Session 3.7 Applying best practice to develop innovative and effective communication practices to improve patient outc

1. Session 3.7 Applying best practice to develop innovative and effective communication practices to improve patient outcomes in NHS Scotland Design, Test and Learn

2. “To discuss how staff have applied and adapted the use of communication tools to support staff to deliver reliable person-centred communication and shared decision making” This session

3. Peter Campbell – Clinical Nurse Manager, RHSC, Edin Fiona Scott – Senior Charge Nurse, Crosshouse ,A&A Dr Ailsa Howie – SPSP Fellow,ST6 Acute Medicine, NHS Lothian Dr Claire Gordon – SPSP Fellow, Consultant in Acute Medicine, NHS Lothian All of you ! Our speakers today

4. Communication is the exchange of thoughts, messages, or information, as by speech, signals, writing, or behavior. Derived from the Latin word "communis", meaning to share. The communication process is complete once the receiver has understood the message of the sender. Feedback is critical to effective communication between participants. Wikipedia Communication, communication, communication

5. communication http://www.youtube.com/watch?v=3EZ32TygD9c

6. The Capacity Safety BriefPeter CampbellClinical Nurse ManagerRHSC Edinburgh

7. Today's Presentation • History • Reason For Change • Format of New Huddle • What has worked well • What hasn’t worked well • Outcomes • Improvement Clinic • Next steps

8. History • Morning bed meeting since 1990’s • Handover from Night Sister • Attended by Senior Nurses • No Medical staff or Service Managers • Could last up to 45 minutes • Complete run down of nurse staffing • Difficult to make decisions • Not clear where the responsibility lay

9. Reason For Change • H1N1 – new format for bed meeting 2009/10 • New Venue • Clinical Director and Service Manager attend • Change in what was being reported on • Further bed meetings as the day progressed • Awareness of national services • Focus on Critical Care & Retrieval Service • Visit to Cincinnati

10. Format of New Huddle – January 2012 • Takes place at 8am prompt in Lecture Theatre • Attended by Charge Nurse or Nurse-in-Charge • Clinical Management Team • Medical leads & CNM’s plus others • New spread sheet to capture data • Ward report sheet • Outcomes

11. What Has Worked Well – Key Safety Points • Current Information being reported • Clinical Coordinator spends less time gathering information • Issues are dealt with and responsibilities are clear • Watchers are being identified • Look back, look ahead & follow up • Given plan for the day • Staffing issues are dealt with • Improved team working with Charge Nurses • ER predicted admissions

12. What hasn’t worked well • Way you are spoken to • Too many private conversations • No clear definition of a ‘Watcher’ • Don’t always summarise status & outcomes • Critical Care dominates the discussion • Look back, look ahead & follow up • No medical ARU Consultant • Site issues not discussed • No feedback from Senior Nurse on call • Theatre discussion too brief

13. Outcomes • Equity of access • Effective prioritisation and triage • Reduction in cancellation of patients • Meeting national targets • Staff attendance at huddle • Briefings take no longer than 10 minutes

14. Improvement Clinic • Select group from ‘huddle’ attendees • Three questions prior to clinic • Collated responses – circulated • Meet for 1 hour – focused discussion • Draw up action plan • Identify who is responsible • Feedback and circulate outcomes

15. Next Steps • Rebrand – Capacity & Safety Brief • Data recording • Site specific issues • Rota to identify who is chairing & CNM for the week • Plan for safety brief – pre winter 2012 • Weekend and PH CBM • Dial in facility for SJH

16. Where We Are

17. NHS Ayrshire & ArranEarly recognition of the deteriorating child - ‘Watchers’Fiona Scott SCNClaire Colvine APNP

18. BACKGROUND Within our children’s inpatient ward we need a reliable system of identifying, monitoring, escalating and communicating information about the children in our care to the right clinicians, at the right time, using the right format. To ensure the early recognition of the deteriorating child or ‘watchers’ 24 hours a day, every day (Cincinnati Children’s Hospital).

19. QUESTIONS WE ASKED OURSELVES What is our model for improvement? People only want a change if they are going to benefit from it Where are we now? Where do we realistically want to be? (What are we trying to accomplish? How will we know change is an improvement?) How are we going to get there? (What change/s can we make that will result in an improvement)?

20. IMPROVEMENT AIM Outcome Primary Drivers Secondary Drivers SBAR (reporting system) PAWS (early warning system) Safety brief Paediatric Global Trigger Tool (PTT) Nursing staff education Effective written and verbal communication at all times To have a reliable system of identifying and successfully managing ‘watchers’ 100% of the time by end Sept 2012 Who? Where? When? Why? Establish multi-disciplinary handovers in ward area at least 3 times per day Agreed standard process Education of MDT Data collection and audit SBAR Visual prompt Effective escalation of concern process

