Quality and Safety

CSIRO PUBLISHING Case Study

www.publish.csiro.au/journals/ahr Australian Health Review, 2010, 34, 400404

ISBAR for clear communication: one hospitals experience

spreading the message

Monica A. Finnigan1,3 MHealthSci, Quality Practise Improvement Manager

Stuart D. Marshall2 MRCA, FANZCA, Simulation Educator, Human Factors Specialist
Brendan T. Flanagan2 FANZCA, Director, Southern Health Simulation Centre
1
Southern Health, 246 Clayton Road, Clayton, VIC 3168, Australia.
2
Southern Health, Southern Health Simulation and Skills Centre, PO Box 72, East Bentleigh, VIC 3165, Australia.
3
Corresponding author. Email: monica.nnigan@southernhealth.org.au

Abstract. All health services rely on efcient and accurate communication between health professionals to ensure safe and
effective patient care. Our health service introduced a standardised technique, ISBAR (Identify, Situation, Background,
Assessment, Request), for telephone communication. We describe and evaluate the implementation of this project;
evaluation was undertaken using program logic mapping. Recommendations for other health services planning to introduce
communication tools into routine clinical use are also provided.

Objectives recognised the signicant risk attached to poor or inadequate

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 rst campus.
Background
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 envi-
ronment. 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 6070% of serious incidents.6 In a large
review of reportable adverse events that led to permanent dis-
ability 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
communication between clinicians; a review of major adverse
events from 2005 to 20088 indicated that communication was a
signicant 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 depen-
dent 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 brieng 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 nal-year medical students
patient safety subject in 2005. SBAR was adapted to ISBAR, the
I for Identify for explicit identication 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 efcacy of the ISBAR tool 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 communi-
cation that were demonstrated the organisation strongly

AHHA 2010 10.1071/AH09823 0156-5788/10/040400

ISBAR for clear communication
supported the teaching of this communication technique through-
out 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, residen-
tial care and community centres. The service employs over 12 000
staff and has more than 1.1 million patient-care episodes per year.
Owing to the large size of the organisation, a decision was made to
pilot the project at one site rst, then stage the roll-out across the
other sites in a systematic fashion. The site chosen to launch the
initiative was the Level 2 hospital, because it represented a self-
contained acute site, with fewer transfers. This hospital is an
outer-suburban 520-bed acute hospital, with over 1400 clinical
staff working across a range of settings, including general med-
ical, surgical, obstetrics, paediatrics, 24-h ED and theatre access,
mental health and rehabilitation units.
Sequence of events
The ve key project milestones were:
1. Development of face-to-face and online ISBAR education
packages.
2. Development and distribution of visual aids and tools to staff
and to wards.
3. Training of all clinical current staff in the ISBAR communi-
cation tool.
4. Training of new staff in the ISBAR communication tool at
induction into the organisation.
5. Development of further applications of the tool in high-risk
areas such as emergency department handover and imaging
requests.
Organisational and executive support
The project had unanimous executive support and was cofunded
by the hospital insurer. An Executive Director acted as the Chair
of the Steering Committee, with direct reporting lines to the Board
and Chief Executive.
Stakeholders from a range of areas were included in the project
team, including clinicians, education, quality and service im-
provement. A project ofcer was appointed and project manage-
ment support was provided through the Quality Unit team.
Education strategy
The education package was redeveloped from the original Sim-
ulation Centre package.13,14 A 45-min interactive session includ-
ed video critique, questions and discussion, and several general
clinical scenarios were developed so that all clinical staff (med-
ical, nursing, allied health) could practice the technique. For
example, the initial case involved a patient admitted to a general
medicine program, the next case was written involving an ob-
stetrics case, followed by a mental health case.
Visual aids were developed to accompany the session, includ-
ing posters, cards (to attach to staff identication tags) and note
pads with prompts (see Fig. 1). These were distributed after each
session. A Train the Trainer Package was also developed for the
Australian Health Review 401
Nurse Education Department so that the training could continue at
the site at the end of the pilot phase.
Communication strategy
The initiative was presented at all key site meetings including
senior executive groups, medical unit heads, nurse unit managers,
clinical leaders and clerical staff. The education session was
deemed to be mandatory using a register to record staff atten-
dance. Overhead announcements were used daily to remind staff
of sessions. Regular email reminders were also sent out to unit
managers. A website was set up to advertise session times, dates
and venues.
Outcomes
The evaluation of the initial phase was designed to assess: (1) the
education package for clinical staff; (2) the perceived value of
the tool in improving communication effectiveness; and (3) any
changes in clinical communication associated with the introduc-
tion of the tool. The evaluation was designed using program logic
mapping, incorporating a combination of qualitative and quan-
titative methods, and including the collection of data from
multiple sources. Program logic is a logical, visual method of
depicting the relationship of elements of a program, describing
both what is planned and what results are expected. It aligns
planning, project management and evaluation, with a focus on
outcomes.15
Success of the training package
Of the 1400 clinical staff members, 1002 (71%) attended training
at 69 sessions, including several night duty sessions. A break-
down of staff that attended the sessions included nursing
(n = 676), medical staff (110), allied health (135), administration
and clerical (79) and students (4). This was short of our aim of a
95% attendance at face-to-face education sessions; however, the
compliance rate increased once the online training was introduced
after the pilot phase. Staff attending the full training sessions
completed a pretraining survey form and, after the sessions, 618
completed an evaluation form.
Prior to the session 72% (n = 446) had never heard of the
ISBAR tool, but after the session 89% (n = 554) found the session
worthwhile to very worthwhile, and 88% believed it was relevant
to them (n = 540) and their colleagues (n = 549).
Interviews following the training
Further in-depth interviews were held three months after com-
pletion of training using the evaluation domains developed by the
program logic mapping framework. Success case methodology
was chosen to collect the appropriate data and 13 participants
across the range of represented professions who attended training
were chosen to participate in the interviews using a stratied
random sampling technique. The success case methodology has
been developed by Robert Brinkerhoff,16 and is used to describe
learning in the workplace. It focuses on evaluation inquiry by
using only a relatively few numbers of learners, using the
principle that valuable information can be gained in an econom-
ical fashion from learners who have been successful in applying
the learning to their work.
402 Australian Health Review M. A. Finnigan et al.

