Patient and Family-Centered I-PASS SCORE Program: Resident and Advanced Care Provider Training Materials

Introduction Patient and family-centered rounds (PFCRs) are an important element of family-centered care often used in the inpatient pediatric setting. However, techniques and best practices vary, and faculty, trainees, nurses, and advanced care providers may not receive formal education in strategies that specifically enhance communication on PFCRs. Methods Harnessing the use of structured communication, we developed the Patient and Family-Centered I-PASS Safer Communication on Rounds Every Time (SCORE) Program. The program uses a standardized framework for rounds communication via the I-PASS mnemonic, principles of health literacy, and techniques for patient/family engagement and bidirectional communication. The resident and advanced care provider training materials, a component of the larger SCORE Program, incorporate a flipped classroom approach as well as interactive exercises, simulations, and virtual learning options to optimize learning and retention via a 90-minute workshop. Results Two hundred forty-six residents completed the training and were evaluated on their knowledge and confidence regarding key elements of the curriculum. Eighty-eight percent of residents agreed/strongly agreed that after training they could activate and engage families and all members of the interprofessional team to create a shared mental model; 90% agreed/strongly agreed that they could discuss the roles/responsibilities of various team members during PFCRs. Discussion The Patient and Family-Centered I-PASS SCORE Program provides a structured framework for teaching advanced communication techniques that can improve provider knowledge of and confidence with engaging and communicating with patients/families and other members of the interprofessional team during PFCRs.

Leveraging the success of the original PFC I-PASS Rounds Program, the PFC I-PASS Safer Communication on Rounds Every Time (SCORE) Program spread the educational bundle to 21 sites across North America as part of the Society of Hospital Medicine Mentored Implementation Program, which pairs sites with experienced mentors to enact improvement initiatives. 9 Our study group has been successful in the creation of programming through mentored implementation, as demonstrated by our previous work with provider handoffs, which has also been published in MedEdPORTAL. [10][11][12][13][14][15][16][17] To develop the PFC I-PASS SCORE Program, we took lessons learned from implementation of the original PFC I-PASS Program and made adaptations and refinements to create a more effective program for the SCORE project. The PFC I-PASS SCORE Program consists of three core intervention elements: (1) structured verbal communication on rounds, (2) structured written communication on rounds, and (3) advanced techniques for communication, teamwork, and application of health literacy best practices to establish a shared mental model among all members of the care team, including the patient and family. The revised curriculum includes a flipped classroom 18 approach, enhanced strategies to engage learners and improve their knowledge retention, identification of defined roles and speaking processes for rounds, and options to allow for virtual or modified in-person options in response to the COVID-19 pandemic.
The PFC I-PASS SCORE resident and advanced care provider training materials include all self-study, in-person, and virtual learning materials needed to effectively train residents and advanced care providers in the program. While the resident and advanced care provider training materials serve as an independent resource for training these groups of individuals, we recommend using them along with the other complementary materials from the PFC I-PASS SCORE Program. The entire PFC I-PASS SCORE Program is a multifaceted collection of modules that provides training and strategic plans for leading every aspect of culture change required to put an effective rounding bundle in place that engages patients, families, and all members of the interprofessional team. The other modules focus on medical students, faculty members, and how to support the overall implementation using best practices in quality improvement and human factors research. While the PFC I-PASS SCORE Program included mentorship from external experts for each site, we believe we have compiled all of the critical training materials and best practices for implementation and sustainment as part of the entire package without need for an external mentor. This suite of materials will allow anyone to successfully implement this program at their home institution.
MedEdPORTAL features a number of publications on PFCRs. [19][20][21][22] These existing educational modules specifically address teaching medical students, promoting autonomy of learners, tips for oral presentations, and assessing and providing feedback to learners on PFCRs. Our module adds to these resources by specifically focusing on teaching residents and including important techniques for PFCRs that can promote general communication, the interprofessional care team, shared understanding, and, importantly, patient safety.

Methods
This project was granted expedited Institutional Review Board (IRB) approval from Boston Children's Hospital. Participating sites secured local IRB approval as determined by their individual institutions.

