Health-Care Team Collaborative Patient-Safe Communication Strategies

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Chapter 13

• Health-Care Team Collaborative Patient-Safe
  Communication Strategies

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High-Reliability Organizations

• Sustain an organizational culture of safety
• Commitment to safety that permeates all levels of
  an organization, from frontline personnel to
  executive management
• Build safety into operations
• Use specific communication strategies to maintain
  collaborative working relationships coordinate
  and synchronize activities
• Have very low rates of harmful events
• Health care organizations are typically NOT
  high-reliability organizations

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Culture of Safety

• Commit to safety at all levels
• Acknowledge high-risk situations
• Encourage voicing concerns of threats to safety
  before harm occurs
• Encourage reporting errors and intercepted errors
  within an atmosphere of trust
• No fear of retribution for reporting errors
• Learn about errors to make safety improvements
• Focus on why and how errors happen

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Just Culture The Systems Approach

• Systems approach
• Recognizes people are fallible and make mistakes
• Does not hold professionals accountable for
  system failures
• Does not tolerate gross misconduct of individuals
• Personal approach
• Traditionally used in health-care organizations
• Unrealistic expectation of perfection of
  professionals
• Blames, names, shames, and retrains individuals
  committing errors
• Belief that bad people make errors
• Errors and near misses often unreported
• Health-care organizations are
• slow in adopting a systems approach

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High-reliability organization systems approach
based on

• Knowledge of communication principles and
  processes
• Knowledge of group process and teamwork
  principles
• Knowledge of strategies and tools to prevent
  harmful events
• Knowledge of an organizational culture of safety
• Knowledge of standardized processes to create
  shared mental models of patients situations

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Patient Safety Through Group Collaboration
Shared Mental Models

• Health-care providers must develop processes to
  form shared mental models of patient clinical
  situations
• Health-care providers make clinical decisions
  based on shared essential patient information

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Patient Safety Through Group Collaboration
Shared Mental Models

• Health-care providers must develop processes to
  form shared mental models of patient clinical
  situations
• Health-care providers make clinical decisions
  based on shared essential patient information
• Example
• Concept Care Map to Form a Shared Mental
  ModelTeam members have a clear picture of the
  medical and nursing problems, with integration of
  pathology, medications, treatments, and
  laboratory and diagnostic testing

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6.Impaired Urinary Elimination I2200 O1800 Polyu
ria 3sugar
Not Sure Acetominophen? Widower?
Concept Care Map
5.Impaired Physical Mobility Fall
risk-4 OOB/chair Weakness Pressure Ulcer Risk-9
Newly Diagnosed Diabetes Signs Symptoms of
hypoglycemia, hyperglycemia, blood sugar, food
intake, VS
4. Impaired Tissue Perfusion, Peripheral Hx
hypertension 138/92 98.4-77-18 VS qid,
TPR Valsartan
3. Readiness for Enhanced Knowledge
Diagnosis Medications Diet Skin Care Foot
Care Exercise
2.Anxiety Expresses concern Over
Performing Injections Diet
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Promoting Effective Health-Care Team
Communication and Collaboration

• Standards for Team Communication
• Be respectful and professional
• Listen actively
• Try to understand the other persons viewpoint
• Model an attitude of collaboration, and expect it
• Identify the bottom line decide what is
  negotiable and non-negotiable in patient care
  management e.g., patient safety is not
  negotiable when staff members take a break is
  negotiable

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Standards for Team Communication

• Acknowledge the other persons thoughts and
  feelings
• Pay attention to your own ideas and what you have
  to offer the group
• Be cooperative
• Be direct
• Identify common, shared goals and concerns
• State your feelings using I statements

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Standards for Team Communication

• Do not take things personally
• Learn to say I was wrong and You could be
  right
• Do not feel pressure to agree instantly
• Think about all possible solutions before a
  meeting, and be willing to adapt if a more
  creative alternative is presented
• Recognize that negotiation and resolution of
  conflict take time and may require several
  interactions

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Group Process

• An understanding of the behavior of people in
  groups trying to solve problems and make
  decisions
• Principles apply to health-care team processes
• All members of the team must be trusted and
  respected
• Share information
• Help each other when needed
• Resolve conflicts
• Have high levels of communication competence

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Classic Group Process

• All team members must understand group process
• Forming
• Storming
• Norming
• Performing
• Adjourning

