown

improvements in provider

satisfaction, handoff-related care

failures, and clinical outcome

with standardization of handoff

processes.6,9,18,19 However, these

studies did not specifically measure

the potential benefit on the efficiency

of care delivery often associated with

standardization in high-reliability

systems.20 A small number of

studies have measured handover

time as a balancing metric; these

5

TABLE 2 Characteristics of Inpatients at Lucile Packard Children’s Hospital During the Study Period

Characteristic Baseline Postintervention P

Age, y 3.1 (0.4–11.8) 3.9 (0.5–14.1) .08

Female gender, n (%) 193 (48.2) 181 (46.8) .7

CVICU LOS, d 9.6 (16.6) 9.4 (17.8) .4

ACU LOS, d 5.7 (9.8) 5.5 (8.9) .77

Total hospital LOS, d 12.4 (19.7) 11.6 (20.8) .57

ACU census 16.3 (2.8) 17.4 (2) <.01

CVICU census 15.9 (3) 18 (2.2) <.01

RACHS-1 3 (2–3) 3 (2–3) .9

Case-mix index 8.25 (5.6) 8.19 (5.5) .85

CVICU 24-hour readmission, n (%) 21 (9.3) 13 (5.3) .16

In-hospital mortality, n (%) 15 (3.8) 8 (2.1) .23

Rapid-response team calls, n (%) 4 (1) 3 (0.8) 1

LOS, length of stay; RACHS-1, Risk Adjusted Congenital Heart Surgery.

FIGURE 2Scatterplot of latency time during patient care transfer categorized by baseline and postintervention periods. The horizontal lines within each group refl ect the mean.

SHETH et al

showed handover protocols to be

noninferior.9,18,21

The coordination of unit teams

with varying patient care agendas

around a patient transfer from the

CVICU to ACU introduces unique

challenges in productivity and

efficiency. Improved efficiency

adds a new dimension to the value

of standardized handover protocols,

which have already been linked to

better patient outcomes and

provider satisfaction. To our

knowledge, this is the first report

showing improved efficiency in

patient care with the use of an

I-PASS–supported handoff bundle

applied to unit-to-unit transfers

between teams.

One notable finding was the

significant baseline variation and

delay between the time of verbal

handover of patient information

and the time of patient transfer

from the CVICU to the ACU. Before

the intervention, the handoff of

information commonly occurred

far ahead of actual patient transfer.

In addition, attending, fellow, and

nursing handover of information

occurred independently from

each other and often excluded

the patient and family. This latent

period between the verbal handoff

of information and patient transfer

is a particularly vulnerable time in

patient care.22 We found that the

I-PASS–supported handoff process

eliminated important redundancy

and delay in patient care transitions

and synchronized communication

into a singular, cross-discipline

handoff at the moment of patient

transfer. This finding is consistent

with production strategies such

as Just In Time,23,24 which deploys

the “right resources (personnel), at

the right place, at the right time” to

improve efficiency. Our finding is

also consistent with high-reliability

organization theory, which suggests

that cross-training, standardization,

and shared situational awareness

lead to decreased variability and

improved efficiency, thereby

promoting safety in complex

environments.20,25

After implementation of the

redesigned handoff process, we

found significant improvements in

CVICU and ACU patient safety culture

survey scores in the “handoff and

transitions” domain. There is ample

evidence that links culture of safety

to reductions in preventable harm

and mortality.26–28 Improvements

in safety culture have also been

associated with reductions in adverse

events within hospitals.29 Yet, only a

few reports have described quality

improvement initiatives associated

with shifts in safety culture over

time. We found that multidisciplinary

participation in a standardized

handoff process was associated

with significant improvements in

handoff-related safety culture

scores for the 2 questions relevant

to between-unit handoffs over a

3-year span.

We found that the inclusion of

families was associated with

improved satisfaction with several

components of the transition. As

previous studies have shown,

transfer from the ICU can be a source

of significant anxiety for a patient

and his/her family.30,31 Families are

increasingly being recognized as an

essential part of the care team, and

6

FIGURE 3Statistical process control chart showing latency time over time during the study period. The intervention was implemented on July 5, 2012. Upper and lower confi dence limits denote 3 SDs. LCL, lower confi dence limit; UCL, upper confi dence limit.

