Presentation on theme: "ISBAR for clear communication"— Presentation transcript:
1ISBAR for clear communication Clinical communication for health employees
2Aim of ISBAR education is to help you to … further develop your communication skillsutilise these skills when making a telephone referralutilise questioning/prompting skills as necessary when receiving a telephone referralstandardise the use of a common agreed toolTelephone referral = any telephone conversation made by a clinician (medical, nursing, allied health) to another member of staff that relates to the immediate care of a patientClarify the term clinician as describing Nurses, Allied health as well as doctors.Clarify the term referral – this is when any clinician wishes to pass patient information to a colleague.
3Structure of session Introduction Video viewing and critique (X2) Explanation of ISBAR toolVideo viewing and critique (x1)ISBAR activity in pairsConclusion / evaluationIntroduce self and outline session componentsStress ISBAR activity is probably most important part of session
4Why is this topic important? Patient care is dependant on effective communication - including telephone communication between all staff involved in the care of the patientEffective communication has become more important as healthcare has become more complex, highly specialised and team-basedJCAHO & Southern Health statisticsAsk why topic important to involve staff.JCAHO Joint commission for Accreditation of Hospital organisations (US) reviewed sentinel events found between % involved communication failure.Southern Health reviewed their sentinel events over last 3 years and found 35% of events had communication failure as a major contributor to the event.In 2008 South Australian Hospital Insurers reported up to 30% of medical litigation cases involved “poor clinician to clinician” communications as significant contributor to the cases
5Why is it important to have a standard approach to telephone communication? It is a daily taskIt is rarely explicitly taughtTelephone referrals can be a source of frustration for both the ‘giver’ and the ‘receiver’Ineffective telephone communication can compromise patient careAsk how many can remember being taught a standardised communication technique in their original training sessions.( you may find that those who have had training also had military experience)Michael Leonard noted that teamwork and communication skills are assumed rather than taught.Styles of communication: Doctors tend to like short concise information styles i.e. in Bullet points or Headlines.RNs are traditionally trained in the narrative style to give the Doctor the complete picture, not to leave anything out. – this results in frustration on both sides – the MO may wish the RN to get to the point and interruptWhereas the RN may wish the MO would wait and allow the story to be told and Not interrupt.Result : A collision of two differently taught stylesISBAR allows a common standard to overcome or bridge these very real frustrations
6Some questions for you… How often do you make or receive a telephone referral?Generally, is making a telephone referral easy or difficult?What have you experienced?If sometimes difficult, why?What information would you like when receiving a referral?The purpose of this slide is to generate discussion and motivate participants to pay attention for the rest of the session. Get them thinking about the challenge of making referrals. What has their experience been? Why is it sometimes difficult?The sorts of reasons may be:Language .Staff for whom English is their second languageIn Dandenong area of Melbourne there are 122 different nationalitiesExperience: Junior staff not always aware of what is or is not relevant.Fear: Junior staff fearful of looking foolish in front of senior colleagues and may try to fix the problem instead of calling for assistance.Simple & complex cases –Young person with appendicitis compared to elderly person with multiple co morbidities: respiratory failure, cardiac failure, arthritis, partner for whom they care has severe Alzheimer's.ISBAR is a skill to be practiced.
7Some of the challenges People are busy and don’t want more work! It can be difficult to summarise a complex case succinctlyThe person making the referralis often asked about things they have already saidmay not get the help they were expectingThe person receiving the referral mayinterrupt mid-sentencemake assumptions about the capability of the person making the referralNotes:Explain that with ISBAR being asked to repeat information is a GOOD thingBecause it is a standard way of giving and receiving information it helps build up the picture of the patientIt is like handing over pieces of a jigsaw puzzle .Senior more experienced staff can assist junior less experienced staff by asking for information that THEY know is relevant but the junior person may not.“Hint & hope technique ” Junior staff are often embarrassed to ask for help outright and read chapter and verse hoping that the senior person will make the diagnosis AND come and see the patient .The ISBAR technique gives then permission to ask for help upfront. It flattens the hierarchy and encourages politeness
8What strategies do you already use to assist the process of making or receiving a telephone referral?The purpose of this slide is to find out what they already know and do.It provides a baseline so that the presentation is pitched at an appropriate level.They can learn from each other and demonstrate that they already possess a degree of skill in this area.Resist the temptation to teach at this stage.If no answers forthcoming suggest prepare by reading recent medical notes and observations and make SHORT notes following ISBARa common easily taught and remembered structure with a track record in the high reliability industries.
