Episode #14 - Christopher Landrigan - Healthcare Communication and I-PASS

How can improved hospital communication protect patients?

  • 00:10:11 - 05:10:11

    Jerrod Bailey  00:04

    Welcome everybody to Reimagining Healthcare: a new dialogue with risk and patient safety leaders presented by Medplace. We're excited to bring you conversations with top risk and patient safety thought leaders from organizations around the country. Please subscribe to get the latest news and content and if you found this episode valuable, please share it with your colleagues and with your communities. We want to start dialogues there. And if you're interested in participating as a guest, by all means reach out to us at speakers@medplace.com. My name is Jared Bailey. I will be playing host today. And I'm actually joined by Dr. Christopher Landrigan. Good afternoon, Dr. Landrigan


    Dr. Christopher Landrigan  00:55

    Hello. Nice to be here.


    Jerrod Bailey  00:57

    Thanks for joining me. We met at a conference recently I heard you speak and it was very compelling some of the things that you're I think it can you and your company are on a similar mission is to us our company approaching it from different perspectives. But I think we have a heart for really causing some real change for the better in inpatient safety and delivery of health care.


    But let me give you a little bit of Dr. Langer Landrigan introduction here. So Christopher Landrigan, MD, MPH is the chief of general pediatrics at Boston Children's Hospital, director of the sleep and Patient Safety Program at Brigham and Women's Hospital, and the William Barron Berg Professor of Pediatrics at Harvard Medical School. He was a founding member of the Harvard work hours Health and Safety Group, and the Founding Chair of the pediatric research in inpatient settings, network, a collaboration of over 100 pediatric hospitals to conduct multicenter research and improvement projects. I'm definitely going to ask you about that.


    Dr. Lang Landrigan has led a series of major studies in the epidemiology of medical errors and interventions designed to reduce their incidents. His most important work has been focused on developing reliable Patient Safety measurement tools and improving the organization of residency programs academic, medical, and academic medical centers. His work on the relationship between resident work hours sleep and patient safety, contributed to national changes in Resident work our standards. More recently, he led the development of I-Pass can be a subject of today's conversation, a multifaceted handoff and communication Improvement Program. He's authored over 150 publications in the medical literature, and has received numerous awards for his research teaching, leadership and innovations. Man, that's a lot you've done more in your career than I think, most have done. But I really zoomed in on a talk that you gave recently, specifically around the work that you've done with  I-Pass. So I'm hoping that we can unpack some of that today. Sounds good.


    Dr. Christopher Landrigan  03:12

    That sounds great. Glad to talk.


    Jerrod Bailey  03:13

    So help us out what is I-Pass, first of all, for those of us who haven't heard of it?


    Dr. Christopher Landrigan  03:17

    I-Pass is a is a bundle of interventions is basically a program to try to help hospitals fix communication, communication, primarily between doctors and nurses. But more recently, we've also thought a lot about communication between clinicians and patients and trying to fix that process as well.


    Jerrod Bailey  03:34

    Great. Okay, we're going to get a little bit more color on that in a second. But a lot of this has to do with improvements, or possible improvements in and around the ways that hospitals facilitate communication. Right. What kind of areas of improvements do you see?


    Dr. Christopher Landrigan  03:57

    Yeah, so  the, the fundamental problem, I think, is that while there are certain pieces of the way that doctors and nurses gathered data, when patients come into the hospital, that's pretty standardized the way that we all ask patients about what's going on the sort of the history and tell me about your past medical problems, things like that, in fact from a patient perspective, they're sometimes driven crazy by being asked that same set of 20 questions by multiple people throughout the hospital. But for all that, that initial data gathering is really standardized and exhaustive and formal.


    Once you're through the doors of the hospital, there was really no structure by which information was passed from one nurse to the next or from one physician to the next to change or shift or if you move around within the hospital. And we found over a decade ago now that that was leading to all kinds of medical errors and downstream problems. And so designed bypass is a way to try to fix that.


