INTERACT Boot Camp Communication Tools August 2013.

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!