These presenters have nothing to disclose 15th Annual International Summit on Improving Patient Care in the Office Practice and the Community Sunday March 9 - Tuesday, March 11, 2014 L4: Getting to Always! Using teach-back to Maximize Patient Learning Gail A Nielsen, Linda Wendt Sheila Tumilty March 10, 2014 Presenters Gail A. Nielsen, BSHCA, FAHRA, RTR Fellow and Faculty, Institute for Healthcare Improvement Linda Wendt, RN, BA, CPHQ System Director of Quality UnityPoint Clinic Sheila Tumilty Senior Project Manager Quality UnityPoint Clinic 2 1
Agenda 9:30 Introductions and Opening 9:50 Importance and Impact 10:30 Role Play 11:00 Break 11:15 Reliability; Deployment; Tools 12:15 What are you eager to try at home? 12:30 Adjourn 3 Who is Here Today? What do you hope to take home from this session? What are your needs in helping patients understand? 4 2
Why We re Here: Objectives Maximize their use of the free, interactive learning modules at www.teachbacktraining.com to teach staff across the care continuum and assess their competence. Form a reliable habit of using Teach-back with all patients and families in the course of their daily work, whether in hospitals, home care settings, or office practices 5 How Might We..gain deeper knowledge of patient and family caregiver understanding and comprehension of clinical and self-care needs after discharge? 6 3
Inadequate Health Literacy Literacy is a predictor of health status Literacy is a stronger predictor than age, income, employment status, educational level or racial or ethnic group Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among medicare managed care enrollees. Am J of Public Health. 2002;92(8):1278-83 Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475-82 7 Your Examples What difficulties have you seen patients suffer from as a result of poor understanding in healthcare? 8 4
Understanding Challenges Medications Appointment slips Informed consents Discharge instructions Health education materials Insurance applications 9 Universal Communication Principles Everyone benefits from clear information Many patients are at risk of misunderstanding and it is difficult to identify them Assessing reading levels in the clinical setting does not ensure patient understanding 10 5
The Universal Problem Health professionals who fear looking dumb to their caregivers or peers Patients who avoid asking questions In a hurry (e.g., last day of hospital stay) Distracted (e.g., family caregivers needs or wants) Preoccupied (e.g., pain, new diagnosis) Unfamiliar (e.g., don t know what they do not know) Fearful (e.g., not knowing what to expect) 11 Safe, Effective Transition Home? Patient with heart failure Readmitted two days after discharge from hospital Reviewed: What do you do to stay well at home? Weigh myself daily Watch my salt intake Did NOT know to report weight gain to her doctor Had gained 9 lbs since discharge Had answered yes to do you understand your discharge instructions? 12 6
In a Hurry to Leave the Hospital 13 Table Exercise Discuss in small group or tables -- personal, family caregiver, or care setting examples of situations where it was: Difficult to understand Hard to ask questions Difficult to take the time Hard to concentrate Not in your/someone s area of expertise 14 7
Reliable Use of Teach-back Making it easier to train everyone in all settings Free, online, interactive training for hospitals, home care and office practices Toolkit For individuals, their managers and coaches 15 www.teachbacktraining.org What can we learn from this Teach-back session? 16 8
This presenter has nothing to disclose Evidence of Impact March 10, 2014 Gail A Nielsen Impact: The Picker Always Events Grant Project: Always Use Teach-back Comparison of health care provider use of teach-back (TB) questions to assess patient understanding of specific selfcare activities during clinical encounters in the hospital, primary care, and home health setting, before and after the Always Use Teach-back! intervention, Iowa, July 2011 June 2012 62 direct observations of nurse, physician assistant, and physician interactions with patients. TB use: any request for patient to express what they were told in their own words. Non-use : no question or a question that can be answered yes or no. 18 9
Improving Teaching Across Settings 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Successful TeachBack Rate Aug-06 to Dec -11 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 7-day Post-discharge Call VNA In Hospital Teaching Using the same teaching materials, Teach Back questions and teaching techniques in hospital, in home by home health care, and a 7-day followup call As staff became more competent and used Teach Back more reliably, more patients could retain more vital information Least retention is seen in the hospital; reinforcement helps 19 Option for validating improvement 3/12/2014 20 10
