Understanding Communication Gaps In the Hospital Consultation Process Cristina Fischer, BS; Victoria Rendell, MD; Emily Winslow, MD, FACS

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Background

• Nearly 50% of inpatients receive ≥1 inpatient consultation

• Consultations are important for diagnosis and treatment

• However…

consultations satisfaction

Why is this?Jordan et al. 2008. BMC Research Notes. Schmocker et al. 2016. The American Journal of Surgery. Douglas et al. 2011. Journal of Clinical Medicine.

Background - Communication Avenues

Patient and Family

Primary Team

Consulting Team 1 Consulting Team 2

Background

• Effective communication is key to coordinating care, and is particularly vital during consultations

• However, poor communication continues to be identified as a root cause of costly medical errors, delays in treatment and patient dissatisfaction

OBJECTIVEQuality improvement project aimed to improve consultant

communication at the University of Wisconsin Hospital and the American Family’s Children’s Hospital

Epstein, RM. 1995. Archives of Family Medicine. Shannon, D. 2012. Physician Executive.Joint Commission on Accreditation of Healthcare Organizations. 2004-2010 Sentinel Event Data Root Causes by Event TypeWolf et al. 2004. The Annals of Family Medicine.Joint Commission. 2009. The Joint Commission Guide to Improving Staff Communication.

Background

STUDY AIMTo evaluate what specific communication issues lend

weaknesses to the inpatient consultation process from the perspective of providers and patients

Methods – Communication Reports

February 2017 – January 2018

782 communication related event reports (PSN)

Clinician and staff submissions

Communication themes identified and enumerated

Qualitative content analysis performed

Methods – Patient Interviews

Semi-structured interviews performed with inpatients who

had a medical oncology (MO) or

general surgery (GS) consult

Communication themes were identified and enumerated

through content analysis

Methods – Patient Interviews

1. How well do you feel your doctors are working together to discuss your case and arrive at a plan for you?

2. How well were your care plan recommendations summarized to you in a way you could understand?

3. What worked well during the explanation of your care plan? What could have been better?

4. During your visit, how consistent (similar) was the message you received about your care from everyone who took care of you?

5. During your stay how clear was it to you who was in charge of your care?

Interview Questions

Results – Communication Reports

782 PSN event reports evaluated

59 (7.5%) involved consult communication

Inadequate chart documentation

Inadequate verbal communication between providers and patient/family

Inadequate verbal communication between providers

Delay in communication

Not accepting consult

Inappropriate Communication

6 Communication Themes

Results – Communication Reports

782 PSN event reports evaluated

59 (7.5%) involved consult communication

Inadequate chart documentation

10%

Inadequate verbal communication between providers and patient/family

10%

Inadequate verbal communication between providers

73%

Delay in communication

3%

Not accepting consult

2%

Inappropriate Communication

2%

6 Communication Themes

Results – Communication Reports

Results – Patient Interviews

63 Interviews

June 2018 – September 2018

42 - General Surgery

21 - Medical Oncology

5 communication themes identified

Results – Patient Interviews

Inadequate verbal communication between

provider(s) and the patient/family

Perceived poor communication

between physicians

Communication with the patient before

consensus on a plan had been reached

Use of excessive medical

terminology

Inadequate non-verbal communication5 Communication Themes

Results – Patient Interviews

Inadequate verbal communication

between provider(s) and the

patient/family

Need for a better explanation of the plan or changes to

the plan

Lack of family members present

for discussion

Lack of clarity regarding which

medical team was taking care of the patient primarily.

“It would be better if all teams were

present, especially when family members

are present”

"I don’t know who is in charge, who the

leader of each team is or who is on each

team"

“It needs to be clear between the teams,

who is communicating what

with the patient." Theme 1

Results – Patient Interviews

Perceived poor communication

between physicians

Communication with the patient

before consensus on a plan had been

reached

Theme 2 Theme 3

“It doesn’t seem as if the consulting team is talking with the primary team”

“Everyone was giving their own opinion on things, and

sometimes this opinion would differ, which became

confusing”

Results – Patient Interviews

Use of excessive medical

terminology

Inadequate non-verbal

communication

Theme 4

Theme 5 “When I am not feeling well, it is hard for me to understand things. A document would be

helpful, so I could review it when I am feeling better”

“Things could have been confusing due to use of acronyms and medical

terminology, however I made sure to ask questions”

Study Conclusion

• Most prevalent communication problems: Inadequate verbal communication between providers and/or the patient

• Many communication events around surgery/procedures in the inpatient setting

• Areas targeted for QI project: the quality and amount of provider to provider, and provider to patient communication

Rules of Engagement for Consult Communication

1. Role Clarity2. Consultation Request3. Documentation for Communication4. Discussion between Teams5. Recommendations to Patients and Families6. Communicating during Transitions of Care

Rules of Engagement for Consult Communication

1. Role Clarityü Introductions and role on teamü Primary team in chargeü Consult team gives input to primary team

2. Consultation Requestü In by 11, out by 7ü Patient and family notified BEFORE consult of who and why

Rules of Engagement for Consult Communication

3. Documentation for Communication

ü Adding standard Core Elements in notesü “Knowledgeable team member” contactü “Preliminary” or “Final” Recommendationsü Plan for ongoing inpatient visits

Dot Phrase Functionality

Rules of Engagement for Consult Communication

4. Discussion between teamsü Knowledgeable team member of primary team will be available to discuss ü Primary team will anticipate and plan for “significant recommendations”ü Knowledgeable team member of consult team will DIRECTLY communicate

recommendationsü Consultants will discuss “significant recommendations” with primary team

BEFORE doing so with the patient 5. Discussion with Patient and Family

ü Knowledgeable team member of primary team will synthesize ü Only consultants who are “adequately trained in the specialty” will give

recommendations to patients

Service Specific Rules of Engagement

Rules of Engagement Fillable Form

Consult Team

• Our plan to get consult recommendations to primary team by 7 PM

• Our plan to get core elements into our daily notes for CONSULT patients:

• Who will be considered a “knowledgeable” team member to communicate and discuss consult recommendations with PRIMARY team (initial and subsequent “significant” recs)?

• Who will be considered “adequately trained about the specialty” to communicate recommendations to patients/families?

Rules of Engagement Fillable Form

Consult Team Continued…• Our list of specific discussions/recommendations that will ONLY be

discussed by staff (or by others with in person oversight by staff) includes:

• Our list of preliminary recommendations made by trainees that can be documented and carried out without discussion with staff includes:

• “Significant” recommendations our service will discuss with PRIMARY team BEFORE discussion with patient (to allow for care conference, coordination with other consults) include:

• Our plan to transition care of consult patients and avoid disruption to established care plan:

Rules of Engagement Fillable Form

Training and Accountability Plan

• Our plan to review these “rules” with residents and new staff:

• Team members who will provide feedback to consult communication team: