Communication and Miscommunication: Say What You Mean and Mean What You Say
Communication and Miscommunication: Say What You Mean and Mean What You Say. Keith B. Armitage, MD Vice Chair for Education, Residency Director Department of Medicine UHCMC. Richard Stein, MD Assistant Clinical Professor of Medicine CWRU. - PowerPoint PPT Presentation
ObjectivesReview 2011 Medicine Quality Summit recommendations and update action plansIdentify communication gaps in -quality, - patient safety - patient satisfactionIdentify communication breakdown and potential solutions Identify improvements to system wide communication University HospitalsProposed action items from 2011 Medicine Quality SummitE-Mail choice of communication and utilized by allInpatient-outpatient handoff -admission standards -discharge standardsDischarge summaries completed time of dischargeEMR integrationUniversity HospitalsCritical & Sentinel EventsDocumentation and/or Communication IssuesThe total number of Critical/Sentinel Events in 2012 (as of 9/24) totaled 18. Of the total, 50% (9) contained documentation and/or communications issues.University HospitalsPaid ClaimsLosses by Negligence Category*Combined includes the following negligence categories: falls, test/study misinterpretation/lab error, retained foreign body, lost property, other, and unknownNote: Chart does not include Extended Care Campus, St. Michael, and Laurelwood claimsUniversity HospitalsCOMMUNICATIONActivity of conveying meaningful informationRequires sender, message, and intended recipientReceiver need not be present or aware of senders intent to communicate at time of communicationUniversity HospitalsCOMMUNICATIONCommunication game---determine how accurate intelligent health care providers can communicate defined data or information bites to one another University HospitalsMEDICAL COMMUNICATIONThree DomainsCommunication with patient/familyCommunication about patientCommunication about health and disease with communityUniversity HospitalsCOMMUNICATIONThree componentsAccurate original informationTransmissionReceptionLACK OF ANY OF THE 3 = FAILURE University HospitalsCOMMUNICATION CASE DISCUSSIONS University HospitalsCase example : Discharge CommunicationM.C. 72 year WM presents to Geneva ER with increased leg swelling and shortness of breathER diagnosis new onset congestive heart failure. Patient transferred to UHCMC as Geneva has no bedsAdmitted to general medical service; echo consistent with diastolic dysfunction. Furosemide (Hctz stopped) and calcium channel blocker are added to medical regimenDischarged on hospital day 4 to follow up with PCP One week after discharge develops maculopapular rash on lower extremities and wife calls PCPPCP, UHMP physician, did not know patient was in hospital and was not aware of changes in patients medications. Checks Portal and sees recent labs and echo, but no discharge summary PCP schedules MC for urgent visit, MC forgets pill bottles and the discharge instructions. University HospitalsCase example: Abnormal Radiology Read JQ 92 y/o admitted with abdominal pain after falling at home. Presented to ER in no distress with normal vital signs and slightly elevated WBC. House physician ordered CT of abdomen and general surgery consult CT read in Israel at 0200 Cleveland time with perforated bowel and free air. Fax was sent.Next morning at 1100 CT scan was officially read by staff radiologist. Surgeon and hospitalist immediately called. The patient coded and died at 11:30 a.m.University HospitalsCase example : Patient NoncompliancePB 72 y/o WM presented with cough for 4 weeks, SOB, fever 102 and yellow sputumLeft infiltrate on CXR and Augmentin 875 mg twice daily prescribedPatient told to phone report MD in 1 week and f/u in office in 4 weeks for repeat CXRPresented 8 months later cough of 2 months, chest pain, SOB, wt. loss and fatigue. He acknowledged he did not follow-up as directedCXR large mass in left lung, biopsy revealed lung cancer He died 8 wks. laterUniversity HospitalsCase example : Readmission RB 72 Y/O WM admitted SOB , palpitations and chest pain. Known diabetic with peripheral vascular disease. Diagnosed with atrial fibrillation, MI R/O treatment beta-blockers and Coumadin.. He discharged after 2 days on Lovenox and 10 mg of Coumadin. Told see physician after gets home (given 60 syringes of Lovenox).Communication email and letter in Portal; Office did not look upPatient called office next day( Friday) wrist pain told no openings. He would be squeezed in following FridayPresented to physician with swollen septic phlebitis of arm and INR too high to quantitateReadmission University HospitalsCase example : Consult Communication P.R 52 year old woman referred to ID clinic for fatigue and question of Lyme diseaseHad extensive workup by primary care physician and has seen Rheumatology and Neurology prior Infectious Disease referralArrives in ID clinic without records from prior treating physiciansID Clinic MD is frustrated and lets patient know this always happens University HospitalsCase example : Patient PrivacyJM 52 y/o WM corporate CEO of Fortune 500 Co. He was admitted to UH for altered mental status and headache. Hes known as innovator and many feel company success is based upon his presence and management skills. You own stock in company and decided to go online into EMR about his health and prognosis. He is diagnosed w/ an inoperable neoplasmYou decided to sell your stock holdings University HospitalsCase presentation: Email Standards and Guidelines Dr. D encourages patients to email questions or problems. Mr. A emails Dr. D with questions about asthma medications and other medical issues. Friday August 4 Mr. A emails Dr. D indicating increasing shortness of breath and is out of Albuterol and Spiriva. Mr. A receives automated reply stating I am out of the office until August 10 and have limited access to email, please call 844-XXXX with questions. Mr. D calls number, it is administrative office of Case Research institute and leaves voice mail. Over next three days hes increasingly short of breath. On 4th day presents to Hillcrest Hospital ER admitted for asthma exacerbation. Upset about not getting call or email back, switches health care to Cleveland Clinic University HospitalsCase example : Collaboration with other team members Hospitalist Dr. R. has reputation with UH Geauga nurses for being short on phone and angry at times when pagedNurse KW takes care of S.J., 70 year BF admitted with large boil on her left armpit that grew MRSA. Patient is under care of Dr. R Treated with Vancomycin for two days and to be discharged on Bactrim. Morning of discharge Dr. R stops to review plan of care . Tells SJ she will be discharged on oral antibiotic Bactrim and follow up with PCP. Completes discharge orders dictates summary, and emails PCP. Nurse KW goes over discharge meds and tells. SJ she will be discharged on antibiotic called trimethoprim/sulfa. SJ recalls years ago took similar medication and got rash Nurse KW calls Dr. R stating- SJ has question about one of her meds. Dr. R angrily tells Nurse KW he reviewed meds- Nurse KW says fine and hangs up. Four days after discharge SJ develops rash which progresses to cover her body and is associated with mouth sours.University HospitalsCase example: inappropriate communication 30 yo JG presented to out patient facility with UTI symptoms Placed in exam room told MD will be in soonHears clinical staff including MD discussing sexually activity from night beforePatient outraged and leaves office University HospitalsCommunication Game University HospitalsCOMMUNICATION NEXT STEPYour concerns and suggestions are valuable, how do WE move process forward?How do WE implement change?University HospitalsThank You.University HospitalsConsultantRespond to consult addressing specific questions askedRespond in timely manorRespond as specifically as possibleAssessment and plan first-----data chart review lastEmergency transfer of information requires direct communicationUniversity HospitalsRequesterTalk or write to consultant to guide consultantBe as specific as possible with questionsEnsure timeliness by finding availability of consultantContinue dialogues of communication until concerns and questions addressedUniversity HospitalsCONCLUSIONSE-Mail RECOMMENDED means of all communication at present sent and read in timely fashionCritical or Emergent information requires direct communication :phone /pagerProfessionalism in communicationDischarge summary completed and sent within 24 hrs of dischargeEMR INTEGRATION and ITUniversity HospitalsCase #1with a history of hypertension, DJD and hyperlipidemia presents to the Geneva ER with increased leg swelling and shortness of breath. In the ER he is hypertensive with a blood pressure of 190/105 and is mildly tachycardic but other vital signs are normal He is found to be have 1 + lower extremity edema and bibasilar rales on exam. Pulse ox is 92 % on room air. Chest X-ray shows small bilateral effusions and bibasilar infiltrates. ECG shows mild interventricular conduction delay and is otherwise unremarkable. Troponin and basic labs are negative. The ER makes a diagnosis of new onset congestive heart failure and the patient is transferred to Case Medical Center as Geneva has no beds.. He is treated with furosemide (and hctz is stopped) and a calcium channel blocker is added to his medical regimen. He is discharged on hospital day 4- and told to follow up with his PCP. One week after discharge he develops a maculopapular rash on his lower extremities and his wife called the PCP for advice. The PCP, a UHMP physician, did not know the patient had been in the hospital and was not aware of any changes in the patients medications. He checks the Portal and sees recent labs and the echocardiogram, but no discharge summary had been done. He schedules MC for an urgent visit, but the patient and wife forget to bring his pill bottles and the discharge instructions. What is expected time frame for discharge summary completion? What is communication to PCP of patient hospital stay?Case #2JQ is a 92 y/o white female admitted after falling at home with abdominal pain. She presented to the ER in no significant distress with normal vital signs and a slightly elevated WBC. A house physician ordered a CT of the abdomen and a general surgery consult was obtained and the patient was seen. The CT was read in Israel at 2 Ocock Cleveland time with a perforated bowel and free air. A fax was sent.The next morning at 11:00 the CT scan was officially read by a staff radiologist and the surgeon and the hospitalist were immediately called. The patient coded and died at 11:30 a.m.How should the initial abnormal radiology results been communicated? Case #3PB is a 72 y/o WM who presented with cough for 4 wks. duration, SOB, fever of 102 and yellow sputum production. He was found to have a BP of 138/82. Temp. 102. Resp. rate 18. PO2 92%, rhonchi at the L base. Exam was otherwise unrevealing. A. He was told to f/u by phone in 1 wk and to f/u in the office in 4 wks. for a repeat CXR.He then presented 8 months later w/ cough of 2 months duration, chest pain, SOB, wt. loss and fatigue. He