Improving patient safety Through Provider communication Strategy Enhancements

My blog homework is “After Reading” Improving Patient Care Through Provider Communication Strategy Enhancements, “post a 300-word response to the study, which was presented in the PDF file (linked under topic” Culture of Communication “in the Course Outline section). The response should include at least one direct quote (cited in APA format). The response should be reflected in the study’s findings, outcomes, purpose, and final discussion. This should not be a summary of the information but an analysis of your opinion, Can you do it? I need this homework in 12 hours.

• Communication skills
• Patients
• Medical personnel
• Evaluation
• Health care
• Implementation
• Patient safety
• Multidisciplinary rounds
• Situation Background Assessment and Recommendations(SBAR)
• Team huddles

• New name: Agency for Healthcare Research and Quality- Old name: National Center for Health Services Research

Utilizing a pre-test/post-test design, this study incorporated baseline data collection and implementation of team communication interventions, followed by data collection and analysis over a 24-month period. The goal of developing a user-friendly toolkit was accomplished as feedback and findings from this study were revised and adapted.

Study Setting

Denver Health Medical Center, an urban public safety-net hospital, provided the site for this study, with specific focus on three care settings utilized for pilot testing. These settings were selected because they each provided a different type of unit organization and staff.

• Phase 1 focused on two settings: the Medical Intensive Care Unit(MICU) and the Acute Care Unit (ACU). The ACU was selected because it had a very diverse patient population, with multiple physician teams and services assigned to the unit at a given time. The MICU was selected because it was a closed unit with fewer physician teams and one primary service with more accessibility to physician consultation.

• Phase 2 focused on behavioral health units: an Adult Psychiatric Unit, an Adolescent Psychiatric Unit, and an Acute Crisis Service (psych ED). The behavioral health units were characterized by a unique patient population and unit milieu, with a more consistent physician group.

Since post-intervention data collection has been completed on the Phase 1 units, this report is focused on specific outcome measures based on Phase 1 results.

Interventions

The following communication strategies were included in the toolkit interventions and can be accessed on the Denver Health Medical Center Web site (www.safecoms.org) for further detail:

Situational briefing guide: SBAR. A standardized communication format, the SBAR, was utilized as a situational briefing guide for staff and provider communication regarding changes in patient status or needs for nonemergent events, related issues, or for events on the unit, in the lab, or within the health care team. SBAR is an acronym for:

• Situation: What is going on with the patient?

• Background: What is the clinical background or context?

• Assessment: What do I think the problem is?

• Recommendation: What do I think needs to be done for the patient?

Since SBAR provides a standardized means for communicating in patient care situations, it is effective in bridging differences in communication styles and helps to get all team members in the “same movie.” SBAR provides a common and predictable structure for communication, can be used in any clinical domain, and has been applied in obstetrics, rapid response teams, ambulatory care, ICUs, and other areas. SBAR also presents guidelines for organizing relevant information when preparing to contact another team member, as well as the framework for presenting the information, appropriate assessments, and recommendations. SBAR has been utilized in Institute for Healthcare Improvement (IHI) collaboratives and has been endorsed by the American College of Healthcare Executives and the American Organization of Nurse Executives.

One important aspect of SBAR is its inherent recognition of nurses’ and other care providers’ expertise so that they are encouraged to assertively make recommendations to physicians, thus facilitating a nonhierarchical structure. In a recent study of nursing home transfers from acute care settings to skilled nursing facilities (SNF), SBAR implementation helped avert breakdowns in communication that had previously resulted in patients arriving with incomplete information and the need for important medications that were not available.

In the current study, SBAR was used initially to organize and present information to communicate changes in patient status. It was also found to be useful in preparing information and for an anticipated difficult conversation with another staff member or provider. As implementation of SBAR expanded across units, a number of various uses were established. It was utilized to provide “kudos” for staff accomplishments, as a framework for reporting on patients, as a means of structuring assessments, and to structure succinct e-mail communications. A diagram of the SBAR process form and guidelines for use are presented in .

Team huddles. Provider and staff team huddles were implemented on the pilot units as a way to communicate and share information concurrently with the team early in the shift. A team huddle was defined as a quick meeting of a functional group to set the day/shift in motion via commentary with key personnel. Huddles are microsystem meetings with a specific focus, based on the function of a particular unit and team. Although both joint rounding and huddles aim to improve team communication and patient safety and care, huddles differ in that they have a primarily operational focus. They are interdisciplinary and include operational and care personnel.