    Jerrod Bailey  04:50

    That's fascinating. It's some things that  in coming from somebody who's done things in healthcare, but other industries it's something that like when you when you're Really looking at something as ever changing as a particular patient and their history and their history of care and their unique things that, you know that we'd need to know, you would think that that would be table stakes for any system is to make sure that that information flows through. But we've seen it, we've all been in healthcare ourselves, we've been recipients, I've been had to answer the same questions over and over again. So, Okay, interesting. So let's dive into it. So one of the questions I had is, how can you use data to actually evaluate communication and a health system? Like is that kind of our starting point?


    Dr. Christopher Landrigan  05:41

    Yeah, so one of the one of the first things that we did, when we began looking into this was just to observe a number of different handoffs in different parts of the hospital and to take a look at what was being conveyed. And what we found out was that not only from one service to the next within a hospital, but even from one provider to the next, the amount of information they were, they were asking for us or the person who were coming on duty, or the amount that they were willing to freely give going off duty was really variable. And there was there were some people that would, they would read you a four page essay on every patient who came to the door, and others would say, you don't have to you don't have to tell me anything, I'll just figure it out if something goes wrong. And there was no sense of what's the right amount of information, one of the really key things, how do we get how do we get people to focus in on the information that's most important for ensuring that important things aren't lost, or that patient suffers and medical errors and consequences of some miscommunication?


    Jerrod Bailey  06:34

    Okay, so I'm buying into the premise so far. So how does I-Pass facilitate that communication?


    Dr. Christopher Landrigan  06:41

    So, a lot of my background, even before I-Pass was in patient safety, thinking about just these little systems of care within our hospitals, and what can we do to tweak them and make them work a little bit better. And, like much of the patient safety community at that point in time I was, I was really starting to think about this idea of bundles the field has kind of evolved from if you sort of think of infectious disease, as one can, one just good example.


    In their very early years, there was a lot of, of kind of the quality improvement and patient safety movements, there was there was a lot of effort on trying to get clinicians just to wash their hands, right? If we could just get people to wash their hands more consistently, we prevent all kinds of hospital acquired infections. And it's true if you can get people to wash their hands more, it does help, it helps a lot, actually. But, but a lot of those, those interventions were sort of sort of dead ends, we just sort of felt like you were beating a beating a dead horse. In some ways, it was kind of hard to make progress. And then a group of clinicians, initially at Johns Hopkins, and then there were, there were programs that help happen and elsewhere in the country began to think of this idea of bundle let's not just focus on hand washing, but let's think about all of these different little steps we could take that together would prevent infection.


    So yes, let's focus on hand washing. But let's also think about things like, let's make sure that we optimize the use of sterile barriers, when we're putting in a central line, let's make sure we don't have those lines in for any more days than is necessary. Let's try to avoid sites that we know from literature are a little bit more dangerous, like putting in a in a femoral line, for example, versus putting in an arm putting in the leg instead of the arm, things like that. And that combination of little steps altogether, all of a sudden, we were seeing 80% reductions, 90% reductions in the frequency that that hospital acquired infections were happening just this massive change, where the hand washing being on the hand washing strategy wasn't working that well at all.


    And so, so for I-Pass, as we began thinking about the problem of communication in hospitals, we tried to take a page from that playbook, and say what would a bundle look like for handoff communications, right? I mean, we want people to speak to one another differently, we want to think about how do we get the right information in there, but it's not going to be enough just to sort of expect that they're going to do that. I mean, they need to, we think they need an organizing framework, they need to be trained in how to use that organizing framework, we need to think about all the little details of what happens during a verbal exchange of information. And we need to think about all the little details of what happens in a written exchange of information what's in the electronic health record? And how do all those things work together? And so I-Pass was, was a bundle, it was this idea of let's make small interventions and each one of those areas and see what they do in the aggregate.


    Jerrod Bailey  09:15

    Interesting. Okay, so can you give me an example then of what that ended up becoming?


