Effective Teamwork and Communication

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Overview

• I. The Nature of Clinical Performance
• II. Communication Failures How and
• Why Do They Occur?
• III. The Role of SBAR in One on One
• and Handoff Communications
• IV. Helpful Hints on Implementation

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The Nature of Clinical Performance

• Complex
• Often Task-oriented
• Multi-tasking
• Interruptions, Distractions
• Reliance on Human Memory
• Fatigue
• Poor Communication

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Where Do Things Fall Through the Cracks?

• Failure to Plan
• Failure of Recognition
• Failure to Rescue
• Communication failures handoffs
• System failures losing information, look-alike
  drugs, etc.

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Foundational Elements of Safety

• Structured communication SBAR
• Critical language I need a little clarity.
• Psychological safety
• Effective leadership

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Why Does This Happen?

• Individual and Interpersonal
• hierarchy
• disconnect in communication styles
• culture of perfection
• individual agency

• Environment/System
• no defined standards of communication
• poor handoffs across continuum
• lack of systems approach and reliable design
• department silos, poor coordination of care
• time pressure

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Case Study Hierarchy

• Individual
• RN-Attending relationship
• Resident attitude towards
• nurses concern
• calling for help
• Environment/System
• Handoff communication norms
• Resident attitude
• Hierarchy
• Individual agency and culture of perfection

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What Studies Show. . .

• 25-40 of nurses would be hesitant to speak up if
  they saw an MD making a mistake
• Often people dont speak up or do so quite
  indirectly
• Seemingly oblique comments become the I tried to
  tell him/her that. . .

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Analysis of Malpractice Claims in Surgery

• Four insurers, three regions
• 444 surgical claims
• Systems factors contributed in 82 of cases
• Communication breakdowns in 1/4 of cases
• inadequate handoffs or personnel changes (11)
• miscellaneous (11) RN-MD communication,
  inability to reach attending surgeon
• failure to establish clear lines of
  responsibility (9)
• Rogers SO et al. Surgery 200614025-33.

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Teamwork Failures Noted in Malpractice Claims

• Medical students, residents, nurses, and support
  staff often hold a critical piece of information,
  have a gut feeling, or observe a pattern that
  they have seen before. Unfortunately, if the
  stage is not set for collaborative practice and
  good team communication, that important piece of
  information is not shared.
• A bad feeling about a fetal heart rate. . .
• Groff H. Forum July 2003 23(3). (Risk Management
  Foundation of the Harvard Medical Institutions)

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The Missing Components

• Respect for each others clinical assessment
• Open communication and a sense of safety in
  asserting an idea
• Use of conflict resolution resources
• A shared plan of care (ambiguity)
• Groff H. Forum July 2003 23(3). (Risk Management
  Foundation of the Harvard Medical Institutions)

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Two Fundamental Issues

• Hierarchy and lack of Psychological Safety
• Recognize difficulties in assertion
• Hierarchies exist between and within disciplines
• Lack of structure and defined standards
• No clear definition of how we communicate to each
  other, when we must communicate, and what
  information to include

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Case Study Structured Communication

• Hes all out of breath. . .
• Hierarchy and lack of psychological safety
• Why didnt the nurse question me?
• Lack of structure and defined standards
• Incomplete picture from the nurse
• Incomplete picture from sign out
• Used to operating with limited information

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How Would SBAR Help Structure The Conversation?

• Situation- the punchline in 5-10 seconds.
• Background- the context, objective
• data, how did we get here?
• Assessment- what is the problem?
• Recommendation- what do we need
• to do?

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The Ideal Conversation

• S- Im worried about Mr. Jones because theres
  been a dramatic change in his condition.
• B- Hes a 74 y.o. male here for a fungal
  infection, hx RF. I just walked him to the
  bathroom and he was so weak he could barely walk.
  Last night he required minimal assistance but
  tonight it took two of us and we were practically
  carrying him back to bed.

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• A- Im not sure whats going on but Im worried
  about this big change in his condition.
• R- Could you come evaluate him?
• After evaluation, additional Recommendations?

