Using SBAR to communicate falls risk and management in rehabilitation teams

Using SBAR to communicate
falls risk and management in

interprofessional
rehabilitation teams
May 7, 2010
Investigators:
Karima Velji, BscN, MSc., RN, PhD, Toronto Rehabilitation Institute
G. Ross Baker, PhD, University of Toronto
Carol Fancott, BScPT, PhD(C), Toronto Rehabilitation Institute
Gaetan Tardif, MD, FRCPC, CSPQ, Toronto Rehabilitation Institute
Elaine Aimone, MSc., BScPT, Toronto Rehabilitation Institute
Sherra Solway, BSc(PT), MSc, MHSc(c), Toronto Rehabilitation Institute
Angie Andreoli, BScPT, MSc (C), Toronto Rehabilitation Institute
Paula Szeto, BScOT, Toronto Rehabilitation Institute
Claudia Hernandez, BScPT, MSc(c), Toronto Rehabilitation Institute
Sheelah Holdsworth, BA, Patient Advocate
Table of Contents
Acknowledgement ......................................................................................................................... 3
Main Messages .............................................................................................................................. 4
Executive Summary ...................................................................................................................... 6
Context ......................................................................................................................................... 12
Implications ................................................................................................................................. 13
Approach, Methodology, Rationale, Assumptions................................................................... 14
Results, Conclusions ................................................................................................................... 21
Recommendations ....................................................................................................................... 33
References .................................................................................................................................... 36
Appendix A: Adapted SBAR tool (full and abbreviated versions) ........................................ 39
Appendix B: Internal presentation of results to research and study teams .......................... 40
Appendix C: Pre- and post-implementation outcome measures ............................................ 40
Appendix D: Patient safety roleplay scenarios......................................................................... 51
Appendix E: Facilitator guide for focus group discussions .................................................... 54
This project is Using SBAR to communicate falls risk

Investigators:
partially and management in interprofessional
Velji et al., 2010
funded by: rehabilitation teams
Acknowledgement
We gratefully acknowledge Research Coordinators Angie Andreoli and Felix Cheng for
their contribution to this project and to Barry Trentham, Education Consultant for his tremendous
skills as a teacher and educator. Thank you also to the staff and leaders on the Geriatric and
Musculoskeletal rehab teams who were such willing partners on this project.
We would also like to acknowledge the Canadian Patient Safety Institute as our funding
partner in this research.

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Main Messages
This study builds on previous pilot work within our organization that adapted the SBAR
(Situation-Background-Situation-Assessment) tool for use beyond acute care and nurse-
physician communication.
The aim of this study was to implement SBAR on two interprofessional rehabilitation
teams with high falls incidence over a 6-month period and evaluate its outcome and
processes related best practices in falls prevention and management.
A series of educations sessions included both clinical and non-clinical staff, and
highlighted a number of topics related to communication breakdown and the adapted
tool. Real-life case examples emphasizing falls prevention and management helped
participants to gain experience and confidence in using the tool.
SBAR was widely used by interprofessional rehabilitation teams and is an effective way
to communicate urgent and non-urgent safety issues as part of a broader program of
safety activities. In particular, we have seen compelling changes in staff perceptions of
safety culture, as well as effective team processes and communication both within study
teams and compared to the rest of the hospital
Both near miss reporting and number of major falls decreased across the organization and
within the study units. Conversely, total falls showed an increasing trend on the study
teams. It does not seem that SBAR had a significant impact on safety reporting due to a
number of factors including the data may be trended across a time frame that is too short.
Staff used SBAR to communicate falls prevention and management; but, they also used
the tool in a variety of other clinical and non-clinical contexts, for example as a
debriefing tool and to discuss changes in team processes. The tool was useful in helping

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to communicate relevant and succinct information, and to close the loop by providing
recommendations and accountabilities for action.
Evaluative and tracking mechanisms throughout the implementation phase reinforced an
iterative learning-in-action approach. This process evaluation (including interviews and
focus groups) provided important contextual understanding of our result and allowed us
to continue to refine the tool and our processes.
Key champions on the clinical units were an effective means to reinforce, encourage, and
model the use of the SBAR tool.
The 2nd edition of a learning toolkit has been developed to help other organizations
implement SBAR into their care setting. This toolkit features a video DVD showing
SBAR in action and uses falls prevention and management as a platform to highlight
ineffective and effective interprofessional team communication.

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Executive Summary
Communication breakdown has long been cited as the leading cause of inadvertent
patient harm, including falls. SBAR (Situation-Background-Assessment-Recommendation) is a
structured communication tool that provides appropriate assertion and predictable structure to
communication. Many healthcare organizations have implemented the SBAR tool with
promising results; however, there is little evidence regarding is evaluation or effectiveness
beyond acute care and nurse-physician communication. This study builds on our previous
CPSI-supported pilot project by implementing and evaluating SBAR on two interprofessional
units with high falls rates at a large, academic rehabilitation and complex continuing care
institution.
Research Questions
1. What are staff perceptions of the SBAR tool as a structured means to communicate patient
issues related to falls prevention and management? Specifically, from staff perspectives:
a. In what falls-related situations is SBAR being used and with whom?
b. What are the perceived benefits of using the SBAR tool for this specific priority
safety issue?
c. What are the enablers of and barriers to its use?
d. How has this communication method helped to facilitate staff awareness and
uptake of falls best practices and policies?
2. What is the effect of the use of the SBAR tool as a structured communication process
specific to falls risk and management on:
a. Incident and near-miss reporting of falls, and severity of injury as a result of a fall
b. Staff perceptions of patient safety culture