UnityPoint at Home System-wide home care progress in spread of use of the Always Use Teach-back! Toolkit: 95% of clinical employees have been trained and competency validated in Teach-back with all sites achieving the goal. (N= 376) by y-end 2013 HHCAPS Did the home health provider explain things to you in a way you could understand? Increased from 78% to: 84% 21 Example: System Regional Integration Integrated Chronic Disease Management Course (ICDMC) includes Always Use Teach-back Initial 6 hour course for all Care Coordinators, Social Workers and clinicians in the region including hospital CardioPulm Rehab, Palliative Care, Hospice, AMT, PT/OT 1 st Q: a 2 hours course for all frontline staff with www.teachbacktraining.org prerequisite and emphasis on Teachback, motivational interviewing (MI), and goal setting 2 nd Q: 90 min course for frontline staff on Teach-back and MI. Instructors use the red/yellow/green tools; hands on and role playing with a practical approach Each dept. champion has a goal related to Teach-back for their units and a process for coaching and mentoring staff. These champions have regular coaching meetings with the ICDMC. 3/12/2014 22 11
Your Examples What data have you been using to understand the impact of your patient teaching? 23 This presenter has nothing to disclose Teach-back Role Play: Frontline Challenges March 10, 2014 Gail A Nielsen 12
Typical (Bad) Teaching Practice Read the following exactly as written - as if you are teaching a patient I am going to talk to you about the signs of heart failure. The signs of heart failure are: Dyspnea on exertion Weight gain from fluid retention Edema in your lower extremities and abdomen Fatigue Dry, hacky cough Difficulty breathing when supine 25 (Good) Teaching Using Simple Language Read the following as written - as if you are teaching a patient. Let s talk about the signs of heart failure. The signs of heart failure are: Shortness of breath Weight gain from fluid build-up Swelling in feet, ankles, legs or stomach Dry, hacky cough Feeling more tired, no energy It s harder for you to breath when lying down 3/12/2014 26 13
Evaluation/Discussion Questions What was the patient s reaction? What was it like for you as the teacher using Teach-back? Did it feel like extra work? How would you build Teach-back into your daily work? How could you use Teach-back to communicate with team members? 3/12/2014 27 Table Exercise With 2 or 3 people, take turns in the role of patient and teacher. If 3, add an observer Teacher explains critical information and asks the patient to say back in his or her own words Patient responds Observer scores the teaching technique Group reviews the discussion questions What did you learn? 28 14
3/12/2014 29 This presenter has nothing to disclose Getting to Always: Reliability Techniques March 10, 2014 Gail A Nielsen 15
How Might We..? 31 Hospital use Teach-back for every patient every time? Primary & Specialty Care Home Health Care Home (Patient & Family Caregivers) Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2012:. Available at www.ihi.org. Your Turn How many teams are using Teach Back? How reliably is it being used? 32 16
Insanity: Doing the same thing over and over again and expecting different results. attributed to Albert Einstein 33 Assessing ways to improve reliability 34 17
Definitions Reliable The process provides the best care for every patient every time Sustainable The process never deteriorates over time regardless of the participants Gail A Nielsen 2013 35 Assessments Is the topic included in strategic aims and plans? Do executive leaders: Demonstrate the topic is a key strategic initiative? Frequently reinforce need to close the gap? Provide progress reports to senior executives? Calendar regular attention to the initiative? Assess and promote leadership commitment? Gail A Nielsen 2013 36 18
Assessments Are Initiatives Connected? Reducing avoidable readmissions Improving patient safety Coordinating care across the continuum Building ACOs Improving patient experiences Gail A Nielsen 2013 37 Assessments Use observation to understand existing processes Ask staff what they have been taught about how to do a process Ask what gets in the way of reliable processes; Use small tests of change to improve reliability Gail A Nielsen 2013 38 19
Small sample Go Ask 5 Pick a process you want reliable that has been taught to frontline staff Review what was taught Ask 5 people who do the process to describe Why the process is important How they do the process How many of 5 got it right? 4 of 5 means only 80% reliability is possible RutherfordRutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations.Cambridge, MA: Institute for Healthcare Improvement; June 2012:. Available at www.ihi.org. 39 Adoption is a SOCIAL thing! A better idea communicated through a social network over time Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press. 20
How Adopters Perceive Change is Critical 41 I will engage faster if The new process works better than the old Testing the change is low risk (to me) The change is easy to understand and adapt to my current work patterns Improvement from the change is easy for potential adopters (me) to see Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press. Sequence: Testing and Improvement Theory and Prediction Test under a variety of conditions Make part of routine operations Implementing a change (HTG) Testing a change Developing a change Spreading a change to other locations Act Plan Study Do Slide by Robert Lloyd 21