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The Value of SBAR

• Tool to help overcome steep hierarchy and
  different communication styles
• Creates common expectations so people dont feel
  out of line
• Gives a full picture, reduces ambiguity
• Synthesis of information and redundancy

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Why the Disconnect in RN-MD Communication Styles?

• Nurses are trained to be narrative and
  descriptive you dont make diagnoses
• report data vs. synthesized information,
  conclusions
• Physicians are trained to be problem solvers
• what do you want me to do just give me the
  headlines
• The result---frustration on both ends
• docs keep waiting for the punchline
• nurses feel interrupted, not listened to

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Two Take Home Points

• Our training puts us on divergent paths
• Nursing school vs. Medical school
• Where hint and hope comes from
• Understanding the root causes of communication
  failures helps reduce the frustration and promote
  collaboration
• MDs actively engage people for input
• teaching moment if your recommendation
  rejected, otherwise that Nurse/RT/Pharmacist will
  hesitate to speak up again
• RNs, other disciplines communicate more directly

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The Value of StructureOrganization and Flow of
Content
Starts with patient

• Excuse me, but I think that continuing your
  patients Toradol for four more doses might help
  her get a better handle on her pain---I noticed
  that her pain worsened after the order expired.
  Can we continue the Toradol?

• The patients pain isnt well-controlled.
• She was doing well on Toradol but the order
  expired.
• I think four more doses might help her get a
  better handle on the pain.
• Can we continue four more doses of Toradol?

From Bartholomew K. Speak your truth Proven
strategies for effective nurse-physician
communication HC Pro 2005, p75.
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The Value of Structure Abbreviated vs. Complete
Conversations

• Did you see the INR?
• S The INR is elevated.
• B INR is up from 3 yesterday to 6 today.
• A/R Should I hold or decrease the warfarin
  tonight?

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Walking Through A Case

• 85 y.o. male POD3 hip repair
• hx CHF, HTN, DM
• was doing well, eating, working with PT
• now SOB, respirations look labored
• RR 26, O2 sat 93
• BP 130/65
• Lungs with crackles 1/2 up, I/O 1500 past 24
  hours
• no chest pain

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Traditional Model of Communication

• Im calling about Mr. Smith, hes SOB.
• Play 20 questions, then come up with a plan that
  may or may not be mutually acceptable

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Using the SBAR Model of Communication

• RN Hmm . . I dont like what Im seeing.
• Problem-solve
• Organize the data/information
• Communicate and collaborate

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Thought Process of RN

• S
• B
• A Hmmm I dont like what I see.
• What am I seeing?
• R

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Thought Process of RN

• S
• B RR is 26, O2 sat is 93, BP is 130/60
• Lungs have crackles 1/2 up, I/O
  1500/24hr
• A Fluid overload?
• R

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SBAR Format

• Situation Im calling about Mr. Smith he says
  hes SOB and his breathing looks labored to me.
• Background Hes POD3 from hip replacement and
  has a hx of HTN, and CHF. Hes been doing well
  until today---he was eating, working with PT. Now
  his RR is 26, O2 sat 93. Lungs have crackles
  halfway up, I/Os 1.5L. HR is 85, BP 140/80.

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SBAR Format

• Assessment I think he might be fluid overloaded.
• Recommendation Can you get here within half an
  hour to evaluate him? In the meantime should I
  hep-lock his IV and get some Lasix?

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What SBAR Can Facilitate
Gut Feeling or Vague Notion
Problem-solve and Package
Articulate

• Bridges gap in communication styles
• Assessment/Recommendation has the potential to
  level the field and empower staff
• How the input is received determines how the next
  conversation will go

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SBAR A Tool for Collaboration
Key dialogue that leads to effective
resolution of differences
unequal power but there is mutual respect.
Scope of practice dictates that physician has
final say but parties are able to work together
to resolve differences
COLLABORATION
Speak your truth Proven strategies for effective
nurse-physician communication Bartholomew K. 2005
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If SBAR Doesnt Work. . .