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c. Team orientation toward communication, perceptions of team, and valuing others
Phase I: Implementation of the Adapted SBAR Tool
The adapted SBAR tool was implemented on the geriatric (GR) and musculoskeletal
(MSK) interprofessional rehabilitation teams over a 6-month period. A total of 91% of the GR
(50/55) and 78% of MSK rehabilitation units (35/45) participated in this demonstration project.
A series of three workshops (total of four hours) were offered to clinical and non-clinical staff
including health disciples, nurses, physicians and students, as well as unit leaders and support
staff. The didactic and interactive workshops highlighted a number of topics related to
communication breakdown, patient safety, and the adapted SBAR tool. Experiential learning
using real-life case examples helped to illustrate how SBAR may be implemented and applied
within a rehabilitation context.
Phase II: Evaluation of the Adapted SBAR Tool
Four main outcome measures of this study examined staff perceptions of patient safety
culture, team effectiveness, staff perceptions of a best practice falls initiative, and falls incidents,
including fall severity and near miss reporting. Outcomes were measured using a pre-post test
design and data from the study teams are presented in aggregate form.
Staff perceptions of team communication and patient safety culture
Over the study period the GR and MSK teams showed clinically meaningful change (greater than
5% change) in all 12 safety dimensions of the Hospital Survey on Patient Safety Culture. Many
of these improvements were greater than 10%, and ranged as high as 28% in the area of
Handoffs & Transitions. Nine of the 12 dimensions were also statistically significant (using
critical ratio tests). While the rest of the organization showed modest improvements pre-post

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implementation, the study teams demonstrated clinically significant change in 10 safety
dimensions and statistically significant change in nine.
Evaluation of falls prevention and management best practices (SAFE)
An adapted scale measuring staff attitude and uptake of best practices was administered as part
of the evaluation framework for our corporate-wide falls initiative called SAFE (Stop Adverse
Falls Events). Both the study teams and the rest of the hospital showed an increasing trend in all
three sections of this scale; however, the study units were statistically higher in their perceptions
of uptake of the initiative.
Team effectiveness
The Team Orientation Scale measures perceptions in team effectiveness. Both the GR and MSK
teams showed significant change in four of the 10 items, including items that emphasized
effective and agreed upon methods of communication, and a belief that a participants
contributions were valued.
Safety reporting
It does not seem that SBAR had a significant impact on safety reporting. Both number of near
misses and major falls demonstrated an overall decreasing trend across the organization and
within the study units. Conversely, total falls showed an increasing trend on the study teams.
This likely reflects multiple confounding variables including the fact that data were not trended
over a long enough period of time.

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Process evaluation How was SBAR used on the study units?
The aim of the process evaluation was to further explore the uptake and use of SBAR on the
study teams and to provide contextual understanding of our results. Information regarding how
the adapted SBAR tool was used, in what contexts and with whom was collected in various
ways, including during weekly team rounds, 1:1 interviews and focus groups. Four main themes
emerged from this evaluation:
SBAR enhanced individual communication by giving staff the confidence and assertion in
what and how they were communicating
SBAR enhanced team communication by increasing accountability and closing the loop
Staff used SBAR to communicate falls prevention and management; but, they also used the
tool in a variety of other clinical and non-clinical contexts, for example as a debriefing tool
and to discuss changes in team processes.
The tool was used in urgent situations (such as changes in a patients health status); but, it
was used more often in a variety non-urgent situations, including changes in a patients
treatment plan and transitions in care.
Conclusion
This study contributes to the safety literature in rehabilitation by examining the influence
that strong interprofessional team collaboration and communication can have on best practice in
falls prevention and management. This study suggests that SBAR was widely used by
interprofessional rehabilitation teams and is an effective way to communicate urgent and non-
urgent safety issues as part of a broader program of safety activities. In particular, we have seen
compelling changes in staff perceptions of safety culture, as well as effective team processes and
communication.

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Recommendations for adoption of SBAR in other clinical settings
We offer the following recommendations to other settings considering adopting a
structured communication tool such as SBAR:
Sustaining the momentum: We found the following strategies effective in sustaining SBAR
on the study units: The first is recognizing the importance of key champions. SBAR
champions emerged naturally from the study teams and were an effective means to
encourage and model the use of SBAR. The second is including both clinical and support
staff at all phases of the study. This makes the SBAR process relevant to the entire
rehabilitation unit and recognizes the key role that support staff play in patient safety.
Finally, we found that reminder tools, in particular telephone prompts and pocket cards,
useful and widely utilized.
Recognize the diversity of the SBAR conversation: We asked teams to structure their
SBAR conversations around communicating the issue of falls risk and management (e.g.
SBAR to communicate falls risk assessment; as a handoff mechanism at shift change to
discuss falls issues; or as a post falls debriefing tool); however, staff also used the tool in a
multitude of other urgent and non-urgent situations. Whatever the context, SBAR was not
randomly utilized: staff consistently used SBAR in that what they perceived to be sensitive or
hierarchical issues.
Consider the value of context-dependent and relevant case examples to reinforce the use
of SBAR during education sessions: We developed role-playing scenarios from clinical
situations that were meaningful to the study teams as an effective means to practice the
SBAR process. We also built in evaluative and tracking mechanisms throughout the

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implementation phase that reinforced an iterative learning-in-action approach. This
approach allowed us to continue to refine the tool and our processes.
Use our Implementation Toolkit: From our previous SBAR work we developed an
implementation toolkit for enhanced uptake of SBAR in other healthcare settings. This
toolkit is currently in its second edition and includes a video DVD showing SBAR in action.
The DVD uses falls prevention and management as a platform to highlight interprofessional
team communication during team rounds and between two clinicians on the nursing unit. The
accompanying facilitators guide emphasizes key teaching moments.

