Upgrading staff communication.

Having multiple disciplines involved in resident care can lead to mass confusion. Here's how one SNF solved it.

In terms of the Optima Award's structure of "Problem," "Targeted Objectives," "Implementation" and "Evaluation/Assessment," here is how our project unfolded.

Problem

1. Non-clarity of resident discharge plans caused confusion for MD, resident, family, nursing, therapies and social worker:

* Discharges were delayed due to last-minute testing and MD visits.

* MD would order discharge before therapy was scheduled to discontinue.

* Disciplines were unaware of residents' home situation and planned disposition.

* Residents were often discharged from therapies with no discharge plan in place.

2. Delayed interventions due to non-identification of resident problems, such as weight loss trends, culture and sensitivity/antibiotic therapy match, confusion/depression progression, etc.

3. Lack of communication/team approach:

* MDs visiting on off shifts were often unable to obtain current therapy and/or discharge planning information.

* Multiple calls were made to MD staff with questions that had not been addressed while the MDs were making rounds.

* PRN staff was often unaware of important resident information.

* Social worker was often unable to prioritize which residents were ready for discharge.

Disciplines focused primarily on their own jobs and were essentially unaware of the total resident picture. There was a general feeling of confusion and frustration on the part of staff, residents/families, MDs and ancillary departments. Communications were fragmented.

Team conferences were held each Tuesday with minimal interdisciplinary participation (e.g., nursing was not included). Residents who had been in the unit for two weeks were the prime focus. We touched on most of the other residents, but nothing was documented and no information was shared outside the meeting.

A UR meeting was also held each Thursday with the social worker and therapists. None of this information was formally shared outside the meeting.

* The average length of stay was 15.9 days.

* The number of admissions/month was 42.

* The Press-Ganey patient satisfaction score for nursing was 90.2.

* The last State Survey resulted in four deficiencies.

Targeted Objectives

1. To improve communication among all disciplines involved in resident care/outcomes. This would be measured by verbal feedback, state inspection reports, resident satisfaction surveys and decreased LOS.

2. To decrease length of stay. Measured by monthly/year-to-date statistics.

3. To increase resident satisfaction. Measured through resident satisfaction surveys and verbal feedback.

4. Early identification/resolution of resident concerns/problems. Measured by QA studies and resident satisfaction surveys.

Implementation

The first thing we did was to combine the two weekly meetings into a two-hour Wednesday morning meeting. This would allow time to assess those admitted over the weekend and give time for discharges to extended care facilities before the weekend. Since the meeting was to be truly interdisciplinary, we made it mandatory for the following to be present: the team RN, Nursing Assistants, PT, OT, ST, Pharmacist, Dietitian, Home Health Care, Social Worker and Activity Therapist. The meeting was facilitated by the UR/MDS+ Coordinator. Anyone unable to attend was responsible for assigning a replacement. Also present at the meetings were the Admissions Coordinator, Administrator, Respiratory Therapist and Hospice Manager.

From approximately 10:00 to 11:00 a.m., we held a combination UR/Team conference on the residents assigned to "Team 1." The physicians of the UR residents were notified as to the time of their resident's scheduled conference and did periodically attend. Then, the RN, STNAs and therapists from "Team II" came in from 11:00 to 12:00 for their UR/Team conference.

We decided to construct a spreadsheet for the conferences based on information we felt would be pertinent, with input from the various disciplines. We have been using this spreadsheet, modified from time to time, for about a year.

Prior to each weekly meeting, the social worker, RN staff, PT/OT and UR/MDS+ Coordinator would update their portion of the sheet. The Administrative Assistant entered the data into the computer (an Excel spreadsheet).

Columns on the UR/Team Conference Sheet included:

TEAM - An "X" was placed in this column if the resident was scheduled for team conference.

UR - All residents had an "X" in this column, as all were discussed at UR.

DIAGNOSIS - Taken off the Admission Coordinator's assessment sheet. We documented both the current diagnosis and any other disease process that could affect the resident's rehabilitation.

