INTERACT Boot Camp Communication Tools

1. INTERACT Boot CampCommunication Tools August 2013

2. Welcome Back Introduce yourselves and share what you learned from reviewing your readmission data.

3. NC ACE: INTERACT BOOT CAMP Year long commitment to work on perfecting your Performance Improvement Project You are Here April Nov. Jan. Outcomes Congress Advanced Care Planning PDSA, Monitor Data, Spread PDSA, Monitor Data, Spread PDSA, Monitor Data, Spread Building your QI Program

4. Rolling out communication tools INTERACT as QI program INTERACT Champion is part of the QAPI Committee Focus on data, PDSA cycles

5. Polling Question Where are you in the INTERACT implementation process? • Have not started yet • Created plan to implement INTERACT with leadership • Started using INTERACT implementation checklist • Reviewed last 3 months of readmissions • Completing QI summary monthly • Using Hospitalization Rate Tracking Tool

6. Open Discussion Share success, challenges, barriers, or solutions you have encountered in the last 3 months of your INTERACT work.

7. A Closer Look at Data Interact2.net

8. Demo of INTERACT Tracking Tool

9. Tips for Hardwiring your Data Look at your process and outcome measures Discuss readmissions Findings from QI Review Tool Share monthly findings from Summary Tool

10. Polling Question What is the most common driver of readmission based on your QI Summary? • Delay in identifying change in condition • Lack of evaluation before calling physician • Physician insistence on transfer • Resident family expectations • Communication problems between nurses, or between nurses and primary care clinicians • Services needed are not available • Delay in advanced care planning • Other

11. Actions for Next 3 Months Ongoing monitoring of data Prioritize areas for improvement Develop your SMART goal Assess your plan of action and make adjustments

12. Staff Education/Communication Share your data at staff meeting: Post your timeline on bulletin boards. Have staff share “Bright Ideas” on implementation. Discuss rollout at staff meeting. Select key staff to be champions. Begin on one unit and spread.

13. INTERACT Program Components Putting the Tools to Work in Everyday Practice • Communication Tools • Decision Support Tools • Advanced Care Planning Tools • QI Tools

14. What This Session Will Cover Review use of STOP and WATCH and SBAR Implementation strategies Common barriers and lessons learned Problem solving for success

15. CommunicationTools Communication Tools

16. Polling Question Who has been trained and is now completing the STOP and WATCH tool on a regular basis in your facility? • CNAs and nurses • All non-nursing staff with direct resident contact • Family and close friends with regular direct contact • 1 and 2 • All of the above

17. Communication Tools STOP and WATCH Seems different • Not their usual self? Change in personality or behavior? Talks or communicates less • Quieter? Drowsier? Confused? Change in speech? Overall needs more help • Needs more assistance? Changes in gait, transfer or balance? Participated in activities less • Withdrawn? Decline in ADLs? Change in normal routine? Pain level increased

18. AND Ate less than usual (Not because of dislike of food) Nobowel movement in 3 days or diarrhea Drank less than usual

19. WATCH Weight gain or loss Agitated or nervous Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, or toileting more than usual

20. Part of Daily Routine • Keep the pocket card with you at all times. • Make it a part of your normal routine. • Complete the Stop and Watch form during your shift before you leave. • Give the Stop and Watch form to the nurse taking care of resident.

21. Implementation • Where will forms be located? • Which nurse will direct care staff give the tool to? • How will the nurse receiving the tool respond back to the person giving it? 4. How will the nurse document resident follow-up and actions taken? • Where will the forms go after follow-up is complete? • Does it need to be electronic?

22. Common Barriers to Communicating Early Changes in Residents CNAs are very busy giving direct care Unit nurses are busy giving medications, taking physician orders, and admitting new residents Stop and Watch can help close the gap!

23. Common Barriers • Why can’t I just tell the nurse? I don’t want to write it. • Too many forms and too much paper. • Not sure where to keep them. • Not all units are consistent. • Staff are not always compliant. • Need other languages. • Hard to get all nurses on board.

