ANSWER
This study aimed to develop, implement, and evaluate a comprehensive provider/team communication strategy, resulting in a toolkit generalizable to other care settings. The specific aims included implementing a structured communication tool; a standardized escalation process; daily multidisciplinary patient-centred rounds using a daily goals sheet; and team huddles. The study setting was the 477-bed medical centre of the Denver Health and Hospital Authority, an integrated, urban safety-net system. Utilizing a pre-test/post-test design, baseline and post-intervention data were collected on pilot units (medical intensive care unit, acute care unit, and inpatient behavioural health units) (medical intensive care unit, acute care unit, and inpatient behavioural health units). Analysis of 495 communication events after toolkit implementation revealed decreased time to treatment, increased nurse satisfaction with communication, and higher rates of resolution of patient issues post-intervention. The resultant toolkit provides healthcare organizations with the means to implement teamwork and communication strategies in their settings.
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Go to:\sIntroduction
Current research indicates that ineffective communication among healthcare professionals is one of the leading causes of medical errors and patient harm.
1, 2, 3 A review of reports from the Joint Commission reveals that communication failures were implicated at the root of over 70 per cent of sentinel events. 4 When asked to select contributing factors to patient care errors, nurses cited communication issues with physicians as one of the two most highly contributing factors, according to the National Council of State Boards of Nursing reports. 5 In a study of 2000 healthcare professionals, the Institute for Safe Medication Practices (ISMP) found intimidation as a root cause of medication error; half the respondents reported feeling pressured into giving a medication, for which they had questioned the safety but felt intimidated and unable to communicate their concerns effectively. 6
The growing body of literature on safety and error prevention reveals that ineffective or insufficient communication among team members contributes significantly to adverse events. In the acute care setting, communication failures lead to increased patient harm, length of stay, and resource use, as well as more intense caregiver dissatisfaction and rapid turnover. 7, 8, 9, 10, 11, 12 In multisite studies of intensive care units (ICUs), poor collaborative communication among nurses and physicians, among other specific factors, contributed to as much as a 1.8-fold increase in patient risk-adjusted mortality and length of stay. 13, 14, 15
Analysis of 421 communication events in the operating room found communication failures in approximately 30 per cent of team exchanges; one-third of these jeopardized patient safety by increasing cognitive load, interrupting routine, and growing tension in the OR setting.
2 The researchers found that communication problems were relatively straightforward and fell into four categories: (1) communications that were too late to be effective, (2) failure to communicate with all the relevant individuals on the team, (3) content that was not consistently complete and accurate, and (4) communications whose purposes were not achieved—i.e., issues were left unresolved until the point of urgency.2
Examining the outcomes of communication, other researchers have found associations between better nurse-physician communication and collaboration and more positive patient outcomes, i.e., lower mortality, higher satisfaction, and lower readmission rates.
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Effective communication among healthcare professionals is challenging due to several interrelated dynamics:
Health care is complex and unpredictable, with professionals from various disciplines involved in providing care multiple times throughout the day, often dispersed over several locations, creating spatial gaps with limited opportunities for regular synchronous interaction.
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Care providers often have their disciplinary view of what the patient needs, with each provider prioritizing the activities in which they act independently.
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Historically, healthcare facilities have a hierarchical organizational structure, with significant power distances between physicians and other healthcare professionals. This frequently leads to a culture of inhibition and restraint in communication rather than a sense of open, safe touch (psychological safety) (psychological safety).
Differences in education and training among professions often result in different communication styles and methods that complicate the scenario and render communication ineffective.
Although teamwork and effective communication are crucial for safe patient care, the educational curricula for most healthcare professions focus primarily on individual technical skills, neglecting teamwork and communication skills.
A cultural barrier in many organizations can be traced to the belief that quality of care and error-free performance result from professional training and effort, ignoring the inherent limitations described in human factors science.
3 In fact, human factors such as cognitive overload; the effects of stress, fatigue, distractions and interruptions; poor interpersonal communications; imperfect information processing; and flawed decision-making are all known to contribute to errors in health care and other complex environments, such as aviation. 3, 6 Failure to recognize and understand these issues can lead to a culture of unrealistic expectations and blame, diverting efforts away from effective team-based error management strategies.
