Communication
Cathy Bachert, RN, Director, Quality
Molly Nadeau, RN, MBA, Director
Case Management
Cape Cod Hospital, Hyannis MA
All Communication is Not
Equal
• “No one would talk much in society if they
knew how often they misunderstood others. “
— Johann Wolfgang Von Goethe
WE STOPPED TALKING TO
EACH OTHER!!!!
The Problem
• Nurses in the SNFs would rely on the
information abstracted from the patient’s
medical record
• There were no planned opportunities to
speak to the nurses at the hospital
• Although they could call, it was generally
not done
We Communicated to the
Wrong People
• SNF Screeners reviewed written materials
and communicated to the SNF Charge
Nurse 7-3
• SNF Admissions were frequently on the 311 shift Nurse at CCH did not know the
patient
Relationships 
• Paper work did not contain those bits of
information that nurses could share one on
one about the patient
• SNF nurses felt intimidated about calling
the hospital nurses. “Don’t want to bother
them”
• Lack of Trust on both sides
Aim Statement
• Aim: Develop a nurse to nurse verbal
communication process between the
Skilled Nursing Facility (SNF) admitting
nurse and the hospital discharging nurse
by April 15th, 2011.
Expected Results
 SNF nurse obtaining all information
needed to care for the patient and make
informed decisions
 Especially helpful when communicating
with physicians about potential need for
transfer back to the hospital
 This communication will ultimately result in
a decrease in readmissions
Create a New Process
• Set an expectation that there would
always be a call for the patient handoff
– Flow of clear identifiable process steps with assigned
responsibilities for both the SNF nurse and the hospital
RN.
– Education of the staff at both SNF and Hospital – Nurses,
Case Managers, and Nurse Unit Managers.
Eliminate the Middle Man
• Create a process for direct communication
between caregivers
• Identify clear defined steps to that process
• Test the process and gain feedback
Nurse to Nurse
Communication
• What if we gave the nurse who was
accepting the patient at the SNF direct
communication about that patient from the
nurse who was discharging the patient?
• Nurse with the most information
gave that information
Nurse to Nurse
Communication
SNF Decision
is made
Hospital Case
Manager will
provide to
liaison or SNF
Admissions
Coordinator
the 4 elements
The SNF fills in
form with the
patient -nurse
identifiers and
the hospital 4
elements
SNF Nurse
reviews patient
info previously
provided by
hospital
Add pertinent
information to the patient
care plan and
communicate to
appropriate staff
Hospital
transfers
patient to SNF
SNF receives
patient
Hospital discharging
Nurse gives hand-off
report to SNF Nurse,
allowing for questions
The SNF Nurse Calls
Hospital Nurse prior to
planned transfer to SNF
SNf Nurse
prepares
questions
based upon
info review
prior to calling
hospital,
utilizing form
SNF RN completes
admission assessment.
Calls hospital with any
unresolved issues or
concerns.
SNF RN
communicates
plan of care and
patient's goals to
care team.
Anticipated Push Back –
“One More Thing”
• How could we create a process that
would pull instead of push back?
• Which Nurse most needed the
information?
• Did the nurses find value in the call?
Let’s Ask The Nurses!!
• Hospital RN Staff Meetings Revealed:
– We don’t have time
– We will end up doing their work for them
– They already get that information, will we be
repeating the same information?
Something Surprised Us and
Helped Us
• Novice Nurses were at the staff meetings
who worked also at the SNFs
• They voiced a valid reason for the call –
All Patients can be “Scarry” especially
without a verbal report
• Appealed to a new EC to Inpatient process
that recently left RNs feeling unsure
Was it Valuable?
• “Did the Nurse to Nurse Call Add Value?”
• We wanted to know: So we asked the
nurses from the SNF and also from the
Hospital side utilizing a formal audit tool
What will we measure?
•
•
•
•
Did the call occur?
Time of the call:
Did call occur prior to transfer?
Did the call add value to the information
needed to care for the patient?
• Duration of call
• Number of calls by SNF about the same
patient
• Did the call address a common cause or a
potential readmission?
Value - Overwhelming Yes
• 95% of the time – Yes
• Time of call = less than 5 minutes per call
• What went wrong?
– SNF nurse not prepared and used call to
screen information already provided in writing
– Hospital Nurse did not always have the same
view of the issues from their perspective
Conclusion
• Nurse to Nurse Communication was and is a
success
• SNF and Hospital Nurses have reconnected
• Trust is being restored
• Readmissions have been avoided – case
study
Molly Nadeau, RN, MSN, Director Case Management
MD COMMUNICATION /
APPOINTMENT
What Happened to PCP
Communication?
• Problem: PCPs were out of the loop on
their patient’s admission and discharge
from the hospital.
• PCPs reported reading about patient
death in the news paper obituary column.
Background
• Hospitalist vs. PCP Attending patients in
hospitals
• Medical Records no longer mailing hard
copies of the discharge summary
• PCPs in offices not computer savvy –
don’t read automatic e-mails
• We stopped talking to each other!
MD Notification Form
• Faxed at discharge
• Unit Secretary responsible
• Form edited several times to include more
detailed information
• Added the Clinical Resume and
Medication List to the faxing
Measuring the Process
• Compliance initially at 67%; Currently at
79%
• Intervention:
– Unit Secretary meeting
– Frequent Rounding and Reinforcement of
form
– Feedback from Physicians – they liked it!!
MD Appointments
• Clear Expectations developed and
communicated:
– Who would be responsible to call MD office?
– What patient population needed MD
appointment?
– How many days after discharge?
– What if the doctor could not accommodate ?
– How is it going?
SNF READMISSION AUDIT
Why Audit SNF
Readmissions?
What Should We Look At?
30 Day All Cause SNF to Hospital Readmission Analysis
February, March, April
2011
Population – All patients readmitted within 30 days of discharge from CCH during the months of
February, March, and April 2011, with a subsequent discharge from your SNF prior to the readmission
back to the hospital.
This population includes:
-
Patients that you transferred back to the hospital
In addition, patients discharged home from SNF and readmitted within 30 days of hospital
admission
Analysis: Do a simple data analysis on data collected.
Conclusions:

What did you learn?

What trends or themes emerged?

What, if anything, surprised you?

What new questions do you have?

What are you curious about?

What do you think you should do next?
 What assumptions about readmission that you held previously are now challenged?
Recommendations: Now that you have studied your population of patients that were readmitted, what
would you recommend for process improvement?
What To Do Next?
•
•
•
What number of patients are sent to the EC and returned? (New Study)
Review “ Real Time” Review of all unplanned readmissions.
Increase Skill Level – Nursing (Critical thinking Education on care
guidelines process)
– IVs
– Low freq. high impact “Support Teams”
– Real time training ( On the Spot )
•
•
Interact Program – Fully Integrated into SNF day to day work
Develop nursing practice guidelines- Disease Specific
– Share Hospital Care Maps and protocols
– VNA Share care maps with SNFs
•
Med Rec – Dovetail.
– Identify patients at risk for readmission on admission
– Refer discharged patients for pharmacy consult with VNA
•
End of life Improvements
Just Do It!
• Create your own “Nurse to Nurse Process”
• PCP Notification
• MD Appointments
• Study the SNF Population:
– Partner for success
Our Staff / Our Greatest
Resource
• Leadership is Key
• Staff left alone to define, revise and
implement will fail
• A Leader will emerge
• It may not be the one you expect
• LEAD THE CHANGE AND
CHALLENGE YOUR TEAM TO
BECOME THE BEST!