150: Social Impediments to Implementation of Structured Handoff in a Professional Context: A Qualitative Study of I-Pass Implementation

Abstract

Background: Literature on high reliability organizations suggests that structured communication can reduce errors. The I-PASS Handoff Bundle aims to improve resident handoff and consists of teamwork training, structured verbal communication using a mnemonic, and an electronic written handoff tool. The program was implemented as part of a nine-site study. This qualitative study examines the implementation of structured handoff in the context of residency training programmes. Objectives: This study examined to what extent I-PASS was adopted amongst residents, what factors facilitate and impede adoption, and in particular the impact of social factors. Design/Methods: Focus groups were conducted with residents (n=54) at eight of nine IPASS sites. The data were analysed using grounded theory techniques to generate insight into how adoption of structured communication could be facilitated in health care. Results: The results were very consistent across sites, and resident perspectives fell into four main themes. 1. Residents expect communication to be efficient. Time is universally regarded as a scarce resource and it is expected that communication should cover only the information necessary for on-going quality patient care. The perception that the I-PASS mnemonic requires that the same information be covered regardless of the professional's level or knowledge of the patient and for all patients regardless of complexity was seen as violating this norm. 2. Residents expect communication to respect professional competence. The standardized nature of the information communicated to colleagues can be seen as insensitive to the requirements of residents at different stages of professional competence. Junior residents were more receptive to comprehensive information while the same information was felt redundant by senior residents. 3. Residents expect allowance for professional judgment and autonomy. The standardized format of IPASS communication, particularly the Synthesis by Receiver step (read back) was seen as limiting professionals' right to exercise judgment in communication. 4. Residents expect informal communication among peers: The standardized format of IPASS was seen as more suited to demonstrating skill to a superior rather than for use among colleagues of the same hierarchical level. Conclusions: These data must be interpreted in the context of residency training. Residents who have varying levels of professional identity formation may vary in their ability to adopt new structured communication practices. Acknowledgement of these norms in the training and ongoing reinforcement phases could lead to more positive attitudes and greater receptivity to ongoing efforts to improve communication, which will be required to bring about transformative change.