TABLE 3 Culture of Safety Survey Results for CVICU and ACU

Survey Question 2012 2014 Pa

Positive, % N Positive, % N

Things “fall between the cracks” when

transferring patients from 1 unit to

another

15.20 46 39.80 83 .005

Problems often occur in the exchange of

information across hospital units

19.60 46 38.80 85 .031

The percentage positive responses are based on those who responded “Strongly disagree” or “Disagree,” or “Never” or

“Rarely” (depending on the response category).a Fisher’s exact test.

PEDIATRICS Volume 137 , number 2 , February 2016

many children’s hospitals are moving

to more family-centered rounding

processes.32 Integrating families into

the handoff process offers several

advantages that are consistent with

the theories behind family-centered

care. We observed a high baseline

level of family satisfaction with

handoffs. We surmise that this high

baseline satisfaction level resulted

from our institution’s previous

adoption and robust integration

of family-centered care before and

during the study period. Still, family

and patient satisfaction significantly

increased during the implementation

period, suggesting that their

formal inclusion in a standardized

process is associated with enhanced

satisfaction adjunctive to a culture

of family centeredness. Similar to

previous single-site studies,18 we

also found that provider satisfaction

was not compromised after the

implementation of a standard

handoff process.

There are several limitations to our

study that deserve discussion. First,

because this is an experience from

a single institution, some of the

success in improving efficiency and

culture observed may be attributed

to unique institutional features.

However, previous studies have

highlighted important patient risk

during transitions in care, so it is

likely that other institutions may

benefit from similar approaches.

Second, because this was a pre-post

study, concurrent improvement

initiatives, the Hawthorne effect,

or unrecognized secular trends

may be important biases that could

have influenced our observations.

For example, we did observe small

differences in CVICU and ACU

censuses between the baseline

and postintervention periods.

Although statistically significant,

we do not think these differences

are clinically significant or likely

to bias our outcome measures. In

fact, the postintervention period

showed higher census activity

than the baseline, suggesting

that transfer efficiency improved

despite increased unit-level activity.

In addition, bias resulting from

concurrent improvement initiatives

is unlikely given the significant and

sustained centerline shift witnessed

in the statistical control chart at the

exact time of the intervention (Fig

3). Third, data regarding satisfaction

were obtained by interview. The

nature of asking the same questions

to the same providers throughout

the implementation period subjects

the process to confirmation bias or

anchoring. Fourth, although we were

able to demonstrate improvements

in transfer efficiency and culture, we

did not evaluate the impact of this

process on clinical harm. Although

the findings of this study include

key measures of the Institute of

Medicine’s 6 specific domains of

quality care (specifically efficient,

timely, and patient-centered

care), future investigations should

focus on the clinical impact of this

7

FIGURE 4Patient and family survey results categorized by pre- and postintervention periods. 3W, acute care unit.

FIGURE 5Provider survey results categorized by pre- and postintervention periods. 3W, acute care unit.

SHETH et al

I-PASS–supported handoff process

when analyzing unit-to-unit transfers

to better understand the impact on

clinical harms.

CONCLUSIONS

We found improvements in transfer

efficiency and handoff-related patient

safety culture during patient care

transitions after the implementation

of an I-PASS–supported handoff

process. The handoff process was

not associated with decreased

provider satisfaction and was, in

fact, associated with improved

satisfaction among patients, families,

and providers. Future studies of this

handoff process should evaluate the

impact on clinical harms, operational

productivity, and cost-effectiveness.

ACKNOWLEDGMENTS

We thank Dr Jeffrey Feinstein,

MD, MPH, for his mentorship and

leadership support and Ms Sherry

Nakamura, RN, Ms Alice Rich, RN,

Ms Alexandra Norloff, RN, and

Ms Danielle Toner, NP, who all

contributed important insights into

the development and sustainability of

this project.

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ABBREVIATIONS

ACU:  acute care unit

CVICU:  cardiovascular ICU

I-PASS:  illness severity, patient

summary, action list,

situation awareness and

contingency plans, and

synthesis by receiver

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

PEDIATRICS Volume 137 , number 2 , February 2016

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