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Breakdown in communication has been determined to be one of the leading causes of error and was cited as the root cause of 68% of sentinel events reported to the Joint Commission between the years 1995-2005.  In January, 2006 the Joint Commission added National Patient Safety Goal 2E, requiring standardized "hand off" communication.  The use of SBAR (Situation, Background, Assessment, and Recommendation) was identified as a framework to organize and pass critical information on to our physicians.   We began work towards this goal in May of 2006 and three years later we have successfully hardwired this into practice by achieving and maintaining 100% compliance. 

We formed a multidisciplinary team including the medical directors as well as several staff nurses to work on this project.  After researching various methods of communication, it was agreed that the SBAR format would be the tool of choice.  We created laminated pocket cards with SBAR examples developed in concert with the physicians and nurses.  Education was done at our annual skills lab and each RN was given a pocket card.  We also started monthly SBAR practice sessions with our medical directors.  In concert with the SBAR training were other efforts to increase nurse competence and confidence.  In order to make this change we had to make a culture change, from one of punitive hierarchy to a collaborative, patient centered culture.  After a full year of work several physicians agreed to monitor and report SBAR usage during their call shifts.  We started with 69% of communications being in SBAR format and reached 100% compliance in six months.  We have continued to track SBAR and have been able to hold the gain and maintain our compliance at 100% for 18 months.   

The keys to our success were having a supportive and engaged multidisciplinary team which included physicians, unit management, staff nurses and senior administration.  The unit manager was effective by communicating to staff that this was a performance expectation.  Our two medical directors were engaged and devoted a significant amount of time to training sessions.  A team of several physicians agreed to help with the tracking; they were instrumental in hardwiring this practice by coaching our staff through their reports and expecting the recommendation.  The recommendation was the most challenging aspect of the SBAR for the nurses.  The Quality Nurse provided information from the literature and spearheaded the monthly tracking.  She was instrumental in providing feedback to the staff in a timely and sensitive way.  She also helped staff work on their SBAR reports before they communicated with the physicians or other members of the healthcare team. 

The reward after a long and arduous process is seeing the phenomenal improvement in professionalism, confidence and respect between all members of the healthcare team.  The reward is well worth the ups and downs of moving a project such as this forward.  We have truly raised the (s)BAR in our communication and are well on our way to creating a culture of safety on our unit.