9ISBARA tool used to help provide structure to communication in a number of settingsAdapted from SBAR, a tool developed by the US Navy to improve communicationWe are proposing the use of ISBAR in relation to making and receiving a telephone referral“We will talk more about ISBAR after the first 2 videos”Further Notes for Nurse educators & Trainers:You may be asked for the clinical evidence base for ISBAR –. There is little evidence in health care. Southern Health in Victoria was the first organisation on the planet to put ISBAR into place and EVALUATE it.It has been implemented at The Kaiser Permanente Hospitals and Veterans Administration Hospitals in the US but results are mostly anecdotal.Much of the information on ISBAR has come from the High Reliability Industries and a has a 30 year historyNASA for example has 500,000 reports on near misses from aircrew.They have a no blame reporting system so that individuals organizations areDe identified.It is recognized that studies of near misses (Incidents) are infinitely preferable the retrospective review of the other end of the continuum -accidentsMilitary very good at simplifying and developing tools to assist staff when organization is working at capacity and under duress.High Reliability Industries : Military, Nuclear Power Generation, Air Traffic controlall actively seek out “near misses” and develop scenarios for staff to practiceTheir error rating has been estimated as being 1:10,000 – this does not mean they do not make mistakes they do but they pick them up and correct them using standardised communication techniques like ISBAR and checklistsIn comparison Healthcare globally has an error rating estimated as between 1:10 to 1:15Running the range of errors from missed medications to pacemaker patients being put into MRIIn many ways healthcare can be more complex than a cockpit,Multiple issues: patients condition and changing treatment plans, staff , families , procedures
10By the end of this session you will be able to… describe the use of the ISBAR tool in making a telephone referralprepare for a ‘mock’ referraldemonstrate the successful use of the ISBAR tool to make a ‘mock’ referralidentify possible situations to use ISBAR in your workplace
11Structure of session Introduction Video viewing and critique (x2) all videos relate to the same caseExplanation of ISBAR toolVideo viewing and critique (x1)ISBAR activity in pairsConclusion / evaluation
12Video OneWhat are your thoughts on this doctor’s attempt at making a referral? What suggestions for improvement would you give him?NOTE The videos ARE Not embedded so click on the Hyperlink.Ask for feedback at end of each video.?What are the many problems with this referral.?Ask, did the doctor in the video do anything well?
13Focused but not prepared The doctor clearly states what he wantshe wants the other doctor to come and see the patientHe checks he is talking to the right personbut …He doesn’t have important information at handThe main problem is lack of preparationhow long does it take to prepare?what things should be prepared before picking up the telephone?Stress being prepared and having the information to hand. Patient notes , Observations, recent results,To take the 4 to 5 minutes required to prepare a good referral.STRESS Patient safety always overrides other factors.
14Video TwoWhat are your thoughts on this doctor’s attempt at making a referral? What suggestions for improvement would you give him?NOTE The video is Not embedded so click on the Hyperlink.HINT : For the longer video (VIDEO No 2) play for first 1 minute and 20 seconds until the DOG is mentioned and then use the mouse to forward the video in 20 second bites. Play for 5 seconds. Then repeat until you reach 3 minutes and allow video to finishThe audience will appreciate the amount of time and the dis-organisation of the referral.Ask for feedbackWhat are the many problems with this referral.?Again ask, did the doctor in the video do anything well?
15Prepared but not focused this is an exaggerated vignette to make a point The person on the other end of the phone gave up because the information was neither concise nor organisedAll the relevant information was included, but …The message was not clearNote: the relevant information needs to be delivered slowly and simply with appropriate emphasis and repetitionThis video is an example of too much unstructured informationA simple rule of thumb for ISBAR is to ask staff to allow seconds on each sectionand include only what is currently relevant.
16Structure of session Introduction Video viewing and critique (x2) Explanation of ISBAR toolVideo viewing and critique (x1)ISBAR activity in pairsConclusion / evaluation
17ISBAR I - Identify S - Situation B - Background A - Assessment R - Request
18ISBAR Provides a standardised structure for communicating Helps prioritise information for both partiesDecreases the chance of forgetting relevant informationHelps to decrease assumptions by making the reason for the call obvious at the outsetNote, many points may already have been covered in the discussion so far. If so, there is no need to repeat every explanation of every point in ISBAR. All points are covered in the power point presentation in case some ideas have not come up in the earlier discussions.
