Communication

Cathy Bachert, RN, Director, QualityMolly Nadeau, RN, MBA, Director

Case ManagementCape Cod Hospital, Hyannis MA

All Communication is Not Equal

• “No one would talk much in society if they knew how often they misunderstood others. “

— Johann Wolfgang Von Goethe

WE STOPPED TALKING TO EACH OTHER!!!!

The Problem

• Nurses in the SNFs would rely on the information abstracted from the patient’s medical record

• There were no planned opportunities to speak to the nurses at the hospital

• Although they could call, it was generally not done

We Communicated to the Wrong People

• SNF Screeners reviewed written materials and communicated to the SNF Charge Nurse 7-3

• SNF Admissions were frequently on the 3-11 shift Nurse at CCH did not know the patient

Relationships

• Paper work did not contain those bits of information that nurses could share one on one about the patient

• SNF nurses felt intimidated about calling the hospital nurses. “Don’t want to bother them”

• Lack of Trust on both sides

Aim Statement

• Aim: Develop a nurse to nurse verbal communication process between the Skilled Nursing Facility (SNF) admitting nurse and the hospital discharging nurse by April 15th, 2011.

Expected Results

SNF nurse obtaining all information needed to care for the patient and make informed decisions

Especially helpful when communicating with physicians about potential need for transfer back to the hospital

This communication will ultimately result in a decrease in readmissions

Create a New Process

• Set an expectation that there would always be a call for the patient handoff

– Flow of clear identifiable process steps with assigned responsibilities for both the SNF nurse and the hospital RN.

 – Education of the staff at both SNF and Hospital – Nurses,

Case Managers, and Nurse Unit Managers.  

Eliminate the Middle Man

• Create a process for direct communication between caregivers

• Identify clear defined steps to that process

• Test the process and gain feedback

Nurse to Nurse Communication

• What if we gave the nurse who was accepting the patient at the SNF direct communication about that patient from the nurse who was discharging the patient?

• Nurse with the most information gave that information

Nurse to Nurse Communication

Anticipated Push Back – “One More Thing”

• How could we create a process that would pull instead of push back?

• Which Nurse most needed the information?

• Did the nurses find value in the call?

Let’s Ask The Nurses!!

• Hospital RN Staff Meetings Revealed:

– We don’t have time

– We will end up doing their work for them

– They already get that information, will we be repeating the same information?

Something Surprised Us and Helped Us

• Novice Nurses were at the staff meetings who worked also at the SNFs

• They voiced a valid reason for the call – All Patients can be “Scarry” especially without a verbal report

• Appealed to a new EC to Inpatient process that recently left RNs feeling unsure

Was it Valuable?

• “Did the Nurse to Nurse Call Add Value?”

• We wanted to know: So we asked the nurses from the SNF and also from the Hospital side utilizing a formal audit tool

What will we measure?

• Did the call occur?• Time of the call:• Did call occur prior to transfer?• Did the call add value to the information

needed to care for the patient?• Duration of call • Number of calls by SNF about the same

patient• Did the call address a common cause or a

potential readmission?

Value - Overwhelming Yes

• 95% of the time – Yes• Time of call = less than 5 minutes per call

• What went wrong?– SNF nurse not prepared and used call to

screen information already provided in writing

– Hospital Nurse did not always have the same view of the issues from their perspective

Conclusion

• Nurse to Nurse Communication was and is a success

• SNF and Hospital Nurses have reconnected

• Trust is being restored

• Readmissions have been avoided – case study

MD COMMUNICATION / APPOINTMENT

Molly Nadeau, RN, MSN, Director Case Management

What Happened to PCP Communication?

• Problem: PCPs were out of the loop on their patient’s admission and discharge from the hospital.

• PCPs reported reading about patient death in the news paper obituary column.

Background

• Hospitalist vs. PCP Attending patients in hospitals

• Medical Records no longer mailing hard copies of the discharge summary

• PCPs in offices not computer savvy – don’t read automatic e-mails

• We stopped talking to each other!

MD Notification Form

• Faxed at discharge

• Unit Secretary responsible

• Form edited several times to include more detailed information

• Added the Clinical Resume and Medication List to the faxing

Measuring the Process

• Compliance initially at 67%; Currently at 79%

• Intervention: – Unit Secretary meeting– Frequent Rounding and Reinforcement of

form– Feedback from Physicians – they liked it!!

MD Appointments

• Clear Expectations developed and communicated:– Who would be responsible to call MD office?– What patient population needed MD

appointment?– How many days after discharge?– What if the doctor could not accommodate ?– How is it going?

SNF READMISSION AUDIT

Why Audit SNF Readmissions?

What Should We Look At?

30 Day All Cause SNF to Hospital Readmission Analysis

February, March, April

2011

Population – All patients readmitted within 30 days of discharge from CCH during the months of February, March, and April 2011, with a subsequent discharge from your SNF prior to the readmission back to the hospital.

This population includes:

- Patients that you transferred back to the hospital - In addition, patients discharged home from SNF and readmitted within 30 days of hospital

admission

Analysis: Do a simple data analysis on data collected.

Conclusions:

What did you learn?

What trends or themes emerged?

What, if anything, surprised you?

What new questions do you have?

What are you curious about?

What do you think you should do next?

What assumptions about readmission that you held previously are now challenged? Recommendations: Now that you have studied your population of patients that were readmitted, what would you recommend for process improvement?

What To Do Next?

• What number of patients are sent to the EC and returned? (New Study)• Review “ Real Time” Review of all unplanned readmissions.• Increase Skill Level – Nursing (Critical thinking Education on care

guidelines process) – IVs– Low freq. high impact “Support Teams”– Real time training ( On the Spot )

• Interact Program – Fully Integrated into SNF day to day work• Develop nursing practice guidelines- Disease Specific

– Share Hospital Care Maps and protocols– VNA Share care maps with SNFs

• Med Rec – Dovetail.– Identify patients at risk for readmission on admission– Refer discharged patients for pharmacy consult with VNA

• End of life Improvements

Just Do It!

• Create your own “Nurse to Nurse Process”

• PCP Notification

• MD Appointments

• Study the SNF Population:– Partner for success

Our Staff / Our Greatest Resource

• Leadership is Key• Staff left alone to define, revise and

implement will fail• A Leader will emerge• It may not be the one you expect

• LEAD THE CHANGE AND CHALLENGE YOUR TEAM TO

BECOME THE BEST!