ADMIT DATE

SKILLED DAYS USED - Updated weekly by the UR/MDS+ Coordinator and including not only the number of skilled days used in our SNF, but any other skilled days used in the current benefit period (i.e., days used prior to our SNF admission were indicated by an asterisk in front of the number). This helped us keep track of Medicare days already used and to alert us when to contact secondary insurances. This was important, because we would admit residents, only to find out that they had exhausted their Medicare benefits, or they would be into their secondary insurance and find out they didn't have skilled coverage. Now the Admission Coordinator assesses each resident before admission for skilled days used and writes this number on the top of the resident's admission assessment sheet. If the resident is into his/her secondary insurance, it is followed up on before admission.

SKILLERS - Updated by the RN staff. The skillers, i.e., the treatment modalities defined by Medicare as justifying a patient's stay in the SNF (e.g., IM/IV medications, PT/OT), changed frequently, and it was very difficult to keep this column current. We now have daily mini-UR meetings that have solved this problem (discussed later).

DISCHARGE PLAN - Included planned disposition, home-going needs, insurance update, other status/post-discharge (S/P) information and decertification dates. Updated by the Social Worker and UR/MDS+ Coordinator. We have since added a PRN and part-time Social Worker to help keep up with the increasing number of admissions/month.

GOALS - Therapy had specific measurable goals written down by nursing, along with an estimated discharge date (EDD), based on the planned disposition of the resident. For example, if a resident was going home alone S/P Total Hip Replacement, then his goal would be independence. However, if he was going home with wife and son, his goals might have been for a minimal assistance level, plus he could continue with PT/OT in the home setting. This made it imperative to have an accurate discharge plan on which to base the goals.

PT/OT had not been documenting specific measurable goals or EDDs. This was difficult for them at first but improved with direction and practice.

EDD - The estimated discharge date based on therapy goals, IV antibiotic stop dates, the resident's rate of progression toward his goals and MD/resident input. This date was not "set in stone." We liked to underestimate it and push it back, rather than overestimate it and scramble at the last minute to firm up discharge plans.

At times, a date could not be ascertained and would remain in question until the resident had stabilized from an acute illness. Sometimes I would put a question mark in front of a date if, for example, we were awaiting a stop date on an IV antibiotic, which might have extended the date. The question mark was removed as we came nearer to the estimated discharge date and it was confirmed.

CURRENT CARE ISSUES - This was an open text area to express concerns, issues and thoughts regarding the resident's progress.

CULTURES - Updated weekly by the RN staff and including all cultures done either while in the SNF or done prior to admission and with relevance to the resident's treatment plan. This allowed us to double-check culture and sensitivity/antibiotic therapy relationships, as well as follow up on the need for repeat cultures.

WEIGHTS - Updated weekly by the RN staff and including the admission weight, present weight and the last recorded previous weight.

PHYSICIAN ORDER NEEDED - (explained later.)

As we discussed each resident, disciplines shared other pertinent information not on the sheet. Initially, team members did not know what information to share or what was expected of them, but with experience and the guidance of our consultant and administrator, all disciplines learned. Their questions and comments during the meetings showed a growing insightfulness as to each resident's total picture, not just one's "area of expertise." Everyone left the meeting with the same focus and goals in mind.

After the meeting, the sheets were updated on the computer. Selected items from each horizontal line were transferred to a physician fax sheet (Figure 1). This sheet was then faxed to each resident's attending and consulting physicians, with a copy placed in each resident's chart. In the "Physician Order Needed" section we posted order requests, comments and questions for the physicians.

For the RN staff to see this column we had it printed separately (Figure 2). We called it our "To Do" list. Both the "To Do" list and the updated spreadsheets were hung at the nurses station. Some of the nurses also made copies of the spreadsheet for quick reference and kept it on their clip boards. In this way, they could answer MD, resident and family questions about discharge planning, therapy goals, progress, etc.

Physicians receiving the faxes were able to see an interdisciplinary update on their resident's progress, as well as questions the team had for them. The fax sheet had the phone number for them to call to verify/update the plan of care. This cut down on physician phone calls and allowed them to call/fax when it was convenient for them (the nurses followed up if they hadn't heard from the physician by noon the next day). The physicians were educated to this process through medical staff/office manager meetings, physician newsletters and one-on-one conferences. Some wrote their responses on the sheet and faxed it back to us. Both the physicians and their office staffs expressed how helpful the faxes were, especially in indicating the estimated discharge dates.