Intervention-focused research that seeks to improve collaborative communication needs to be improved.
19 As a means of improving patient safety and outcomes, interventions should focus on integrating the critical attributes of collaboration, including open communication, shared responsibilities for planning and problem-solving, shared decisionmaking, and coordination. 19, 20 Additionally, translating the theories and practices of teamwork and communication from aviation to health care is gaining support from several researchers citing common elements in both industries. Training efforts—such as crew resource management (CRM) and a focus on the critical concepts of leadership, briefings, monitoring, cross-checking, decision-making, and review and modification of plans—have enhanced communication and teamwork, thus providing a mechanism for increased safety and a change in crew attitudes and behaviour. 21
Drawing on current research, the purpose of this study was to develop, implement, and evaluate a comprehensive team communication strategy, resulting in a toolkit that can be generalized to other care settings. The specific aims included:
Implementation of a standardized communication tool, the SBAR (see description on next page), as a guide for communicating changes in patient status.
Implementation of an escalation process tool to facilitate timely communication.
Daily multidisciplinary patient-centred rounds using a daily goals sheet.
Team huddles during each shift.
Go to: \sMethods
Utilizing a pre-test/post-test design, this study incorporated baseline data collection and implementation of team communication interventions, followed by data collection and analysis over 24 months. The goal of developing a user-friendly toolkit was accomplished as feedback and findings from this study were revised and adapted.
Study Setting
Denver Health Medical Center, an urban public safety-net hospital, provided the site for this study, with a specific focus on three care settings utilized for pilot testing. These settings were selected because each provided a different type of unit organization and staff.
Phase 1 focused on two settings: the Medical Intensive Care Unit(MICU) and the Acute Care Unit (ACU) (ACU). The ACU was selected because it had a very diverse patient population, with multiple physician teams and services assigned to the unit at a given time. The MICU was chosen because it was a closed unit with fewer physician teams and one primary service with more accessibility to physician consultation.
Phase 2 focused on behavioural health units: an Adult Psychiatric Unit, an Adolescent Psychiatric Unit, and an Acute Crisis Service (psych ED) (psych ED). The behavioural health units were characterized by a unique patient population and unit milieu, with a more consistent physician group.
Since post-intervention data collection has been completed on the Phase 1 units, this report is focused on specific outcome measures based on Phase 1 results.
Interventions
The following communication strategies were included in the toolkit interventions and can be accessed on the Denver Health Medical Center Web site (www.safecoms.org) for further detail:
Situational briefing guide: SBAR. A standardized communication format, the SBAR, was utilized as a situational briefing guide for staff and provider communication regarding changes in patient status or needs for nonemergent events, related issues, or events on the unit, in the lab, or within the health care team. SBAR is an acronym for:
Situation: What is going on with the patient?
Background: What is the clinical experience or context?
Assessment: What do I think the problem is?
Recommendation: What needs to be done for the patient?
Since SBAR provides a standardized means for communicating in patient care situations, it effectively bridges differences in communication styles. It helps to get all team members into the “same movie.”
3 SBAR provides a familiar and predictable structure for communication, can be used in any clinical domain and has been applied in obstetrics, rapid response teams, ambulatory care, ICUs, and other areas. SBAR also presents guidelines for organizing relevant information when preparing to contact another team member, as well as the framework for presenting the information, appropriate assessments, and recommendations. 6 SBAR has been utilized in Institute for Healthcare Improvement (IHI) collaboratives and has been endorsed by the American College of Healthcare Executives and the American Organization of Nurse Executives.