24. Ways to Monitor and Improve Use • Clinical champion and/or DON • Monitor • Who completes tool? • Who the tool is reported to? • Action taken by the nurse • Documentation • Final outcome • Computerized summary or paper flow • Daily, weekly, monthly

25. Suggestions from the Field • Print on carbon paper. • Keep forms handy, near linen room and time clock. • Duplicate copy goes to DON who follows up with nurse. • Fine tune it to facility needs. • Make CNAs more aware. • Incorporate into EHR. • Emphasize benefit of written proof that CNA reported change.

26. Suggestions from the Field • Monthly drawing for person using most S&W • Bulletin board to recognize CNAs who use it • Nurses need to encourage CNAs to use tool • Automatically goes to nurses’ electronic dashboard. • Embed in new employee orientation and all in-services. • Monthly meeting with CNAs.

27. Use QAPI to Get Started Planning for PDSA • Select one unit. Make 25 copies of Stop and Watch for use. • Laminate a copy for each CNA on the unit so that it fits easily into pocket. • Make blank copies and put within easy access for all direct care staff. • Ask lead CNAs and key nurses to teach all direct care staff and nurses working on the unit how to use the tool.

28. STOP and WATCH PDSA D – Implement on unit S – Data to collect: • Number of times tool is used • Flow of tool use and responses • Staff input about barriers and what is working A – Huddle with staff • What needs to be modified? • If no modification, then spread to other shifts and then facility wide

29. Polling Question What type of training has been most helpful in training nurses to use SBAR in your facility? • In-person group training • 1:1 training • Online training • Unit-based training • All of the above • Other

30. Polling Question What percentage of nurses complete the SBAR successfully in your facility? • 10% or less • 25% • 50% • 75% • 100%

31. Communication Tools SBAR Tool Situation Background Assessment/Appearance Request

32. SBAR: More than one purpose • Communication tool • Contact MD/NP • Change of shift report • Morning meeting/huddle/change of status meeting • Documentation tool • Progress note • Transfer note to send to ED • Educational tool • Just in time and scheduled in-service

33. Barriers • It is too long. • Not all MDs like it. • If you suggest an intervention and it is not done, facility is liable. • Overwhelming for nurses without good clinical assessment skills. • Time and frustration • Nurses are not trained for this.

34. Suggestions from the Field • Education, education, education (nurses and physicians) • Adapt it to facility needs. • Fax it to MD who may fax it back or use telephone order. • Review in weekly nurse meetings. • Changed “request” to “response.” • Instruct MDs and NPs to ask nurse to complete SBAR. • Ask MDs and NPs to show gratitude for improved communication due to SBAR.

35. Suggestions from the Field • Tie use to prevention of hospital transfer and reward staff for successful prevention of transfer. • Supervisor reviews SBAR and goes over it with nurse. • Incorporate into EHR. • Use SBAR in interdisciplinary team resident reviews as the “nurses note.” • Use SBAR as first step in QI Review Tool.

36. Use QAPI to Get Started PDSA P – Nurse input, current process, eliminate duplication, train staff, involve MD and NP, design accountability, adjust or modify based on input D –Begin with smaller group or unit, reinforce in daily huddle, continue to train as needed, use in team meeting review S – Data to collect: • Number of times tool is used • Number of times hospital transfer averted • Nurse and physician input A – What is working? What needs to be modified? If no modification, then spread to other shifts or units.

37. Medication Reconciliation Makes adjustments Clarifyorders Clarify orders Verify any discrepancies

38. Polling Question Where do most of your medication errors occur? • Upon admission with FL2 • MD clarification • Transcription • Pharmacy review • Pharmacy fill • Administration • Adverse reaction

39. How to Roll Out INTERACT QI Program QAPI Leadership Team INTERACT Med Rec Tool Implementation

40. Communication with Hospital What have you accomplished in last 3 months? • Shared Nursing Home Capability List • Met with hospital and discussed readmission • Shared potential goals you could work on • Participating in coalition with other LTC and hospital

41. Call to Action Next 3 months Work on hardwiring Stop and Watch and SBAR Monitor process and modify as needed Review medication errors with nursing and pharmacy Continue communication with hospital

42. Thank you! This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-BI-C7-13-95