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National Patient Safety Goals
Kathleen M. Haig, R.N.
Staci Sutton, R.N.
A Shared Mental Model for John Whittington, M.D.
Improving Communication Department Editors: Marcia M. Piotrowski, R.N., M.S., Peter Angood, M.D., Paula Griswold, M.S., Gina Pugliese, R.N., M.S., Sanjay Saint, M.D., M.P.H., Susan E. Between Clinicians Sheridan, M.I.M., M.B.A., Kaveh G. Shojania, M.D. Readers may submit National Patient Safety Goals inquiries and submissions to Steven Berman ( and Marcia Piotrowski (
Breakdowns in verbal and written communica- tion between health care providers are a major concern in the delivery of care. Suboptimal com- munication is not only a common occurrence but is also Background: The importance of sharing a common
associated with untoward events. The Joint Commission mental model in communication prompted efforts to on the Accreditation of Healthcare Organizations notes spread the use of the SBAR (Situation, Background,
that 65% of sentinel events,1 and 90% of root cause Assessment, and Recommendation) tool at OSF St.
analyses conducted at OSF St. Joseph Medical Center Joseph Medical Center, Bloomington, Illinois. (Bloomington, Illinois) include communication as a con- Case Study: An elderly patient was on warfarin sodi-
tributing factor. On January 1, 2006, a new requirement um (Coumadin) 2.5 mg daily. The nurse received a call went into effect, associated with the Joint Commission's from the lab regarding an elevated international nor- National Patient Safety Goal 2, which strives to improve malized ratio (INR) but did not write down the results the effectiveness of communication among caregivers.2 (she was providing care to another patient). On the This new requirement (2E) states that facilities must basis of the previous lab cumulative summary, the implement a standardized approach to hand-off commu- physician increased the warfarin dose for the patient; a nications, including an opportunity to ask and respond dangerously high INR resulted.
Actions Taken: The medical center initiated a col-
Communication handoffs are critically important in laborative to implement the use of the SBAR communi- creating a shared mental model around the patient's cation tool. Education was incorporated into team condition. Without a good shared model, we lose situ- resource management training and general orientation.
ational awareness. This loss of situational awareness Tools included SBAR pocket cards for clinicians and has led to well-known tragedies.3 Daily experience in laminated SBAR "cheat sheets" posted at each phone.
health care has taught us that there are many opportu- SBAR became the communication methodology from nities for improving the passage of information during leadership to the microsystem in all forms of reporting. Discussion: Staff adapted quickly to the use of SBAR,
Many barriers can potentially contribute to commu- although hesitancy was noted in providing the "recom- nication difficulties between clinicians. A lack of mendation" to physicians. Medical staff were encouraged structure and standardization for communications, to listen for the SBAR components and encourage staff to uncertainty about who is responsible for the patient's share their recommendation if not initially provided. March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations care management (quarterback of the team), hierar- the warfarin sodium dose for the patient, resulting in a chy, sex, and ethnic background may all be contribut- dangerously elevated INR. ing factors.4 Differences in communication styles In 2003, to promote a culture of safety, OSF St.