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Context
The physical, psychological, social, and economic consequences of falls and falls-related
injuries have been well documented in the literature. Each year in Canada approximately one-
third of healthy, community-dwelling older adults experience a fall [Registered Nurses
Association of Ontario (RNAO), 2007]; falls in hospitals are almost three times this rate and
account for up to 84% of all inpatient incidents (Halfon et al. 2001). The costs of falls are high.
Falls are the leading cause of overall injury costs in Canada and account for $6.2 billion or 31%
of total costs of all injuries (SmartRisk, 2009). There is compelling evidence, however, that falls
can be prevented through timely risk detection and appropriate management. Numerous
guidelines have emerged over the past decade outlining best practice for falls risk prevention and
management within healthcare settings and in the community (American Geriatrics Society,
British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls
Prevention, 2001; Queensland Health, 2003; RNAO, 2007). Inherent within these approaches is
the need for strong interprofessional team collaboration and communication. Effective
communication is a prerequisite for every aspect of team performance (Heinemann & Zeiss,
2002). Effective teamwork and communication are related to decreased risk-adjusted length of
stay (Shortell et al., 1994), improved client-centred care (Cott, 2005), greater efficiency and
improved clinical outcomes (Aiken, 2001; Gitell et al., 2000; Risser et al., 1999) and improved
patient satisfaction (Firth-Cozens, 2001; Majzun, 1998; Sexton Thomas, & Helmreich, 2000).
Communication breakdown has long been cited as the leading cause of inadvertent
patient harm, including falls (Joint Commission on Accreditation of Health Care Organizations,
2004). All too frequently, however, communication is context or personality dependent, and

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influenced by a myriad of factors including gender, culture, profession, and structured
hierarchies within healthcare. (Leonard et al. 2004).
Implications
The Toronto Rehabilitation Institute (Toronto Rehab), a large academic rehabilitation and
complex continuing care (CCC) hospital, has embarked on a novel patient safety strategy to
improve team communication. The SBAR (Situation-Background-Assessment-
Recommendation) tool is a situational briefing model that provides appropriate assertion,
awareness and education to a situation. In essence, it bridges the gaps between communication
styles, professional hierarchies and gender and cultural differences by providing a common and
predictable structure to communication. The tool has its roots in high reliability industry and has
been applied to a variety of clinical domains including rapid response teams, obstetrics and the
ICU (Leonard et al., 2004). In a previous CSPI-supported study, we adapted, implemented and
evaluated this structured communication tool for use a rehabilitation setting, with promising
results (Boaro et al., 2010; Velji et al., 2008). Many organizations have implemented the SBAR
tool into their settings (Beckett & Kipnis, 2009; Marshall et al., 2009; Thomas, et al., 2009);
however, there is little evidence regarding its evaluation, or its effectiveness beyond acute care
and nurse-physician communication.
Falls within our organization are a growing concern. We know from root cause analysis
performed in one sentinel falls event within Toronto Rehab, that earlier communication among
healthcare professionals would have minimized the risk of a serious patient fall. Concurrent with
this study, our organization implemented a corporate-wide best practice initiative in falls
prevention and management across all of our six clinical programs, including cardiac, geriatric,
musculoskeletal, neuro and spinal cord rehabilitation, and CCC. This initiative, called SAFE

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(Stop Adverse Fall Events), responded to the the fact that despite considerable work on
development of protocols for falls prevention, it is difficult to achieve and sustain reductions in
incidence and impact (OConnor, et al., 2006). The goal of SAFE is to reduce falls by
identifying patients who are high risk of falls and mitigating this risk through a comprehensive
and patient-specific prevention and management plan. At the core of SAFE are concepts of
respect for patient autonomy, risk-taking and self-determination.
The aim of this study is to further develop the SBAR process in rehabilitation and CCC,
as well as to provide an avenue for improving the uptake the of the SAFE best practice initiative.
Our initial pilot study offered preliminary insights into how SBAR may be used and evaluated
within rehabilitation and CCC (see Appendix A for the Adapted SBAR tool). This current study
builds upon the key learnings of our initial pilot project in three ways: it focuses team
communication around the high priority issue of falls prevention and management; it implements
SBAR on two interprofessional rehabilitation units with high falls rates; and it evaluates process
and outcomes specific to falls incidence, patient safety culture, and team communication and
falls best practices.
Approach, Methodology, Rationale, Assumptions
Methodology
This project had 2 distinct phases: In Phase I we implemented the adapted SBAR tool
onto two rehabilitation teams over a 6-month period; in Phase II we evaluated its processes and
outcomes related to falls best practices.
a) Study teams: Toronto Rehab is comprised of seven clinical programs of care, including
neuro, spinal cord, musculoskeletal, cardiac, and geriatric rehabilitation, complex continuing
care, and long term care. The geriatric rehabilitation (GR) and the musculoskeletal (MSK)

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rehabilitation units were chosen for this study. Both units are similar in size, admit similar
patient populations (geriatric patients with multiple co-morbidities), and have similar length
of stays (ranging from 35 40 days). They are also comparable in terms of falls incidents. In
the two years leading up to the study, falls on these units constituted 43% of all reported falls
in our organization (excluding long term care). Fifteen of these falls on these two units were
severe, requiring transfers back to acute care.
b) Participants: All clinical and non-clinical staff members and leaders of the GR and MSK
rehabilitation units were invited to participate in this study. Participants included health
professionals who deliver direct patient care (e.g. health disciplines, nurses, physicians), and
unit leaders (e.g. educators, managers and practice leaders), as well as support staff who have
a critical role within the unit (e.g. housekeeping, porters, volunteers). Based on learning from
our pilot work, and supported in the literature, critical success factors for implementing an
innovation such as SBAR include visible support from senior management and strong
clinical leadership (Leonard et al., 2004). Senior leaders have been closely involved in
research in this area as lead or co-investigators; as well, other team members are leaders
within the study units, and were instrumental in providing front-line clinical leadership.
c) Education sessions: An experienced quality and education consultant helped develop and
deliver a series of three SBAR workshops (total of four hours). These sessions were offered
at varying times to maximize attendance. The didactic and interactive workshops (Sessions
#1 and #2 respectively) highlighted a number of topics related to communication, safety, and
the adapted SBAR tool and introduced staff to key elements of patient safety including,
communication breakdown in health care, patient safety culture, openness to reporting
incidents and near misses, and the use SBAR to facilitate communication. We developed

