Download Call from - Children`s Mercy Hospital

Communication
A Chiasm of Perspective
If men are from Mars and women from Venus, where are
doctors and nurses from?
Jodi Jackson, MD
Section of Neonatology
Children’s Mercy Hospitals and Clinics
Kansas City, MO
Some slides adapted from Michael Leonard, MD presentation on
“Effective Teamwork and Communication in Delivering Safe Care”
December 2005
Example
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2 am
Lots of detail
Very tired provider
Unclear expectations
Communication failure
Before We Start
• Please take a few minutes, and discuss with
the people around you a recent phone call
you made or received to/from a colleague,
nurse, doctor consultation, other
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Write down purpose of call
Who call was to or from
Pertinent issues you remember
Why the call was made
What were the expectations of the call
Did the call meet your expectations
Anything else significant
• Was the purpose of the call clear to the
caller and person receiving the call
Yes
or
No
• Where the expectations of the call met
Yes
or
No
Video Example
• http://scope/QI/Data/04_ps17.htm
Your Examples
Example 1
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Title—
Purpose of call—
Call from—
Call to—
Expectations—
Pertinent issues—
Expectations met—
Opportunities for improvement—
Example 2
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Title—
Purpose of call—
Call from—
Call to—
Expectations—
Pertinent issues—
Expectations met—
Opportunities for improvement—
Example 3
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Title—
Purpose of call—
Call from—
Call to—
Expectations—
Pertinent issues—
Expectations met—
Opportunities for improvement—
Why Communication?
* The overwhelming majority of untoward
events involve communication failure
* The clinical environment has evolved
beyond the limitations of individual
human performance
Where Do Things Fall Through
the Cracks ?
* Systems – information, tests,
diagnoses
* Communication
* Hand offs
• An Institute of Medicine report concluded in
2000 that up to 98,000 Americans die each year
because of medical mistakes. The report called
on governments, doctors, and private industry to
launch a massive effort to increase error
prevention.
• http://www.webmd.com/news/20070403/studymedical-errors-still-aproblem?ecd=wnl_lbt_042507
Effective Communication Requires:
* Structured communication – SBAR
* Assertion/critical language – key
words, the ability to speak up and stop
the show
* Psychological safety – an environment
of respect
Misunderstandings
Movie Clip
Need for Communication
“The less innate understanding there is
concerning a specific task, the more
disparity there will be between the
intended result and the actual result.”
Human Error Is Inevitable
Because:
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*
*
*
Inherent human limitations
Complex, unsafe systems
Safety is often assumed, not assured
Culture of the expert individual
Error Is Inevitable Because of
Human Limitations
* Limited memory capacity – 5 to 7 pieces of
information in short-term memory
* Negative effects of stress – error rates
* tunnel vision
* Negative influence of fatigue and other
physiological factors
* Limited ability to multitask – cell phones
and driving
THEN WE HAVE HUMAN JUDGMENT
Error Management
* The best approach is effective
teamwork and communication –
everyone in the same movie
* And having predictability, so people
know what is supposed to happen
MD–RN: Different
Communication Styles
* Nurses are trained to be narrative and
descriptive
* Physicians are trained to be problem
solvers “what do you want me to do” –
“ just give me the headlines”
* Complicating factors: gender, national
culture, the pecking order, prior
relationship
* Perceptions of teamwork depend on your
point of view
Example
• Communication of frequent
desaturation events
– Does communicator have an expectation
regarding response to call
– Is the communicator concerned or just
reporting
– Does the communicator know how this
relates to previous findings
Example
• Call from outside referral
– No context in which to frame information
– No order to information given
– No clear reason for all
Situational Briefing Model
S-B-A-R
* Situation
* Background
* Assessment
* Recommendation
SBAR in OB
• S – Impending uterine rupture
• B – VBAC, dense epidural,
persistent breakthrough pain,
complete
• A – I’m concerned, something’s wrong
• R – I think she needs a C-S. I need you
now
SBAR Patient Communication TOOL
NICU
1. State your name and pod
2. Assure attention of call recipient
Situation
S
1. I am calling about: ________________(Patient’s Name, pod space)
2. The reason I am calling is::_____________________________
State if this is a serious problem
Background
1. The context, background relevant to the current problem (see
below)__________________________________________________
B
Assessment
What do you think the problem is?____________________________
Recommendation or Request
What you think would help or needs to be done__________________
A
And time frame it needs to be done in ___________________
___________________________________________________________________
Background: (could include GA, DOL, major diagnoses, current level of respiratory
support, current plan of care (ie weaning vent, increasing support etc), Stability of the
situation)
R
(Could include data to support your current concern; Vital signs, labs, results, physical
assessment pertinent to the problem, especially changes, interventions taken so fare)
(Limit non-relevant information, it makes it harder to understand the important issues)
Assessment: (could include our conclusions about the present situation and how severe
it seems to be. If the situation is unclear at least try to indicate what body system might
be involved or what is ruled out)
Recommendations: (could include medicines, tests, x-rays, physician evaluation)
Write down and read back any orders. Clarify questions and under what circumstances to
call back. DOCUMENT THE CHANGE IN CONDITION & THE PHYSICIAN NOTIFICATION.
SBAR Communication TOOl
NICU
Before making a call, think about your expectations for the response,
what components of a response will be helpful to you.
Situation
1. State your name
2. I am calling about: ________________(Patient’s Name, and pod space)
3. The reason I am calling is::_____________________________
State if this is a serious problem
S
Background
1. The context, background relevant to the current problem ________________
(could include GA, DOL, major diagnoses, current level of respiratory support, current plan of care (ie
weaning vent, increasing support etc), Stability of the situation, data to support your current concern;
Vital signs, labs, results, physical assessment pertinent to the problem, especially changes, interventions
taken so fare)
Assessment
B
What do you think the problem is?____________________________
(Your conclusions about the present situation and how severe it seems to be. If the situation is unclear at
least try to indicate what body system might be involved or what is ruled out)
Recommendation or Request
What you think would help or needs to be done (what are your expectations
for this call)_____________________________________________________
(Could include medicines, tests, x-rays, physician evaluation, or nothing)
A
And time frame it needs to be done in ___________________
Write down and read back any orders. Clarify questions and under what circumstances to call
back. DOCUMENT THE CHANGE CONDITION & THE PHYSICIAN NOTIFICATION.
______________________________________________________
Response
1. Response time (circle one)
R
Less than 5 minutes
5-10 minutes
10-15 minutes
2. Response met expectation
> 15 minutes
Yes
No
(concerns address, plan made, with clear next steps and criteria for call back)
3. Response was cordial and non-threatening
Yes
No
4. I generally feel comfortable calling the doctor
Yes
No
When Receiving a Call
• How often are you given a clear:
--Situation
Never 1
2
3
4
5
Always
When Receiving a Call
• How often are you given a clear:
--Background
Never 1
2
3
4
5
Always
When Receiving a Call
• How often are you given a clear:
--Assessment
Never
1
2
3
4
5
Always
When Receiving a Call
• How often are you given a clear:
-- Recommendation
Never
1
2
3
4
5
always
When Receiving a Call
• How often to you really understand the
expectation of the call:
Never
1
2
3
4
5
always
When Receiving a Call
• How often do you ask (in a subtle way)
“why are you calling”?
Never
1
2
3
4
5
always
SBAR
* Situation – the punch line 5 to 10
seconds
* Background – the context, objective
data, how did we get here?
* Assessment – what is the problem?
* Recommendation – what do we
need to do?
Assertion – What Is It?
“Individuals speak up, and
state their information with
appropriate persistence until
there is a clear resolution.”
Assertion
• Model to guide and
improve assertion in
the interest of
patient safety
GET PERSON’S
ATTENTION
REACH
*
DECISION
PROPOSE
ACTION
EXPRESS
CONCERN
STATE
PROBLEM
nt
Pe
ta
l
ab
s/
In
te
r
tL
s
Te
st
ns
Si
gn
n
e
Ca
r
or
t
O
L
va
t io
er
/O
bs
rti
ne
n
Ex
am
Vi
D
Si
tu
at
io
of
s
G
A
rn
up
p
fs
an
of
Pl
ve
lo
ilit
y
le
St
ab
ur
re
e
is
os
on
ce
ia
gn
C
D
le
r
Na
m
Ca
l
C
ve
nt
on
io
cl
n
us
io
W
n
St
ha
at
tI
ed
ne
ed
fro
Ti
m
m
yo
ef
ra
u
m
cl
e
ar
of
ifi
ca
ne
it o
ed
ns
o
--w
rd
e
rit
rs
e
gi
do
ve
w
n
n/
re
ad
ba
ca
llb
ck
ac
k
sp
ec
ifi
Va
cs
lid
N
(li
st
wi
se
)
C
of
tie
nt
fic
ng
ec
i
it t
i
m
Sp
Ad
Pa
ID
Percent
Some Data
• Baseline data regarding information shared
during phone calls
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
SBAR QA Form
NICU data, CMH
Situation
Y
N
Background
Y
N
Assessment
Y
N
Recommendatio
Y
n
ID of caller
Gestational Age
Vital Signs
What I need from you
Patient Name
Day of life
Exam / Observations
Timeframe of Need
Admitting Diagnosis
Current level of support
Pertinent Labs / Tests
Orders given
Specific Concern
Plan of Care
Interventions
Clarification –
Write down / Read
back
Stability of Situation
Conclusion Stated
Callback Specifics
Directions:
1.Once you have taken and completed a call, please fill out the questionnaire on SBAR.
2.The Y means “yes” the caller gave you the information without you asking for it. The N means “no” you did not get
the information or you had to ask for it.
N
Practice
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Please form some small groups
Look at your examples
See if formatting into a form is helpful
Report back
Your Examples
• Who has examples they would like to
share?
Next Steps
• JCAHO recommendation for all
caregivers
• In order to be effective, doctors need
to accept and mentor nurses in their
transition to using SBAR
– Recommendation part is hard to get
around
• why is recommendation accepted or not
• a great teaching opportunity to make sure
everyone is on the “same page”
Thank you for your attention.
Comments?