21. VISUAL PROMPT Ward 1B

22. SMALL TESTS OF CHANGE - PDSA CYCLES Cycle 4 – Prediction: It continues to work. Plan: nurse in charge, registrars on duty, every 9pm handover in ward area. Results: All team members see benefit of change to the children and themselves. Learn: to maintain high level of communication with all. Action: Monitor continuity of process. Cycle 3 – Prediction: that process will work. Plan: one nurse, one registrar, one 9pm handover in ward area. Results: It worked mainly because of registrar buy- in and same registrar on for next 4 nights. Learn: continuity of key personnel who see a benefit is essential. Action: share the verbal benefits to MDT. Cycle 2 – Prediction: that process would work. Plan: one nurse, one registrar, one 9pm handover in ward area. Results: right people, right place, right format, wrong time. Learn: ensure staff are aware of timing to ensure handover happens as planned and staff get off duty on time. Action: update progress report to discuss at morning MDT handover. Cycle 1 – Prediction: that process would work. Plan: one nurse, one registrar, one 9pm hand over in ward area. Result: right time, right people, right format, wrong venue. Learn: ensure registrar aware of where handover to happen and reasons why. Action: email to all registrars.

23. How do we know a changeis an improvement? Quantative data collection and analysis (keeping record on safety brief measuring attendance compliance by nurse in charge) Qualitative anonymous questionnaire given to middle grade medical staff and senior nursing staff for completion

24. RESULTSData collected from safety brief notices Enthusiastic Registrar Monthly Compliance (mean) 77% Unenthusiastic Registrar Locum Registrar Cover

25. RESULTSData collected from safety brief notices Monthly Compliance (mean) 77% * * 3 day week

26. Registrar stuck in resuscitation Locum registrar unaware of normal practice

27. RESULTS Are we ready to do the handover?

28. LEARNING AND CHALLENGES Learning Good quality communication is essential Buy in from all members of MDT is vital to success Benefit of change obvious to all Challenges Keep the process rolling – make it the norm Regular audit to ensure continuation of change Staff education (ensuring new medical staff are aware of process and responsibilities)

29. NEXT STEPS Widen to the healthcare team to physio, pharmacist, dietician and others; Consideration of medical staff attending huddle at 3pm and 3am; Comparison of quality of escalation when lack of compliance with MDT handover.

30. Applying Best Practice to Develop Innovative and Effective Communication Practices to Improve Patient OutcomesMedical HandoversDr Ailsa Howie ST6 Acute Medicine SPSP Fellow

31. WHAT IS A HANDOVER ? • The transfer of professional responsibility and accountability for some or all aspects of the care of a patient or group of patients to another person or professional group on a temporary or permanent basis

32. OR IS IT A BIT MORE LIKE THIS?

33. Relies on a clear and comprehensive system of communication Transfer of critical information Ensure seamless continuity of patient care and safety

34. WHY IS GOOD COMMUNICATION SO IMPORTANT ? • Communication failure leads to • uncertainty in decisions in patient care • inefficient, suboptimal care • patient harm • Communication problems are the most common cause of preventable in hospital disability or death.

35. 78% of communication breakdowns occurred within a single department 19% occurred across departments 2% across institutions. 92% of the breakdowns were verbal 64% occurred between a single transmitter and a single receiver. Cross-disciplinary and intra-disciplinary communication breakdowns occurred with approximately the same frequency. Most commonly, information was never transmitted (49%) LITTLE BIT OF EVIDENCE Caprice C Greenberg et al. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients. J Am Coll Surg

36. WHY SHOULD WE TRY TO IMPROVE HOSPITAL AT NIGHT HANDOVERS? • Current Handovers • Lack Structure • Not valued by participants • Junior doctors find them stressful • Potential for patient harm

37. HANDOVER IMPROVEMENTS • Formal Structure • Ensure a set time and place that is free of interruptions, with senior supervision. • A standardised process • Standard proforma • Education • Focus on Foundation Doctors

38. STANDARDISATION OF THE PROCESS • How should patient’s be handed over? • Patients who need to be reviewed • Patients “to be aware of” • Patients who need to be admitted • Tasks that require completion

39. THE PROFORMA • Based on SBAR • Situation • Background • Assessment • Recommendation • Initially paper based • Now on TRAK (In Royal Infirmary Edinburgh)

42. HOW DO WE KNOW A CHANGE HAS LEAD TO AN IMPROVEMENT? • Process measures • Percentage of SBAR handover forms completed compared to reviews requested.

43. Process Measures • Number of patients being handed over per month

44. OutcomeMeasures Number of “surprises” per month A surprise is defined as a patient requiring review overnight who should have been identified at the handover process.

45. GOOD HANDOVER files.me.com/simonfairway/fnjhp7.mov https://vimeo.com/40182588

46. WHERE SHOULD WE FOCUS ATTENTION? Foundation Doctors Education Lecture and role play Doctors on line training module Difficult Decisions Identify the patients at risk of deterioration during ward rounds Make decisions regarding escalation of care

47. OPPORTUNITIES !? • Internal ward handovers • Evening handovers • Weekend handovers

48. ANY QUESTIONS? THANK YOU

49. Structured Ward Rounds Claire Gordon Consultant in Acute Medicine NHS Lothian SPSP Fellow

50. Variation: area to area, disciplines, practice and performance Many functions: decision making, communication, ‘housekeeping’? No ‘standards’, no definition But definitely important? Background