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real life case scenarios related to falls risk assessment, prevention, and management that
helped participants reflect on verbal and non-verbal communication. Using role play,
participants applied SBAR to relevant clinical situations, which provided participants with
powerful feedback in learning how to use the tool (see Appendix D). Education Session #3
involved an informal focus group to discuss how participants were using the adapted SBAR
tool in different clinical and non-clinical situations, enablers of and barriers to using SBAR,
and insights into the use and sustainability of the SBAR process in their teams and work
environments.
d) Sustaining the use of SBAR on the units: Our previous work supported the use of local
champions to reinforce the use of SBAR during the implementation phase and beyond. We
also used a series of reminder tools including pocket cards, posters, telephone prompts, and
educational binders that were located strategically on the units. A member of the research
team or SBAR champion also attended weekly team rounds as a way to further reinforce the
use of SBAR, and to understand the situations in which SBAR was being used (or not used),
with whom, and in what context.
Phase II: Evaluation of the adapted SBAR tool:
A pre-post test design was used for this study. The following describes the data collection
and outcome measures for each of the four main outcomes of this project, including staff
perceptions of team communication and patient safety culture, staff perceptions of safety best
practices, team effectiveness, and safety reporting.
a) Staff perceptions of patient safety culture
Staff perceptions of patient safety culture were measured using the Hospital Survey on Patient
Safety Culture (HSOPSC) (Westat, 2004). The 43-item survey was developed by the Agency for

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Healthcare Research and Quality and is widely used in the United States
(http://www.ahrq.gov/qual/hospculture). The HSOPSC can be used to track changes in patient
safety culture over time, as well as evaluate the impact of patient safety interventions both at the
organization and unit level. It consists of 12 patient safety domains and has been found to be
valid and reliable for all use with both clinical and non-clinical groups (See Appendix C). This
survey was mailed to all staff across the organization (n=1700) in the spring of 2008 and 2009
(pre- and post-implementation).
b) Perceived Characteristics of Innovating (PCI) for Best Practice Implementation and

Perceived Worth of Best Practices (Evaluation of the SAFE Best Practice Initiative)
Based on the work of Edwards and colleagues (2004) related to the implementation and
evaluation of nursing best practice guidelines, we adapted two scales to better understand staff
attitudes and uptake of falls best practices in our organization. Nine items (using a 4-point Likert
scale) from the Perceived PCI instrument (Moore & Benblast, 1991) were included (of 25 from
the shortened version). The PCI was designed to investigate how perceptions affect individuals
actual use of technology based on Rogers diffusion theory (1995). We also used four additional
items (rated on a 10-point Likert scale) related to perceived worth of best practice guidelines.
The scale on the Perceived Worth of Best Practices is intended to assess the overall worth of
guideline recommendations. Examples of items include the degree to which staff think they will
continue using the best practices, as well as their perception of the best practices impact on care
(refer to Appendix C for questions from both scales). Both scales have been found to be valid
and reliable (Edwards et al, 2004; Moore & Benbasat, 1991) and were administered as part of the
evaluation framework for our corporate-wide falls best practice initiative called SAFE.
c) Team Orientation Scale

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The Team Survey was developed by Millward and Ramsay (1998) to measure the team
dimensions identified in the cognitive-motivational model of team effectiveness. The survey is
comprised of three components: the Team Questionnaire (which is based on the cognitive-
motivational model by Millward & Purvis, 1998), Psychological Contract Scale, and Team
Orientation Scale (which includes communication, team perspectives, and valuing others). For
the purposes of this study, the Team Orientation portion of this survey was used as it deals
directly with the issue of team processes, particularly related to communication. The survey and
domains have been found to be valid and reliable (coefficients 0.70 or higher) (Millward &
Jeffries, 2001). In particular, the strongest predictor of team performance was Team Orientation.
d) Safety Reporting
Falls incident and near miss reporting, as well as falls severity were examined through our on-
line reporting system. Severity ratings were categorized in four levels (No Harm, Minor,
Moderate, Major) and tracked over an 18-month period, including six months leading up to and
following the study period

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Process Evaluation
A key part of this study was our process evaluation. This multimodal approach took an in depth
looked at how SBAR was being used on the study units. In essence, it aimed to understand the
situations in which SBAR was being used (or not used), with whom, and in what context.
a) Evaluation of the educational sessions: Part of each education session was devoted to
evaluating the workshop for content, format and facilitator effectiveness. We also assessed
participants confidence in using the SBAR tool and applying it within their teams and units
(rated on a 10-point Likert scale).
b) Tracking the use of the adapted SBAR within the study teams: Information regarding how
the adapted SBAR tool was used, in what contexts (both urgent and non-urgent), and with
whom, was collected in three different ways throughout the 6-month implementation phase.
For each of these processes we developed tracking forms that can be found within the 2nd
edition of the SBAR Implementation Toolkit (Trentham et al, 2010).
Individual face-to-face interviews. Interviews were conducted with all staff members who
participated in the educational workshops (n=85) mid-way through the study. The research
coordinator or co-investigators who were also front-line clinicians, used a brief interview
guide to facilitate discussion about participants use and perceptions of the adapted SBAR
process. Questions explored how the tool was used, in what situations and with whom, as
well as perceived usefulness of SBAR and suggestions for improvement.
Confidence and Implementation Tracking Form. This form was completed in conjunction
with the individual interviews. The purpose was to ascertain the confidence level of staff
members in using the SBAR process, as well as their confidence in the overall success of the
implementation process.