    Dr. Christopher Landrigan  09:20

    Yeah, so the so the mnemonic I-Pass itself is pretty simple. It's, it's, it's the letters and the mnemonic stands for the key things we want people to convey a change of shift for the patient was location. So the idea was, we took P, the P and I-Pass, which stands for patient summaries, that core nugget of clinical information that you're going to pass off a change of shift. But we wanted to surround that with the other elements that the patient safety literature tell us are the things that are most frequently forgotten and hand off and that often lead to disastrous down the road.


    And so we start with an upfront statement of how sick a patient is, that's the illness severity statement or I then we move into the patient summary. Then we go to the Action List, which is just a checklist of what things need to have happen right now historically what would happen is you'd have this, you might have this very complicated plan that was part of the patient summary. But some of those things were what needed to happen now. And some of those things needed to happen two weeks from now, and people will get confused. So, so we pull those things out intentionally the action list, then the first S in I-Pass stands for situational awareness, contingency planning this idea of, don't just tell me what I have to do right now. But if there are particular things you're worried about overnight, let's make sure that those things get conveyed as well.


    And then lastly, synthesis, the final S in I-Pass is a read back or check back by the person who's receiving the handoff, which is a principle that goes everywhere from aviation to Chinese food. And when you sort of are or didn't occur, where you expect at this point, I think things have shifted a little bit over the past 20 years, where if I call up an order takeout, and they don't read it back to me, I'm feeling a little bit nervous, right, that they might miss something, or you're going to get the wrong kind of chicken or whatever, whatever it is. And so we want to do the same thing here. It's not in our case, it's not necessarily an exhaustive rereading of the entire handoff. But we want to make sure there's a so-called shared mental model that you as the receiver, understand the key things that I'm trying to tell you. And we're going to be on top of things that need to happen right now. now.


    Jerrod Bailey  11:11

    it's interesting, this I come from a technology background, and like around human centered design, and things like that. So I've worked on a lot of large scale technology projects. And there's something that I learned probably a decade ago, to make those things go easier and sounds very similar, right. And it's essentially it's a, it's a, an upfront preamble, or a synopsis of what the project is, because you may have different groups of developers and business stakeholders all contributing at some point in the lifecycle of this project, offshore people, contractors, and being able to communicate something very complex very succinctly. And then to be able to have that handoff of communication and the confirmation is something that you see in other industries, and it's quite effective, right. So it sounds like you kind of looked at what, what's best practices in general drawing a lot of your own experiences. And that's what you ended up implementing. So what's the what's the punchline of this? What have you seen by pulling by deploying iPads in the wild?


    Dr. Christopher Landrigan  12:16

    Right, so well, so two things? The first is that I think that's exactly right. We were we were looking at what we thought best practices were, what the literature suggested best practices were we tried to put those together something that was really simple. But I think we also knew from prior experiences, both our own and others that just putting together that synopsis that summary and kind of dropping it into the wild, all by itself was not going to do anything. we knew that we needed to combine that with a change management plan how do you train people to use this thing, once they've been trained in how to use it, we believe we had to do workplace-based observation and feedback, basically, an audit back type of an approach to get people to really use this and give them feedback on how well they were doing. We had to have leadership support within institutions, we had to have a campaign across the institution, all these different pieces had to come together.


    And so we really thought of I-Pass as that whole package, the whole thing, right? It's not just the mnemonic, it's the mnemonic plus the changes in verbal process, changing computerized written process, and then the surrounding structure. And so when we did all that together, and we intentionally did it all together, we didn't try to separate out the individual pieces. We found in an initial pilot study that's really rapid drop-off in medical errors at my institution. And then that became the preliminary data for a larger federally funded study where we rolled this out across nine pediatric hospitals in the US and Canada, and found a 30% drop off and injuries due to medical errors and process nine sites after we rolled this out. Wow. Yeah, seems credible, pretty exciting.