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Classic Group Process

• Forming Relationship developmentteam
  orientation, identification of role expectations
  beginning team interactions, explorations, and
  boundary setting
• Storming Interpersonal interaction and
  reactiondealing with tension, conflict, and
  confrontation

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Classic Group Process

• Norming Effective cooperation and
  collaborationpersonal opinions are expressed,
  resolution of conflict with formation of
  solidified goals and increased group cohesiveness
• Performing Group maturity and stable
  relationships team roles become more functional
  and flexible, structural issues are resolved
  leading to supportive task performance through
  group-directed collaboration and resource sharing

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Classic Group Process

• Adjourning Termination and consolidation team
  goals were met, closure occurs after evaluation,
  and review of outcomes

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Team Leader Coordination of Health-Care Team
Patient-Safe Communication Behaviors

• An effective team leader
• Organizes the teamutilizes resources to maximize
  performance, balance workload, and delegate tasks
  and assignments as appropriate
• Articulates clear goals
• Makes decisions based on input of team members
• Empowers team members to speak up and openly
  challenge, when appropriate

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Team Leader Coordination of Health-Care Team
Patient-Safe Communication Behaviors

• An effective team leader
• Promotes and facilitates good teamwork e.g.,
  briefs, huddles, debriefs
• Resolves conflict e.g., uses the two-challenge
  rule, CUS, and DESC

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Team BriefsCoordination and Collaboration

• BriefsPlanning sessions
• Designate team roles and responsibilities
• Establish team goals
• Develop short- and long-term plans

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Team HuddleCoordination and Collaboration

• HuddleProblem-solving sessions
• Touch-base meetings to gain awareness of new
  developments in a situation
• Discuss emerging events, express concerns
• Anticipate contingencies and anticipate outcomes
• Adjust plans and reallocate resources to meet
  changing needs of situation

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Team DebriefCoordination and Collaboration

• DebriefGroup process to improve team performance
  next time
• Informal feedback session with informal
  information exchange
• Designed to improve team outcomes
• Accurate reconstruction of key events
• Analysis of what worked and what did not
• Revise plans focused on what should be done
  differently next time

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Conflict Resolution

• Patient advocacy and assertion
• Advocate for the patient When you believe
  patient safety is in jeopardy and you do not
  agree with the primary decision maker (physician)
• Use assertiveness in a firm and respectful manner
  to indicate a correction in care of the patient

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Conflict Resolution Two-Challenge Rule

• When an initial patient-safety assertion is
  ignored
• It is your responsibility to voice your concern
  at least 2 times to make sure it was heard
• The team member must acknowledge that it was
  heard
• If the outcome is not acceptable
• Contact a supervisor

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How to Make Assertive Statements Using the
Two-Challenge Rule

• Make an opening- Dr. ____, Mr./Mrs. ___ is
  supposed to be discharged.
• State the concern (1 challenge) I am concerned
  about the patients BP and pulse, which are
  substantially elevated (patient admitted for an
  MI)
• Physician says, Dont worry about that.
• Restate the problem (2 challenge)- The patient
  is supposed to be discharged, but these appear to
  be significant alterations.
• Offer a solution Would you assess the patient
  further?
• Reach an agreement Physician further assesses,
  or sends a resident, or says not to worry.
• If physician fails to address concerns, contact a
  supervisor.

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ASSERTIVE STATEMENTS to Promote Conflict
Resolution Using CUS

• C I am Concerned.
• U I am Uncomfortable.
• S This is a Safety issue.

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Conflict Resolution Using DESC

• Sit down and discuss work-related conflicts can
  be done with a supervisor present or between two
  professionals
• Strive for consensus and a win-win outcome
• DDescribe the situation
• EExpress concerns about the situation
• SSuggest alternatives and seek agreement
• CConsequences of behaviors that are blocking
  attainment of team goals

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High-Reliability Patient-Safe Communication
Strategies

• Guidelines for effective handoff
• Medication reconciliation
• Guidelines for written documentation in health
  records
• Strategies to avoid errors due to
  look-alike/sound-alike medications
• Readback/hearback
• SBAR

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Effective HandoffDuring Transitions of Care

• Transfer information during shift-to-shift,
  unit-to-unit, hospital-to-long term care
  facility, etc.
• Ensure
• All relevant information communicated
• Information clearly conveyed, plainly understood
• Communications are concise
• There is an opportunity to ask questions
• Information is clarified
• Information is confirmed, validated, and
  acknowledged by the nurse assuming responsibility
  for patient care