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Tracking SBAR use during team rounds. A key champion on the unit or the research
coordinator attended weekly modular rounds with the clinical team (patients on the units are
assigned to one of three modules) and gathered information from the team regarding their
use of the adapted SBAR tool and process. A tracking form was used to facilitate the
discussion pertaining to the use of SBAR, in what situations, and with whom, and to gather
suggestions for improvements.
c) Team focus groups: We conducted two focus groups (one focus group per clinical unit) at
the end of the implementation period. Each focus group was conducted by an experienced
moderator, audiotaped, with the permission of the participants, and transcribed verbatim by a
professional transcriptionist. A second moderator was also in attendance to act as an observer
and take notes throughout the focus group. We developed a semi-structured interview guide
to allow for consistency of core open-ended questions, with follow-up probing questions (see
Appendix E). We also collected demographic information from each participant at the start of
the session. This information was used solely to describe the main features of the focus
group participants.

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Results, Conclusions
Results
Phase I: Implementation of the Adapted SBAR Tool
A total of 91% of the GR (50/55) and 78% of MSK rehabilitation units (35/45)
participated in this study. Participating team members included staff from dietetics, medicine,
nursing, pharmacy, physiotherapy, occupational therapy, rehabilitation therapy, speech language
pathology and social work. In both study groups all (100%) of the health disciplines, physicians
and unit leaders participated. The hardest group to capture was our night nursing staff, many of
whom worked a permanent night shift. In addition we had strong participation from non-clinical
support staff on the units, including housekeeping, unit support, porters and volunteers. A
response rate of 97% for the evaluation of the educational sessions was obtained. Overall,
participants rated the sessions highly, with adequate amount and relevant information presented
in an appropriate timeframe. In particular, participants reported that the second session focusing
on experiential learning and real-life clinical safety scenarios was the most helpful in learning
how to use the adapted SBAR tool
Phase II: Outcome and Process Evaluation of the Adapted SBAR Tool
The four main outcome measures of this study examined staff perceptions of patient safety
culture, staff perceptions of the SAFE best practice initiative, team effectiveness, and falls
incidents, including fall severity and near miss reporting. Outcomes were measured using a pre-
post test design and data from the study teams are presented in aggregate form. The process
evaluation involved a multimodal approach that aimed to better understand the context and
uptake of SBAR on the two interprofessional teams.
A. Outcome Evaluation

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Staff perceptions of safety culture
All Toronto Rehab staff (n=1700) were sent the survey prior to the implementation of
SBAR and approximately 12 months later. Response rates pre- and post-intervention were 31%
(n=520) and 33% (n=569) respectively. The study teams had a response rate of 87% (n=74) pre-
intervention and 69% (n=59) post-intervention. Surveys were analyzed in two ways. The first
was using the 5% rule of thumb as suggested by the survey authors (Westat 2004), that is,
results must be at least 5% higher or lower to be considered clinically significant. The second
was for statistical significance using critical ratio tests. These tests compared the study units pre-
and post-implementation, as well as to the rest of the hospital which served as our control group.
All data was entered into an SPSS database and analyzed by a statistician familiar with the
HSOPSC.
Study teams pre- and post-intervention
Over the study period the GR and MSK teams showed clinically meaningful change (using the
5% rule of thumb) in all 12 safety dimensions of the HSOPSC. Many of these improvements
were greater than 10%, and ranged as high as 28% in the Handoffs & Transitions dimension,
which is an area of emphasis for the organization. Nine of the 12 safety dimensions were also
statistically significant. Not surprising, many of these dimensions were related to team work and
communication, including Teamwork Within and Across Units, Communication Openness, and
Feedback and Communication About Error. See Table 1 for details.

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Table 1. Study teams pre- and post-intervention
Change Critical Ratio

Safety Dimension Pre-Intervention (%) Post-Intervention (%)
(%) Test (Z > 1.96)
Overall Perceptions of Safety 38 59 20 4.43
Frequency of Events Reported 45 52 8 1.29
Manager Expectations
77 82 5 1.11
Promoting Safety
Organizational Learning 72 85 14 3.04
Teamwork Within Units 73 82 9 2.23
Communication Openness 42 54 13 2.33
Feedback & Communication
52 67 15 2.70
About Error
Non-Punitive Response to Error 39 51 13 2.31
Staffing 40 56 16 3.49
Management Support for
71 78 8 1.57
Patient Safety
Teamwork Across Hospital
63 79 17 3.82
Units
Handoffs & Transitions 30 57 28 5.76
Legend
Clinically improved (5%)
Statistically improved (Z > 1.96)
No change
Study teams compared to the rest of the hospital pre- and post-intervention
At baseline the GR and MSK aggregated results scored clinically lower than the rest of
the hospital in nine of the 12 safety dimensions, and statistically lower in six dimensions (Table
2). Again, most of these dimensions were related to teamwork and communication. Post-
intervention, the study teams scored clinically higher in four safety dimensions: Manager
Expectations Promoting Safety, Organization Learning Continuous Improvement, Teamwork
Across Units, and Handoffs & Transitions. Two of these dimensions were also statistically
significant.
Table 2. Study teams compared to the rest of the hospital pre- and post-intervention

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Pre-Intervention Post-Intervention
Critical Critical
Study Rest of Study Rest of
Safety Difference Ratio Difference Ratio
Units Hospital Units Hospital
Dimension (%) Test (%) Test
(%) (%) (%) (%)
(Z > 1.96) (Z > 1.96)
Overall
Perceptions of 38 59 -21 6.60 59 63 -4 1.045197
Safety
Frequency of
Events 45 53 -8 1.95 52 56 -4 0.685883
Reported
Manager
Expectations
77 76 1 0,46 82 76 6 1.928337
Promoting
Safety
Organizational
72 72 0 0.18 85 77 8 2.371567
Learning
Teamwork
73 79 -5 2.09 82 81 1 0.336259
Within Units
Communication
42 58 -16 4.35 54 56 -2 0.390512
Openness
Feedback &
Communication 52 62 -10 2.58 67 64 3 0.716443
About Error
Non-Punitive
Response to 39 45 -6 1.77 51 48 3 0.705769
Error
Staffing 40 52 -12 3.64 56 52 4 0.914534
Management
Support for 71 76 -5 1.60 78 80 -2 0.474603
Patient Safety
Teamwork
Across Hospital 63 65 -2 0.68 79 67 12 3.410914
Units
Handoffs &
30 47 -17 4.90 57 51 6 1.623607
Transitions
Legend
Statistically improved
Statistically worse
No change
Clinically worse ( 5%)
Table 3 examines these change scores in greater detail. It compares the changes within the study
units and the control group pre- and post-intervention. While the organization showed modest
improvements in clinical (one dimension) and statistical scores (four dimensions) over time, the