Some physicians asked whether we were "telling them when to discharge." We explained that the EDD was only an estimated date and was usually based on the absence of a skiller. We would then ask the physician what he/she anticipated as a discharge date. Most, as it turned out, agreed with us.

Though the weekly meetings worked very well for us, our admission rate began to increase due to our decreased length of stay. The information received on Wednesday was obsolete by even the next day. Therefore, we decided to have a mini-UR meeting each morning, lasting approximately 20 minutes. The RNs brought the residents' Kardexes in with them and wrote down the EDD so it was there for all to see during report. Present were the team RN, social workers, Admission Coordinator and the UR/MDS+ Coordinator. We discussed each resident and updated the spreadsheet and the "To Do" list. Therapies, dietary and other disciplines e-mailed us if they had any updates, changes or questions, and we would add this information to the spreadsheet and "To Do" list.

We also made a list of planned discharges for the next few days. This was by request of the nurses so they could check off if the discharge paperwork was done, physicians notified and discharge orders received. The new sheets replaced the old ones at the desk and RN med carts.

Evaluation/Assessment

Our revised interdisciplinary communication system has made a tremendous impact upon the quality of care for our residents, as well for the staff. At first, many did not "buy into" the system - it seemed like needless work and the spreadsheet was not used - and it didn't seem to matter much if some disciplines didn't attend. Now, if even one person is missing from a meeting or a day goes by without updated information, there seems to be a huge void in continuity of care. In fact, if anyone doesn't do his part, it is glaringly obvious. The resulting peer pressure, along with the great pride we have in our accomplishments, continues to make this system a success. And, the longer it is in place, the more responsibility everyone takes in driving it.

Some of our measurable outcomes:

* Our number of admissions/month increased from 42 in the first quarter of 1996 to 69 in the first quarter of 1997. We had 83 admissions in April 1997.

* Our State Survey in 1996 had four deficiencies. There were no citations or deficiencies in 1997.

* Our average length of stay declined from 15.9 days in the first quarter of 1996 to 11.1 days in the first quarter of 1997.

* Our nursing score on the Press-Ganey resident satisfaction survey went from 90.2 in the first quarter of 1996 to 93.5 in the first quarter of 1997. We received the highest scores in the nursing category of the 15 participating Skilled Nursing Facilities in our area and placed first among the 15 facilities overall.

More meaningful than any of the above statistics are our residents' daily expressions of appreciation and the smiles on their faces. They know that we are on their side - that we are all on their side.

Figure 1. MD Fax Sheet.

Patient:

Room Number:             215-1

Age:                     81

Diagnoses:               Hydropneumothorax, Hx: DM, ASHD, L.
                         ventricular heart failure, abnormal
                         gammaglobinopathy

Admit Date:              5/27/97

Skilled Days Used:       *15

Skillet:                 IV Lasix, IV Fortaz, PT, SO insulin;
                         coverage - need teaching? Nursing - monitor
                         respiratory status and blood sugars.

Goals:                   Strengthening. No OT needed.
                         Await PT EDD.

Current Care Issues:     5/28 AM blood sugar - 142.
                         Resident had insulin coverage on last
                         admission, but did not go home on it.
                         Will this be the case this time also?

Discharge Plan:          Home with daughter and HHC

Target Discharge Date:   ?

PHYSICIAN ORDER          What is stop date for IV Fortaz?
NEEDED RE:               On Aricept. Does resident have a diagnosis
                         of Alzheimer's? If so, please document in
                         progress notes. Thank you.

Please contact SNF RN at 843-4330 to verify/update Plan of Care as
stated above.
Figure 2. "To Do" List.

          What is stop date for IV Fortaz? On Aricept. Does resident
          have a diagnosis of Alzheimer's? If so, please document in
          progress notes.
215-1     Thank you.

          What is indication for SO Epogen? Will this continue at
          home? Social Services will see if this is covered at home
          under hospice. (PT/OT will discharge by 6/4).
216-1     Thank you.

          When can resident be discharged home with HHC? Her only
          skiller is IV Lasix. She can receive this via HHC.
218       Thank you.

Gale Franko, RN, was UR/MDS+ Coordinator for the Parma Hospital Skilled Nursing Facility, Parma, OH, at the time of this writing. She now works in the Cardiac Rehabilitation Unit at Parma Hospital. Administrator: Elaine Connolly.