Development of the Curriculum
The original PFC I-PASS training materials were developed for the PFC I-PASS Study that occurred from 2014 to 2016. 8 These materials were coproduced in a rigorous fashion with input from medical educators, nurses, health literacy experts, health services researchers, patient safety experts, and, most importantly, patients and family members. The materials took 1 year to develop using Kern's six steps for curriculum development 23 and a conceptual model for PFCRs. For the PFC I-PASS SCORE Program, the materials underwent full revision and editing based upon feedback from the original study sites and subjects. Figure 1 details the entire evolution of the PFC I-PASS SCORE Program. The program consisted of self-study training components (Appendices A-C) and in-person training components (Appendices D-N). Highlights of the edits that were made to the training materials include the following: r To shorten the length of the in-person training workshops, which were upwards of 3 hours in the first PFC I-PASS Study, we incorporated a flipped classroom 18 approach by developing a 29-minute core content module (Appendix A) and an approximately 10-minute health literacy exercise (Appendix B) for residents or advanced care providers to complete in advance of the in-person training. This helped to decrease the cognitive load placed on learners and to reinforce key concepts. The new in-person workshop (Appendix D) took roughly 90 minutes to complete in total.
r In response to the COVID-19 pandemic, which limited inperson training options, we created workshops (Appendix D), simulations (Appendices F and G), and activities (Appendix J) that could be done on a virtual training platform. This provided flexibility for training options based upon space and personal protective equipment limitations.
r To address feedback that individual learner types were unsure of their roles on rounds, we created a Do Every Time Process (Figure 2) detailing the exact order of rounds flow and defining clear roles for each team member before and during rounds.
Overview of the Curricular Materials Self-study training components: The self-study training components (Appendices A-C) are intended to be completed prior to the in-person training. They provide background information on PFCRs, the history of PFC I-PASS, the importance of communication and health literacy, and how to incorporate the PFC I-PASS format, as well as an opportunity to develop a written update utilizing health literacy principles. The self-study training components should take approximately 45 minutes for learners to complete and include the following:  r The 5-minute core content module evaluation (Appendix C).
In-person or synchronous virtual workshop components: The following educational materials, accompanied by a facilitator guide (Appendix E), are intended to be used during the 90-minute workshop (Appendix D). This workshop (Appendix D) reinforces the key concepts from the self-study training (Appendices A-C), allowing discussion of the health literacy exercise (Appendix B) and practice through interactive exercises of the structured communication utilized in the PFC I-PASS rounding format (Appendix F). Through use of a PowerPoint presentation and additional interactive exercises (Appendix D), residents and advanced care providers are oriented to the varying roles and responsibilities of all members of the interprofessional team on PFCRs, special considerations for situations that may impact rounds communication, and advanced communication techniques and considerations based on developmental age, limited English proficiency, discussion of sensitive topics, and teaching on rounds. The in-person training components consist of the following:

PFC I-PASS Study
Group, an interprofessional and mulƟdisciplinary group comprising parents, pediatric nurses, pediatric hospitalists, a pediatric hospitalist fellow, quality improvement experts, a health literacy commiƩee, pediatric residency program directors, and pediatric clerkship directors.

Strategic Approach
Kern's six steps of curriculum development for medical educaƟon to develop the framework, starƟng with an extensive review of the literature and needs assessment.

PFCRs SubcommiƩee Formed
Developed a novel process for PFCRs and corresponding curriculum.

Fall/Winter 2014 PFC I-PASS Curriculum
Taught at seven study sites in three staggered waves. Each site was encouraged and allowed to adapt content to their local site.

ReflecƟon and AdaptaƟon
RepresentaƟves from the PFC I-PASS Study Group, including parƟcipants from each study site, met in person to reflect on implementaƟon. This group collected the customized materials from each site and incorporated feedback and adaptaƟon from the study sites into the primary curriculum when deemed appropriate.

Summer 2017 PFC I-PASS SCORE Created
The   Additionally, the participants acting in the role-play need the written handoff for the rounds role-play (Appendix H).
The instructions for the roles involve some challenging rounding scenarios, such as the primary presenter utilizing medical jargon. The remaining learners serve in the role of observers, utilizing the observer tool for the rounds role-play (Appendix I), and participate in a large-group discussion exploring aspects that went well, opportunities for improvement, and how they might have handled the situation encountered (e.g., needing to redirect the primary presenter). 7. Through the PowerPoint presentation (Appendix D), learners are oriented to the rounds report, a written document that augments verbal communication on rounds and summarizes key points from rounds for the patient/family, followed by an opportunity to practice the completion of a rounds report (Appendix J). The completion of the rounds report activity should take about 5 minutes. 8. The workshop concludes with recommendations on how to incorporate teaching points that can be optimized at the bedside for all members of the team and how to identify what topics and focus are more fitting in another educational environment.

Evaluation of the Curriculum
The PFC I-PASS SCORE resident physician/advanced care provider training was evaluated using both process and outcome measures via two separate postparticipation surveys (Appendices C and K) corresponding to the self-study and inperson training components, respectively. Process measures included assessment of training penetration (number of training sessions at each site and number of residents/advanced care providers trained at each site). Additionally, surveys collected demographic data, including provider type, year in training, gender, age, and race and ethnicity. Outcome measures included asking learners to self-rate their ability to activate and engage families and interprofessional team members on rounds, apply health literacy principles, incorporate I-PASS structured communication on PFCRs, demonstrate use of written communication to effectively facilitate communication with families and the interprofessional team, list appropriate educational activities for PFCRs, and discuss roles and responsibility for various team members. Participants were also asked about the degree to which the workshop's materials provided knowledge and skills relevant to their patient care activities, the balance between didactic and interactive elements, and the pace and length of the workshop.