between nurses and physicians are also a major con- Joseph Medical Center selected SBAR as a mechanism tributing factor.5 Because of varied training approach- to support open, honest communication for sharing es, nurses tend to be very descriptive and detailed information, asking questions, and providing sugges- in their communications, whereas physicians tend to tions. However, SBAR was not aggressively implement- use brief statements summarizing salient patient infor- ed at that time. mation, sometimes called "bullet points" or "head- The framework for spread of SBAR entailed leader- lines." Variations in communication style can cause ship, better ideas, set-up, and the social system.8 As leadership support has been found to be key to the suc- In Fall 2002, OSF St. Joseph Medical Center recog- cess in previous projects, this topic was selected in nized that some of the communication problems 2004 as a key project in the system strategic map for between clinicians could be linked to variations in fiscal year (FY) 2005. Goals were aligned with incen- communication styles. We started looking for ideas to tives by naming the chief nurse officer (CNO) as the improve communication. Michael Leonard, M.D., executive leader of the team, with a portion of her physician leader for patient safety at Kaiser compensation being based on achieving the goal. The Permanente (Denver) introduced us to a model of CNO asked staff questions regarding SBAR during her structured communication that would help clinicians rounding and requested that requests and/or reporting have a shared mental model for the patient's clinical of issues be forwarded using the SBAR format. In addi- condition. He called this structured communication tion, the medical director was named as an executive sponsor to champion the use of SBAR among medical staff peers. The medical director not only promoted the use of SBAR among staff when reporting a patient Implementing Use of SBAR at the
condition to him but also encouraged his peers to lis- ten for the use of SBAR and to encourage the staff to Investigation of near-miss occurrences and results provide the "R" or recommendation. The patient safety of root cause analyses resulted in identification of a officer [K.H.] was delegated as the project's day-to-day need to develop a standardized approach to hand-off communications among caregivers. Stories of actual The interdisciplinary Spread Team, representing cases demonstrated the impact of misinterpreted com- multiple nursing units, pharmacy, rehab, medical imag- munication from nurse-to-nurse, nurse-to-physician, ing, education staff, and media relations was estab- and physician-to-physician. One such story involved lished. It met biweekly for one hour for a period of one an elderly patient who was on warfarin sodium year (September 2004–September 2005). The team's (Coumadin) 2.5 mg daily. The nurse received a call aims, as stated in its charter, were as follows: from the lab regarding an elevated international ■ Improve communication among clinical caregivers normalized ratio (INR) for this patient but did not ■ Provide timely and accurate information through write down the results, as she was in the process spread of the use of the SBAR communication tool of providing care to another patient. Later, when she ■ Extend education relative to team resource manage- saw the physician, she asked him if he saw the ment concepts9–13 to improve the efficiency, timeliness, patient's INR results to which he responded, "Yes." and effectiveness of team interventions throughout the However, he was looking at a cumulative summary from the lab which did not include the most recent ele- In September 2004, the spread team was assigned vated INR results. On the basis of the information on the task of developing "better ideas" to describe the the lab cumulative summary, the physician increased case for use of SBAR to reduce communication deficits March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations as a contributing factor to potential adverse events.
Table 1. Reporting Documents Incorporating
The first better idea was development of an "elevator Situation, Background, Assessment, and
speech"—a description of SBAR in a few short sen- tences—to explain the project's intent. ■ Shift report hand-off tools specific to specialty The set-up targeted the clinical caregivers, including nursing units (labor, postpartum, nursery) nurses, lab personnel, medical imaging personnel, rehab ■ Strategic goal-reporting personnel, dieticians, social services personnel, pharma- ■ Emergency medical services run reports cists, and physicians for the initial spread plan. Initial ■ SBAR briefings for emergency department cardiac key messengers to spread the Better Ideas included team arrests and/or trauma patients members and Nursing Practice Council members. These ■ Charge nurse to charge nurse briefing tool members were asked to select one peer who was an ■ Incident reports early adopter to create a Social System for the spread of SBAR. Technical support aided knowledge management Shift hand-off reports, including certified nursingassistants by providing measurement and feedback to the adopter ■ Case review descriptions ■ Hospital forms (including administrative staff Addressing the Spread of SBAR
meeting minutes, the ethics committee issue form,and the inpatient and outpatient satisfaction Efforts to promote the use of SBAR began in April 2004, approximately five months before the ■ A service excellence report to report patient and/or formal team formation, through introduction of the staff opportunities for improvement to managers of concept in clinical educational settings. Baseline infor- all hospital departments mation was obtained in August 2004, during the pro- ject's pre-implementation phase, through a "secret shoppers" survey. Ten staff members were called at began on a general medical nursing unit in October random by either the corporate or the internal patient 2004. Tests of change were conducted with tools creat- safety officer. They were asked to describe what SBAR ed by the team, and revisions were made on the basis of stood for and then provide an example of how this con- input from the front-line staff members who piloted the cept is used in their daily communications. Results of tool. Tests were small, using one person for one day and the monthly survey were displayed on a run chart and gradually increasing those involved in the test until a shared throughout the organization for feedback. The workable tool was obtained. Once this was achieved, baseline data demonstrated that, on average, staff the SBAR trigger tool was spread to the surgical unit in were able to respond correctly 60% of the time.