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study teams demonstrated clinically significant change in 10 dimensions and statistically
significant change in nine.
Table 3. Comparison in change scores within the study teams and rest of the organization
Pre-Post
Pre-Post Study Team
Rest of Hospital
Critical Ratio Test Critical Ratio Test
Safety Dimension % Change % Change
(Z > 1.96) (Z > 1.96)
Overall Perceptions of Safety 17 4.43 4 1.98
Frequency of Events Reported 4 1.29 3 1.50
Manager Expectations Promoting Safety 5 1.11 0 0.17
Organizational Learning 8 3.04 5 2.39
Teamwork Within Units 6 2.23 3 1.43
Communication Openness 15 2.33 -2 0.61
Feedback & Communication About Error 13 2.70 2 0.88
Non-Punitive Response to Error 9 2.31 3 1.19
Staffing 16 3.49 0 0.39
Management Support for Patient Safety 3 1.57 4 2.69
Teamwork Across Hospital Units 14 3.82 2 1.28
Handoffs & Transitions 23 5.76 4 2.04
Legend
No change
Perceived Characteristics of Innovating (PCI) for Best Practice Implementation and

Perceived Worth of Best Practices (Evaluation of SAFE)
The study teams pre- and post intervention were compared with the aggregated program-
specific data from across the organization (which included six clinical programs). Post-
intervention the study teams showed significant change in two of the three sections of the PCI for
Best Practice Implementation and Perceived Worth of Best Practices, which we also referred to

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as SAFE. Specifically, the study teams showed improvement (using unpaired t-tests p < 0.5)
in staff perceptions of the extent the SAFE initiative, as well as organizational support for SAFE.
Figure 1. SAFE Study teams pre- versus post-intervention
9.00 8.63
8.00
8.03
7.00
6.00 4.38
5.00
Mean Score 3.45
4.00 3.64
Pre
3.00 3.09
Post
2.00
1.00
Post
0.00
A: Extent of SAFE Pre

Initiative* B: Organizational
Support for Best C: Perceived
Practice* Worth of Best
Practice
This study was implemented in conjunction with a corporate-wide falls initiative that
aimed to reduce falls by assessing all patients for their fall risk on admission to Toronto Rehab
and mitigating risk through an appropriate, patient-specific plan that involves prevention,
management and re-assessment. At the core of initiative are concepts of respect for patient
autonomy, risk-taking and self-determination. Both the study teams and the control group (the
rest of the hospital) showed an increasing trend in all three sections of SAFE, one of which
(Extent of the SAFE Initiative) was statistically significant (see Figure 2). This suggests that
SAFE was effective as a best practice initiative, and that while SBAR likely enhanced this
initiative on the study units, SAFE would have been effective with or without the
implementation of SBAR.

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Figure 2. Study teams compared to rest of hospital (post)
9.00 8.63
8.00 8.34
7.00
6.00 4.38
5.00
Mean Score 3.45
4.00 3.81
Control
3.29
3.00 Study
2.00
1.00
Study
0.00
A: Extent of SAFE Control

Initiative* B: Organizational
Support for Best C: Perceived
Practice Worth of Best
Practice
Team Orientation Scale
The Team Orientation Scale was administered to the study teams pre- and post-
intervention and analyzed using critical ratio tests. The GR and MSK teams showed significant
change in four of the 10 items, including items that emphasized effective and agreed upon
methods of communication, and a belief that a participants contributions were valued (Table 4).

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Table 4. Team Orientation Scale pre- and post-intervention
Pre- Post- Critical Ratio

%
Item Intervention Intervention Test
Change
(% Agree) (% Agree) (Z > 1.96)
1. Team members act upon the information I
74 83 9 1.00
communicate to them.
2. I am able to communicate effectively with team
74 91 17 2.12
members.
3. This team has agreed methods for communication.
40 79 39 4.16
4. Communication between team members is unclear.
37 69 32 3.33
5. I regularly communicate with other members of the
team. 96 94 -2 -0.04
6. I act upon the information that other members of the
96 96 0 -0.38
team communicate to me.
7. All team members perspectives are important. 100 96 -4 0.95
8. This team believes it is important to consider the
perspectives of all team members. 82 87 5 0.49
9. I believe other team members value my contribution
78 93 15 1.97
to our work.
10. Each team member plays a valuable role within the
95 96 1 0.003
team.
Legend
No change
Safety reporting
It does not seem that SBAR had a significant impact on safety reporting. Both near miss
reporting and number of major falls demonstrated an overall decreasing trend across the
organization and within the study units. Conversely, total falls showed an increasing trend on the
study teams (Figure 3). However, this data do not account for repeat fallers, nor do they consider
whether falls increased on these units, or if staff were simply reporting more incidents.

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Figure 3. Total number of falls on the study teams compared to the entire organization
300 35
250 30
28
25 25
# of Falls
200
191
183 All Programs
169 20 20
163 MSK
150 148
16 GR
129 15 15 15
14
13 13
100 11
10
8
7
50 5
0 0
2008/09 Q1 2008/09 Q2 2008/09 Q3 2008/09 Q4 2009/10 Q1 2009/10 Q2
Study Period
Figure 4 shows the total number of major falls, or falls causing serious injury in the 6-months
leading up to and following the implementation phase. Both the study teams and the
organization showed a decreasing trend in major falls.
Figure 4. Total number of major falls on the study teams compared to the entire
organization
4 4
3 3
# of severe fa
3
All Programs
MSK
GR
2 2 2 2
1 1 1 1 1
0 0 0 0 0 0 0
Mar - Jun 08 Jul - Sep 08 Oct - Dec 09 Jan - Mar 09 Apr - Jun 09 Jul - Sep 09
B: Process evaluation
Study Period How was SBAR used?