Results
A total of 246 residents underwent the PFC I-PASS SCORE resident physician/advanced care provider training from August 2019 through August 2020. Of the 246 residents who participated, 135 were interns (55%), 61 were second-year residents (25%), and 50 were third-year residents (20%). No advanced care providers completed the self-study training components or participated in the in-person training.

Self-Study Training Components
Overall, 59% of residents completed the self-study training components inclusive of the PFC I-PASS core content module (Appendix A), the health literacy exercise (Appendix B), and the core content module evaluation (Appendix C) prior to attending the in-person training. Of those residents who completed the selfstudy components, most responded to the open-ended prompt "List the most effective elements of the core content module" with the example video embedded within. Additional responses included becoming familiar with the I-PASS framework and the ability to learn at one's own pace.
In-Person Training Components Measures were based on resident self-rating utilizing a 5-point scale (strongly disagree, disagree, neutral, agree, strongly agree). Residents were asked to delineate their perceived knowledge and skill ability regarding the following objectives after completion of the training: Most residents agreed or strongly agreed that that the training provided knowledge and confidence in skills ability for all five stated objectives, with objective 1 (Activate and engage families and all members of the interprofessional team to create a shared mental model) and objective 5 (Discuss the roles and responsibilities for various team members during PFCRs) rated the highest, at 88% and 90%, respectively (Table 1).
Additionally, residents were asked to rate the training provided in the workshop using the same 5-point scale for the following outcome measures: 1. Provided me with knowledge and skills relevant to my patient care activities. 2. Was designed with an appropriate balance of didactic and interactive elements. 3. Had an appropriate pace. 4. Seemed to be the correct length to address the content.
Overall, most respondents rated the training highly, agreeing or strongly agreeing regarding provision of knowledge and skills relevant to patient care activities (82% of respondents) and the design of the training balancing didactic and interactive elements (82% of respondents). Although 80% of respondents found the training to have an appropriate pace, only 75% found the length to be correct to address the content (Table 2). In openprompt responses, some participants suggested that the didactic portions in the in-person training be further trimmed down as they found it repetitive, and many would have liked to dedicate more time to the interactive exercise components.

Discussion
Participation in the PFC I-PASS SCORE resident physician/advanced care provider training improved residents' knowledge and increased their confidence in their ability to effectively communicate with patients, families, and other members of the interprofessional team during PFCRs. Utilizing multiple interactive techniques to solidify new concepts provided residents with self-reported confidence in engaging and activating families using communication strategies to achieve a shared mental model regarding patient care and application of health literacy principles. Additionally, residents reported confidence in their abilities to use the I-PASS structured communication tool to communicate with families and members of the interprofessional team. Using Kirkpatrick's model, 24 this curriculum was well received (Level 1) and improved knowledge and confidence (Level 2).
Development of the PFC I-PASS SCORE Program involved experts in a variety of fields, including family-centered care, medical education, health literacy, and quality improvement. This expertise added to the robustness, quality, and uniqueness of the curriculum. The use of a flipped classroom 18 approach supplemented by simulations and interactive exercises enhanced the applicability of the tools in real-life settings. The balance of didactic and interactive elements was well received by learners. At the onset of the COVID-19 pandemic, adaptations for curricular training were made to accommodate the need for virtual training platforms. Furthermore, materials were augmented with recommendations on how to conduct PFCRs A novel strength of this program is the role of nonphysicians in the coproduction of the training. As a best practice, we recommend inviting trained nurses, patient/family advisors, and/or additional ancillary staff within one's own institution to be facilitators who can provide additional perspective and suggestions to enhance interprofessional collaboration. Training programs can also consider the use of resident champions, allowing more senior residents the opportunity to cofacilitate subsequent trainings or refreshers for new learners.
A limitation of this program includes the fact that although the curriculum focused on interprofessional communication, many of the workshops were not consistently attended or facilitated by interprofessional teams. Additionally, given variability from site to site, tailoring of curriculum content to fit the local context was necessary. A little over half of participating residents completed the self-study training materials. To further improve adherence, faculty may want to provide timely reminders and engage residency leadership to incorporate the completion of these activities during a time when residents are not challenged by competing tasks. Despite our attempts to decrease the overall duration of the training, many residents still found it to be lengthy. Facilitators can consider utilizing just-in-time training before beginning an inpatient rotation or other educational venues to reinforce skills or review concepts. To sustain culture change, we recommend ongoing provision of feedback and periodic faculty observations on rounds.
In summary, the PFC I-PASS SCORE resident physician/advanced care provider training improved resident knowledge and confidence globally in several aspects of PFC care, especially how to activate and engage families and all members of the interprofessional team to create a shared mental model utilizing a structured framework to conduct PFCRs with incorporation of key health literacy principles and enhanced communication techniques.