Communication Challenges Overcoming the Barriers to Improve Quality Presented by: Christy Brinkman LNHA Laura Seleen RN 6-16-16
Objectives The participant will be able to identify a process to follow to define the facilities problem The participant will understand the use of the Fish Bone Diagram to assist in identifying communication barriers The participant will describe resources and tools available to improve communication Understand the challenges of communicating through the electronic medical record
Essentia Health West Region First Care Living Center in Fosston is a 50 bed SNF located in Fosston Minnesota. Grace Home is a non-profit, 45 bed skilled nursing facility located in Northern Big Stone County in Graceville, MN Oak Crossing in Detroit Lakes has 4 distinct neighborhoods totaling 96 licensed beds. It has a transitional care program with 23 dedicated beds. The facility utilizes the Neighborhood model with a modified universal worker approach to care.
PIPP 10-1-15 9-30-17 Improving the system of communications for our care partners Outcome Measures- will achieve a 15% improvement on average over baseline for the participating facilities on 2 of the following Minnesota Risk-adjusted Quality Indicator Domain Scores (Physical Functioning).
Root Cause of errors (Joint Commission 2000-2012) Human Factors: intentional/unintentional errors We cannot change the human condition, but we can change the conditions under which humans work. James Reason Leadership: Lack of leadership in system control and patient safety commitment. Communication: Failures, or inadequate communication flow
Communication is a challenge
How did we know we had a problem? Despite efforts in Nursing restorative programs, physical functioning is decreasing in all three facilities WHY? Employee Satisfaction Survey pointing to communication scores low WHY? OHFC reports for falls due to Care Plan not being followed WHY? LTC AHRQ patient safety survey pointing to low communication scores WHY?
Collaborative AHRQ patient safety scores Communication Openness: Only 55.7% positive Hand offs: Only 62.75% positive Compliance with procedures (staff taking shortcuts in their work): Only 64% positive
Staff survey (Vital Signs) Vital Signs Survey Question: % FAVORABLE RESPONSES Fosston, Graceville, Detroit Lakes Communication between shifts is effective in my work unit 35% 64% 56% Things rarely fall through the cracks when residents are transferred from one unit to another 32% 74% 64% Different units work well together in the organization 42% 57% 61%
Fishbone Diagram Stratis Health RCA Tool kit
Fishbone (see handout)
Cause and effect exercise Using your hand out, work with 1-3 people close to you Think of a common problem that you have in your facility and write it in the mouth of the fish Now ask your team Why do we have this problem Write the responses in the categories that might be associated From this create your causal statements
Collaborative example
Why is there a decrease in Physical functioning? Root Cause 1: Multiple Documentation Systems Written documentation from the interdisciplinary Care Partner team is not documented in 1 system. Nursing documents in Achieve Matrix Care. Therapy staff documents in Smart Therapy or on paper depending on the site. This means that therapy evaluations, progress notes, orders, and recommendations are not integrated into the interdisciplinary team s documentation within Matrix Care. Therapy documentation is scanned into Matrix Care. Delays occur in the scanning process or errors occur in the scanning process. Nursing staff may not find the scanned document or individual nurses may not review the therapy information as part of their daily workflow. Matrix Care does not have electronic charting for restorative care daily tasks. As such, documentation is on paper in the work unit. This is more challenging for supervisors to monitor on a shift-by-shift basis, and thus, staff may not be held accountable to provide this care according to each resident s plan of care.
Why Continued Root Cause 2: No Systematic Approach for Verbal Communication Staff s knowledge of the care plan and care plan interventions is often based on word of mouth between Care Partners; staff does not have enough time to read the lengthy care plans for each of the residents on their unit during orientation or every time there is a change. Communication about changes in the resident care plan is often by word of mouth, not through a standard process of verbal or written communication. Information about resident s care or interventions may reside in multiple places (such as shift huddle reports, whiteboards, care plan documents, cheat sheets). All information is not in 1 place, and information may not match the written care plan. Care Plans may not be updated in a timely manner which delays the handoff of information to all Care Partners.
Why Continued Root Cause 3: Poor Hand-offs between Therapy and Nursing for functional maintenance programs (ADL, mobility, transferring, and swallowing) At the time the resident is being discharged from therapy, the treating therapist typically communicates to 1 or 2 nursing staff on the unit, a small fraction of the total nursing staff caring for the resident. This may be a unit nurse, the RN clinical coordinator, or a C.N.A. There is not a common expectation of what this Care Partner is to do when receiving the hand-off information from therapy, and therefore it may not be passed on to other Care Partners or may not be entered into the written plan of care. The information is stated from a therapy perspective and is not translated into common nursing language or nursing interventions. Information may not be understood or may be lost in the hand-off.
Conclusion to RCA As evidenced by the 3 root cause statements, it is obvious that our Care Partners do not have complete, accurate, or just-in-time knowledge of the care plan and care plan interventions. Because staff may not feel emotionally safe to report concerns to leadership, the cycle or poor communication continues, to be seen the next time an adverse event occurs.
