Interprofessional Patient Safety and Quality Improvement Project

1. Interprofessional Patient Safety and Quality Improvement Project • The Ratchets: • Katie Compton, Amanda Koski, Michelle Gomes, Sarah Lemings, Bill Robison, Sonia Singh, Heather Thomasson 1

2. Members of team • Physicians • Nurses • Nursing support staff • Pharmacy • Lab • EMS • Insurance companies • Patients • Family of Patients • Administrative personnel • External health care facilities • Education Facilities

3. Problem Statement • Suboptimal patient care related to ineffective communication during transitions in healthcare settings.

4. According to Yoder-Wise • “…nurses are challenged by inconsistencies and breakdowns in communication.” (Yoder-Wise, 2011 pp. 213) • While Yoder-Wise identifies that patient care hand-offs are safer when the patent's information is available, there are still areas of concern related to communication including mislabeled bar codes, order entry mistakes related to unclear software features and information management.

5. National Context • National Patient Safety Foundation regarding patients perception of where medical errors come from: • “What do you think is the main cause of medical mistakes?” • Carelessness/negligence 29% • Staff overworked/hurried/stressed/understaffed 27% • Miscommunication/lack of communication 13% • Improperly trained/incompetent staff 10% • Human error 8% • Misdiagnosis 6% • Misread RX / pharmacy error 6% • None 5% • Other 10% • Don’t know 5%

6. National Context • Why Are Health Communication and Health Information Technology Important? • Effective use of communication and technology by health care and public health professionals can bring about an age of patient- and public – centered health information and services. By strategically combining health IT tools and effective health communication processes, there is the potential to: • Improve health care quality and safety. • Increase the efficiency of health care and public health service delivery. • Improve the public health information infrastructure. • Support care in the community and at home. • Facilitate clinical and consumer decision-making. • Build health skills and knowledge.

7. National Context • Guidelines for safe handoffs focus on standardizing the signout mechanism. • “Educate patients/families about enhancing their own safety through measures such as [TJC & AHRQ] patient fact sheets on tips to prevent medical errors.” (Collins, 2005)

8. National Context • The Joint Commission patient safety standards • Identify patients correctly (NPSG.01.01.01) • Improve staff communication (NPSG.02.03.01) • Prevent infection (NPSG.07.01.01) • Identify patient safety risks (NPSG.15.01.01) • “the Joint Commission reports that sentinel events can consistently be traced back to problems with communication” (The Joint Commission, 2008)

9. Background Issues related to transfer of care • Cause: • lack of standardization in communication methods • lack of training on communication and what needs to be included • lack of adequate time • distractions/ interruptions • lack of patient-centered-care • Effect : • Suboptimal patient care related to ineffective communication during transitions in healthcare settings.

10. Review of Evidence

11. Review of Evidence

12. Review of Evidence

13. Review of Evidence

14. Brief summary of case • Nurses are at the forefront of ongoing patient care and are involved in transitions at all levels of care. Nurses are in a prime position to ensure communication is effective so that patient care is not adversely impacted. • Resources are diminishing. This is challenging the workplace by bringing in the potential to compromise communication between providers and contributes to an environment where unsafe practices are often overlooked or excused.

15. Case Study: Matthews Story

16. Dad emails surgeon who performed his own procedure in the past. He waits for him to return from vacation then struggles to have test results sent to him. Visits family physician Dad's surgeon decides that pt needs to have the tumor removed Family physician sends results to doctors more familiar with pt's condition Doctors request CT scan and MRI. A few days later through a teleconference with pt's surgeon, they decide to perform surgery to remove tumor After heated discussion specialist refuses to work with dad Family physician sends referral to specialit's office and discusses the procedure. Dad's surgeon requests CT scan and MRI Performs Tele-endoscopy, where physicians confirm pt has a small mass in his stomach. A biopsy is performed and sent to lab. Specialist's office never received referral Pt's pain intensifies and he has difficulty sleeping Family told to wait and see how things progress Pt experiences pains in stomach Surgery is successful and pt makes full recovery Dad wants specialist to speak with surgeon who performed his own surgery Family physician consults with specialist Biopsy results inconclusive Flow Chart: Matthew No Specialist ignores request Yes Specialist grants request

17. Fishbone Diagram

18. Top 3 Root Cause Analysis • Lack of patient centered care • Lack of communication skills • Lack of Standardization

19. Interventions we considered

20. Interventions Recommended 2x2 RESOURCES High IMPACT Low

21. Proposed Improvement Project • NURS 470 - Nurse Communications • 2 credit course incorporated into Senior I or Senior II semester • Online curriculum via Sakai • Focus is on communications strategies for various populations and situations including patients across the lifespan and colleagues. • Course requirements include textbook information, online forums and final group project. • Final group project: student groups will host an evidence-based educational training session with staff at hospital.

