Chapter 13

1. Chapter 13 Health-Care Team Collaborative Patient-Safe Communication Strategies

2. 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

3. 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

4. “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

5. 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

6. 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

7. 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

8. 1.Imbalanced Nutrition: Less than Body Requirements Polydipsia I=2200 O=1800 Weakness Humulin N Glucose (450) 120 Accu-check Glyco Hgb 12% Cholesterol 240 1800 ADA 6.Impaired Urinary Elimination I=2200 O=1800 Polyuria 3+sugar 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

9. Promoting Effective Health-Care Team Communication and Collaboration Standards for Team Communication • Be respectful and professional • Listen actively • Try to understand the other person’s 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

10. Standards for Team Communication • Acknowledge the other person’s 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

11. 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

12. 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

13. Classic Group Process • All team members must understand group process • Forming • Storming • Norming • Performing • Adjourning

14. Classic Group Process • Forming: Relationship development—team orientation, identification of role expectations; beginning team interactions, explorations, and boundary setting • Storming: Interpersonal interaction and reaction—dealing with tension, conflict, and confrontation

15. Classic Group Process • Norming: Effective cooperation and collaboration—personal 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

16. Classic Group Process • Adjourning: Termination and consolidation— team goals were met, closure occurs after evaluation, and review of outcomes

17. Team Leader: Coordination of Health-Care Team Patient-Safe Communication Behaviors • An effective team leader: • Organizes the team—utilizes 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

18. 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

19. Team BriefsCoordination and Collaboration Briefs—Planning sessions • Designate team roles and responsibilities • Establish team goals • Develop short- and long-term plans

20. Team HuddleCoordination and Collaboration Huddle—Problem-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

21. Team DebriefCoordination and Collaboration Debrief—Group 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

22. 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

23. 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

24. 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 patient’s BP and pulse, which are substantially elevated (patient admitted for an MI) • Physician says, “Don’t 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.

25. ASSERTIVE STATEMENTS to Promote Conflict Resolution Using CUS • C: “I am Concerned.” • U: “I am Uncomfortable.” • S: “This is a Safety issue.”

26. 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: • D—Describe the situation • E—Express concerns about the situation • S—Suggest alternatives and seek agreement • C—Consequences of behaviors that are blocking attainment of team goals

27. 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

28. 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

29. 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

30. 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

31. 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 patient’s records

32. Guidelines for Written Documentation • Write legibly—print 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

33. Readback/Hearback:Face-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”

34. 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

35. 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

36. 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 patient’s condition • Critical lab values • A lack of response to current treatment/intervention

37. 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

38. 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 patient’s condition is deteriorating.

39. 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

40. 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

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