Current literature indicates daily team huddles result in fewer interruptions during the rest of the day and immediate clarification of issues. Team members know there is a fixed time when they will have everyone else’s attention. Daily briefings (similar to those used in huddles) have been shown to be useful for a team to quickly assess changes in clinical workload, identify relevant issues of the day, and provide a means to prioritize. In a very short time, members of a care team can all be “on the same page” for the day and be ensured that relevant issues are being addressed.

Guidelines for huddles include the following:

• Set a standard time each day.

• Use a consistent location.

• Stand up, don’t sit down.

• Make attendance mandatory.

• Limit duration to 15 minutes.

• Attempt to have the same structure every day.

• Keep the agenda to limited items.

Initial pilot testing of huddles occurred within two departments: radiology and laboratory services. Huddle participants included all departmental and unit level staff members present at the time. They typically occurred at the beginning of the day or shift, lasted approximately 9 to 20 minutes, and were led by a shift supervisor or department head.

Huddles were utilized to review pertinent issues of the day (e.g., inoperable equipment or rooms), to go over the day’s schedule, and to plan for possible variations/problems. Information sharing included relevant system-level messages of the day, information from recent management meetings, and departmental issues or problems. Brief discussion of specific issues, such as errors (e.g., mismarked films) was integrated with a review of the process, system issues, and reminders on how to avoid the errors. On nursing units, huddles typically were led by the nurse manager, charge nurse, or clinical nurse educator. Interviews revealed several benefits of huddles, including:

• Preparing staff for the shift/day.

• Face-to-face communication.

• Immediate response to questions.

• Streamlined resolution of issues or concerns.

• Timely response to issues or concerns.

• Efficient dissemination of information.

• Improvement in teamwork and effective communication.

• Staff involvement in decisionmaking.

In some instances, if a huddle had been skipped for a particular shift/day, staff members took notice and inquired about it. Huddles also served to enhance teamwork and the staff’s sense of cohesion.

Multidisciplinary rounds using Daily Goals Sheet. Multidisciplinary rounds were implemented in the MICU with the leadership and support of the unit medical director and nurse manager. Rounds were patient-centered and could include any staff member or provider involved in the patient’s care, such as a physician (e.g., attending, resident, intern, and fellow), respiratory therapist (RT), physical therapist, occupational therapist, social worker (SW), pharmacist, charge nurse, individual patient’s nurse, and pastoral care provider.

Rounds were focused on open and collaborative communication, decisionmaking, information sharing, care planning, patient safety issues, cost and quality of care issues, setting daily goals of care, and communicating with patients and/or family members as they were able. Information shared during rounds was supplemented by communication at shift changes between the incoming and the outgoing care providers.

The Daily Goals Sheet was an interdisciplinary communication tool that served as a simple way of clarifying work goals among providers. It provided the means for the care team and patient (when able) to explicitly define the goals for the day. The form was typically completed during rounds on each patient, signed by the fellow or attending physician, and given to the patient’s nurse. The care team—physicians, nurses, RTs, and pharmacists—provided input and reviewed the goals for the day. The form was updated as the goals of care changed. Current literature supports the value of multidisciplinary rounding. In a study of multidisciplinary rounding focused on daily care goals in intensive care, the results showed improved communication among providers, significant improvement in the proportion of physicians and nurses who understood the goals of care for the day (from 10 to 95 percent), and a 50 percent reduction in ICU length of stay.

Prior to utilizing the patient-centered daily goals format, patient care rounds were provider-centric and lacked clarity about tasks and care plans for the day. Staff often lacked understanding of the tasks they needed to accomplish and the plan for communicating with patients, families, and other caregivers. Physicians and nurses perceived that using this format improved communication and patient care. The benefits of the goals sheet are founded on the theories of CRM (crew resource management) and are currently used in a number of ICUs participating in IHI and Veterans’ Health Administration improvement efforts.

Escalation Process

The intent of the original study proposal was the development and implementation of an escalation process algorithm for provider communication regarding changes in patient conditions for noncode situations. The goal of the escalation process was timely, appropriate communication between nursing staff and providers as changes in patient conditions occurred. Previously, no standardized process existed at Denver Health for this purpose, resulting in ambiguities in the decisionmaking process for each type of patient situation.

Peer-reviewed case studies revealed that the absence of a standardized and well-defined communication process had led to confusion and delay in appropriate and adequate patient care, when the need for escalating a concern existed. These issues are particularly relevant at academic medical centers similar to Denver Health, since the organizational structure includes layers of providers, such as attending physicians, fellows, senior and junior residents, and interns.

However, concurrent to the implementation phase of the project, the Department of Patient Safety and Quality developed Rapid Response Escalation Criteria, which provided nurses with patient parameters for escalation and an outline of providers to call along with a timeframe; the criteria utilized SBAR for communicating changes in a patient’s condition.

