Improving Clinical Communication

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• Improving Clinical Communication
• Through
• Structured Conversation and Skill Building
• By Mary Lou Manning, RN, PhD, CPNP
• Senior Vice President, Programs
• July 19, 2006
• National Patient Safety Foundation
• www.npsf.org

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• Why Focus on Communication?
• Growing interest in relationship between teamwork
  and patient safety
• Communication is an associated teamwork behavior
• Clinician communication patterns are highly
  variable
• Relationship between communication and patient
  outcomes

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• How would you answer?
• I participate in setting the goals for each
  patient in my care every day.
• I always speak up if I perceive a problem with
  patient care.
• I am consistently clear, concise, and to the
  point in communicating what I need to care for
  patients.
• The care team works together and is
  well-coordinated for every patient, every day.
• I know the first and last names of all the
  personnel I worked with during my last shift.
• I am always confident and comfortable approaching
  all members of the health care team.

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• Institute of Medicine Reports

November, 2003
April, 2003
January, 2003
March, 2001
November, 1999
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JCAHO Sentinel Events
www.jcaho.org
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• The difference between the right word and the
  almost right word is the difference between
  lightning and a lightning bug.
• Mark Twain

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• Effective Communication
• Frequent, timely, clear, concise, accurate
• Everyone contributes
• Active listening
• Willingness to consider other ideas and ask for
  opinions
• Questioning
• Nonhierarchical

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• Human Factor Considerations
• Gender, culture
• Individual perspectives
• Establish hierarchies
• Education differences
• Work environment

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• Limitations of Human Performance
• Cognitive load memory capacity is 5-7 pieces of
  information in short term memory
• Negative effects of stress tunnel vision
• Negative influence of fatigue, change in routine
• Limited ability to multi-task overwhelms the
  ability to remember
• Emotional tension

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• Communication Failures
• System failures necessary channels of
  communication do not exist, or are not
  functioning, or are not regularly used.
• Message failures channels exist but the
  necessary information is not transmitted.
• Reception failures channels exist, the right
  message is sent, but it is either misinterpreted
  by the recipient or arrives too late.
• James Reason, 2003

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• Communication Failure Outcomes
• Patient errors, adverse events
• Uncertainty during patient care decisions
• Ambiguity
• Inefficiency, delays, work-arounds
• Team tension
• Resource waste
• Patient inconvenience
• False sense of safety when communication yields
  no immediate visible effect

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• Communication Tools
• Daily Patient Goal Sheets
• Huddles
• SBAR
• Bedside Rounds

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Daily Patient Goal Sheet

• A tool designed to create a clear understanding
  among all the team members of the patient goals
  for the day.

Daily Goals/Communication Plan Patient Name
______________ Room ________ Date _______
Provonost et al Improving Communication in the
ICU using daily goals. Journal of Critical Care
18 (2), June 1993 PP 71-75
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• Daily Patient Goal Sheet
• Prompts the care team to identify and clarify
  work needed
• Can be easily modified to meet the needs of any
  patient population
• Using an interdisciplinary communications tool is
  more important than the specific statements on
  the form
• Provides a mechanism for communicating daily
  goals to the family as well as the care team

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• Daily Patient Goal Sheets Challenges

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• Huddles
• Short briefings to stay informed, anticipate
  needs, make plans, review work

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• Patient Safety Huddles
• Assemble at pre-determined times each day to
  anticipate patient and staff needs.

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• SBAR
• (Situation-Background-Assessment-Request)
• Provides a framework for communication between
  members of the health care team
• Standardizes the type of information to be
  briefed
• Sets the expectation that specific informational
  elements are going to be communicated every time
  a patient is discussed.

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• (S) Situation
• State your name
• I am calling about (patient name and location)
• The problem I am calling about is (be specific)
• I am concerned about (vital signs, change in
• statusin other words list your
• observations and data related to the problem
  that
• you are calling about

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• (B) Background
• Briefly state the history of the problem you are
  
• calling about. State any pertinent related
• information
• Give a brief synopsis of the treatment to date

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• (A) Assessment
• I think the problem is _________ or,
• I am not sure what the problem is but the
  patient
• is deteriorating or,
• The patient is unstable and we need to do
• something

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• (R) Request/Recommendation
• I need you to (e.g. come see the patient now)
  or,
• I think we should.or,
• I was wondering if, or
• If a change in treatment is ordered, then ask
• specifically when would you like an update
  on
• this patient? How long do you expect until
  we see
• improvement? If the patient does not improve,
  
• when would you like me to call again?

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• Example
• Mrs. Walker is a 72 year old patient admitted
  yesterday to a general medical with a diagnosis
  of congestive heart failure. She is becoming
  increasingly short of breath and restless.

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• Without SBAR Approach
• Nurse Mrs. Walker on 8 South is having some
  trouble breathing. Her daughter is with her and
  is nervous that she is getting worse. Can you
  take a look at her when you get a minute?
• MD Im on rounds. Ill get there when I
  can.
• Nurse Okay.

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• With SBAR Approach
• Situation
• Hi, Im Mary Lou, the nurse caring for Mrs.
  Walker on 8 South. Are you familiar with this
  patient?
• MD Yes.
• Background
• This is the second day Ive cared for her. She
  has bilateral rales and is increasingly short of
  breath and restless.

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• Assessment
• Her breathing is significantly more labored than
  yesterday and Im concerned that her congestive
  failure is worsening.
• MD Im on rounds and will get there when I
  can.

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• Recommendation/Request
• I need someone to see her within the next 15
  minutes. If you are not able see her who else
  should I call?

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• SBAR Lessons Learned
• Focus is on the problem, not the people
• Rapidly gets people on the same page
• Develops critical thinking skills
• Enables nurses to effectively contribute
• to the decision-making process
• Reduces ambiguity and confusion
• Aids in eliminating the emotional climate

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• Bedside Rounds
• American Academy of Pediatrics Policy Statement
• Family-Centered Care and the Pediatricians
  Role
• Conducting attending physicians rounds (i.e.
  patient presentations and rounds discussions) in
  patients rooms with the family present should be
  standard practice.
• Pediatrics, September 2003

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• Bedside Rounds Benefits
• Family centered care
• Improved family satisfaction
• Communication with all team members
• Consensus of patients plan
• Daily Goal Sheet
• Physiologic discharge criteria
• Timed discharge criteria
• Assures nurse participation

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• Bedside Rounds Benefits
• Demonstrate physical findings
• Demonstrate skills of talking with family
• Evaluate skills of trainees to talk with families
  and rapport theyve developed
• Improved patient flow

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• Common Physician Concerns
• Patient and family comfort
• Learner comfort
• Attending comfort
• Efficiency
• Teaching effectiveness

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• Summary
• Improving clinical communication is the
  cornerstone to creating effective strategies to
  prevent, capture, and mitigate future errors
  before they become adverse outcomes