Communication: simple right? Two-way process of reaching mutual understanding, in which participants not only exchange (encode-decode) information, news, ideas and feelings but also create and share meaning. In general, communication is a means of connecting people or places. In business, it is a key function of management--an organization cannot operate without communication between levels, departments and employees.
Change Package and communication The Change Package was developed from a series of ten site visits to nursing homes across the country, and the themes that emerged regarding how they approached quality and carried out their work. It focuses on the successful practices of high performing nursing homes.
Strategy 4 Nourish teamwork and communication: Teamwork and communication among staff and between staff and residents is nourished by disseminating information in a complete, consistent and timely manner. Strong communication links people and build relationships between staff and residents. High-functioning teams respect one another and work interdependently towards common goals.
4.a Expect and support effective communication with staff and between staff. 4.a.1 Implement a formal method for communication between shifts. For example, face to face meetings or huddles between shifts, Nursing Assistant shift-to-shift bedside report, and a communication journal in residents rooms. 4.a.2 Conduct regular staff surveys and share results with staff, including opportunities for staff response and questions. 4.a.3 Establish the use of learning circles and huddles to foster relationships and create an opportunity for all to be heard. 4.a.4 Establish a process of updating care plans that supports effective communication, is sustainable in practice and requires measurement. 4.a.5 Include all voices that have a stake in what is being discussed. For example, if you are discussing an issue that pertains to a household you need to include the nursing assistants, dining, housekeeping, nurses, residents, families, etc. Use methods that encourage open and honest communication, especially to get at concerns. For example, staff may be more willing to share concerns in an anonymous survey.
Change Package 4a cont. 4.a.6 Develop communication plans that use multiple approaches (e-mail, verbal, newsletters, etc.) based on content and audience to ensure a consistent message is disseminated throughout the facility and across all shifts. Do not rely on word-of-mouth. 4.a.7 Include all shifts in communications. 4.a.8 Establish regular neighborhood meetings on each shift for the purpose of identifying what is working well as well as opportunities to improve. 4.a.9 Remove boundaries between departments. For example: Shadow other disciplines at the time of hiring so they know what everyone needs to do to make the household run. Have housekeepers become CNAs which fosters communication and understanding between roles. Use interdisciplinary teams for problem solving. Hold neighborhood meetings that all disciplines attend.
Communication tools TeamSTEPPS Communication skills interact directly with leadership, situation monitoring, and mutual support: Team leaders require effective communication skills to convey clear information, provide awareness of roles and responsibilities, and provide feedback. Team members monitor situations by communicating any changes to keep the team informed and the patient protected. Communication facilitates a culture of mutual support when team members request or offer assistance and verbally advocate for the patient. Communication tools that can enhance teamwork include the SBAR, callout, check-back, and handoff. These tools facilitate effective and efficient communication within and across teams. Good communication facilitates the development of shared mental models, adaptability, mutual trust, and patient safety.
Communication Tools: Check-Back
Communication Tools: Situational Awareness The state of knowing the current conditions affecting the team s work. Knowing the status of a particular event Knowing the status of the team s residents Understanding the operational issues affecting the team Maintaining mindfulness
Communication Tools: CUS I am Concerned I am Uncomfortable This is a Safety Issue Please use CUS words, but only when appropriate Use CUS in huddles and shift reports EVERYDAY!!!
Communication Tools: Debrief Process improvement Brief, informal information exchange and feedback sessions Occur after an event or shift Designed to improve teamwork skills Designed to improve outcomes An accurate reconstruction of key events Analysis of why the even occurred What should be done differently next time
Communication Tools: Huddle Problem solving Hold touch-base meetings to regain situation awareness Discuss critical issues and emerging events Anticipate outcomes and likely contingencies Assign resources Express concerns
Communication Tool: Brief Held for planning purposes sometimes referred to as a team meeting Form a team Designate team roles and responsibilities Establish climate and goals Engage team in short and long-term planning
Tools: SBAR Situation- Background- Assessment- Recommendation Provides a framework for team members to effectively communicate information to one another: Situation- What is going on with the resident? Background- What is the clinical background or context? Assessment- What do I think the problem is? Recommendation- What would I recommend?
Using Mapping/flowcharting as a tool Once you determine there is a process not working, you can map to document current state, and then map to future state (the desired process). This will lead you to action steps or interventions
Mapping example
Mapping Continued
PDSA
Celebrate the Teams Project Manager Fosston PIPP team Graceville PIPP Team Detroit Lakes PIPP Team
Key Lessons Learned Refrain from putting the cart before the horse Use you most valuable resource your direct care staff for problem identification and workable solutions Pull together your data what is the story the data is telling you? Leaders need to understand the benefits vs risk of communication flow as you implement your EMR s