    Jerrod Bailey  13:44

    There's no there's not a lot that's putting up numbers like that across the board for medical errors. I mean, that's really, really encouraging. Thanks. Yeah, we thought that's what that's what made me like, pop my head up when I heard you speaking like that. It's really, really incredible. So interesting. So there's so many questions that come out of this. But so that was a little bit of the data, if you feel like there's any more data that came out of the come out of the program that you want to talk to feel free, but like what kind of measurement tools or have you guys been involved in creating around this is sort of one of my questions. Like, what can you unpack here for me?


    Dr. Christopher Landrigan  14:25

    Yeah, yeah, so, so our measurements really intensive, but sort of expensive or require big federal grants to pull it off. We basically did a combination of direct observation of the handoff process. And then we hired research nurses across all of those hospitals who are combing through the medical records on a daily basis and also debriefing, debriefing staff as they were coming off duty to ask them about any communication problems and medical errors that might have occurred in the during the prior shift. And so the combination of that really intensive surveillance, plus the sort of direct observational measures is what is what kind of gave us what we needed to say


    Jerrod Bailey  15:00

    That's incredible. You know, I'm curious if there's any, are there any differences that you guys have seen in like rural health systems versus large systems? Have you been able to look at cross sections of the industry?


    Dr. Christopher Landrigan  15:14

    Yeah. So that's kind of where we've gone since that original, those original couple of studies we've gotten further funding since then to try to adapt this to all different types of contexts. And the first thing we did is we got, we got funding from the Agency for Healthcare Research and Quality, which is a corner of the federal government to look at this across 32 more hospitals, including adult hospitals, pediatric hospitals, community hospitals, academic centers, across different specialty areas.


    We've also done studies now and nurses applying it in that context, and then we and then we've extended it to start looking at different types of transitions as well. So not just within the hospital now. But what about the inpatient outpatient transition or the outpatient inpatient transition? And even most recently, using this to look at communications with patients and families? if we take the same communication strategies and apply them to rounds with families in the morning? Are we able to achieve any additional benefits?


    And it turns out, we do, we sort of see benefits across all those different contexts and applying this these kinds of strategies. And now have, I think, over 30 publications that have looked at this in different in different ways, in different places, different sets of studies, looking at this, it's proven, effective thing that's kind of translatable across settings, really,


    Jerrod Bailey  16:25

    any kind of interesting or anecdotal or observations. Like just coming out of some of that work, like I mean, we talked about rural versus, yeah, more urban type environments, like anything that's kind of notable in your mind.


    Dr. Christopher Landrigan  16:39

    Yeah, I mean, that the exciting part to me is, it seems like it's worked pretty well, in all of them. we looked at what adult hospitals versus pediatric hospitals that work pretty recently, we looked at community hospitals versus academic centers, it seemed to work pretty equivalently there to trainees have different seniority levels, nurses versus physicians that it really seems like it's in all these contexts, we're seeing ballpark 30 to 50% reductions in, in errors that cause our interest.


    Jerrod Bailey  17:07

    Interesting. That's fascinating. So Medplace, we sit a lot in the medical malpractice space, among others. And we talked about the push and pull between insurers and patients, things like that. Where do you guys sit near? There's other sort of advocates and others sort of in this cloud of stakeholders in that process? And just curious where you guys sit in that? And right, how do you influence that?


    Dr. Christopher Landrigan  17:36

    Yeah, I think it's a great question. It's a complicated space. And part of the challenge here is, as I'm sure you know, living in this world, is that you have all these different constituencies that look at the world a little bit differently, and have different interests and trying to tackle the patient safety or malpractice problem or what have you. And so we realized probably five years ago now that we were all clinicians, right? We were kind of coming at this from a clinical space, we didn't really know the malpractice world at all, but it occurred to us that it was important, and we ought to be doing something to try to look at it through that lens as well. We did a study a couple of years ago, looking at, well from malpractice database standpoint, what do we know about the role of miscommunications in malpractice claims? How many of those look like they're directly to the handoff problem versus other types of miscommunication problems? And could I-Pass potentially have averted some of those. So we got access to the comparative benchmarking system, which is this big database represent about a third of all malpractice claims in the US that was curated by Krakow, which is our guy.


    Jerrod Bailey  18:36

    I was going to say is that their database? Yep.