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The aim of the process evaluation was to further explore the uptake of SBAR on the
interprofessional rehabilitation teams and to provide contextual understanding of our results.
This evaluation was multimodal and involved four main approaches tracking how SBAR was
used, in what contexts and with whom at both the individual and group level.
The confidence level of all participants was measured at the final education session.
Ninety-two percent of all participants felt confident or highly confident about their
use of
SBAR and that the tool would be successfully implemented into their team. We gathered
information during weekly team rounds, at a time when the team met regularly. While this
method was only able to capture input from the clinical team, it was useful to understand when
staff used the SBAR process with non-clinical participants (for example, with their unit manager
or family member). SBAR was widely used by all of the interprofessional staff that had been
trained in its use; for some, it was used with increasing frequency and consistency as it became
integrated into their practice. Specifically, over the six-month implementation period, 25 100%
of the participants used SBAR at least once in the seven day period in which SBAR use was
tracked; many used it multiple times. SBAR was used to communicate urgent safety issues (e.g.
changes in patient status); however, staff indicated that they used the adapted SBAR tool
primarily to discuss non-urgent patient care issues pertaining to changes in treatment and care
plans or protocols, discharge planning, changes in team process or scheduling, at shift change,
with temporary or relief staff and for conflict resolution. Some staff indicated that the SBAR
process also helped them to problem solve with a family member, as they were able to
methodically work through the situation, background, current assessment, and come to
recommendations together.

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We also held focus groups (n=18) on each of the study units at the end of the
implementation period. Each focus group was conducted by two experienced moderators, and
audiotaped and transcribed verbatim. These focus groups provided us with an in depth
understanding of the contexts in which SBAR was used (or not used) on the unit and explored
some of the enablers of and barriers to using structured communication on interprofessional
teams. For example, at the beginning of the study, participants on both study teams regularly
said to us, We are good communicators? Why do we need SBAR we do this already! At the
end of the study, this notion had changed. Many participants expressed that while they are good
at providing the Situation and Background of an issue, they only sometimes offered their
Assessment of the situation and only rarely suggest a Recommendation. Participants also shared
their perceptions on the use of the adapted SBAR in relation to falls issues, perceived
effectiveness of individual and team communication, and enablers of and barriers to its use. The
groups recognized SBAR as a mechanism to heighten staff awareness and uptake of falls
prevention and management policies and practices. Finally, we also used this opportunity to
discuss the sustainability of SBAR on the study units, including how to integrate the tool into
routine processes and new staff orientation. Our process evaluation revealed the following main
themes:
o SBAR enhanced individual communication by giving staff the confidence and assertion
to communicate relevant and succinct information
o SBAR enhanced team communication by closing the loop and providing
recommendations and accountabilities for action

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o Staff used SBAR to communicate falls prevention and management; but, they also used
the tool in a variety of other clinical and non-clinical contexts, for example as a
debriefing tool and to discuss changes in team processes.
o Participants used SBAR in situations that they perceived to be sensitive or hierarchical in
nature (for example, when approaching their manager or during conflict resolution).
o The tool was used in urgent situations (such as changes in a patients health status); but, it
was used more often in a variety non-urgent situations, including changes in a patients
treatment plan and transitions in care.
Study Limitations
We used falls incident and near miss reporting, as well as severity of falls as proxy
measures for safety. While near miss and total major falls showed a decreasing trend, total falls
on the study units increased. It does not seem that SBAR had a significant impact on these
measures for a few reasons. First, the data may be trended across a time frame that is too short to
determine accurate results, and may therefore be inconclusive. Second, the nature of
rehabilitation is to push patients to the limits of their abilities in order to maximize function. In
this way, risk of falls and other events are an inherent part of the rehabilitation process.
We cannot attribute changes in safety reporting and perceptions of patient safety solely as
a result of this study; instead, these changes should be considered within the context of a broad
range of patient safety initiatives at Toronto Rehab. For example, new initiatives regarding
leader engagement and training related to safety culture, safety communications from senior
management, staff training regarding the online reporting system, and a corporate-wide falls best
practice initiative, have all increased awareness of safety and incident reporting within the
organization.

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We used the 5% rule of thumb to suggest clinically significant change in the HSOPSC;
however, this guideline was meant to be used with large sample sizes. We chose to aggregate the
study results for a number of reasons including statistical power. It would also be interesting to
look at the study units individually with the specific purpose to share key learnings across our
organization.
Conclusions and next steps
The purpose of this study was to implement and evaluate the adapted SBAR tool for use
on two interprofessional rehabilitation teams for the specific priority issue of falls prevention and
management. Issues of patient safety and communication have been studied in the literature;
however, usually from the perspective of the acute care and involving physician-nurse
communication. This study contributes to the literature in patient safety by examining the
influence that strong interprofessional team collaboration and communication can have on best
practice in falls prevention and management in the context of rehabilitation and complex
continuing care. This study suggests that the adapted SBAR process is an effective way to
communicate urgent and non-urgent safety issues and has the potential to be widely used among
interprofessional teams. Our next steps are to consider SBAR as one of our organizational best
practices and as part of, how we do business at our organization. While SBAR has been
adapted for use within our setting, it is just one of a number of structured team communication
tools. Our hope is that these learnings are transferable to other healthcare settings, settings that
also emphasize the importance (and challenges) of working in interprofessional teams.
Recommendations
Recommendations for Adoption of SBAR in Other Clinical Settings

