Bringing I-PASS to the Bedside and
the Unit
Faculty Development
Learning Objectives
• Activate and engage families and all members of the
inter-professional team to create a shared mental
model
• Apply health literacy principles to improve
communication
• Incorporate I-PASS structured communication as an
organizing framework for Family Centered Rounds
• Demonstrate effective use of written information to
facilitate communication with families and the interprofessional team
• Describe the new paradigm for faculty/attending level
workflow
• List appropriate educational activities for Family
Centered Rounds
• Articulate how team communication occurs
throughout the day
Patient and Family Centered I-PASS Study
We aim to:
• Reduce serious medical errors
• Improve FCR and daily communication
• Improve the shared understanding of care plans between providers and
patients and families
• Improve the patient and provider experience
Guiding principles:
• Change FCR to enhance shared understanding
• Optimize workflow
• Maintain education time by reassigning “displaced” teaching
Patient and Family Centered
I-PASS Study Organizational Chart
PRIS Executive
Council
Raj, Srivastava, Chair
Christopher P.Landrigan
Jay Berry
Patrick Conway
Ron Keren
Sanjay Mahant
Karen Wilson
Theo Zaoutis
Dissemination
Committee
I-PASS Executive
Council
Theodore C. Sectish, Chair
Christopher P. Landrigan, P.I.
Nancy D. Spector, Chair
Christopher P. Landrigan. P.I.
Theodore C. Sectish
Amy J. Starmer
Rajendu Srivastava
Daniel C. West
Scientific Oversight
Committee
Patient and Family Centered
I-PASS Coordinating Council
Alisa Khan, Co-Chair
Daniel C. West, Co-Chair
Christopher P. Landrigan. P.I.
Dorene Balmer
Maitreya Coffey
Sarah Collins
Katie Litterer
Rita Pickler
Nancy D. Spector
Amy J. Starmer
Christopher P. Landrigan. P.I., Chair
Alisa Khan, Project Leader
Michele Ashland
Benard Dreyer
Kate Langrish
Theodore C. Sectish
Nancy D. Spector
Amy J. Starmer
Rajendu Srivastava
Daniel C. West
Education Executive
Committee
Rounds Subcommittee
Lauren Destino, Co-Chair
Jennifer Everhart, Co-Chair
Anupama Subramony, Co-Chair
Brenda Allair
Claire Alminde
Marisa Atsatt
Sharon Cray
Liz Kruvand
Nicholas Kuzma
Glenn Rosenbluth Doug Thompson
Becky Blankenburg Roben Harris
Jennifer Baird
Amy Guiot
Leigh Anne Bakel
PRIS Advisory
Board
Donald Berwick, IHI
Brent C. James, IH
Charles Homer, NICHQ
QI and Implementation
Subcommittee
Data Coordinating
Center
Anuj K. Dalal, P.I.
Stuart R. Lipsitz
Kathy Zigmont
Doernbecher
Children’s
Hospital OHSU
Pilot Site
Megan Aylor*
Sarah Green
Windy Stevenson
Anne Bateman
Mary Pozsgai
St. Louis Children’s
Hospital
Mentor Site
F. Sessions Cole*
Kevin T. Barton
Roben Harris
Elizabeth Kruvand
Michele Lane
Kimberly Sauder
Michael P. Turmelle
Andrew J. White
Amy J. Starmer, Chair
Jennifer O’Toole
Glenn Rosenbluth
Daniel West
Nancy Spector
Ted Sectish
Maria Obermeyer
Jenni Baird
Alisa Khan
Ckaire Alminde
Sharon Cray
Shilpa Patel
Advisory Board
Alisa Khan, Co-Chair
Theodore C. Sectish, Co-Chair
Nancy D. Spector, Co-Chair
Brenda Allair
Jenni Baird
Claire Alminde
Becky Blankenburg
Sharon Calaman
Lauren Destino
Benard Dreyer
Jennifer Everhart
Jennifer Hepps
Christopher P. Landrigan, P.I.
