SBAR: A Shared Mental Model for Improving Communication Between Clinicians

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Article-at-a-Glance

Background

The importance of sharing a common mental model in communication prompted efforts to spread the use of the SBAR (Situation, Background, Assessment, and Recommendation) tool at OSF St. Joseph Medical Center, Bloomington, Illinois.

Case Study

An elderly patient was on warfarin sodium (Coumadin) 2.5 mg daily. The nurse received a call from the lab regarding an elevated international normalized ratio (INR) but did not write down the results (she was providing care to another patient). On the basis of the previous lab cumulative summary, the physician increased the warfarin dose for the patient; a dangerously high INR resulted.

Actions Taken

The medical center initiated a collaborative to implement the use of the SBAR communication tool. Education was incorporated into team resource management training and general orientation. Tools included SBAR pocket cards for clinicians and laminated SBAR “cheat sheets” posted at each phone. SBAR became the communication methodology from leadership to the microsystem in all forms of reporting.

Discussion

Staff adapted quickly to the use of SBAR, although hesitancy was noted in providing the “recommendation” to physicians. Medical staff were encouraged to listen for the SBAR components and encourage staff to share their recommendation if not initially provided.

Section snippets

Implementing Use of SBAR at the Medical Center

Investigation of near-miss occurrences and results of root cause analyses resulted in identification of a need to develop a standardized approach to hand-off communications among caregivers. Stories of actual cases demonstrated the impact of misinterpreted communication from nurse-to-nurse, nurse-to-physician, and physician-to-physician. One such story involved an elderly patient who was on warfarin sodium (Coumadin) 2.5 mg daily. The nurse received a call from the lab regarding an elevated

Addressing the Spread of SBAR

Efforts to promote the use of SBAR began in April 2004, approximately five months before the formal team formation, through introduction of the concept in clinical educational settings. Baseline information was obtained in August 2004, during the project’s pre-implementation phase, through a “secret shoppers” survey. Ten staff members were called at random by either the corporate or the internal patient safety officer. They were asked to describe what SBAR stood for and then provide an example

Identifying and Implementing Solutions

Better ideas included incorporation of SBAR into a variety of reporting documents, as listed in Table 1 (above). Multiple mechanisms were used to spread the use of SBAR, including those listed in Table 2 (page 170). The laminated poster is shown in Figure 1 (page 171), the nurse’s report to a physician in Figure 2 (page 172), and the hand-off form in Figure 3 (page 173).

Feasibility and Implementation Issues

Implementation approaches included the following strategies:

  • Leadership: key strategic initiative, goals, and incentives are aligned, and an executive sponsor was delegated

  • Better ideas: develop the case and describe the ideas

  • Set-up—target population: early adopters

  • Social system and communication: key messengers, communication strategies, and technical support

  • Measurement and feedback

Stories were shared that demonstrated missed opportunities and the resulting impact, as well as success stories in

Process Measure: Use of SBAR

St. Joseph Medical Center realized a mean of 96% use of SBAR in FY 2005 (Figure 4, page 174). Team resource management training was conducted with 98.3% of targeted staff, exceeding a goal of 90%. Retraining was completed with 87% of targeted staff. Abbreviated versions of team resource management training was provided to 39% of physicians and midlevel practitioners, exceeding the goal of 25%.

Outcome Measures: Medication Reconciliation and Adverse Events

The spread team considered medication reconciliation and adverse events as separate processes not

Reflections

The power of top management’s involvement in performance improvement projects was realized. Select leaders from the top management team were not only involved in implementing SBAR but also provided human, technological, and financial resources.

Flattening of the hierarchy among nursing staff and physicians led to a cooperative effort to improve communication and improved satisfaction for each of those populations. It was helpful to start with a small group, which included a few key members and

Summary and Conclusions

For OSF St. Joseph Medical Center, use of SBAR in both oral and written communication has improved patient safety by providing clear, accurate feedback of information between caregivers. There are fewer incidents of missed information during handoffs since SBAR was implemented because concise facts are shared in an organized format.

Staff members are encouraged to “recommend” on the basis of their observations, and this assists physicians with situational awareness through the eyes of the

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Cited by (0)

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. 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 ([email protected]) and Marcia Piotrowski ([email protected]).

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