January 2005 and to the critical care unit in March 2005.
In September 2004, the team set an aim to increase Finally, SBAR was spread housewide in April 2005, fol- the use of the SBAR communication tool to 90% by lowing meetings with managers of nonclinical areas, September 2005. Starting in November 2004, team such as social services, rehabilitation, medical imaging, resource management on the SBAR concept was con- ducted in multiple areas, specifically the intensive care unit/post-intensive care unit (ICU/PICU), respiratory, Identifying and Implementing Solutions
cardiac rehabilitation, cardiac catheterization lab, inter- Better ideas included incorporation of SBAR into a vari- ventional radiology, medical, surgical, float/registry, ety of reporting documents, as listed in Table 1 (above).
pediatrics, transitional care unit, and supervision staff.
Multiple mechanisms were used to spread the use of This training was selected as an organizational goal to SBAR, including those listed in Table 2 (page 170). The support the improvement efforts. laminated poster is shown in Figure 1 (page 171), the Using the Plan, Do, Study, Act (PDSA) performance nurse's report to a physician in Figure 2 (page 172), and improvement methodology, efforts to incorporate SBAR the hand-off form in Figure 3 (page 173). March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations Table 2. Mechanisms to Spread Use of
■ Leadership: key strategic initiative, goals, and Situation, Background, Assessment, and
incentives are aligned, and an executive sponsor was delegated■ Better ideas: develop the case and describe the ideas ■ Laminated posters displayed on the units ■ Set-up—target population: early adopters ■ Stickers placed on each phone at the nursing units ■ Social system and communication: key messengers, ■ Middle managers shared stories of staff's SBAR use, communication strategies, and technical support and these staff members were recruited as spread ■ Measurement and feedback agents to their peers Stories were shared that demonstrated missed oppor- ■ Examples developed for nonclinical areas tunities and the resulting impact, as well as success sto- ■ Staff on the obstetrics unit conducted peer obser- ries in which SBAR facilitated a shared mental model.
vation for the use of SBAR in nurse-physician com- Decision aids, standardization, redundancy of SBAR in munication and shift hand-off reports hospital forms, and forcing functions in reporting tools ■ Input from the patient services practice council led to early successes. was obtained in development of a user-friendlytool for shift hand-off reports Educational training was provided for current and new staff. Constant reminders by leadership in requiring Staff "practiced" their SBAR hand-off reports to physicians with peers before making the documentation to be in the SBAR format assisted in early adoption. Spread efforts were advanced to all ■ Monthly games/quizzes, with rewards departments, including nonclinical areas, for use in com- ■ Good examples of SBAR were recognized by being munication and documentation. published on Web sites, on hospital bulletin boards, The spread team found it difficult to identify outcome in hospital publications, and so on measures and sought advice from behavior experts. The ■ Peer assist meetings* were held to brainstorm ideas team then arrived at the following two outcome meas- for use of SBAR among different departments ■ A shared drive was developed to share data and ■ Consistent use of the medication reconciliation
process. Timely and accurate communication between
■ The medical director asked physicians to listen for nurses, pharmacists, and physicians is critical to accom- use of SBAR in communication from nursing staff plish medication reconciliation. This communication and encourage nursing staff to give the "R" part of must occur at multiple points during the inpatient stay, SBAR (recommendation) including admission, transfer between units, and dis- ■ SBAR training and a follow-up quiz were added to charge.14–17 Variances in medication lists can result in all new employees' orientation duplication, omission, wrong doses, and so on, poten- ■ SBAR was incorporated into annual safety educa- tion for all employees tially resulting in patient harm. Using SBAR communica- tion techniques should result in improved use of the SBAR was included in team resource managementtraining medication reconciliation process.