    Dr. Christopher Landrigan  18:39

    And now called Candela, actually, is they've named changed, but same dataset and, and it's really powerful dataset. And they had actually done some preliminary work themselves demonstrating that communications looked like they were a big part of claims when you sort of start looking at things across specialty silos rather than just silo by silo. And we got access to that data set and did a random sampling of 500 of those claims and took a deep dive into them. And we found that about 50% of claims 49% had miscommunication as one of the key root causes of what had happened, I'm just an absolutely huge proportion. And of those, about 40% were directly we could see they were their hand off problems that were in there. And of those more than 75% potentially could have been averted with something like iPads. So you sort of boil all that down. And it looked to us like just about 20% Just shy of 20% of all the claims in the data set potentially could have been averted with a tool like this.


    Jerrod Bailey  19:34

    I mean, there's there is real dollars and cents calculable dollars and cents that can be applied to that it's a that's a direct benefit to anyone who's going through a carrier or self-insuring or just recognizing costs associated with risk events. That's a really compelling number. I haven't heard many numbers that can affect that much of that problem, right? If I was going to do the back of the napkin math and just a reduction of medical errors even that is sort of a direct calculation that you can do to what these hospitals are recognizing and carriers and others are recognizing downstream as a result of all those things. So I've got to think anybody that's insuring doctors and hospitals should be looking at something like this as a program that they should be recommending, to their insurance, what is available to hospitals and others who might want to look into this or be part of you've got various studies going on as this? How does that work? For those interested in getting to know more?


    Dr. Christopher Landrigan  20:52

    So as we, as we started walking down this journey, I guess, from single center study, the nine Center study to 32 centers study, we came to the point, a number of years ago, I think it's six years ago, or seven years ago that look, this looks like it's really successful from an academic standpoint. But the reality is, even in the 32 centers study, if you sort of are critical about it, what we were seeing is we were planning 32 tiny seeds and 32 Gigantic organizations, right. We were intervening on the Internal Medicine Service over here, and the pediatric service at the next Hospital and the obstetrical service at the next hospital. But in no cases was this strategy for communication filtering out to the entire organization and becoming a standard for care, which is really what we want, if we're going to take a bite out of patient safety in a real way.


    Yeah, we ended up forming the I-PASS Institute, which is a it's a company that we- none of us are business people, but background of the founders, the original clinical founders, we never thought we'd be going in this direction. But it got to the point that if we want to have a bigger impact, we knew we had to scale our intervention up and have some tools and processes that would allow hospitals to really do this, at a scale bigger than a single residency program within the organization.


    And so the IPSs do was formed basically to, to, in order to allow us to build some of the tools that would allow for that. And so over the past five or six years, we have been building a series of cloud based tools that make just to give you an example, our original method of training people how to do this was we would pull residents aside or nurses aside and do about a three or four-hour workshop where we would they have a chance to be the giver of a handoff, the receiver of a handoff, they would do some role-playing, we would teach them some redacting information about handoffs, best practices, things like that, which worked really well. But it's also labor intensive, and logistics and scale, can't scale it.


    And so I-PASS Institute took that, and with the help of a lot of the medical educators in our group built this immersive 3d software that you basically you can pick, I'm an ICU nurse, you get dropped into this 3d environment where you're learning about a patient, things change over the course of the shift, and then you're taught the basics of bypass, and then at the end of the shift, you have to hand that patient off using an I-Pass format at first in writing. And then the cool part is you actually record yourself into the computer giving an eye pass handoff, and then as you hit the playback button, the kind of answer key pops up, and you sort of see all the things you should have been including in that in that handoff, and you can kind of give yourself a score, I got that one, I missed that I got that I missed that. So it's sort of engaging it. It's specific, so people feel that it's relevant to the clinicians doing the training like it and they kind of find it engaging.