acknowledged the fact that he never f/u and in fact remembered he was supposed to get a CXR he never got around to it. CXR showed a large mass in the L lung, subsequent bx. revealed a lung CA, and he died 8 wks. later. This scenario can also be presented w/o him remembering the need for f/u CXR.EMR reminders flags for follow up testingDocument patient made aware of follow up instructionsCase #4 Readmission RB is a 72 Y/O white male admitted with SOB , palpitatations and chest pain. He is a known diabetic with peripheral vascular disease. He is diagnosed with atrial fibrillation, MI is R/O and he is treated with beta-blockers and Coumadin.. He does well and after 2 days he is discharged on a lovenox bridge and 10 mgs. of Coumadin. He is told to see his physician after he gets home (incidentally he is given 60 syringes of lovenox). He calls the next day (Friday) complaining of wrist pain and is told there are no openings ,but that he would be squeezed in the following Friday. An e-mail was sent to the physician by the hospitalist and a discharge letter was dictated. The physician did not use E-mail.One week later when the patient presented to his physician he had a swollen septic phlebitis of his arm and an INR that was too high to quantitate. He was readmitted to the hospital.What is the expected frequency for providers to check emailed patient hand offs?Should UH Case emails be correct and utilized by all providers?What is the expected utilization of the Physician Portal? Case #5P.R is a 52 year old woman referred to the ID clinic for fatigue and a question of Lyme disease. She has had an extensive workup by her primary care physician and has seen Rheumatology and Neurology prior to the referral to ID. She arrives in the ID clinic with no additional records, and no records were received by the prior treating physicians. The ID clinic physician calls his/her secretary with the patient in the room and expresses extreme displeasure with the lack of referral data- and tells the patient he/she is sorry, but this always happens when I get patients from that practice.What communication process is ideal for information flow between referring and consulting MD? Case #6JM is a 52 y/o WM who is a corporate CEO of a Fortune 500 Co. He was admitted to UH for altered mental status and headache. He is a known innovator and many feel is co. success is based upon his presence and management skills. You own stock in the co. and decided to go online into his EMR about his health and prognosis. He is diagnosed w/ an inoperable neoplasm. You decided to sell your stock holdings. When is it acceptable to access EMR and other systems Mechanism to report and protect patient privacy When you sign into view chart it is recorded as entryCase #7Dr. D encourages his patients to email him with questions or problems, as he prefers this to phone tag and voice mail. Mr. A appreciates this approach, and emails Dr. D with questions about his asthma medications and other medical issues. On Friday August 4 Mr. A emails Dr. D indicating he has increasing shortness of breath and is out of both albuterol and spiriva. He receives an automated reply from Dr. D stating I am out of the office until August 10 and have limited access to email, please call 844-XXXX with questions. Mr. D calls this number, which is the administrative office for the Case research institute which Dr. D co-directs, and leaves a voice mail. Over the next three days he is increasingly short of breath, and presents to the Hillcrest Hospital ER on the 4rth day where he is admitted for asthma exacerbation. Upset about not getting a call or email back, he switches his health care to the CCF system. Should a standard office process be developed when appropriate for patient to email provider ? Case #8Hospitalist Dr. D.R. has a reputation with the nurses at Geauga Regional Medical Center for being somewhat short on the phone and sometimes being angry when paged. Nurse KW is taking care of S.J., a 70 year old woman who is admitted with a large boil on her left armpit that grew MRSA. Patient SJ is under the care of Dr. DR and is treated with vancomycin for two days and is to be discharged on Bactrim. On the morning of discharge Dr. D.R stops by to review the plan of care and to tell Ms. SJ that she will be discharged on an oral antibiotic called Bactrim and she can follow up with her PCP. He completes the discharge orders dictates a quick summary, and emails the PCP. Nurse KW goes over the discharge meds and tells MS. SJ that she will be discharged on an antibiotic called trimethoprim/sulfa. Ms. SJ recalls that years ago she took a similar medication and got a rash. Nurse KW calls Dr. DR to ask about this issue- stating she thinks Ms. SJ has a question about one of her meds. Dr. DR angrily tells Nurse KW he already reviewed the meds- and Nurse KW says fine and hangs up. Four days after discharge MS. SJ develops a rash which progresses to cover her body and is associated with mouth sours. Are patient orders and instructions being communicated to nursing and other services in appropriate manner? When is it time for crucial conversations related to communication? Case #9JG is a 30 y/o WF who presents to an out pt. facility w/ symptoms of an UTI including frequency and dysuria. She was placed in an exam room and told the Dr. will be in shortly. 10 mins. later she hears lots of laughing and loud speech outside the exam room. She can actually hear that the med. assists and Drs. were speaking about their sexual activity the night before. She is outraged and leaves the office.