Structured communication tools are increasingly recognised as valuable in improving communication and safety. The aim of this project was to introduce the ISBAR communication technique across the whole of a large multisite health service for internal clinical communication. Given the large size of the organisation, having over 12 000 staff members, the project was divided into two phases. The initial phase, based at one campus, was followed by a second phase during which the project was rolled out site by site. This paper discusses the lessons learned from the roll-out at the first campus.
Health care today is practised in an increasingly complex clinical environment. Patients receive input from multidisciplinary teams, each made of up several clinicians with differing backgrounds, training and expertise.1 Effective clinical communication amongst these professional groups is essential in order to provide high-quality, safe patient care within this ever-changing environment. Poor communication was highlighted as a contributing factor during the organisational review of the system failure at Bristol2 and during the judicial inquiry into the premature death of an abused child, Victoria Climbie, in Britain.3 Breakdown in communication has been described as a preventable factor in diagnostic errors4 and has been linked to delays in referrals and appropriate care, increasing morbidity and mortality.5
Furthermore, failures in communication have been estimated to be the major factor in 60-70% of serious incidents.6 In a large review of reportable adverse events that led to permanent disability in Australia 11% were estimated to be attributable to communication issues; this is almost double that attributed to inadequate skill levels of clinicians.7 Our health service recognised the significant risk attached to poor or inadequate communication between clinicians; a review of major adverse events from 2005 to 20088 indicated that communication was a significant contributor in 35% of cases. These data were extracted from the RiskMan (RiskMan.net Incident Risk Management Database, April 2008) electronic data collection, which is dependent upon the voluntary reporting of adverse events.
The use of a structured methodology of communication using a standardised tool can improve the quality of information exchange. One such tool that has been demonstrated to improve communication is the situation briefing tool, SBAR.9 This tool was developed in the US Navy to standardise important and urgent communication in nuclear submarines. SBAR (Situation, Background, Assessment, Recommendation) was implemented into the health care environment by a multidisciplinary team at Kaiser Permanente of Colorado10 and is a commonly used effective tool, adapted for a large variety of clinical scenarios in the USA.11
The Simulation Centre at our health service introduced the SBAR communication tool into the final-year medical students' patient safety subject in 2005. SBAR was adapted to ISBAR, the 'I' for 'Identify' for explicit identification of self, the person to whom the information is given and where the person is calling from. This was thought to be vital in a large multisite service. The 'R' for 'Request' was changed from 'Recommendation', as it was thought to help junior clinicians ask for help by minimising any hierarchy gradient. A controlled trial was undertaken to evaluate the efficacy of theISBARtool for telephone referral by junior staff and concluded that '. . .training in the use of ISBAR is feasible, effective and likely to result in improved communication in the clinical environment'.12
Given the improvements in content and clarity of communication that were demonstrated the organisation strongly supported the teaching of this communication technique throughout the health service.
Setting and participants
Our health service is a large service consisting of a tertiary referral centre, a Level 2 hospital with an intensive care unit (ICU), a peripheral centre with an emergency department (ED) but no ICU, two predominantly surgical hospitals and rehabilitation, residential care and community centres. …