The Rapid Response form served both as a guide for identifying a patient’s condition that could trigger a Rapid Response call and as a communication tool for physicians to convey their assessment and plan of care. Instructions were also provided for physicians for followup with senior/attending physicians within a 4-hour timeframe. This well-documented, standardized escalation process provided role clarification and cleare patient parameters within a realistic timeframe, defining whom to call and when, in a way that could be understood by all health care team members.

Implementation

Staff and provider education and development were primary components of the communication strategy implementation. An “Implementation Toolkit” was developed to serve as a guide for the education and integration of communication and teamwork factors in clinical practice. Although specific units served as pilot areas for pre- and post-data collection, it was necessary to involve all departments and a maximum number of staff members due to the interdepartmental nature of communication. The challenge to capture a broad audience of health care team members mandated the creation of a standardized curriculum, teaching materials, and methods that could be used by multiple disciplines in a variety of forums (e.g., new employees, department orientation, student rotations, initial education, and ongoing refreshers for current employees). Health care team members participating in this intervention included nurses, unlicensed assistive personnel, physicians, respiratory therapists, occupational/physical therapists, dietitians, social workers, pharmacists, chaplains, clerical/support staff, and radiology and laboratory staff.

The nature of the acute care hospital setting presented particular challenges that required multiple teaching strategies to introduce the concepts, reinforce learning, facilitate translation of the concepts into practice, and sustain the practice changes ().

Table 2

Implementation methods for provider/staff education.

The goals of the education program included:

• Provide consistent education for all members of the health care team on the concepts of teamwork, psychological safety, and open, effective communication and its impact on patient safety.

• Integrate safe communication strategies into the organizational culture.

• Sustain the culture of teamwork, psychological safety, and open, effective communication.

• Maintain consistency and high quality in all educational efforts.

• Develop educational tools that allow for flexibility in use and application in diverse practice settings.

The education plan was composed of two parts: one, initial education and two, followup education.

The initial (interdisciplinary) education component engaged team members and introduced the foundational concepts of human factors, effective teamwork, and communication. More than 650 health care providers (representing all health care disciplines) attended presentations by a nationally recognized patient safety expert, Michael Leonard, MD. Using “real-life” anecdotes and an evidence-based approach to factors that influence health care workers’ practice, Dr. Leonard fostered a commitment from providers to work toward improving the organizational culture of patient safety.

In addition to the lecture portion of the presentation, attendees also participated in interactive group activities. They applied the SBAR format to “real-life” patient situations and coached each other in communicating patient needs. Involving an outside expert created a certain “buzz” throughout the staff and organization that facilitated interest and involvement in the topic. Feedback surveys of the initial education/presentation were overwhelmingly positive ().

Table 3

Feedback from initial expert presentation.

The followup (unit/department) education component focused on a review of the initial concepts, practice of effective communication skills, and strategies to create and sustain a culture of patient safety. In contrast to the initial “kick-off” education sessions, the followup education was a sustained effort over an extended period of time (months). Ongoing education and reinforcement of learning were achieved through formal and informal sessions on the patient care unit. A number of educational strategies were utilized including: “fast talks,” worksheets, posters, visual cues and reminders, PowerPoint® presentations, unit-level champions, and a video of Dr. Leonard’s initial presentation (see ).

Fast talks. Feedback from direct caregivers, managers, and clinical educators indicated a need for practical teaching strategies that could fit into staff’s daily work and routine. “Fast talks,” a format that is concise (15 minutes), focused, and taken directly to staff members on the unit fit these criteria. Key selected topics were presented and discussed with staff as they gathered informally at convenient times during their shifts. Whenever possible, effort was made to include a multidisciplinary group.

The implementation toolkit included a fast talk notebook of teaching materials for discussion topics on concept review, practice scenarios, and practice implementation. Key concepts were presented on 1 to 2 pages that included a headline sentence to convey the essential implications for practice. Brief bulleted statements served as a guide for more detailed review. Discipline- and patient population-specific practice scenarios were also included in the notebook. A narrative described a scenario followed by appropriate SBAR format prompts. Participants worked either as a group or individually to structure the required communications. A facilitator guide included examples of potential communications.

SBAR blank communication forms/worksheets. Pads of tear-off sheets that included the SBAR, instructions for use, and a guide for preparing to contact another team member or provider were created (). Feedback from staff indicated the importance of meeting the needs of both novice and expert team members. “Novice” forms included expanded cues for section content. “Expert” forms were more streamlined. These sheets were used for practice/learning and to prepare/organize upcoming communications about actual patient situations. Tablets of the communication forms were placed on units in strategic locations (e.g., near the phone) and utilized in presentations as handouts.

