Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

Khan A1,2, Spector ND3,4, Baird JD5, Ashland M6, Starmer AJ1,2, Rosenbluth G7,8, Garcia BM7,2, Litterer KP9, Rogers JE10, Dalal AK1,11, Lipsitz S1,11, Yoon CS11, Zigmont KR11, Guiot A12,13, O'Toole JK12,13, Patel A14,15, Bismilla Z16,17, Coffey M16,17, Langrish K18,19, Blankenburg RL20,21, Destino LA20,21, Everhart JL20,21, Good BP22,23, Kocolas I22,23, Srivastava R22,23, Calaman S3,4, Cray S24, Kuzma N3,4, Lewis K3,4, Thompson ED3,4, Hepps JH25,26, Lopreiato JO25, Yu CE25,26, Haskell H27, Kruvand E28,29, Micalizzi DA30, Alvarado-Little W31,31, Dreyer BP32,33, Yin HS32,34, Subramony A35,36, Patel SJ37,38, Sectish TC1,2, West DC7,8, Landrigan CP1,2,39.

Author information

1: Harvard Medical School, Boston, MA, USA.
2: Department of Medicine and Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.
3: Drexel University College of Medicine, Philadelphia, PA, USA.
4: Department of Pediatrics, St Christopher's Hospital for Children, Philadelphia, PA, USA.
5: Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA, USA.
6: Family-Centered Care Department, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
7: University of California San Francisco School of Medicine, San Francisco, CA, USA.
8: Department of Pediatrics, Benioff Children's Hospital, San Francisco, CA, USA.
9: Office of Experience, Boston Children's Hospital, Boston, MA, USA.
10: Inpatient Medicine, Boston Children's Hospital, Boston, MA, USA.
11: Center for Patient Safety Research, Division of General Medicine, Department of Medicine at Brigham and Women's Hospital, Boston, MA, USA.
12: University of Cincinnati College of Medicine, Cincinnati, OH, USA.
13: Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
14: University of California San Diego School of Medicine, San Diego, CA, USA.
15: Division of Pediatric Hospital Medicine, Rady Children's Hospital San Diego, San Diego, CA, USA.
16: Pediatrics, University of Toronto, Toronto, ON, Canada.
17: Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.
18: Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
19: Division of Pediatric Hospital Medicine, Hospital for Sick Children, Toronto, ON, Canada.
20: Stanford School of Medicine, Palo Alto, CA, USA.
21: Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
22: University of Utah School of Medicine, Salt Lake City, UT, USA.
23: Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT, USA.
24: Family Advisory Council, St Christopher's Hospital for Children, Philadelphia, PA, USA.
25: Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
26: Walter Reed National Military Medical Center, Bethesda, MD, USA.
27: Mothers Against Medical Error, Columbia, SC, USA.
28: Family Partner Program, St Louis Children's Hospital, St Louis, MO, USA.
29: St Louis Children's Hospital, St Louis, MO, USA.
30: The Justin's HOPE Project, Task Force for Global Health, Decatur, GA, USA.
31: New York State Department of Health, New York, NY, USA.
32: New York University School of Medicine, New York, NY, USA.
33: Division of Developmental-Behavioral Pediatrics, New York University Langone Medical Center, New York, NY, USA.
34: Departments of Pediatrics and Population Health at New York University Langone Medical Center, New York, NY, USA.
35: Cohen Children's Medical Center, New York, NY, USA.
36: Hofstra Northwell School of Medicine, Queens, NY, USA.
37: University of Hawaii John A Burns School of Medicine, Honolulu, HI, USA.
38: Hawai'i Pacific Health, Honolulu, HI, USA.
39: Brigham and Women's Hospital, Boston, MA, USA.

Abstract

OBJECTIVE:

To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds.

DESIGN:

Prospective, multicenter before and after intervention study.

SETTING:

Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017.

PARTICIPANTS:

All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents.

INTERVENTION:

Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement.

MAIN OUTCOME MEASURES:

Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting.

RESULTS:

The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, "excellent") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly.

CONCLUSIONS:

Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds.

TRIAL REGISTRATION:

ClinicalTrials.gov NCT02320175.

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