19I - Identify Identify yourself - name, position, location Identify the person you are talking to if not already doneIdentify the patient and unique ID number“Hello. My name is Jasmine Sass, I’m a Division 1 RN working on Ward 2 at …. Hospital. Are you the medical registrar on for ward referrals today? … I didn’t catch your name?…I’m calling about a patient - Terry Jones - a 56 year old man in our surgical ward at ….. Hospital”In services with Multi sites it is important to state which ward AND facility you are calling from .There are documented cases of senior medical registrars staff being called out and going to the WRONG hospital.or phone calls being disconnected and no one knowing who they had been speaking to or where the call originated.
20I - Identify continued… Why give your name?it is polite and professional to do soWhy give your position?helps the information receiver to know at what level to pitch their response/adviceWhy state where you are calling from?the information receiver may work at multiple sitesWhy identify the person you are speaking to?to make sure it is the appropriate personWhy do you need their name?to document in the notes for future referenceWhy identify the patient - name, age, sex, location?helps identify the patient and helps the receiver to develop a mental picture of the patient
21S - Situation Explanation of WHY you are calling “I am calling you about a patient, Mr Jones*. He is a 56 year old man, 2 days post hernia repair who has developed new atrial fibrillation with a blood pressure of 105/66. He looks pale and feels unwell. I would like you to come and assess this patient please”If urgent, make this clear at the start“Mr Jones is a 56 year old man who is 2 days post hernia repair. He has gone into atrial fibrillation. He is stable at present with a blood pressure of 105/66 but he is normally hypertensive. He looks pale and feels unwell. I am concerned about him and would appreciate it if you could come and help us to stabilise him”*No need to repeat patient’s name age and sex if already included in IDENTIFY
22S - Situation Continued Stating the purpose of the call at the start of the conversation helps the receiver focus their attention appropriately when listening to the story
23B - Background Tell the story “I’ll tell you the story…”“I’ll give you the background information…”Provide RELEVANT information only. Deciding what is relevant is a skill that comes with experienceDon’t forget ‘less is often more’you may get the message across better with less informationInclude aspects of history, examination, investigations and management where relevant
24B - Background Continued… The volume of information will depend on the situationLessif the receiver will see the patient themselves shortly. No background may be quite appropriate in this situation.if the receiver already knows the patientMoreif you are wanting management advice over the phone without the receiver seeing the patientThe receiver can always fill any important gaps in your story with questionsWhen both staff are using ISBAR it becomes a mutual assistance AND Learning / Teaching technique.It enables the senior person to guide the junior person.
25A - AssessmentState what you think is going on. Give your interpretation of the situationDon’t leave the receiver to guess what you are thinking - tell themStating the obvious is helpful hereInclude your degree of certainty
26A - Assessment cont…“… the patient is febrile and I can’t find a source of infection”“The patient has improved but I am concerned they have had a pulmonary embolus”“The patient has acute coronary syndrome”
27R - RequestState what you want from them“We would be grateful for your opinion regarding the need for surgery”“I need help urgently, are you able to come now? … If not, who should I call?”Ask questions“What would be the most appropriate antibiotic in this situation?”“What are the priority tasks for me while you are on your way?”The request usually comes down to 2 options :Please come and see the patient OR please give me management advice.
28Additional points…NB: What you say for Situation may be a concise summary of what you say for Assessment and Request. This repetition is helpful as it emphasises the key purpose of the referralSometimes the receiver will lead the conversation – you can still use ISBAR as a guideDon’t forget, the receiver may not be familiar with ISBARISBAR is a flexible toolSo the REQUEST may be also summarised in the SITUATION to attract attentionFor example a request for a sleeping tablet is unlikely to require a full history
29Preparation for the call Preparation is vital - use ISBAR to prepareMake sure YOU are clear on the reason for referral before callingWrite down your questionsDocument a written referral in the notes if this is the practice for formal referrals in your hospital or include in nursing notesGather relevant patient details, notes, charts, ECGs, observations etc before making the callHave pen and paper on hand to write down names, numbers and instructionsSome of this may already be covered after the first video.
30Structure of session Introduction Video viewing and critique (x2) Explanation of ISBAR toolVideo viewing and critique (x1)ISBAR activity in pairsConclusion / evaluation
31Video ThreeWhat are your thoughts on this attempt at making a referral? This is an example of ISBAR in action…There may not be much left to discuss at this point.Move onto the activity.
