eing a hospitalized patient often means losing control. Patients are admitted to the neurology floors because of a devastating event: a stroke, a seizure, an obscure neuromuscular disorder, or a progressive degenerative disorder like ALS. No matter who you are, entering the hospital means you’re losing control of your day-to-day activities and your long-term condition.
How the team works together and communicates with you builds trust and confidence. If a patient doesn’t receive a test result or is told someone will return in the afternoon and they never do, the patient wonders about the quality of their care. If the patient believes they’re receiving lackluster care, it doesn't matter how good we think we’re doing.
Miscommunication is not just frustrating for the patient—it’s frustrating for everyone on the team. Nurses receive the brunt of complaints, which isn’t fair to them. When they get push back from the family, it’s often because we’re not communicating enough. Mistakes don’t happen if we work together effectively.
Reliable teams communicate reliably: I.N.U.P.
We took a hard look at our processes on inpatient physician rounds. We were fortunate to see what our colleagues in Internal Medicine were doing to improve communication with patients experience on the hospitalist service. It quickly became apparent that many of our rounding practices were based on an attending physician’s behaviors and institutional memory.
So how could we improve? At the beginning of this work, we used a 14-point checklist, but it produced checklist fatigue. How many things can you check off at once? We used an electronic checklist to sample rounding habits on three separate occasions and honed in on four things we believed could have the biggest impact.
We settled on four things (the INUP acronym):
|Acronym||What it stands for||What we implemented|
|Introduction of all members of the team||Team introductions sheet. Downloads: PDF | PPT|
|Nurse present during rounds.||Just-in-time call to nursing to allow 10 to 15 minutes before entering the next room and optimize the chance of a nurse being present.|
|Update plan on whiteboard.||Assigned specific duties to team members: introductions by attending doctor, plan written on whiteboard by senior residents, information on who would round on patient in afternoon.|
Convincing your colleagues to change
Change is challenging because people inherently don't want to change anything that doesn’t seem broken. If you aren’t clear about potential impact, then no one will see the reason to change. Change means disrupting your habits–you have to make things easy for people. Here are three strategies to reach the tipping point.
#1 No pitchforks = Ready to give it a try
First, explain clearly what the problem is while making sure you don't stress the system too much at any one time. Make a pitch to your team to get buy-in. If there isn’t resistance, take that as a good thing. If people are lukewarm to the idea, its time to try it.
#2 The importance of the team
The sum of the parts far exceeds the whole. Having nursing and pharmacy present can make a positive difference in the delivery of care for patients. It makes my job much more fun and collaborative. That’s actually one of the reasons I came to U of U Health to train.
Susan Clark, nurse manager of Neuro Acute Care (NAC), has been amazing. A lot of the improvement occurred because of Susan’s involvement with Dr. Dana DeWitt, who is Medical Director of the NAC. Susan and Dana spearheaded afternoon conversations with patients to discern what's been going well, what issues still remain, and what we can do better. I couldn't ask for a better partner on the NAC.
#3 Motivate for results
Going after low-hanging fruit early instead of shooting for the moon and failing the first time builds team momentum and buy-in. Incremental results really help the team. Sharing feedback from patients builds momentum.
Improvement work is exciting—you can make your daily work better through small, incremental changes that are easy to implement on the fly. It doesn't take a formal IRB or a massive study. If you identify a problem, propose a solution, and try it, everyone can see whether it will work or not. That kind of improvement can make your job more satisfying, less problematic, and more efficient.
Collaborative rounding greatly reduces the risk of communication errors and can increase efficiency of care. We have a culture of problem-solving together on NAC. We hold multidisciplinary monthly quality improvement (QI) meetings with Nursing, PT/OT/ST, Pharmacy, Dana Dewitt, Susan Clark, myself, the QI team, the Stroke Center, and at times EEG and Neurosurgery. We review the HCHAPS scores, falls rates, Medication RLs, CAUTI rates, and stroke metrics. All of those have been a major factor in making changes on the NAC.
Good communication is the hallmark of excellent, compassionate patient care. After 12 months of working on this project, we hear from patients that they are less frustrated. Attendings feel like they’re far more involved. When you don't run into that firestorm in the morning because things weren't taken care of the night before, it makes patient care so much more pleasurable.
Annotated transcript from Pete Hannon's presentation at the April 2, 2018, Leader Development Institute in Salt Lake City, Utah.
Originally posted September 2018