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Results from this study suggest that SBAR was widely and effectively used by interprofessional
rehabilitation teams as part of a broader program of safety activities. In particular, we have seen
compelling changes in staff perceptions of safety culture, as well as effective team processes and
communication. Based on our experiences in both our pilot and expanded studies, we offer the
following recommendations to other settings considering adopting structured communication
tools:
Sustaining the momentum: We found the following strategies effective in sustaining
SBAR on the study units: The first is recognizing the importance of key champions.
SBAR champions emerged naturally from the study teams and were an effective means
to reinforce, encourage, and model the use of SBAR. We also included clinical and
support staff in both phases of the study, which made the SBAR process more universally
relevant to the entire rehabilitation unit. It also recognized the key role that support staff
play in patient safety within the organization. Finally, we found that reminder tools, in
particular telephone prompts and pocket cards, useful and widely utilized.
Recognize the diversity of the SBAR conversation; We asked teams to structure their
SBAR conversations around communicating the issue of falls risk and management (e.g.
SBAR to communicate falls risk assessment; as a handoff mechanism at shift change to
discuss falls issues; or as a post falls debriefing tool); however, staff also used the tool in
a multitude of other urgent and non-urgent situations. Whatever the context, SBAR was
not randomly utilized: staff consistently used SBAR in that what they perceived to be
sensitive or hierarchical issues.
Consider the value of context-dependent and relevant case examples to reinforce the
use of SBAR during education sessions: We developed role-playing scenarios from

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clinical situations that were meaningful to the study teams as an effective means to
practice the SBAR process. We also built in evaluative and tracking mechanisms
throughout the implementation phase that reinforced an iterative learning-in-action
approach. This approach allowed us to continue to refine the tool and our processes.
Consider implementing SBAR in clinical environments with teams that may be
underperforming: We implemented SBAR onto two teams with a high falls incidence.
Implementing change initiatives, even pilot studies, on high performing teams may be a
lost opportunity. Staff found the tool useful in helping to communicate relevant and
succinct information, and to close the loop by providing recommendations and
accountabilities for action.
Use our Implementation Toolkit: From our previous SBAR work we developed an
implementation toolkit for enhanced uptake in other healthcare settings. This toolkit is
currently in its second edition and includes a video DVD showing SBAR in action. The
DVD uses falls prevention and management as a platform to highlight interprofessional
team communication in two different scenarios: during team rounds; and between two
clinicians on the nursing unit. Each of these scenarios demonstrates both ineffective and
effective team communication. The accompanying facilitators guide outlines the context,
overview and summary of the videos and emphasizes key teaching moments for
educators to consider when facilitating discussion during SBAR education sessions. The
toolkit and DVD are available free of charge at www.torontorehab.com (search term
SBAR).

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Appendix A: Adapted SBAR tool (full and abbreviated versions)

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Appendix B: Internal presentation of results to research and study teams

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Appendix C: Pre- and post-implementation outcome measures
1) Hospital Survey on Patient Safety Culture

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2) SAFE

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Appendix D: Patient safety roleplay scenarios

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Appendix E: Facilitator guide for focus group discussions

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Using SBAR to communicate

falls risk and management in

Main Messages .............................................................................................................................. 4

Executive Summary ...................................................................................................................... 6

Approach, Methodology, Rationale, Assumptions................................................................... 14

Results, Conclusions ................................................................................................................... 21

Appendix A: Adapted SBAR tool (full and abbreviated versions) ........................................ 39

Appendix B: Internal presentation of results to research and study teams .......................... 40

Appendix C: Pre- and post-implementation outcome measures ............................................ 40

Appendix D: Patient safety roleplay scenarios......................................................................... 51

Appendix E: Facilitator guide for focus group discussions .................................................... 54

This project is Using SBAR to communicate falls risk

partner in this research.

This project is Using SBAR to communicate falls risk

(Situation-Background-Situation-Assessment) tool for use beyond acute care and nurse-

processes related best practices in falls prevention and management.

highlighted a number of topics related to communication breakdown and the adapted

participants to gain experience and confidence in using the tool.

to communicate urgent and non-urgent safety issues as part of a broader program of

safety activities. In particular, we have seen compelling changes in staff perceptions of

teams and compared to the rest of the hospital

This project is Using SBAR to communicate falls risk

recommendations and accountabilities for action.

Evaluative and tracking mechanisms throughout the implementation phase reinforced an

iterative learning-in-action approach. This process evaluation (including interviews and

to continue to refine the tool and our processes.

model the use of the SBAR tool.

ineffective and effective interprofessional team communication.

This project is Using SBAR to communicate falls risk

patient harm, including falls. SBAR (Situation-Background-Assessment-Recommendation) is a

promising results; however, there is little evidence regarding is evaluation or effectiveness

CPSI-supported pilot project by implementing and evaluating SBAR on two interprofessional

a. In what falls-related situations is SBAR being used and with whom?

c. What are the enablers of and barriers to its use?

uptake of falls best practices and policies?

specific to falls risk and management on:

b. Staff perceptions of patient safety culture

This project is Using SBAR to communicate falls risk

Phase I: Implementation of the Adapted SBAR Tool

within a rehabilitation context.

Phase II: Evaluation of the Adapted SBAR Tool

Staff perceptions of team communication and patient safety culture

This project is Using SBAR to communicate falls risk

dimensions and statistically significant change in nine.

Evaluation of falls prevention and management best practices (SAFE)

of uptake of the initiative.

contributions were valued.

over a long enough period of time.

This project is Using SBAR to communicate falls risk

emerged from this evaluation:

what and how they were communicating

and to discuss changes in team processes.

treatment plan and transitions in care.

This project is Using SBAR to communicate falls risk

We offer the following recommendations to other settings considering adopting a

structured communication tool such as SBAR:

useful and widely utilized.

SBAR to communicate falls risk assessment; as a handoff mechanism at shift change to

of SBAR during education sessions: We developed role-playing scenarios from clinical

This project is Using SBAR to communicate falls risk

approach allowed us to continue to refine the tool and our processes.

accompanying facilitators guide emphasizes key teaching moments.