Monitoring Impact (Outcomes) 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Aug-06 Oct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Successful TeachBack Rate Aug-06 to Dec -11 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 7-day Post-discharge Call VNA In Hospital Teaching Using the same teaching materials, Teach Back questions and teaching techniques in hospital, in home by home health care, and a 7-day follow-up call As staff became more competent and used Teach Back more reliably, more patients could retain more vital information Least retention is seen in the hospital; reinforcement helps 43 Monitoring Process Measures 44 22
Improving High Reliability Once a process is in place and reliability is increasing, how do you reach the level of every patient every time experiencing teach-back when it is needed? 45 Use 5 Whys Root Cause Analysis 46 23
Table Work: Use a Local Example Why s must hang together reading top to bottom and bottom to top Last Why? must be singular and testable 47 5 Whys Root Cause Analysis Did Mrs. A. fall in the bathroom? Didn t comply with assistance instructions Didn t understand No Teach-back Use of Teach-back not reliable RutherfordRutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations.Cambridge, MA: Institute for Healthcare Improvement; June 2012:. Available at www.ihi.org. 48 24
We can t solve problems by using the same kind of thinking we used when we created them. Albert Einstein 49 Teaching New Processes 50 OLD WAY Teach & leave Static slides During busy staff meetings Teach in remote conference rooms NEW WAY (TWI) Test to reliable process Specify the process Design education - Include help aids Teach test group in workplace Stick around to see if they can do it as taught If needed, redesign education, process or both Teach the next group; can they do it as taught? Gail A Nielsen 2012 25
How Do People Learn Their Jobs? 1. Identify key jobs 2. Break down by teacher** Know what Know how Know why 3.Teach one-on-one 4. If the student hasn t learned, the teacher hasn t taught. * the way to get a person to quickly remember to do a job correctly, safely and conscientiously. p. 73 ** Supervisor Slide by Kevin Little, IHI 51 Help Mid-level Managers Coach Honor the current work through observation. Understand that change is hard and uncomfortable. Resistance to change is natural; comes from fear of change. Promote new skill development. Build confidence to integrate the new habit into work patterns. Build reliability. Manage relapses. www.teachbacktraining.org 52 26
Screenshot from Online Documentation 3/12/2014 53 Screenshot from Online Documentation 3/12/2014 54 27
Teach Back in the clinic setting- Reliability Tools Conviction & Confidence Scale Before deployment (send prior to 1 st session) At 1 month At 3 months http://www.teachbacktraining.com/assets/files/ PDFS/Teach%20Back%20- %20Conviction%20and%20Confidence%20S cale.pdf 3/12/2014 55 Teach Back in the clinic setting- Reliability Tools Observations Conduct 4 or more patient observations at initial session Videos http://www.youtube.com/watch?v=cgttz_vxjya (PM facilitator YouTube link) http://classes.kumc.edu/general/amaliteracy/a MA_NEW3.html (Provider/Clinic Link) 3/12/2014 56 28
Teach Back in the clinic setting- Provider/Coach Discussion Identify opportunities/barriers to Teach- Back Select an opportunity to use Teach-Back Open discussion on learning during session 3/12/2014 57 Teach Back in the clinic setting- Teach-Back Real Time Huddle with provider to identify area of focus for Teach-Back PM facilitator will observe during the visit Huddle after the visit with provider for review Repeat cycle until provider comfort level is achieved (PDSA) (This may require additional coaching from staff coach or PM facilitator) 3/12/2014 58 29
Teach Back in the clinic setting- Development of Net Learning Module from Always Use Teach-back site Testing of module within our Reducing Readmissions Focus Groups Selection of staff coaches for Teach-back Developed training for coaches and deployed through Focus Group Coaches to provide feedback real-time Gather feedback from PDSA / 5 Why s of new module prior to spread Deployment via Patient Centered Medical Home model- NCQA standard 3/12/2014 59 Reliable Use of Teach-back Making it easier to train everyone in all settings Free, online, interactive training for hospitals, home care and office practices Toolkit For individuals, their managers and coaches 60 www.teachbacktraining.org 30
61 www.teachbacktraining.com www.teachbacktraining.org Your Turn Share with the large group: Your examples of improving reliability How have you engaged: Frontline staff? Senior executives? 62 31
Reflections What ideas did you hear that you might apply? What was most exciting for you? What was confusing? Need more information about.? 63 Your Turn What are you most eager to go home and work on next week? 64 32