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Handoffs should include

• Diagnosis
• Allergies
• Current condition
• Recent changes in condition
• Ongoing treatment
• Possible changes or complications that might
  occur
• Plan of action if complications occur

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High-Reliability Handoffs

• Face to face with interactive questioning
• Topics initiated by person assuming
  responsibility as well as by the person being
  replaced
• Repeating back important information by the
  incoming person
• Information presented in the same order every
  time
• Limited interruptions
• Written summary of activities that occurred
  during the shift

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Medication Reconciliation at Handoff During
Admission and Discharge

• Almost 50 of medications errors occur during
  admission and discharge
• Write complete list of medications taken at home
• Compare list with admission, transfer, and
  discharge orders, looking for discrepancies
• Keep list updated
• Communicate list to the next provider
• Keep list in a visible location in the patients
  records

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Guidelines for Written Documentation

• Write legiblyprint drug names and dosages
• Do not use dangerous abbreviations
• Locate Do not use lists in each facility
• Instead of U, u, IU, write units
• Instead of QD, write daily instead of QOD, write
  every other day, etc.
• Always use a zero before a decimal point
• 0.5 mg
• Do not write a zero after a decimal point because
  trailing zeros lead to tenfold dosage errors
• 1 mg (not 1.0 mg)
• Use tall man lettering for look-alike,
  sound-alike drugs
• LamiCTAL and LamiSIL

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Readback/HearbackFace-to-face and Telephone

• Ensure messages are clearly received and
  understood
• Sender states information concisely to the
  receiver
• Receiver first writes down, then reads back what
  was written
• Sender provides a hearback acknowledging that the
  readback was correct or makes a correction
• The readback/hearback continues until shared
  understanding between sender and receiver is
  created.
• Drug doses are expressed in single-digit format,
  e.g., 14 units of insulin verified and read
  back as 14-one, four-units of insulin

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Guidelines for Telephone Communications SBAR

• S- Situation
• B-Background
• A-Assessment
• R-Recommendations
• Michael Leonard, MD, Doug Bonacum, and Suzanne
  Graham
• Kaiser Permanente of Evergreen, Colorado

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Pre-SBAR Before Calling the Physician or Nurse
Practitioner

• Assess patient take complete vital signs
• Review medical record for the appropriate
  physician to call
• Know the admitting diagnosis and admission date
• Read the most recent physician and nursing notes
• Have the medical record available and be ready to
  report Code status, allergies, medications, IV
  fluids, lab and test results
• Focus on the problem be concise
• Review with charge nurse/resource staff/preceptor
  prior to calling

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S Situation

• State your name and your department
• (say) I am calling about (patient name, room
  number, code status)
• (say) The reason(s) I am calling is (are) (state
  specific problem)
• A change in patients condition
• Critical lab values
• A lack of response to current treatment/interventi
  on

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B Background

• State the admission diagnosis, date, and brief
  summary of treatment to date
• State name of the primary physician when speaking
  to an on-call physician
• State the relevant medical history

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A Assessment

• State the most recent vital signs, oximetry, and
  pain level
• Give the physical assessment pertinent to the
  problem, stating changes from the prior
  assessment, mental status, and complaint given by
  the patient
• State how severe the problem seems to be.
  Examples (say) I think the problem is
  ________(briefly describe the problem) or (say)
  I am not sure what the problem is, but the
  patients condition is deteriorating.

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R Recommendation

• State what you think needs to be done.
• Would you consider ______?
• I need you to _________.
• I would like to suggest_____.
• I would like you to______.
• Would you consider transferring the patient to
  higher level of care?
• I need you to come see the patient.
• I suggest ordering/discontinuing medications
  such as IVF, antibiotic, transfusion, pharmacy
  protocol, etc.
• Would you consider ordering tests such as CXR,
  ABGs, EKG, CT for PE, blood work, etc.?
• Clarify how often to monitor the patient and
  under what circumstances to call again

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Communication Failures

• Leading safety hazard in health-care
  organizations
• Result in lack of collaboration, coordination,
  and synchronization of patient care
• It is critical that nurses develop high-level
  communication competence to avoid communication
  failures leading to harmful events

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References

• References for this content can be found in the
  text.
• Chapter 12 Pp. 173-175
• Chapter 13 Pp. 189-191