Establishing a Multisite Education and Research Project Requires Leadership, Expertise, Collaboration, and an Important Aim
This is the first in a series of articles to highlight the projects that were chosen for implementation by the IIPE Review Committee; each represents a work in progress. We wanted the readership to be aware of innovations that are underway and what the investigators have learned even though they are early in the process. The first article in this series focuses on building a multi-institutional collaborative project that links educational and patient care outcomes.Carol Carraccio, MD, MA
Communication and handoff (sign-out) failures are a root cause of two-thirds of sentinel events in hospitals. Therefore, the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission have declared improving handoffs a national priority.1,–,7 As a response to that declaration, we have designed and implemented a multisite education and research project aimed at determining the effectiveness of a resident handoff bundle (team training, use of a verbal mnemonic, and written/computerized tools to supplement verbal handoffs) in standardizing the handoff process in 9 pediatric residency programs. This project, supported by the Initiative for Innovation in Pediatric Education (IIPE) and the Pediatric Research in Inpatient Settings (PRIS) Network, is a unique example of a multisite collaborative that links improved educational outcomes with patient outcomes. Our report, at this early stage, shares lessons learned and illustrates key considerations for the effective development of a similar collaborative multisite education and research project that exists at the interface between education and patient care.
TIMING, CONCEPT, LEADERSHIP, AND NETWORKING
Our project started when 1 of the authors (Dr Sectish) attended an institutional quality conference at which a pilot research study that examined resident handoffs was presented by a faculty member (Dr Landrigan) and a health services research fellow (Dr Starmer). The study measured the impact of a resident handoff bundle on patient safety. The 3 colleagues met after the conference and began the process of establishing a multisite education and research project, formed a network, and submitted a letter of intent to the IIPE (at a time at which letters of intent were required).
Several key factors contributed to the success of this process: (1) the project concept; (2) existing professional relationships and networks; and (3) leadership experience of project organizers. The concept of improving patient handoffs to increase patient safety is, as noted above, an urgent national need. The 3 original project leaders had worked together in the past on a previous multisite study as well as on several national initiatives. Two had conducted the pilot study as mentor and mentee. The project leaders' professional networks and leadership experience were also critical to the process. One author, Dr Sectish, was a past president of the Association of Pediatric Program Directors. Dr Landrigan was past chair and a current PRIS Executive Council member, and a third, Dr Starmer, was the chair of the American Academy of Pediatrics Section on Medical Students, Residents, and Fellowship Trainees. Strong connections to national organizations coupled with a convergence of interests, goals, and values of the project leaders and their professional organizations created synergies that facilitated the project's launch.
NEXT STEPS IN THE PROCESS
Development of Network of Sites
The 3 project leaders approached members within the Association of Pediatric Program Directors and the PRIS Executive Council who had proven track records of success in implementing education and research projects. Nine sites were selected and, in turn, formed the multisite collaborative (see Fig 1). At each site, program directors, hospitalists, and educators formed a team with a designated site principal investigator.
Project leaders provided each principal investigator with a description of the study's aims, methods, and costs. It was recognized that costs would vary depending on the scope of the intervention and the data to be collected. The costs of active error detection are significant; therefore, the necessity of obtaining grant funding was determined to be a priority. There was also an expectation for in-kind or institutional support for educational interventions, information technology support, and resources from existing quality-improvement programs.
Institutional support was garnered because (1) the topic of patient safety was important to department chairs and hospital administrators, (2) the opportunity to collaborate with other institutions was appealing, and (3) the decision to seek external funding provided the incentive to participate.
Initial Application Process
Four distinct phases for the research project were delineated: planning; implementation; data analysis; and dissemination (abstracts, presentations, manuscripts, and curricular toolkit). The planning phase included the development of network sites, the initial application process for the IIPE (letter of intent and full proposal), and grant-application process.
The IIPE letter of intent required signatures from key leaders in each of the 9 institutions, including the program director, department chair, designated institutional official, and hospital chief executive officer. This step, although a logistic challenge, enabled the site teams to unite and create interest within institutions. Once invited to draft a full IIPE proposal, a subgroup with expertise in research methodology designed the methods and drafted a time line. A design was chosen with preintervention and postintervention data collection, and a federal grant proposal was submitted.