    But anyway, the I-PASS Institute is built, has built that tool it's built. So quality improvement software, it's built a tool that integrates into the electronic health record, that sort of, again, in a very customizable way that works across different specialty areas in the hospital, it pulls data from the EHR format, and I-Pass way you added some pre tech stuff to kind of get some synthesis information in there. And then that's available for people as they're kind of doing their work. And the combination of all these tools is basically allowed us to take this methodology that we developed in a research context, and make it much more scalable. So I-Pass Institute is now working with 35 or 40 hospitals around the country at this point, helping them to push this out. And in some cases, it's still at a small scale, but there are several medical centers now that are doing this hospital wide with us and we're talking to a couple health systems right now about pushing this out of their system.


    Jerrod Bailey  24:26

    Well, it sounds powerful, and the numbers behind it to really justify anybody who's interested in patient safety to look at how and where this fits into their program. And I think you and I should be huddling on the on the med mal carrier side, because anything that can be done upstream that would affect downstream, there's real economic value there and the talk to great folks out there and that's not a hard equation to draw. So it's fascinating. Well, Anything else that you want to tell me before you tell me how people can find you?


    Dr. Christopher Landrigan  25:06

    Yeah just, I guess to amplify your point a moment ago we would love to work with med mal carriers that are interested in doing this. In fact, we just recently over the past six months or so have started talking to a couple and one of the ideas that came up from you, some of them have been interested, one, in particular, is interested in indirectly funding a little bit of this work and picking out some of its leading insured institutions to roll it out and give it a try and see if they can generate the same types of benefits that we've been saying so far with other organizations. I think there's definitely potential there. And it does look like some of the med malpractice carriers, at least are interested in investing in this, which would be great.


    Jerrod Bailey  25:47

    Yeah, well, that's great. Well, I have some we work with quite a few of them. I bet some to introduce you to but yeah, this is really, this is really hopeful work that you're doing. And it's really great to see that as all of us are also recipients of health care. I think we all want to know that this is happening. And it's happening with the deliberateness and care that you've designed into the process. So, thanks for attacking a big problem with that level of care. Well, great. So Chris, how do people find you guys? We'll certainly link to you in the show notes. But how do we get ahold of you?


    Dr. Christopher Landrigan  26:29

    So if you just search for I-Pass Institute, or I-Pass Patient Safety Institute on Google, you'll pop up. You'll find our website right away and it's easy to kind of contact us through that. I think if people want to reach out to me directly, that's fine as well. And my email is Christopher.Landrigan@Childrens.harvard.edu


    Jerrod Bailey  26:49

    Fantastic. Well Dr. Landrigan thanks for, for being a guest today for the great work that you're doing in this space. And definitely want to see and keep following I-Pass on what you guys are doing and seeing what comes out of it. But thanks again for joining.


    Dr. Christopher Landrigan  27:08

    Thanks so much for your interest, Jerrod. Really appreciate it.


    Jerrod Bailey  27:10

    For everyone else. This has been the reimagining healthcare podcast and new dialogue with risk patient safety leaders presented by that place. If you guys are interested in joining the conversation, maybe even being a speaker. Let us know just email us at speakers@Medplace.com. And in the meantime, Chris, thanks again for being guest and looking forward to following you guys on LinkedIn and elsewhere seeing the success.


    Dr. Christopher Landrigan  27:38

    Thank you so much. Appreciate all right. We'll talk soon

Dr. Christopher Landrigan discusses how hospital communication impacts the quality of care, and how technology and standardization can improve patient outcomes. Dr. Landrigan also tells the story of I-PASS, his blueprint for strong communication between caregivers, and how it substantially improved patient safety in several health systems.

Dr. Christopher Landrigan

Guest - Dr. Christopher Landrigan

Chief, Division of General Pediatrics at Boston Children's Hospital

Chief of General Pediatrics at Boston Children’s Hospital, Director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, the William Berenberg Professor of Pediatrics at Harvard Medical School, and a practicing pediatric hospitalist. Dr. Landrigan is also the founding chair and Executive Council Member of the Pediatric Research in Inpatient Settings (PRIS) Network, a collaboration of over 100 pediatric hospitals working together to study and improve the quality of hospital care.

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