1. Coordinating care Small Things Count 2012

2. Outline of presentation Why coordinate care Tools for coordinating care The roles of the Attending Physician, residents and staff in coordinating care Some exercises

3. Why coordinate care When a patient is admitted to The Medical City, she is entrusted to at least ten people, all of whom should know how to care for her safely. Sicker patients can have even more care providers.

4. Please raise your hand if the following are not rare events in your practice: 1.You don’t know the people to whom you are referring patients for special tests or treatments. 2.You don’t hear back from a specialist after a consultation. 3.Your patient complains that the specialist didn’t seem to know why s/he was being referred. 4.A referral doesn’t address your clinical question. 5.Your patient doesn’t come back to see you after you refer her to another specialist. 6.A specialist duplicates tests you have already performed. 7.You are unaware that your patient was seen in the ER. 8.You were unaware that your patient was hospitalized.

5. Poor Coordination: Nearly Half Report Failures to Coordinate Care Percent U.S. adults reported in past two years: Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008. No one contacted you about test results, or you had to call repeatedly to get results Test results/medical records were not available at the time of appointment Your primary care doctor did not receive a report back from a specialist Any of the above Doctors failed to provide important medical information to other doctors or nurses you think should have it Your specialist did not receive basic medical information from your primary care doctor

6. Tools for effective care coordination Single care plan The Attending Physician is responsible for integrating the individual care plans of doctors, nurses and other allied medical staff members into a single care plan for a patient.

7. Tools for effective care coordination Pathways Pathways are multidisciplinary care plans that can inform care team members of each other’s pre-programmed interventions and expected outcomes. All care team members must daily review the pathway for variances (deviations) from ordered treatments and from expected discharge outcomes.

8. Tools for effective care coordination Hand offs The Medical City Patient Passport is a checklist that our nurses and support staff use for endorsing patients who are temporarily transferred to other settings for procedures. The recipient of the patient reads aloud each item in the checklist and ticks them as he receives verbal confirmation from the endorser.

9. Tools for effective care coordination Safe Surgery Checklist The WHO Sign In (briefing) – Time Out – Sign Out (debriefing) protocol is used for ANY INPATIENT OR OUTPATIENT PROCEDURE that involves cutting, altering tissues or inserting scopes. The items in the checklist are read aloud by the circulating nurse or any other member of the procedure team and are individually confirmed by the staff members performing the procedure.

10. Tools for effective care coordination Team conferences Face to face conferences among doctors, nurses, therapists and other hospital committees must be called by the Attendings of all high-risk patients or patients with more than 3 MDs in the team to (1) review of the care goals; (2) assessment of the benefits and harms of current and planned interventions; (3) revision of care plans. Summary minutes are written on the Notes & Orders sheet.

11. Tools for effective care coordination Discharge planning Discharge planning is required for patients who need extended or long term health care. Shortly after admission, the care team must agree on what clinical outcomes must be achieved to safely discharge patients out of the hospital. An integrated Plan of Care is included in the SOAP. The estimated LOS is written in the admitting SOAP. Patients and caregivers are educated to prepare them to assume care responsibilities at home.

12. Tools for effective care coordination SBAR The SBAR (Situation – Background – Assessment – Recommendation) method is used by doctors, nurses and staff in communicating in clear and logical terms during critical situations.

13. Tools for effective care coordination Read back for labs and orders When critical information such as orders and lab test results are communicated verbally, either face to face or by phone, the recipient of the information must (1) write the information heard, (2) repeat the written information, and (3) require confirmation of correctness by the sender of information

14. The role of MDs Write clearly and completely on the patient’s chart. Write all assessments and orders legibly, sign, print your full name and date. Use only legal abbreviations. Avoid illegal abbreviations. Write the clinical indication when ordering a test or drug. When correcting written entries on the chart, draw a single line across the entry to be corrected, write “ERROR” and your initials beside the line, and write the correct entry above or after the cancelled entry.