The multisite project will test the hypothesis that rates of serious medical errors, verbal and written miscommunications, and time spent gathering and handing over data will decrease after implementation of the handoff bundle. Following the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, data on site-specific contextual factors will be captured to facilitate dissemination outside of the controlled setting of a study.8 Best practices and implementation strategies, including the use of electronic tools, simulation, and supervision of handoffs, will be compared and contrasted.
Project Governance Structure and Time Line
Project leaders recognized the importance of governance and designed an organizational structure that included the Scientific Oversight Committee, along with other subcommittees (see Fig 1). Key leaders and members of each group were chosen on the basis of individuals' areas of expertise. The Educational Executive Committee will design, implement, and evaluate the curriculum for team training, standardize teaching of handoff techniques, provide faculty development, and develop ways to disseminate and diffuse the knowledge gained. The Scientific Oversight Committee will focus on scientific methodologies, data collection, and analysis. The implementation time line will be staggered for clusters of sites to enable the incorporation of lessons learned into subsequent rounds of the intervention and to facilitate data collection.
Key Factors for Early Success in the Management of Large Multisite Projects
Early success in the management of this multisite project required active leadership and deliberate attention to effective communication and the development of specific project teams that included members with unique expertise and innovative potential. Key factors for success include:
building close working relationships early with face-to-face meetings;
using communication technologies wisely (conference calls with large groups are most effective for information broadcasts or updating, whereas conference calls with small groups are most effective for active participation and work achievement); and
using team members and their skill sets and engaging them early in work assignments in smaller groups to accelerate the momentum of the project.
The establishment of a multisite education and research project depends on several key elements. First, the study aim must be important for others to want to join the project. Transformational change efforts require urgency to call people into action.9 Second, leadership, personal relationships, and professional networks greatly contribute to the initiation of a large project.10 Third, leadership expertise in executing a multisite research project provides the group with guidance and confidence.11 Finally, there must be an explicit and overt process to form trusting, collegial relationships based on shared goals, interests, and values,12 and if they align with those of the institution, there is a greater likelihood of endorsement, resources, and support.
Dr Landrigan is partially supported by the Child Health Corporation of America for his work as a member of the PRIS Network Executive Council.
The IIPE-PRIS Accelerating Safe Sign-outs (I-PASS) Study Group currently includes James F. Bale, MD, Kathleen Berchelman, MD, Sharon Calaman, MD, Maitreya Coffey, MD, F. Sessions Cole, MD, Lauren Destino, MD, Javier Gonzalez del Rey, MD, MEd, MSPH, Madelyn Kahana, MD, Carol Keohane, RN, Christopher P. Landrigan, MD, MPH, Stuart Lipsitz, PhD, Joseph Loprieato, MD, MPH, Sanjay Mahant, MSc(c), MPH, Anne Matlow, MD, Robert McGregor, MD, Jennifer O'Toole, MD, Shilpa Patel, MD, Glenn Rosenbluth, MD, Jeffrey Rothschild, MD, MPH, Theodore C. Sectish, MD, Paul Sharek, MD, MPH, Nancy D. Spector, MD, Rajendu Srivastava, MD, MPH, Amy J. Starmer, MD, MPH, Adam T. Stevenson, MD, Daniel C. West, MD, Andrew White, MD, Karen Wilson, MD, MPH, and Clifton E. Yu, MD. Dorene Balmer, PhD, RD, and Alan Schwartz, PhD, serve the I-PASS Study Group as part of the IIPE Research Support Team.
- Accepted July 27, 2010.
- Address correspondence to Theodore C. Sectish, MD, Department of Medicine, Hunnewell 2, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mail:
The IIPE is the entity that recognizes innovative educational proposals for pediatric residency training programs (more information can be found at www.innovatepedsgme.org).
The PRIS is a collaborative hospitalist research network sponsored by the American Academy of Pediatrics, the Academic Pediatric Association, the Society of Hospital Medicine, and the Child Health Corporation of America (details are available at www.ambpeds.org/research/research_pris.cfm).
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- IIPE =
- Initiative for Innovation in Pediatric Education •
- PRIS =
- Pediatric Research in Inpatient Settings
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