• Re-assess how the conversation went
• Information complete?
• Clear and concise?
• Appropriate level of concern/urgency conveyed?
• Ask a colleague for input
• Re-assert as necessary
• Decision reached?
• Escalate if necessary-Chain of Command

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SBAR Needs Supporting Pillars
SBAR
Organizational Climate and Expectations
Individual
Organizational Processes
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Tips on Implementation
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Origins of SBAR

• The Navy
• Submarine briefings- Doug Bonacum at KP
• Adapted for healthcare
• Michael Leonard, Suzanne Graham
• Incorporated into Perinatal Safety and Human
  Factors Training
• One on one and team communication
• part of assertion module
• Handoffs
• part of Nurse Knowledge Exchange

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Critical Success Factors

• Organizational commitment to patient safety
• Larger context for SBAR
• training that provides a framework or foundation
• team model with physician and nurse
• inclusive, interdisciplinary training
• Dedicated time
• physician champion
• project manager role
• Physicians actively inviting input from others
• Practice opportunities and mentoring

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Context and Culture

• Learnings from different approaches
• Unit-based training with focus on safety culture
• SBAR was one component of one module in human
  factors training where entire department was
  trained
• high success
• Broad-based training with focus on mechanics
• low success
• Incorporated into Rapid Response Teams
• medium to high success

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Similarities Between SOAP and SBAR

• Swhats going on
• Bdata to support conclusion
• Aconclusion
• Rthe plan

X

• S
• O
• A
• P

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Differences in Assessment

• SOAP-Nursing
• Subjective
• Objective
• Assessment
• (vitals)
• Plan

• SOAP-Physician
• Subjective
• Objective
• Assessment
• (diagnostic impression)
• Plan

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The Cost-Benefit Equation

• Upsides
• reduces ambiguity
• promotes mutual respect
• gets what is needed for patients
• gives staff a clear mechanism to address patient
  issues
• can prevent failure to rescue
• can be more efficient, less frustrating

• Downsides
• risky--puts you out on a limb with hierarchy
• being wrong can subject you to repercussions
• scope of practice perceptions-some feel very
  uncomfortable
• huge behavioral and cultural change
• requires time/energy to learn

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Remember. . .

• Cultural transformation Many years of tradition
  and culture to undo
• Dont focus only on the mechanics, look at the
  social structure as well

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Handoffs

• Acuity
• patients in the hospital are much sicker
• leave the hospital much sooner
• Complexity
• subspecialty
• technology
• medications
• Discontinuity
• hospitalists
• resident work hour rules

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The Landscape and Literature

• Transitions of Care and Handoffs are a big topic
  now, but. . .
• Not much evidence, tested interventions on
  exactly how to do this and what works

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SBAR For Handoffs

• Focus on painting a clear clinical picture
• Streamline the number of elements attached to the
  four letters
• Strategic placement of static information
  related to tasks, demographics, diet, etc.
• Focus on handoff process and quality of
  information
• Good transfer of good information
• NOT good transfer of poor information
• NOT poor transfer of good information

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Pilot study to show loss of important data in
nursing handover

• Three methods studied
• Verbal only loss of all data after 3 cycles
• Note-taking 31 data transferred after 5 cycles
• Typed sheet verbal minimal data loss after 5
  cycles

Br J Nurs 2005 Nov10-2314(20)1090-3.
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Themes in Successful Handoffs

• Change in both process and content
• Nurse Knowledge Exchange KP
• bedside handoff using printout and SBAR format
• Provena St. Joseph
• voice technology to record report using SBAR
  format
• Johns Hopkins ICU Daily Goals
• interdisciplinary format

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Sample Elements of SBAR

• Introduction
• Situation top 2-3 medical problems
• Background VS, including mental status care
  provided and response
• Assessment recap of top 2-3 issues/goals whats
  still needed
• Recommendation pending labs, consults, what
  needs to be done in the next 2 hours, engage
  patient in teachback

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Operationalizing SBAR in Handoff Communication

• Clearly defining What do I need to know. . .
• How will the information I need be delivered
  consistently?
• Content and process
• a list thats realistic
• a list/terms that everybody understands
• a process thats realistic and effective, i.e.
  fax is convenient but not two-way

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The Relationship Between Teamwork, Communication,
and Patient Outcome
Communication (Micro or Macro)
Coordination of Care (Teamwork)
Quality and Quantity of Information

Patient Outcome
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It Takes Leadership. . .
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• Thank You!