15. The role of MDs 10 things to review in the patient’s chart 1.Informed Consents, ensuring all required entries and signatures are complete 2.Admitting SOAPs, ensuring discharge planning is begun for high risk and vulnerable patients and that the LOS is specified 3.Vulnerable Patients Screening Form, and acting on patient’s specific vulnerabilities 4.Resident’s Patient Database Form, ensuring correct assessments, diagnoses and plans of care 5.Records of tests and procedures done prior to admission, especially those done outside TMC (e.g., biopsies)

16. The role of MDs 10 things to review in the patient’s chart 6.Nurses’ Patient Assessment Form, noting and discussing the patient’s risk for nutritional problems, fall, bedsore and communication problems 7.Nutrition Management Service Form, approving recommended nutritional interventions 8. Medication Reconciliation Form, comparing and approving drugs to be continued and discontinued 9.Patient Education Form. 10.The Nursing Notes, checking the patient’s current problem list and nursing interventions

17. The role of MDs Check if your activated pathways are being followed. Deviations from mandatory orders or from approved optional orders must be immediately addressed before they threaten patient safety and timely discharge. During rounds, verify that pathway orders are indeed being followed and that expected outcomes that must be achieved for the day are being checked.

18. The role of MDs Round with care team members. Whenever possible, conduct a team huddle before rounding patients. Figure out how the patient is doing, check all test results and agree on the working clinical impression. Show patients that you have gotten it all together before entering the room and talking to them. Suggest a team conference whenever three or more doctors are caring for a patient, when patient care needs are complex or when unexpected patient outcomes occur.

19. The role of MDs Tell your patients how you are coordinating care Because patients are often anxious about how so many staff members can understand and remember their specific needs, you must deliberately tell them that information about their medical problems and concerns is being shared by all care team members. In other words, do not just educate your patients about their diseases; tell them how your team is integrating care for them. Hold conferences for high risk patients and families and make sure the team is there to show unanimity of purpose.

20. The role of MDs Encourage your colleagues to speak up. Research has shown that nurses find it particularly difficult to speak up when they see doctors and others take shortcuts, appear unsure or less than fully competent and when they are verbally abused by doctors. They then fail to alert you of risks to your patient’s safety, leading to patient harm. Nurses must be respectfully assertive. Doctors must actively seek out the insights of nurses and other staff about their patients. Abusive behaviour must never be displayed nor tolerated, no matter how stressful the situation..

21. The role of MDs and nurses Practice respectful assertiveness The components of an assertive statement are the following: 1.Get attention - Call the person by name 2.Express concern- “I am concerned that....” 3.State the problem - Brief, clear, objective. State in 10 seconds or less. Goal is to get immediate attention 4.Propose a solution - “We or Let’s...”

22. The role of MDs and nurses Patients have the right to knowingly refuse or default from continuing care. TMC Attending Physicians must 1.Provide full disclosure of risks and consequences 2.Address barriers to continuing treatment 3.Execute high risk discharge planning 4.Facilitate discharge and referral to external providers 5.Inform the patient’s family physician, if available 6.Make a follow-up phone call to check patient’s health status and reinforce discharge instructions 7.Write all these actions on the patient’s chart...

23. The role of MDs and nurses Patients have the right to knowingly refuse or default from continuing care. If a patient is being actively treated for a critical illness or an urgent need AND denial of the intervention will clearly be harmful to the patient, heads of outpatient unit are also obligated to make a phone call to check on the patient’s status, confirm their continuing consent for treatment and discuss how barriers to continuing treatment, if any, can be addressed. This phone call can be documented on the patient’s chart or on a logbook designed for this purpose.

24. Exercise A You are rounding a 80/M, Mr A, who was newly admitted for pneumonia and dehydration. Can you name the chart forms that you need to review, evaluate and discuss with the care team in order to ensure care coordination?

25. Exercise B You are on night duty and, while rounding Mr A, was informed by his watcher than he had been sleeping and snoring loudly for the past 6 hours. You try waking him up and found that he could not be aroused, although he was breathing regularly and his BP was normal. Draft your SBAR statements to the Attending Physician over the phone.

26. Exercise C Prior to beginning a procedure, the physician, Dr. Ree Sistant, does not wish to conduct the entire PreProcedure Briefing, since there’s no laterality involved and it’s a simple procedure (PEG tube insertion). He ultimately does so, but states “thank goodness we did that, or we would have mistakenly stuck this tube in the patient’s ear”. Draft an Assertive Statement from any team member to Dr. Ree Sistant: