Intermountain Primary Children’s Hospital, Intermountain Medical Center, and Physician Partners at University of Utah School of Medicine Receive Prestigious Eisenberg Award for Innovation in Patient Safety

Intermountain Healthcare’s Primary Children’s Hospital, the Department of Pediatrics at the University of Utah School of Medicine, and the shock trauma intensive care unit at Intermountain Medical Center are among the recipients of the 2016 John M. Eisenberg Award for Innovation in Patient Safety and Quality for their work as part of a patient safety research group. 

The prestigious Eisenberg Award is presented annually by The Joint Commission and the National Quality Forum (NQF), two leading national organizations that set standards in patient care. 

Intermountain Primary Children’s and the University of Utah School of Medicine were among the original nine members of the pediatric I-PASS Study Group, which since has expanded to more than 50 adult and children’s hospitals from across North America. 

The Study Group is dedicated to improving patient safety by standardizing provider communication during patient handoffs to reduce miscommunication that can lead to harmful medical errors. I-PASS is the acronym for the Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver. 

“It’s incredibly humbling to have realized that the work of so many people across the country is being brought to fruition through this award,” said Raj Srivastava, MD, assistant vice president of Research for Intermountain Healthcare and one of six members of the national I-PASS Executive Council and part of the Primary Children’s research team. “Really, it’s a culmination of so many people in different roles, the front-line caregivers across all these 50 hospitals, all working on this relentless journey toward keeping our patients safer and delivering the highest quality care.” 

I-PASS is a proven bundle of interventions created to reduce communication failures during patient handoffs. In a large multi-center study published in the New England Journal of Medicine in 2014, implementation of I-PASS was associated with a 30 percent reduction in medical errors that harm patients. An estimated 80 percent of the most serious medical errors can be linked to communication failures, particularly during patient handoffs. Handoffs occur at all changes of shift and whenever a patient changes location in a hospital. 

In 2015, the I-PASS handoff tool was implemented in the Shock-Trauma Intensive Care Unit at Intermountain Medical Center and 32 other internal medical programs nationwide.
“Standardized handoffs using the I-PASS methodology at Intermountain Medical Center has resulted in improved patient safety without a major effect on efficiency,” says Scott Stevens, MD, director of the transitional year residency program and vice-chair of the Department of Medicine at Intermountain Medical Center. “Since it was first implemented in our Shock-Trauma ICU, it resulted in a 23 percent reduction in medical errors, a 30 percent reduction in preventable adverse events, and a 21 percent reduction in near-misses — while increasing the time per handoff only minimally, from 2.4 minutes to 2.5 minutes.”

Primary Children’s and the University of Utah School of Medicine are participating in another study using the I-PASS model to gauge how family-centered rounding affects medical errors. Family-centered rounding is a practice in which doctors’ daily patient rounds are done in the presence of the patient and his or her family. This enables open discussion of a child’s diagnosis, treatment, and care plan, and allows families and nurses to ask questions and provide input as part of that process. 

“The I-PASS model is way of looking at health care and its delivery, and finding innate ways to integrate interventions within the system to improve patient safety,” said Brian Good, MD, University of Utah School of Medicine and Hospitalist at Primary Children’s, one of the study’s lead physicians. In family-centered rounding, “it starts a discussion,” he said. “In the end, patients are better off for that.”