Christy Ledford
Amanda Mangan
Jennifer O’Toole
Shilpa Patel
Glenn Rosenbluth
Raj Srivastava
Amy Starmer
Anupama Subramony
Daniel West
Clifton Yu
Maria Obermeyer
Health Literacy
Subcommittee
Benard Dreyer. Chair
Wilma Alvarado-Little
Cindy Brach
Fernando Mendoza
Vineeta Mittal
Lee Sanders
Michael Wolf
Shonna Yin
Faculty Development
Subcommittee
Shilpa Patel, Chair
Jennifer K. O’Toole
Nancy D. Spector
Clifton E. Yu
Ted Sectish
Dan West
Anu Subramony
Sharon Calaman
Arabella Simpkin
Jennifer Hepps
Education Committee
Subcommittees and Advisory Groups
Simulation and
Educational Strategies
Support Team
Written Communication
Tool Subcommittee
Glenn Rosenbluth, Chair
Benard Dreyer
Brian Good
Christy Ledford
Dale Micalizzi
Aarti Patel
Jennifer Baird
Doug Thompson
Sally Coghlan McDonald
Boston Children’s
Hospital
Pilot Site
Christopher P. Landrigan*
Brenda Allair
Kelly Dunn
Alisa Khan
Katie Litterer
Jayne Rogers
Theodore C. Sectish
Amy J. Starmer
Laura Wood
Jenni Baird
Sharon Calaman, Co-Chair
Jennifer Hepps, Co-Chair
Jenni Baird
Zia Bismilla
Roben Harris Kheyandra
Lewis
Joe Lopreiato Clifton E. Yu
Team Communication
Subcommittee
Clifton Yu, Chair
Michelle Ashland Christy Ledford
Nursing Rep
Family Rep
Campaign Subcommittee
Glenn Rosenbluth, Chair
Roben Harris
Kheyandra Lewis
Jennifer K. O’Toole Shilpa J. Patel
Theodore C. Sectish Nancy D. Spector
Clifton E. Yu
James Bale
Dorene Balmer
F. Sessions Cole
Kelly Dunn
Benard Dreyer
Helen Haskell
Katherine Litterer
Joseph Lopreiato
Sanjay Mahant
Christopher Maloney
Dale Ann Micalizzi
Vineeta Mittal
Terrence O’Malley
Mary Ottolini
Jayne Rogers
Samir Shah
E. Douglas Thompson
Clifton Yu
Family Advisory
Council
Dale Ann Micalizzi, Co-Chair
Helen Haskell, Co-Chair
Brenda Allair
Michele Ashland
Marisa Atsatt
Eileen Christensen
Amanda Choudhary
Sharon Cray
Roben Harris
Elizabeth Kruvand
Katie Litterer
Sally Coughlin McDonald
Laquanna Williams
Chelsea Welch
Pat Katsis
Peggy Markle
Cindy Warnick
Mary Pozsgai
Nursing Advisory
Council
Jayne Rogers, Chair
Claire Alminde
Anne Bateman
Kelly Dunn
Michele Lane
Kate Langrish
Amanda Mangan
Kimberly Sauder
Stephanie Wintch
Laura Wood
Jenni Baird
Annie Guerrero
Maria Obermeyer
Laura Trueman
Debbie Chandler
LeAnn Gubler
Resident Focus Group
Ad hoc members
St. Christopher’s
Hospital for
Children
Cincinnati
Children’s
Hospital
Lucile Packard
Children’s
Hospital
UCSF Benioff
Children’s
Hospital
Hospital for Sick
Children
(Toronto)
Walter Reed
Military Medical
Center
Primary
Children’s
Hospital (Utah)
Sharon Calaman*
Sharon Cray
Doug Thompson
Nick Kuzma
Kheyandra Lewis
Nancy D. Spector
Claire Alminde
Laquanna Williams
Jennifer K. O’Toole*
Aarti Patel
Maria Obermeyer
Laura Trueman
Debbie Chandler
Lauren Destino*
Michele Ashland
Marisa Atsatt
Becky Blankenburg
Jennifer Everhart
Joseph Kim
Stephanie Wintch
Glenn Rosenbluth*
Daniel C. West
Amanda Mangan
Sally McDonald
Zia Bismilla*
Carolyn Beck
Maitreya Coffey*
Kate Langrish
Pat Katsis
Jennifer Hepps*
Joseph O. Lopreiato*
Clifton E. Yu*
Peggy Markle
James F. Bale*
Brian Good*
Amanda Choudhary
Rajendu Srivastava
Cindy Warnick
Eileen Christensen
Chelsea Welch
LeAnn Gubler
Annie Guerrero
Communication on Family Centered Rounds
Pilot Data
• Pilot data from Boston
Children’s Hospital
– 45% discordance rate for
understanding the plan of care
between families and the
medical team
This is a patient safety issue!
Khan A. Physician-Parent miscommunication in the hospital at night. PAS
Meeting Vancouver, Canada; May 3, 2014.
Patient and Family Centered I-PASS
Educational Intervention Bundle
Everyone has a role during FCR
Team Member
Role
Patient & family
Equal partners, speak first, give “illness
severity” and “synthesis by receiver”
Coach, advocate, provide information
Orient, invite, introductions, I-PASS
presentation/discussion
Orient, invite, introductions, I-PASS
presentation/discussion
Oversee medical decision making, teaching,
feedback
Oversee medical decision making, teaching,
feedback
Interpret
Ad hoc
Nurses
Medical students
Interns
Senior residents
Attending
Interpreters
Other (SW, pharm,
CM, RD, PT/ OT)
Preparation For And
Oversight Of Rounds
What Am I Responsible For as the Attending?