One crucial aspect of SBAR is its inherent recognition of nurses and other care providers’ expertise so that they are encouraged to assertively make recommendations to physicians, thus facilitating a nonhierarchical structure. In a recent study of nursing home transfers from acute care settings to skilled nursing facilities (SNF), SBAR implementation helped avert breakdowns in communication that had previously resulted in patients arriving with incomplete information and the need for essential medications not available. 3
In the current study, SBAR was used initially to organize and present information to communicate changes in patient status. It was also helpful in preparing the report and for an anticipated difficult conversation with another staff member or provider. As the implementation of SBAR expanded across units, several uses were established. It was utilized to provide “kudos” for staff accomplishments as a framework for reporting on patients, structuring assessments, and structuring succinct e-mail communications. A diagram of the SBAR process form and guidelines for use are presented in Table 1.
Table 1. SBAR Practice Sheet.
Table 1 \sSBAR Practice Sheet.
Team huddles. Provider and staff team huddles were implemented on the pilot units to communicate and share information concurrently with the team early in the shift. A team huddle was defined as a quick meeting of a functional group to set the day/shift in motion via commentary with key personnel. Huddles are microsystem meetings with a specific focus based on the function of a particular unit and team. Although both joint rounding and huddles aim to improve team communication and patient safety and care, huddles differ in that they have a primarily operational focus. They are interdisciplinary and include active care personnel.
Current literature indicates daily team huddles result in fewer interruptions during the rest of the day and immediate clarification of issues.
22 Team members know there is a fixed time when they will have everyone else’s attention. Daily briefings (similar to those used in huddles) are helpful for a team to quickly assess changes in clinical workload, identify relevant issues of the day, and provide a means to prioritize. 3 In a short time, members of a care team can all be “on the same page” for the day and be ensured that relevant issues are being addressed. 3
Guidelines for huddles include the following:
Set a standard time each day.
Use a consistent location.
Stand up, don’t sit down.
Make attendance mandatory.
Limit duration to 15 minutes.
Begin and end on time.
Attempt to have the same structure every day.
Keep the agenda to restricted items.
Initial pilot testing of huddles occurred in radiology and laboratory services. Huddle participants included all departmental and unit-level staff members present at the time. They typically happened at the beginning of the day or shift, lasted approximately 9 to 20 minutes, and were led by a shift supervisor or department head.
Huddles were utilized to review pertinent issues of the day (e.g., inoperable equipment or rooms), to go over the day’s schedule, and to plan for possible variations/problems. Information sharing included relevant system-level messages of the day, information from recent management meetings, and departmental issues or concerns. A brief discussion of the specific problems, such as errors (e.g., mismarked films), was integrated with a review of the process, system issues, and reminders on how to avoid the mistakes. On nursing units, huddles typically were led by the nurse manager, charge nurse, or clinical nurse educator. Interviews revealed several benefits of huddles, including:
Preparing staff for the shift/day.
Face-to-face communication.
Immediate response to questions.
Streamlined resolution of issues or concerns.
Timely response to issues or concerns.
Efficient dissemination of information.
Improvement in teamwork and effective communication.
Staff involvement in decision-making.
In some instances, if a huddle had been skipped for a particular shift/day, staff members took notice and inquired about it. Huddles also served to enhance teamwork and the staff’s sense of cohesion.
Multidisciplinary rounds using Daily Goals Sheet. Multidisciplinary rounds were implemented in the MICU with the leadership and support of the unit medical director and nurse manager. Games were patient-centred and could include any staff member or provider involved in the patient’s care, such as a physician (e.g., attending, resident, intern, and fellow), respiratory therapist (RT), physical therapist, occupational therapist, social worker (SW), pharmacist, charge nurse, individual patient’s nurse, and pastoral care provider.
Rounds were focused on open and collaborative communication, decision-making, information sharing, care planning, patient safety issues, cost and quality of care issues, setting daily goals of care, and communicating with patients or family members as they were able. Information shared during rounds was supplemented by communication between incoming and outgoing care providers during shift changes.
