parallel session 3.7 applying best practice to develop innovative and effective communication...
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Session 3.7 Applying best practice to develop innovative and effective communication practices to improve patient outcomes in NHS Scotland
Design, Test and Learn
“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
• 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
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
The Capacity Safety Brief
Peter CampbellClinical Nurse Manager
RHSC Edinburgh
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
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
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
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
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
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
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
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
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
Where We Are
NHS Ayrshire & Arran
Early recognition of the deteriorating child - ‘Watchers’
Fiona Scott SCNClaire Colvine APNP
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).
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)?
IMPROVEMENT AIM
To have a reliable system of identifying
and successfully managing ‘watchers’100% of the time by
end Sept 2012
Effective writtenand verbal
communicationat all times
Establishmulti-disciplinary
handovers inward area at least 3
times per day
SBAR (reporting system)PAWS (early warning system)Safety briefPaediatric Global Trigger Tool (PTT)Nursing staff education
Who?Where?When?Why?
Outcome Primary Drivers Secondary Drivers
Agreed standard processEducation of MDTData collection and auditSBARVisual prompt
Effective escalation of
concern process
VISUAL PROMPT
Ward 1B
SMALL TESTS OF CHANGE - PDSA CYCLES
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.
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 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 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.
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
RESULTSData collected from safety brief notices
Monthly Compliance (mean) 77%
Enthusiastic Registrar
Locum Registrar Cover
Unenthusiastic Registrar
RESULTSData collected from safety brief notices
** 3 day week
Monthly Compliance (mean) 77%
February March April May
February; Series1; 98
March; Series1; 100
April; Series1; 96
May; Series1; 100
Percentage compliance with 9pm handover Feb-May 2012
Locum registrar unaware of normal
practice
Registrar stuck in resuscitation
RESULTS
Are we ready to do the handover?
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)
NEXT STEPS
1. Widen to the healthcare team to physio, pharmacist, dietician and others;
2. Consideration of medical staff attending huddle at 3pm and 3am;
3. Comparison of quality of escalation when lack of compliance with MDT handover.
Applying Best Practice to Develop Innovative and Effective Communication Practices to Improve Patient Outcomes
Medical HandoversDr Ailsa HowieST6 Acute Medicine
SPSP Fellow
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
OR IS IT A BIT MORE LIKE THIS?
• Relies on a clear and comprehensive system of communication
• Transfer of critical information• Ensure seamless continuity of patient care
and safety
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.
LITTLE BIT OF EVIDENCE
• 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%)
Caprice C Greenberg et al. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients. J Am Coll Surg
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
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
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
THE PROFORMA
• Based on SBAR• Situation • Background• Assessment• Recommendation
• Initially paper based• Now on TRAK (In Royal Infirmary
Edinburgh)
HOW DO WE KNOW A CHANGE HAS LEAD TO AN IMPROVEMENT?
Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Feb; Subgroup; 0.0March ; Subgroup; 0.0April; Subgroup; 0.0
May; Subgroup; 0.8
June; Subgroup; 0.5
July; Subgroup; 0.4
Aug; Subgroup; 0.6
Sept; Subgroup; 1.0
Oct ; Subgroup; 0.9
Feb; Subgroup; 1.0Feb; Center; 1.0 March ; Center; 1.0April; Center; 1.0 May; Center; 1.0 June; Center; 1.0July; Center; 1.0 Aug; Center; 1.0 Sept; Center; 1.0 Oct ; Center; 1.0 Nov; Center; 1.0 Dec; Center; 1.0 Jan; Center; 1.0 Feb; Center; 1.0 March ; Center; 1.0
Feb; UCL; 0.0 March ; UCL; 0.0 April; UCL; 0.0
May; UCL; 1.0 June; UCL; 1.0 July; UCL; 1.0 Aug; UCL; 1.0 Sept; UCL; 1.0 Oct ; UCL; 1.0 Nov; UCL; 1.0 Dec; UCL; 1.0 Jan; UCL; 1.0 Feb; UCL; 1.0 March ; UCL; 1.0
Feb; LCL; 0.0 March ; LCL; 0.0 April; LCL; 0.0
May; LCL; 0.9 June; LCL; 0.9 July; LCL; 0.9 Aug; LCL; 0.9 Sept; LCL; 0.9 Oct ; LCL; 0.9 Nov; LCL; 0.9 Dec; LCL; 0.9 Jan; LCL; 0.9 Feb; LCL; 0.9 March ; LCL; 0.9
% of SBAR Forms Completed for Reviews Requested RIE
Months
• Process measures• Percentage of SBAR handover forms completed
compared to reviews requested.
Process MeasuresNumber of patients being handed over per
month
Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March 0
50
100
150
200
250
300
May; Total Number of Reviews Re-
quested; 82June; Total Number
of Reviews Re-quested; 73
July; Total Number of Reviews Re-quested; 131
Aug; Total Number of Reviews Re-quested; 167
Sept; Total Number of Reviews Re-quested; 204
Oct ; Total Number of Reviews Re-quested; 239Nov; Total Number
of Reviews Re-quested; 211Dec; Total Number
of Reviews Re-quested; 170
Jan; Total Number of Reviews Re-quested; 259Feb; Total Number
of Reviews Re-quested; 229
March ; Total Number of Re-
views Requested; 220
Total Number of Reviews Requested per Month RIE
Total Number of Reviews Requested
Outcome Measures
• Number of “surprises” per month– A surprise is defined as a patient requiring review
overnight who should have been identified at the handover process.
Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March 0
102030405060708090
April; Subgroup; 39
May; Subgroup; 22
June; Subgroup; 15July; Subgroup; 12
Aug; Subgroup; 7
Sept; Subgroup; 60
Oct ; Subgroup; 85
Nov; Subgroup; 40Dec; Subgroup; 37
Jan; Subgroup; 27
Feb; Subgroup; 43
March ; Subgroup; 19
Feb; Center; 33.8333333333333
March ; Center; 33.8333333333333
April; Center; 33.8333333333333
May; Center; 33.8333333333333
June; Center; 33.8333333333333
July; Center; 33.8333333333333
Aug; Center; 33.8333333333333
Sept; Center; 33.8333333333333
Oct ; Center; 33.8333333333333
Nov; Center; 33.8333333333333
Dec; Center; 33.8333333333333
Jan; Center; 33.8333333333333
Feb; Center; 33.8333333333333
March ; Center; 33.8333333333333
Feb; UCL; 51.2832616999482
March ; UCL; 51.2832616999482
April; UCL; 51.2832616999482
May; UCL; 51.2832616999482
June; UCL; 51.2832616999482
July; UCL; 51.2832616999482
Aug; UCL; 51.2832616999482
Sept; UCL; 51.2832616999482
Oct ; UCL; 51.2832616999482
Nov; UCL; 51.2832616999482
Dec; UCL; 51.2832616999482
Jan; UCL; 51.2832616999482
Feb; UCL; 51.2832616999482
March ; UCL; 51.2832616999482
Feb; LCL; 16.3834049667182
March ; LCL; 16.3834049667182
April; LCL; 16.3834049667182
May; LCL; 16.3834049667182
June; LCL; 16.3834049667182
July; LCL; 16.3834049667182
Aug; LCL; 16.3834049667182
Sept; LCL; 16.3834049667182
Oct ; LCL; 16.3834049667182
Nov; LCL; 16.3834049667182
Dec; LCL; 16.3834049667182
Jan; LCL; 16.3834049667182
Feb; LCL; 16.3834049667182
March ; LCL; 16.3834049667182
Total Number of Surprises per Month RIE
Months
GOOD HANDOVER
•files.me.com/simonfairway/fnjhp7.mov•https://vimeo.com/40182588
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
OPPORTUNITIES !?
• Internal ward handovers• Evening handovers• Weekend handovers
ANY QUESTIONS?
THANK YOU
Structured Ward Rounds
Claire GordonConsultant in Acute Medicine
NHS LothianSPSP Fellow
Background
• Variation: area to area, disciplines, practice and performance
• Many functions: decision making, communication, ‘housekeeping’?
• No ‘standards’, no definition• But definitely important?
• Clinical diagnosis
• Reviewing patients progress against anticipated trajectory
• Making decisions about future investigations and treatments
• Discharge arrangements
• Communicating with pt, interested others and MDT
• Active safety checking to mitigate against avoidable harm
• Training and development of healthcare professionals
Person centred, safe and effective care
Patient centred care
• Patient perspective – of central importance in collectively caring for and communicating with patient
• Pt ‘centre of attention’, empowered• Need engagement of clinicians,
managers and organisations to improve ward round quality
• Protect time and resources
Multidisciplinary Team Ward Rounds
• Effective multi-disciplinary team-working improves patient outcomes
• Pharmacist on the ward round – improves prescribing, med rec, reduces errors
• Allows thorough discharge planning
• ?board round/ huddles/ run-down
Background – Patient Safety
• SPSP fellowship• Daily goals in ICU• Post take ward round checklist• Apply ‘daily goals’ to general medical
patients• Communication issues between ‘silos’• MDT ward round• Boarding
What changes were made
• Old model: Doctors go round• Handover to nursing staff at end• New model: attempt to have nurse on WR• Formal MDT huddle at 11.45• Structured WR/ daily goals proforma
Date……………….. Time……………WR………………….
ReviewDaily goals:1)…………………………………………………
2)…………………………………………………3)…………………………………………………4)…………………………………………………5)…………………………………………………
Nursing: PVC Y/N Needed Y/N Review siteIncontinent? Diarrhoea?For LCP?
Pharmacy: Antibiotics………………..………………Thromboprophylaxis Y/NDosette box Y/NPatient at risk of deterioration Y/N FOR ESCALATION/ NOT FOR ESCALATION/
UNDECIDEDFOR CPR/ DNACPR/ UNDECIDEDSigned………………………….. Bleep………………….
Structured Ward Round Outcomes• LoS: reduced by 0.7• <11am discharge increased to 18%• Transfers to critical care: 3.2% to 0.7%• PVC bundle compliance 52% to 93%• Cardiac arrest calls 2 to 0• Number of outliers 15 to 9.4• Number of 4h breaches 20.8 to 10.8• Antibiotic prescribing 100% from 85%
Structured ward round outcomes
• The less measurable…– DNACPR– Palliative care referrals– Complaints/ communication
• The not so good: – readmissions 7.8% from 6.3%
Patient Centred Care
• Care rounding• ‘go at the pace of the patient’• Communication round v business
round• Patient communication sheet
Name________________________________Date__________________Problems: 1)
2)3)4)5)
Plan: 1)2)3)4)5)
Consultant: Claire Gordon Please feel free to write any comments or questions on the reverse of this.Patient’s property
Vision
• Patient held record• Problem list• Daily goals – MDT and patient• Aid to communication for patients and
relatives/ carers
QUESTIONS ?