Concept posters. One-line headlines capturing key concepts were developed into laminated posters and placed on units in strategic locations (e.g., nurse’s stations, staff bulletin boards, and resident work stations). Clinical nurse educators, managers, and unit champions used the posters to review key concepts and reinforce previous teaching during staff meetings, huddles, and/or on an individual basis.

Visual reminders. Visual reminders—such as phone cards, bookmarks, name badge holders, T-shirts, pocket cards, and pocket notebooks—were developed to provide ongoing reminders and maintain awareness until practice changes were incorporated into unit/organization culture. These items were also used as incentives for participating in education events and to reward observed practice changes. Visual reminder “giveaways” were particularly effective because staff members and providers were eager to obtain them, and because they reinforced previously presented concepts, providing reminders throughout the day.

PowerPoint® presentation. Developed for use in unit meetings, orientation classes, and other occasions, these presentations provided a standardized introduction and brief overview of key concepts. PowerPoint presentations were typically utilized during staff meetings and new employee orientations.

Champion role. Unit-based champions were identified by unit leadership and served as implementation “experts,” reinforcing effective learning strategies and culture changes. Champions embraced the key concepts of teamwork and communication, sharing their strategies with other units. Examples included advertising educational events using SBAR format and developing an “SBAR Kudos” form to recognize coworker contributions to the unit.

Data Collection

This implementation project was evaluated using several different approaches:

• Process analysis of communication events, based on observations of communication between health care providers.

• Evaluation of patient occurrence reports: hospital data from the University Healthsystems Consortium Web-based occurrence reporting system (Patient Safety Net).

• Hospital Survey on Patient Safety Culture: staff survey responses to the Agency for Healthcare Research and Quality (AHRQ)-developed patient safety culture survey.

• Evaluation of staff understanding of patient daily goals: a brief self-report survey on individual providers’ understanding of the patient plan of care.

• Focus group interviews with hospital staff.

This report will focus on the process analysis of communication events, both pre- and post-implementation on Phase 1 units. Further results from other evaluation methods will be reviewed in future publications.

We defined process analysis as focused observations that utilized trained data collectors to record their observations on the communication process within the health care team. Our process analysis data collection methods were founded on the concepts of industrial engineering and observational research methodology. The data collection team—which was made up of nursing staff from various clinical, research, and administrative backgrounds—worked closely with an industrial engineer, who was trained in analyzing and improving processes. Guided by the study’s co-principal investigator and industrial engineer, the team developed standard data collection guidelines, data collection tools, and coding guides.

Initial training involved observation of communication on units in teams of two or more, pilot testing the data collection forms and tools, and debriefing the data collection process. Particular attention was given to team consensus on the various components of the communication events. Observations were also reviewed to ensure inter-rater reliability.

The team defined a “communication event” as nurse-initiated communication with another health care team member (e.g., physician, respiratory therapist, pharmacist) regarding an existing or potential problem/issue related to a patient’s health status or plan of care. The communication event was considered complete once an answer or resolution of the particular patient issue was received. An “event” may not necessarily end in an immediate treatment. However, it can give the nurse further direction for the plan of care ().

Figure 1

Graphic presentation of a process analysis communication event.

Observations were made by one or two data collectors, who remained on the study unit for 1 to 4 hours at a time at different periods throughout the day and night shifts. Stationing observers on the nursing unit allowed data collectors to record communication events from multiple nurses at one geographic location. Data collectors took field notes on their observations using a standard form, asked questions of health care team members to clarify what they were observing, and asked nurses their perceptions of the communication event.

Data collected about the communication event included: who was communicating; the patient’s issue or problem; method of communication (e.g., phone, page, face-to-face contact); any activities taking place during the event (e.g., searching for a phone number, traveling to a different part of the unit, finding a part of the medical record); the amount of time needed to communicate and resolve the issue; and followup questions on the nurse’s perceptions about the resolution of the issue, including his/her satisfaction with the communication. Following observation of a communication event, data collectors asked nurses two questions:

• To what extent do you think this patient issue has been resolved?

• How satisfied were you with the interaction/communication?

Nurses answered on a 3- or 4-point Likert scale, depending on the question: 1 - not resolved; 2 - somewhat resolved; 3 - resolved; and 1 - not satisfied; 2 - somewhat satisfied; 3 - satisfied; 4 - very satisfied. Resolution and satisfaction scores were then recoded into positive and nonpositive responses (i.e., resolved, satisfied, or very satisfied).

The data collection team observed and analyzed 495 discrete communication events: 224 (112 pre-intervention and 112 post-intervention) on the MICU and 271 events (135 pre-intervention and 136 post-intervention) on the ACU.

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