Oversight Of Team Activation
• The attending is responsible for ensuring the
patient, family and all team members are
activated during rounds
• Encourage team to let patient/families speak first
• Ensure that nurses and other members of the
care team get a chance to speak
• Utilize TeamSTEPPS communication techniques
Standardized Communication Techniques Support
Situational Awareness and Shared Mental Model
Technique
Function
Example
Brief
Plan team activities
Day one discussion for
team orientation
Debrief
Analyze an interim event
Recap of events at the end
of a shift
Huddle
Problem solve
Planning for a procedure
Cross monitoring /
Feedback
Improve performance
Commenting about a
decision (selected test)
Assertive statement
Advocate for safe, high
quality care
Recognizing a potential
error
Check back
Ensure accurate
information transfer
Reading back a verbal order
Handoff
Transfer care and
responsibility
Transitions of care
The Brief
• Review situation awareness
prior to rounds
– Census and workflow
– Admissions and discharges
– Social considerations
– Priorities
• Sickest patients
• Time sensitive decisions
– Wean Albuterol
– Schedule imaging procedures
Huddles
Before Going Into a Room
• Occasional events
• Provide opportunities to
– Prioritize family’s questions and
issues
– Clarify care plans
– Discuss sensitive issues
– Prime learners to educational
opportunities
• Should not be a formal rounds
presentation
Debriefs
Between Patients
• Occasional events
• Opportunities to
– Clarify issues
– Revisit teaching objectives
– Give brief feedback
• Be sensitive
– Not within earshot
– Not within sight
Mid-Shift Huddle
• Inter-professional team meeting
typically late afternoon and on
overnight rounds
• Update on watchers
• Concerns or problems
• Changes in clinical status
• Family concerns
• Impediments to key action items
• High level discussion of
admissions and discharges
Oversight Of Communication
During Rounds
• To keep the focus on the patient/family it is crucial that
attendings
• Ensure learners are using the principles of effective
patient/family centered communication
• Re-direct learners if presentations if they stray from the
patient/family friendly format
• Model effective use of interpreters and the rounds report
printed tool
Oversight of Team Positioning
Senior
Intern Attending
Physicians and
Medical Students
Nurse
Patient and
Family
Interpreter
Other Team
Members
Attendings should facilitate proper positioning of team,
computers
The I-PASS Mnemonic
I
Illness Severity
• Getting better, getting worse, about the same
P
Patient Summary
• Problem oriented
• Ongoing assessment and plan
A
Action List
• To-do list
S
Situation Awareness & Contingency Planning
• Knowing what’s going on
• Planning for what might happen
S
Synthesis by Receiver
• Check back: receiver summarizes what was heard, asks questions,
restates key action/to do items
Introductions First
Presenter
• Invites parents and patients to join FCR
• Determines location
• Reviews concepts and goals of FCR
• Reviews time allotment and future check-ins
• Introduces team members
• Reinforces patient and parent roles as team members
• Inquires about concerns
Family Concerns
• Provide the family with an
opportunity to raise questions
and concerns
• Discuss concerns in the
beginning to promote the
development of a shared
mental model
Concerns
Illness Severity
• Articulate Illness Severity to assist
in the development of a shared
mental model
• Provide the family an opportunity
for their assessment of illness
severity
• May reveal a discordant
understanding and offer an
opportunity for clarification
Illness Severity
Patient Summary:
Rethinking Oral Presentations on FCR
• Problem-based discussion with the family
– Move away from the formal presentation
– Provide a brief summary statement/one-liner
– Discuss problems in order of priority
– Use evidence/data to support your A&P
•
•
•
•
Overnight events
Vital signs as applicable
Physical findings
Labs, test results
– Use plain language
= Pertinent
Positives & Negatives
Action List
• Medical student or intern
• Summary of main action items from the plan
– Orders, consults, studies, procedures
– Timeline: today, this week, before discharge
• Order entry in real time
• Ownership
• Follow-up
Situation Awareness &
Contingency Planning
• Problem solving before things go wrong
• If this happens, then… from patient/
family/RN perspective
Synthesis by Receiver
• Brief synthesis of essential
information
• Opportunity for receiver to clarify
information and have an active
role on rounds
• Demonstrates information is
received and understood
• Promotes a shared mental model
Synthesis by Receiver
• How do you ask a parent to
synthesize?