■ Screensavers were used to promote knowledge and ■ Number of adverse patient events. Improved
communication should improve the efficiency and effec- ■ A safety hotline using SBAR was created tiveness of teamwork and thus result in a reduction of all types of adverse events to patients. * Dixon N.M.: Does your organization have an asking problem?Knowledge Management Review 7:18–23, May–Jun. 2004.
Process Measure: Use of SBAR
Feasibility and Implementation Issues
St. Joseph Medical Center realized a mean of 96% Implementation approaches included the following use of SBAR in FY 2005 (Figure 4, page 174). Team resource management training was conducted with March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations

Figure 1. The information on the laminated poster, also reproduced on the pocket cards for clinicians, describes the
Situation, Background, Assessment, and Recommendation (SBAR) steps, with an example for each.

98.3% of targeted staff, exceeding a goal of 90%.
The frequency of medication reconciliation demon- Retraining was completed with 87% of targeted staff.
strated notable gains from October 2002–August Abbreviated versions of team resource management 2004 to September 2004–December 2005—admission training was provided to 39% of physicians and midlev- reconciliation improved from a mean of 72% to a mean el practitioners, exceeding the goal of 25%. of 88% (Figure 5, page 174), and discharge reconcilia- tion improved from a mean of 53% to a mean of 89% Outcome Measures: Medication Reconciliation and (Figure 6, page 175). The rate of adverse events was measured using the The spread team considered medication reconcilia- Global Trigger Tool, which contains a list of multiple tion and adverse events as separate processes not direct- triggers appropriate for general care, surgical care, ly dependent on SBAR. However, the team's thinking intensive care, emergency department, medication, was that better communication, reflecting SBAR use, laboratory and perinatal care that prompt the reviewer would improve reconciliation and the incidence of to look further for evidence of an adverse event.18–20 The rate of events per 1,000 patient days is measured March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations

Nurse's Report to a Physician
Figure 2. The Situation, Background, Assessment, and Recommendation (SBAR) Report to a Physician is intended
for a nurse making a report to a physician.

March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations

Figure 3. The hand-off form can be used by nurses at shift change.
March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations by calculating the total number of SBAR Use, 2004–2005
events, dividing by the total of length of stay for all charts reviewed, and multiplying by 1000. Each month, 20 charts were chosen at random to be reviewed. The rate of events was reduced from a baseline of 89.9 per 1,000 patient days in October 2004 to 39.96 per 1,000 patient days overall in Adverse drug events identified through use of the Global Trigger Tool decreased from a baseline of 29.97 per 1,000 patient days to 17.64 per 1,000 Figure 4. Use of Situation, Background, Assessment, and Recommendation
patient days.
(SBAR) reached a mean of 96% in fiscal year 2005. Reflections
The power of top management's
Use of SBAR in Admission Reconciliation,
involvement in performance improve- ment projects was realized. Select leaders from the top management team were not only involved in imple- menting SBAR but also provided human, technological, and financial Flattening of the hierarchy among nursing staff and physicians led to a cooperative effort to improve communication and improved satis- faction for each of those populations.