ISBAR
for clear communication

I dentify:

S ituation:

B ackground:

A ssessment:

R equest:

Fig. 1. Note pad to support ISBAR.

Acceptability of ISBAR A colleague always says Lets ISBAR it. [Interviewee

Most participants used ISBAR (either in telephone referral or in
the written format) and all could accurately recall the acronym
correctly. Most (9 of 13) had no problem with the tool, but:
like any change it does take time. [Interviewee 1, Reg-
istered Nurse]
The use of the visual prompts varied, with pads being found the
most useful:
I am comfortable with having the pads next to the phone.
[Interviewee 2, Nurse Educator]
Staff often found multiple prompts useful and some found
visual prompts more useful initially:
Its good to have the prompts so you are not forgetting.
[Interviewee 1, Registered Nurse]
One staff member commented that now:
2, Nurse Educator]
Value of ISBAR
All staff interviewed found merit in using the ISBAR structure,
particularly in making telephone conversations more efcient and
expecting the information in order.
It is a most thorough way and helps identify all the key
aspects that you are trying to communicate. [Interviewee 1,
Registered Nurse]
One recurring theme was that it was recognised to be most
benecial for junior staff:
I think it is very important for junior staff, who are not used
to formulating a referral. [Interviewee 8, Midwife]
Other uses for the tool in addition to telephone communication
were found one medical staff member added:
ISBAR for clear communication
It is particularly good for handovers at the end of a shift;
when someone is tired it does make the expectations of what
information needs to be handed over and it helps the person
receiving to clarify the handover further. [Interviewee 3,
HMO]
None of the respondents found any negative aspects to the tool.
Effects of ISBAR
Although only half (7 of 13) of the respondents found that ISBAR
made a difference in communications, this was tempered by the
recognition that many senior staff were already good commu-
nicators. Most found that the structure did assist with preparation
before referral, for example:
Senior people are saying to the juniors, now think about
what you are going to say. [Interviewee 6, Midwife]
All agreed that it provided a clearer picture regarding the
clinical situation:
It has not reinvented the wheel, but it has made the wheel
more obvious. [Interviewee 5, Registrar]
Problems encountered
This project appeared to resonate with staff at all levels of the
organisation and assisted with the ease with which this commu-
nication tool was disseminated. There were, however, some
difculties that were expected when dealing with such a large
organisation.
Attendance of medical staff at training
Some of the medical staff were difcult to reach with the training
owing to their workloads and this was a factor in considering the
length of time of the training session. Shorter training was adopted
for those time-poor experienced clinicians and some of the
medical staff from the committee were engaged to run these
sessions. Some after-hours sessions were also held.
Training venues
Initially the training was going to be held on the wards; this was
altered to general lecture theatres and seminar rooms during the
project as there was not enough room for the training and
insufcient equipment.
Staff registration
Staff names were recorded at the time of training but cross-
checking with databases proved problematic. Staff movements
between campuses and other general issues regarding name
changes were difcult to sort.
Lessons learnt
Achieving the aim of introducing this communication technique
to clinicians can be attributed to several key factors:
1. Engagement of all levels of the organisation, particularly at the
executive level. This assisted particularly with getting staff to
attend training as the executive decision enabled the project
group to mandate training.
Australian Health Review 403
2. Conducting the initial stage of the project at one site as this
enabled the project to be easily managed in the early stages.
This site management was particularly helpful, assisting with
the arrangement of sessions and appropriate venues, allowing
night duty sessions and assisting with organising staff for
interviews, etc.
3. Reminding staff to attend sessions by way of the overhead
announcements boosted attendance.
4. Teaching craft-specic professional groups allowed the ses-
sions to be tailored to those groups and seemed to increase staff
engagement in the process.
5. Creating a shortened version of the training for the senior
medical clinicians who were already experienced but were
time poor.
6. Support of the training from the Nurse Educators assisted with
the continuation of training at the site after the initial phase.
This project continues to be rolled out across the other
campuses within the organisation. It has grown and evolved from
the initial phase as described. An E-learning package has been
added, which can be accessed both in hospital and at home via the
internet. During and after the initial phase, two documents have
been developed using the structure, the diagnostic imaging form
and a transfer from ED to ward form. These have been highly
successful and driven by the staff in the areas.
Final evaluation of the whole project should be available by
early 2010.
Competing interests
None declared.
Acknowledgements
Many thanks to the Southern Health Steering Group (Wayne Ramsey, Bill
Shearer, Brendan Flanagen, Chris Fraser, Paul Ormrod, Kate MacRae,
Carmen Walker, Jennine Harbrow) and the Victorian Managed Insurance
Authority who supported the project.
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