32ISBAR can be done briefly - 1 I - “Hi, I’m Joe, an intern in ED”S - “I would like to refer a 66 year old man with pneumonia”B - “He has been on oral antibiotics for 1 week with no improvement. He is stable and we have commenced IV antibiotics”A - “His presentation of pneumonia is classic”R - “Are you able to see him with a view to admission?”The video examples are all long. This brief example is included to show that a brief referral is also possible using ISBAR
33ISBAR can be done briefly - 2 I - “Hi, I’m Sue, an ANUM on Ward 2”S - “I would like you to come and see a 21 year old man who has had a significant skin reaction to an IV antibiotic”B - “He was admitted this morning for treatment of an appendicectomy wound infection. He is a type 1 diabetic. He has just had his first dose of Gentamicin, Metronidazole and Ampicillin”A - “He is anxious and appears flushed with an erythemous rash on his chest and arms. His blood pressure is normal”R - “Are you able to see him urgently?”“What would you like me to do in the meantime?”
34If you are receiving the referral Don’t forget you can helpAre we using the ISBAR format?Can you give this to me in ISBAR format?Can you please identify ….?patient’s name, locationWhat is the Situation?What is the Background?What is your Assessment?What do you think needs to happen?ISBAR is a two way processYou can “Reverse ISBAR” to EXTRACT the information you know you needYou can guide ( and teach) the less experienced colleague as to what information is required for this type of patient.
35Structure of session Introduction Video viewing and critique (x2) Explanation of ISBAR toolVideo viewing and critique (x1)ISBAR activity in pairsConclusion / evaluationISBAR PracticeProbably the most important part of the sessionAsk them to take 5 to 10 minutes to prepare a referral from the most appropriate scenario provided.Reassure that there will be no marking -it is rather like riding a bike - may be tricky at first but becomes second nature with a little practiceGive them the handouts of the example answers.
36Other applications of ISBAR Making a written referralPresenting a case on a ‘ward round’Handing over a complicated patient to covering staffWhen transferring or receiving a patient from ED‘Standardised Forms’ development
37Structure of session Introduction Video viewing and critique (x2) Explanation of ISBAR toolVideo viewing and critique (x1)ISBAR activity in pairsConclusion / evaluation
38ConclusionISBAR is a simple tool that enables a standardised approach to telephone referrals7001 Medical Nursing & Allied Health staff trained at Southern Health4760 attended sessions, 2813 evaluations completed % worthwhile, 91.66% relevant to them % relevant to colleaguesConclude that the power of ISBAR lies in its standardisation – a technique that everyone uses.There are other techniques but few with such a track record such as ISBAR which has a 30 year track record in the high reliability industriesSuch as Air traffic control, nuclear power generation and the military.3838
39ISBAR in Practice Diagnostic Imaging: reduction in error (Interim results - Southern Health 2009 )Reduced inpatient misidentification: 9% to 2 %Reduced incorrect procedure verification: 30% to 4%Reduced incorrect side and site verification: 55% to 5%Referrer Audit: improved compliance. Clinical detailsprovided 100% of timeContact details: non conformance reduced:15% to 2%These are the interim results since ISBAR was introduced into the Diagnostic Imaging form in 2008.These are significant improvements.
40ISBAR forms Emergency Dept to ward transfer form Emergency surgery booking formMedical Referral FormPain Consultancy Request FormNew ISBAR forms discovered during evaluationBirth Suite record of telephone contactWound Assessment Request
41ISBAR in practiceSimulation Centre Study : Medical students assessed in SIM Centre. ISBAR trainees outperformed non trainees each time. 88% of Junior Staff using ISBAR tool six months later Marshall et all Qual Saf Health care 2009,18(2):137-40There is leading evidence that ISBAR promotes improved patient safety and outcomesSim Centre StudyMed students (un knowingly ) divided into two groups One group trained in ISBAR the other was notThe groups attended the simulation sessions and asked to make a referral which was recorded and analysed.Consistently over a 3 year period even lowest performing ISBAR trained people ALWAYS out performed the best NON ISBAR person when making a referral.6 month follow up by SIM centre showed junior staff still using the ISBAR technique in their practiceAnd they reported it gave them structure and confidence when reporting to senior or other colleaguesAsk Staff to start using ISBAR when they return to work after this session and encourage teach and practice technique in their clinical
42Questions? Thank you for supporting the use of ISBAR in our organisationISBAR tools (2010) – developed by Southern Health in partnership with the VMIA