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 Monitor Data, Outcomes Congress April

Rolling out communication tools INTERACT as QI program INTERACT Champion is part of the QAPI Committee Focus on data, PDSA cycles

Where are you in the INTERACT implementation process? Polling Question Where are you in the INTERACT implementation process? Have not started yet Created plan to implement INTERACT with leadership Started using INTERACT implementation checklist Reviewed last 3 months of readmissions Completing QI summary monthly 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 Look at your process and outcome measures Have Admissions enter the resident info daily Review every morning during standup Run monthly reports and share with leadership and staff Discuss readmissions Findings from QI Review Tool Share monthly findings from Summary Tool

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 14

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? CNAs and nurses All non-nursing staff with direct resident contact Family and close friends with regular direct contact 1 and 2 All of the above

STOP and WATCH Seems different Talks or communicates less Communication Tools STOP and WATCH Seems 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 17

AND Ate less than usual (Not because of dislike of food) No bowel movement in 3 days or diarrhea Drank less than usual 18

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 19

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. 20

Implementation Where will forms be located? Which nurse will direct care staff give the tool to? 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? Where will the forms go after follow-up is complete? Does it need to be electronic? 21

Common Barriers to Communicating Early Changes in Residents Unit nurses are busy giving medications, taking physician orders, and admitting new residents CNAs are very busy giving direct care Stop and Watch can help close the gap! 22

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. Your facility’s project champion is responsible for coordinating INTERACT implementation. She or he may ask you to complete specific activities. Suggested activities include: Select one unit. Make 25 copies of the Stop and Watch tool. See the INTERACT website to print a copy. Go to www.interact2.net, Click on INTERACT Tools, Click on “Early Warning Tool” Laminate a copy for each CNA on the unit so that it fits easily into a pocket and can be used for easy reference. Make blank copies and put within easy access for all direct care staff. Ask lead CNAs and key nurses to teach all frontline staff and nurses working on the unit how to use the tool. Try using the Stop and Watch for a week. Track its use as suggested. Meet with staff to discuss how it was used, what barriers arose, and ways to improve. How many times a shift was the tool used? How did the nurses respond? Try again for another week and continue to identify areas of success as well as those that need improvement. 27

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%

Assessment/Appearance Request Communication Tools SBAR Tool Situation Background Assessment/Appearance Request

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 PDSA P – 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 Makes adjustments Clarify orders Clarify orders Verify any discrepancies

Where do most of your medication errors occur? 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 Rec Tool 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

Thank you! 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