interact boot camp communication tools august 2013
TRANSCRIPT
INTERACT Boot Camp
Communication Tools
August 2013
Welcome Back
Introduce yourselves and share what you learned
from reviewing your readmission data.
NC ACE: INTERACT BOOT CAMP
Year long commitment to work on perfecting your
Performance Improvement Project
Boot Camp Communication Tools
Decision Support
Tools
Advanced Care
Planning
You are Here
Building your QI Program
Nov. Jan.
PDSA, Monitor Data,Spread
PDSA, Monitor Data,Spread
PDSA, Monitor Data,Spread
Outcomes Congress
April
INTERACT as QI program
INTERACT Champion is part of the QAPI Committee
Focus on data, PDSA cycles
Rolling out communication tools
Polling Question
Where are you in the INTERACT
implementation process?
1. Have not started yet
2. Created plan to implement INTERACT with leadership
3. Started using INTERACT implementation checklist
4. Reviewed last 3 months of readmissions
5. Completing QI summary monthly
6. Using Hospitalization Rate Tracking Tool
Open Discussion
Share success, challenges, barriers, or solutions you have
encountered in the last 3 months of your INTERACT work.
A Closer Look at Data
Interact2.net
Demo of INTERACT Tracking Tool
Tips for Hardwiring your Data
Have Admissions enter the resident
info daily
Review every morning during
standup
Run monthly reports and share with leadership
and staff
Discuss readmissionsFindings from QI Review ToolShare monthly findings from Summary Tool
Look at your process and outcome measures
Polling Question
What is the most common driver of
readmission based on your QI Summary?
• Delay in identifying change in condition• Lack of evaluation before calling physician• Physician insistence on transfer• Resident family expectations• Communication problems between nurses, or between nurses
and primary care clinicians• Services needed are not available• Delay in advanced care planning• Other
Actions for Next 3 Months
• Ongoing monitoring of data• Prioritize areas for improvement• Develop your SMART goal• Assess your plan of action and
make adjustments
Staff Education/Communication
Share your data at staff meeting:• Post your timeline on bulletin boards.• Have staff share “Bright Ideas” on implementation.• Discuss rollout at staff meeting.• Select key staff to be champions.• Begin on one unit and spread.
INTERACT Program Components
Putting the Tools to Work in Everyday Practice
• Communication Tools
• Decision Support Tools
• Advanced Care Planning Tools
• QI Tools
What This Session Will Cover
• Review use of STOP and WATCH and SBAR
• Implementation strategies
• Common barriers and lessons learned
• Problem solving for success
Communication Tools
Communication Tools
Polling Question
Who has been trained and is now completing the STOP
and WATCH tool on a regular basis in your facility?
1. CNAs and nurses2. All non-nursing staff with direct resident contact3. Family and close friends with regular direct contact4. 1 and 25. All of the above
Communication Tools
STOP and WATCHSeems different
• Not their usual self? Change in personality or behavior?
Talks or communicates less• Quieter? Drowsier? Confused? Change in speech?
Overall needs more help• Needs more assistance? Changes in gait, transfer or balance?
Participated in activities less• Withdrawn? Decline in ADLs? Change in normal routine?
Pain level increased
AND
Ate less than usual
(Not because of dislike of food)
No bowel movement in 3 days or diarrhea
Drank less than usual
WATCH
Weight gain or loss
Agitated or nervous
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, or toileting more than usual
Part of Daily Routine
• Keep the pocket card with you at all times.
• Make it a part of your normal routine.
• Complete the Stop and Watch form during your shift
before you leave.
• Give the Stop and Watch form to the nurse taking care
of resident.
Implementation
1. Where will forms be located?
2. Which nurse will direct care staff give the tool to?
3. How will the nurse receiving the tool respond back to
the person giving it?
4. How will the nurse document resident follow-up and
actions taken?
5. Where will the forms go after follow-up is complete?
6. Does it need to be electronic?
Unit nurses are busy giving medications,
taking physician orders, and admitting
new residents
CNAs are very busy giving direct care
Stop and Watchcan help
close the gap!
Common Barriers to Communicating Early Changes in Residents
Common Barriers
• Why can’t I just tell the nurse? I don’t want to write it.
• Too many forms and too much paper.
• Not sure where to keep them.
• Not all units are consistent.
• Staff are not always compliant.
• Need other languages.
• Hard to get all nurses on board.
Ways to Monitor and Improve Use
• Clinical champion and/or DON• Monitor
• Who completes tool?• Who the tool is reported to?• Action taken by the nurse• Documentation• Final outcome
• Computerized summary or paper flow • Daily, weekly, monthly
Suggestions from the Field
• Print on carbon paper.
• Keep forms handy, near linen room and time clock.
• Duplicate copy goes to DON who follows up with nurse.
• Fine tune it to facility needs.
• Make CNAs more aware.
• Incorporate into EHR.
• Emphasize benefit of written proof that CNA reported
change.
Suggestions from the Field
• Monthly drawing for person using most S&W
• Bulletin board to recognize CNAs who use it
• Nurses need to encourage CNAs to use tool
• Automatically goes to nurses’ electronic dashboard.
• Embed in new employee orientation and all in-services.
• Monthly meeting with CNAs.
Use QAPI to Get Started
Planning for PDSA
• Select one unit. Make 25 copies of Stop and Watch for use.
• Laminate a copy for each CNA on the unit so that it fits easily into pocket.
• Make blank copies and put within easy access for all direct care staff.
• Ask lead CNAs and key nurses to teach all direct care staff and nurses working on the unit how to use the tool.
STOP and WATCH PDSA
D – Implement on unit
S – Data to collect:– Number of times tool is used– Flow of tool use and responses– Staff input about barriers and what is working
A – Huddle with staff– What needs to be modified? – If no modification, then spread to other shifts and then
facility wide
Polling Question
What type of training has been most helpful in training nurses to use SBAR in your facility?
• In-person group training
• 1:1 training
• Online training
• Unit-based training
• All of the above
• Other
Polling Question
What percentage of nurses complete the SBAR successfully in your facility?• 10% or less
• 25%
• 50%
• 75%
• 100%
SBAR Tool
Situation
Background
Assessment/Appearance
Request
Communication Tools
SBAR: More than one purpose
• Communication tool– Contact MD/NP– Change of shift report– Morning meeting/huddle/change of status meeting
• Documentation tool– Progress note– Transfer note to send to ED
• Educational tool– Just in time and scheduled in-service
Barriers
• It is too long.
• Not all MDs like it.
• If you suggest an intervention and it is not done,
facility is liable.
• Overwhelming for nurses without good clinical
assessment skills.
• Time and frustration
• Nurses are not trained for this.
Suggestions from the Field
• Education, education, education (nurses and physicians)• Adapt it to facility needs.• Fax it to MD who may fax it back or use telephone order. • Review in weekly nurse meetings.• Changed “request” to “response.”• Instruct MDs and NPs to ask nurse to complete SBAR.• Ask MDs and NPs to show gratitude for improved
communication due to SBAR.
Suggestions from the Field
• Tie use to prevention of hospital transfer and reward staff
for successful prevention of transfer.
• Supervisor reviews SBAR and goes over it with nurse.
• Incorporate into EHR.
• Use SBAR in interdisciplinary team resident reviews as
the “nurses note.”
• Use SBAR as first step in QI Review Tool.
Use QAPI to Get Started
PDSAP – Nurse input, current process, eliminate duplication, train staff, involve MD
and NP, design accountability, adjust or modify based on input
D –Begin with smaller group or unit, reinforce in daily huddle, continue to train
as needed, use in team meeting review
S – Data to collect:
– Number of times tool is used
– Number of times hospital transfer averted
– Nurse and physician input
A – What is working? What needs to
be modified? If no modification,
then spread to other shifts or units.
Medication Reconciliation
Receive Admission
Med from FL2
Nurse completes
review
Fax Med List to MD
Fax list to pharmacy
Nurse completes
MAR
MD approves list
Meds delivered by pharmacy
Nurse checks meds
Place in med cart
Clarify orders Clarify orders
Makes adjustments
Verify any discrepancies
Polling Question
Where do most of your medication errors
occur?• Upon admission with FL2 • MD clarification• Transcription • Pharmacy review• Pharmacy fill• Administration• Adverse reaction
How to Roll Out INTERACT QI Program
QAPI Leadership Team
INTERACT
Med RecTool
Implementation
Communication with Hospital
What have you accomplished in last 3 months?
• Shared Nursing Home Capability List• Met with hospital and discussed readmission• Shared potential goals you could work on• Participating in coalition with other LTC and hospital
Call to Action
Next 3 months
• Work on hardwiring Stop and Watch and SBAR
• Monitor process and modify as needed
• Review medication errors with nursing and pharmacy
• Continue communication with hospital
www.ccmemedicare.org • (NC) 800-682-2650 • (SC) 800-922-3089
This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South
Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy. 10SOW-BI-C7-13-95
Thank you!