The Daily Goals Sheet was an interdisciplinary communication tool that served as a simple way of clarifying work goals among providers. It provided the means for the care team and patient (when able) to explicitly define the plans for the day. The form was typically completed during rounds on each patient, signed by the fellow or attending physician, and given to the patient’s nurse. The care team—physicians, nurses, RTs, and pharmacists—provided input and reviewed the goals for the day. The form was updated as the plans of care changed. Current literature supports the value of multidisciplinary rounding. In a study of interdisciplinary rounding focused on daily care goals in intensive care, the results showed improved communication among providers, significant improvement in the proportion of physicians and nurses who understood the ideals of respect for the day (from 10 to 95 per cent), and a 50 per cent reduction in ICU length of stay. 23
Before utilizing the patient-centred daily goals format, patient care rounds were provider-centric and lacked clarity about tasks and care plans for the day. Staff often needed more understanding of the tasks they needed to accomplish and the method for communicating with patients, families, and other caregivers. Physicians and nurses perceived that using this format improved communication and patient care. The benefits of the goals sheet are founded on the theories of CRM (crew resource management). They are currently used in several ICUs participating in IHI and Veterans’ Health Administration improvement efforts. 23
Escalation Process
The original study proposal intended to develop and implement an escalation process algorithm for provider communication regarding changes in patient conditions for non-code situations. The goal of the escalation process was timely, appropriate communication between nursing staff and providers as changes in patient conditions occurred. Previously, no standardized process existed at Denver Health for this purpose, resulting in ambiguities in the decision-making process for each patient situation.
Peer-reviewed case studies revealed that a standardized and well-defined communication process had led to clarity and delays in appropriate and adequate patient care when the need for escalating a concern existed. These issues are particularly relevant at academic medical centres similar to Denver Health since the organizational structure includes layers of providers, such as attending physicians, fellows, senior and junior residents, and interns.
However, concurrent with the implementation phase of the project, the Department of Patient Safety and Quality developed Rapid Response Escalation Criteria, which provided nurses with patient parameters for escalation and an outline of providers to call along with a timeframe; the criteria utilized SBAR for communicating changes in a patient’s condition.
The Rapid Response form served as a guide for identifying a patient’s condition that could trigger a Rapid Response call and as a communication tool for physicians to convey their assessment and care plan. Instructions were also provided for physicians for follow-up with senior/attending physicians within a 4-hour timeframe. This well-documented, standardized escalation process provided role clarification and more precise patient parameters within a realistic timeframe, defining whom to call and when in a way that all healthcare team members could understand.
Implementation
Staff and provider education and development were primary components of the communication strategy implementation. An “Implementation Toolkit” was developed to guide the education and integration of communication and teamwork factors in clinical practice. Although specific units served as pilot areas for pre- and post-data collection, it was necessary to involve all departments and a maximum number of staff members due to the interdepartmental nature of communication. The challenge to capture a broad audience of healthcare team members mandated the creation of a standardized curriculum, teaching materials, and methods that could be used by multiple disciplines in a variety of forums (e.g., new employees, department orientation, student rotations, initial education, and ongoing refreshers for current employees) (e.g., new employees, department orientation, student rotations, initial education, and ongoing refreshers for current employees). Healthcare team members participating in this intervention included nurses, unlicensed assistive personnel, physicians, respiratory therapists, occupational/physical therapists, dietitians, social workers, pharmacists, chaplains, clerical/support staff, and radiology and laboratory staff.
The nature of the acute care hospital setting presented challenges that required multiple teaching strategies to introduce the concepts, reinforce learning, facilitate translation of the ideas into practice, and sustain the practice changes.
QUESTION
Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the I-SBAR-R Download I-SBAR-Rtemplate or your own document.
72, Caucasian, Female, Obese
You should include the following:
(S) Situation: What is the situation you are calling about?
Identify self, unit, patient, room number.
Briefly state the problem, what it is, when it happened or started, and how severe.
(B) Background: Pertinent background information related to the situation could include the following:
The admitting diagnosis and date of admission
List of current medications, allergies, IV fluids, and labs
Most recent vital signs
Lab results: provide the date and time test was done and results of previous tests for comparison
Other clinical information
Code status
(A) Assessment: What is the nurse’s assessment of the situation?
(R) Recommendation:
What is the nurse’s recommendation, or what does he/she want?
Examples: notification that patient has been admitted, patient needs to be seen now, order change
Document the change in the patient’s condition and physician notification
Citation
Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/SampleSBARCommunicationTool.aspx