– Use open-ended questions
• Not testing questions
– Create a safe and welcoming
environment
– Be attuned to non-verbal
cues that you observe in
family members
Oversight Of Communication
During Rounds
• Addressing discordant understanding
– When illness severity is elicited
– With check back for every patient
• Learners will likely struggle with this skill; attendings will
have to model how to execute effectively
• Check back must occur in a way to not make
patients/families feel like they are being tested
– Encourage learners to:
• Use close-ended probing questions
• Articulate individual components of the A/P
• Consider one-on-one discussion after rounds, written
communication
Preparing For Rounds As An Attending
A Paradigm Shift
• Rounds is now about the patient/family, and
not for sharing information with the
attending
• Prior to rounds attendings must
– Read admission note
• Formal presentation from learners not necessary
– Review notes and recommendations
– Assist early learners
• Set expectations for oral presentations
– Not the traditional long H+P
• Focus on clinical reasoning, gaps in knowledge, and
rationale
Rounds Report
• Information intake is influenced by:
– Stress, fatigue
– Literacy level, learning styles, language
– Access to technology
• Benefits of Rounds Report:
– Provides a document for families to refer to
• Don’t have to remember everything
• Can write down notes and questions
– Can update as things change
– May include pictures and diagrams
Rounds Report
Key Data Elements
•
•
•
•
Name
Date
Parental concerns or questions
Illness severity
– Overall, how is your child doing compared to
yesterday?
• Patient summary
– Updates
• What is new or changed
• What needs to happen before the child is ready
to leave the hospital
• Action list
– What should be done today
• Situational Awareness and
Contingency Plan
– Things that might happen and what to do
about them
Teaching on FCR
• Benefits
– Enhancement of clinical education through
exposure to multiple patients by all team
members
– Ability to teach, model, observe, and evaluate
clinical skills more effectively than “sitting” rounds
• Challenges
– Not all teaching topics amenable to discussion in
presence of patient/family
– Perceptions about rounding inefficiency if not
done correctly
General Rules on Teaching Topics
• At the bedside
– Physical examination
– Clinical reasoning (assessment, prioritized DDx, work-up/treatment
options)
– Provider-patient communication
– Anticipatory guidance
– Professionalism
– Other things that benefit the family and learners
• Outside patient room; pre-round/educational huddles
–
–
–
–
–
–
Psychosocial issues
Pathophysiology
Sensitive differential diagnosis discussions
Issues unrelated to patient care
Longer/foundational teaching sessions
Formal presentations
Educational Huddle
Venue for Teaching Residents and Students
• Brief teaching
– On FCR between patients
– After FCR at other times of the day
• Teaching topics
– Pathophysiology
– Communication skills (priming,
debriefing)
– Review of overnight events
– Systems-based practice
– Sensitive social issues
– Practice sessions for performing
formal presentations
Sample Bedside Teaching Techniques
• 1 minute preceptor
• Rounding like a Ninja and
Karate Kid
Physical Exam Skills
• Focus on a single physical exam skill
• Involve the child and child’s family
– Respiratory distress in an infant: Let’s go look at the belly
together to have a shared understanding of what
respiratory distress looks like and what is normal
breathing
• Allow parent to be close to the child
• Preserve modesty
http://www.med-ed.virginia.edu/courses/pom1/PhysicalExamLinkPage.cfm
http://www.easyauscultation.com/
http://www.med.ucla.edu/wilkes/
http://www.blaufuss.org/
www.learnpediatrics.com
Communication Skills
• Role modeling
• When possible
– Prime
• “We are about to see a patient with an ambiguous
diagnosis, pay attention to how the intern introduces…”
– Debrief
• “The family is understandably upset by the delays in
care. What did you notice the senior doing to address
their concerns? What else could our team have done
to let them know we were listening?”
How to Make Teaching Family Centered
Do
• Explain that teaching is an important part of
rounds
• Highlight when teaching is happening
• Acknowledge family's input into teaching
• Consider the impact of discussions outside the
room when visible to parents
– Alleviate family anxiety by explaining the need to have
some deeper discussions about the medicine
• Reframe a learner’s incorrect answers as thought
processes
• Model critical thinking and medical decisionmaking
How to Make Teaching Family Centered
Don’t
• Assume families cannot understand clinical terms
– Families may be more knowledgeable and can be
quick studies
• Engage in teaching behaviors that remove the child
and family from the experience
– Relate to the patient during the physical exam
• Recite medical information about the patient as if
they were not present
• Tell families things are not relevant to their child
– Save that for an educational huddle
How to Respond to Wrong Answers
• “That is an interesting thought…however, in Johnny’s case,
symptoms A and B make me think that diagnosis X might be
more likely.”
• “Tell me more about that.”
• “It is good we are having this discussion and considering all of
the possibilities.”
• Don’t say: “We’ll talk more about that later.”
Large Group Discussion
• Do you incorporate any of these practices into your rounding
workflow already?
– Benefits?
– Challenges?
• How do you think this will impact your workflow?
• How do you think this will impact learner education?
• How do you think this will impact the experience of
patients/families?