It was helpful to start with a small Figure 5. Use of Situation, Background, Assessment, and Recommendation
group, which included a few key (SBAR) in medication reconciliation at admission improved from a mean members and early adopters, and of 72% to a mean of 88%. then spread the change to peers. Use of story-telling promoted the benefits of good Summary and Conclusions
communication and the potential hazards of poor For OSF St. Joseph Medical Center, use of SBAR in both communication. Selecting team members from areas oral and written communication has improved patient in which SBAR plays a crucial role led to early safety by providing clear, accurate feedback of informa- adoption and buy-in of the concept. The addition tion between caregivers. There are fewer incidents of of a media relations staff member and the incorpora- missed information during handoffs since SBAR was tion of information technology assisted the team in implemented because concise facts are shared in an organized format. Next steps include integration of SBAR into the elec- Staff members are encouraged to "recommend" tronic medical record for documentation by all clinical on the basis of their observations, and this assists physicians with situational awareness through the March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations Use of SBAR in Discharge Reconciliation,
eyes of the bedside caregiver. Staff members feel empowered and have influence over decisions that affect work life using SBAR, thus improving job satisfaction. Currently, SBAR tools are being tested in communica- tion handoffs between shifts, for transfers to other departments (for example, radiology, operating room), and with patients admitted from the emergency department. SBAR pro- motes the six aims of the Institute of Medicine in providing safe, effi- cient, effective, equitable, timely, and Figure 5. Use of Situation, Background, Assessment, and Recommendation
(SBAR) in medication reconciliation at discharge improved from a mean of

patient-centered lines of communica- 53% to a mean of 89%. tion.21 J
8 Institute for Healthcare Improvement: Framework for Spread.
Kathleen M. Haig, R.N., is Director, Quality Resource
Management/Risk Manager/Patient Safety Officer, and Staci Sutton, R.N., is Emergency Services Manager, OSF St.
9. Helmreich R.L., Merritt A.C.: Culture at Work in Aviation and Joseph Medical Center, Bloomington, Illinois. John
Medicine: National, Organizational and Professional Influences.
Aldershot, U.K.: Ashgate, 2001.
Whittington, M.D., is Patient Safety Officer/Director
10. Helmreich RL. On error management: Lessons from aviation. BMJ of Knowledge Management, OSF Healthcare System, 320(7237):781–785, Mar. 2000. Peoria, Illinois. Please address correspondence to John 11. Kosnik L.K.: The new paradigm of crew resource management: just what is needed to re-engage the stalled collaborative movement? 12. Risser D.T., et al.: The potential for improved teamwork to reducemedical errors in the emergency department. The MedTeams Research Consortium. 13. Wiener E.L., Kanki B.G., Helmreich R.L.: Cockpit Resource 1. Joint Commission on Accreditation of Healthcare Organizations: Management. San Diego: Harcourt Brace, 1993.
Sentinel Event Statistics-June 30, 2005. 14. Gleason K.M., et al.: Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. accessed Jan. 24, 2006).
2. Joint Commission on Accreditation of Healthcare Organizations: 15. Pronovost P., et al.: Medication reconciliation tool: A practical tool to 2006 Critical Access Hospital and Hospital National Patient reduce medication errors during patient transfer from an intensive care unit. Journal of Clinical Outcomes Management 11:26–33, Jan. 2004.
16. Rozich J.D., et al.: Medication safety: One organization's approach to the challenge. Journal of Clinical Outcomes Management 8:27–34, 3. Wachter R.M., Shojania K.G.: Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York: 17. Whittington J., Cohen H.: OSF healthcare's journey in patient safe- Rugged Land, 2004. 4. Thomas E.J., Sexton J.B., Helmreich R.L.: Discrepant attitudes about 18. Resar R.K., Rozich J.D., Classen D.: Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 12 (suppl 2):ii39–ii45, Dec. 2003. 5. Greenfield L.J.: Doctors and nurses: A troubled partnership. 19. Rozich J.D., Haraden C.R., Resar R.K.: Adverse drug event trigger tool: A practical methodology for measuring medication related harm.
6. Leonard M., Graham S., Bonacum D.: The human factor: The crit- ical importance of effective teamwork and communication in pro- 20. Institute for Healthcare Improvement: Global Trigger Tool for viding safe care. Qual Saf Health Care 13 (suppl 1):i85–i90, Oct.
Measuring Adverse Events (IHI Tool). 7. McFerran S.C., et al.: Perinatal patient safety project: A multicenter 21. Institute of Medicine: Crossing the Quality Chasm. Washington, D.C.: National Academy Press, 2001.
March 2006 Volume 32 Number 3 Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations


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