Project Summary

This implementation project is complete.

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project expanded the use of Patient and Family-Centered I-PASS, a program shown to improve communication among doctors, nurses, and families and reduce serious adverse events that can lead to patient injury or death.

Each year, thousands of patients are harmed due to medical errors and adverse events in hospitals. An adverse event occurs when health care causes harm. Including families in discussions about their child’s care can help prevent errors and improve patient safety in the hospital.

What was the goal of this implementation project?

Medical errors and adverse events in hospitals are not uncommon. A PCORI-funded research study found that the Patient and Family-Centered I-PASS, or PFC I-PASS, program reduced the rate of adverse events among children in the hospital. The program trains doctors and nurses to communicate better and actively include patients and families during medical rounds. Rounds are daily meetings to review patients’ progress and come up with a care plan for the day.

This project expanded the use of PFC I-PASS in large and small hospitals that care for children to improve staff communication with families and reduce adverse events.

What did this project do?

The project team worked with 21 hospitals that care for children in 16 states across the United States to set up the PFC I-PASS program. With the program:

  • Doctors, nurses, and other staff receive training on how to communicate with and include families in daily rounds. Training includes in-person workshop sessions and an online video. It is tailored for clinician groups including medical residents, nurse practitioners, and nurses.
  • Staff make sure rounds cover everything important for the patient’s care.
  • After rounds, doctors and nurses give families written summaries about what was discussed.

At each hospital, a team of PFC I-PASS mentors helped sites put the program in place in a way that worked with how the hospital delivered care. The mentors had experience and expertise with the program. They conducted site visits and held monthly calls with each site. The Society of Hospital Medicine assisted PFC I-PASS mentors with this effort.

The project team also provided sites with monthly feedback reports on their progress, which mentors discussed during these calls. Over the project period, sites took on increasing independence for their PFC I-PASS program.

To make the program part of routine care, each hospital had a team of champions that included a doctor, nurse, and family member. This team worked with the PFC I-PASS mentors and coached and supported doctors and nurses in their hospital to use the program effectively.

The project team created a guide to help other hospitals put the program in place.

What was the impact of this project?

The project team successfully put the PFC I-PASS program in place at 21 hospitals. The hospitals were different sizes and types and served diverse communities. Due to the COVID-19 pandemic, many hospitals changed their processes for rounds. The project team worked with sites to find ways to continue including families in rounds, like doing them virtually.

During the project, more than 83,000 patients and their families and more than 3,500 doctors and nurses took part in the program. The project’s evaluation showed that hospitals improved on best practices for rounding after putting the program in place.

In observations of rounding before and after the program:

  • Rounding at the bedside with families increased from 76% to 90%.
  • Following all components of the PFC I-PASS process increased from 26% to 61%.
  • Involving families in rounds increased from 71% to 88%.
  • Involving nurses in rounds increased from 33% to 63%.
  • Use of plain language by doctors and nurses during rounds increased from 50% to 61%.
  • Providing families with a written summary of rounds increased from 30% to 72%.

Clinician-reported harms didn’t change overall before and after the program. But harms decreased by 38% at larger hospitals (p=0.006) and by 41% at hospitals that had more nurse involvement during rounds. Also, harms decreased by 24% at hospitals with higher adherence to the PFC I-PASS program (p<0.05).

Patient- and family-reported satisfaction with communication didn’t change overall before and after the program. But measures of satisfaction with communication improved by 5% in larger hospitals (p=0.002).

Clinicians overall reported an improvement in hospitals’ safety climate (p<0.05). Patients and families didn’t report a change in safety climate.

Hospitals reported that they intend to continue to use the program and plan to expand use to other sites.

More about this implementation project:

Stakeholders Involved in This Project

  • PRIS Network
  • Society of Hospital Medicine
  • Institute for Healthcare Improvement
  • National Patient Safety Foundation
  • American Academy of Pediatrics
  • Children’s Hospital Association
  • Hospital Research and Educational Trust
  • Beryl Institute
  • Patients’ View Institute
  • Consumers Advancing Patient Safety
  • Mothers Against Medical Error
  • Leapfrog Group
  • Connecticut Center for Patient Safety
  • American Academy of Nursing
  • Society of Pediatric Nurses

Publicly Accessible Project Materials

For more information about these materials, please contact the project team at [email protected].

The project team developed these materials, which may be available for free or require a fee to access. Please note that the materials do not necessarily represent the views of PCORI and that PCORI cannot guarantee their accuracy or reliability.

Project Achievements

  • Implemented PFC I-PASS program in 21 diverse pediatric and community hospitals.
  • Reached 83,000 patients and families, 2,300 doctors, and 1,300 nurses.
  • Developed comprehensive education and training materials.
  • Created an implementation guide for future sites.
  • Provided CHW asthma home visits to 155 low-income patients with poorly controlled asthma

Implementation Strategies

  • Adapted the program to work with existing hospital resources and workflows.
  • Provided sites with web-based tools to support implementation (e.g., to coordinate mentor-mentee activities, provide access to feedback reports, and share resources and best practices).
  • Trained physicians and nurses to use the program.
  • Trained mentors to support local implementation activities using an in-person course and structured guide.
  • Used a phased implementation approach, launching the program in three waves.
  • Conducted cyclical small tests of change.
  • Provided sites with monthly audit and feedback reports.
  • Provided educational materials to patients.
  • Identified and prepared local champions at sites, including physicians, nurses, and family representatives.
  • Conducted site visits.
  • Provided technical assistance to sites, including ongoing monthly mentor-mentee consultations while sites took on increasing responsibility for implementing the program.
  • Partnered with national stakeholder organization to promote implementation.

Evaluation Measures

To document implementation:

  • Use of intervention
  • Fidelity of delivery (in-person observation, review of discussions in the family-centered rounds)

To assess healthcare and health outcomes:

  • Clinician-reported adverse events
  • Institutional safety ratings (clinician survey)
  • Patient and family satisfaction with communication (patient and family surveys)

More to Explore...

PCORI Stories

Hearing All Voices in Planning a Child’s Hospital Care
A PCORI-funded team folded parents into daily care conversations with doctors and nurses at pediatric units in hospitals, leading to a marked reduction in medical errors and an improvement in patient care. Now, with this PCORI Dissemination and Implementation Award, the project team is spreading the program to 21 hospitals across the country.

Project Information

Christopher Landrigan, MD, MPH
The Children's Hospital Corporation
Disseminating and Implementing Patient- and Family-Centered I-PASS to Improve Patient Safety

Key Dates

July 2018
January 2023

Study Registration Information

Initial PCORI-Funded Research Study

This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Does a Patient- and Family-Centered Hospital Communications Program Reduce Medical Errors?


Project Status
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Project Details Type
Last updated: August 9, 2023