22. Proposed educational textbook • Interpersonal Relationships: Professional Communication skills for nurses • Covers all mandated topics for nursing professionals, from beginning students to staff development in a variety of settings, including professional collaboration, health team communication, patient-centered care, safety, and hand-off communication. • Discusses nursing, behavioral, developmental, family, and communication theories, providing an essential foundation and a theoretical perspective of effective communication. • A timely NEW Communicating for a Safe Environment chapter provides practice guidelines in line with The Joint Commission National Patient Safety Goals on improved communication among caregivers. http://search.barnesandnoble.com/Interpersonal-Relationships-Elizabeth-C-Arnold-PhD/e/9781437709445?r=1&cm_mmc=GooglePLA-_-PrintBuyTextbook-_-Q000000633-_-9781437709445&cm_mmca2=pla

23. Our AIM is evidence-based • Robinsons study, Perceptions of Effective and Ineffective Nurse-Physician Communication in Hospitals, identified communication themes: • Effective communication: clarify and precision of message that relies on verification, collaborative problem solving, calm and supportive demeanor under stress, maintenance of mutual respect, and authentic understanding of the unique role. • Ineffective communication: making someone less than, dependence on electronic systems, and linguistic and cultural barriers. “Given that interprofessional education is a key strategy to improve quality care and patient safety, the themes could be used to design learning activities for nursing and medical students, including discussions, simulations, and role playing” (Robinson, 2010)

24. Process or Outcomes Data to Track

25. Estimated Return on Investment • Patient safety > reduces unnecessary mistakes that lead to longer hospital stays > decreases medical costs for patient and hospital • Improved communication within the hospital > reduction in medical errors > reduction in costs • Patient safety > saves lives > increases patient satisfaction > patient returns to hospital > increased hospital profits • Standardization > saves time > reduces mistakes > reduction in patient and hospital cost • Improved continuity > increases patient satisfaction >increased hospital revenues

26. Summary of Lessons Learned • You can't change the busy healthcare environment but you can implement tools and protocols to ensure patient safety. • This is a multifaceted problem. • The solution must have a multidisciplinary approach. • Effective communication skills should be taught in nursing and medical schools. • Hospitals should require mandatory continuing education classes regarding effective communication between staff and patients. • Nursing evidence has shown a theme in effective communication.

27. References • Boutilier, S. (2007). Leaving critical care: facilitating a smooth transition. Dimensions Of Critical Care Nursing, 26(4), 137-142. • Collins, S. (2005). Collins on current issues: health care communication. Pennsylvania Nurse, 60(4), 3. • Dufault, M., Duquette, C., Ehmann, J., Hehl, R., Lavin, M., Martin, V., & ... Willey, C. (2010). Translating an evidence-based protocol for nurse- to-nurse shift handoffs. Worldviews On Evidence-Based Nursing, 7(2), 59-75. doi:10.1111/j.1741- 6787.2010.00189.x • Krautscheid, L. (2008). Improving communication among healthcare providers: preparing student nurses for practice. International Journal Of Nursing Education Scholarship, 5(1), 1-15. • 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 11-0089, September 2011. Agency for Healthcare Research and Quality, Rockville, MD. H ttp://www.ahrq.gov/consumer/20tips.htm • Author unknown. (2009). Matthew's story: A child's experience of cancer diagnosis and treatment. Patient First. Retrieved from http://www.health.gov.sk.ca/Default.aspx?DN=d744f3aa-00cc-40cb-9406- 0d8ec1cbe223 • Baxter, K. (2006). Multi-disciplinary team (MDT) management in an outpatient cancer setting. St. Vincents & Mater Health Sydney Nursing Monograph. Retrieved from EBSCOhost. • Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. (Prepared by the Island Peer • Review Organization, Inc., under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research • and Quality. December 2011. • California hospital develops electronic med rec application. (2010). Briefings on Patient Safety, 11(3), 8-9. • Baker DP, Gustafson S, Beaubien J, Salas E, Barach P. Medical Teamwork and Patient Safety: The Evidence-based Relation. Literature Review. AHRQ Publication No. 05-0053, April 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/medteam/ • Good communication smooths transitions. (2011). Hospital Case Management, 19(12), 182-187.  • Hustey, F., & Palmer, R. (2010). An Internet-based communication network for information transfer during patient transitions from skilled nursing facility to the emergency department. Journal Of The American Geriatrics Society, 58(6), 1148-1152. doi:10.1111/j.1532-5415.2010.02864.x  • Gregory, B. (2006). Patient safety first. Standardizing hand-off processes. AORN Journal, 84(6), 1059-1061. • Bitterman, R. (2008). Fumbled handoffs at shift change: a common liability source for emergency physicians. ED Legal Letter, 19(3), 25-28. • LaMantia, M., Scheunemann, L., Viera, A., Busby-Whitehead, J., & Hanson, L. (2010). Interventions to improve transitional care between nursing homes • Arbaje, A., Maron, D., Yu, Q., Wendel, V., Tanner, E., Boult, C., & ... Durso, S. (2010). The Geriatric Floating Interdisciplinary Transition Team. Journal Of The American Geriatrics Society, 58(2), 364-370. doi:10.1111/j.1532-5415.2009.02682.x • Transition initiated during pre-admit screen: Educate, plan discharge before surgery. (2011). Hospital Case Management,19(4), 60-62. • Hill, W., & Nyce, J. (2010). Human factors in clinical shift handover communication: review of reliability and resilience principles applied to change of shift report. Canadian Journal Of Respiratory Therapy, 46(1), 44-51. • http://www.jointcommission.org/assets/1/6/2012_NPSG_HAP.pdf • http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=18