Patient and Family Engagement Communication Strategies Welcome to our call everyone. The Georgia Hospital Association members are some of my favorite to work with and I am happy to be back with you all again as we strive to achieve the Hospital Engagement Network goals and make care better in the state of Georgia. Karen Cook, RN www.studergroup.com © 2012 Studer Group

Nurses – The Most Trusted Profession Communication… The act or process of using words, sounds, signs, or behaviors to express or exchange information or to express your ideas, thoughts, feelings, etc., to someone else It’s the foundation of all interactions with patients and families Research shows patient-centered communication can improve: Patient safety More than 70% of adverse events caused by breakdowns in communication Patient outcomes, including emotional health, functioning, and pain control Patient experiences of care www.studergroup.com © 2012 Studer Group

HCAHPS Correlation Studies Source: The table above was updated 5.3.13 using 3Q11-2Q12 CMS data.

Georgia Hospitals Average Trend

Georgia Vs. Nation Vs. SG Partners Meeting Title Here (on Notes Master) Georgia Vs. Nation Vs. SG Partners GA Hospitals Change in one year +.64 Source: The graph compares the change In one year in “top box” results achieved by Studer Group partners vs. non-partners. Change is from 3Q10-2Q11 to 3Q11-2Q12. The “top-box” is the most positive response to HCAHPS survey questions. www.studergroup.com © 2012 Studer Group®

Communicating with Empathy Conscious Verbal Connectivity Non-Verbal Trust Feelings Influence Actions Compliance Clinical Outcomes Excellence The researchers identified 384 "empathetic opportunities," but found physicians responded with empathy to only 39 of them. Archives of Internal Medicine, Sept, 2008. www.studergroup.com © 2011 Studer Group

Nonverbal Communication and Empathy Eye contact most highly linked to empathy TWO Social touches (not associated with tasks such as handshake, healing touch, pat on arm, etc.) Source: Journal of Participatory Medicine.. August 14, 2013. Vol. 5

Physician Empathy = Positive Clinical Outcomes "Our results show that physicians with high empathy scores had better clinical outcomes than other physicians with lower empathy scores." good control* (A1c<7.0 percent) good control* (LDL<100mg/dL) Higher Empathy Good Control Lower Empathy Poor Control Empathy moderate control* (A1c≥ 7.0% and A1c≤ 9.0%) moderate control* (LDL≥ 100 and ≤ 130 mg/dL) poor control* (A1c>9.0 percent) poor control* (LDL>130 mg/dL) *Source: Thomas Jefferson University, Physician's Empathy Directly Associated With Positive Clinical Outcomes In Diabetic Patients

Meeting Title Here (on Notes Master) Patients’ Perception of Care = Quality Vascular Catheter-Associated Infection We are starting to see more and more evidence that demonstrates that clinical quality such as CLABSI infections are correlated with specific questions on the HCAHPS survey.. Maybe this is because they do bedside handover and visually inspect all core measure patients at each shift change? www.studergroup.com © 2010 Studer Group

Patients and Families as Partners How do they know this? We tell them “You know your health better than we do and we need your help to help you get healthy again.” “You are the only one that can tell us if we are delivering on excellent care from your perspective so we need your input on…” “We want to help you manage your pain.”

Benefits of Patient and Family Engagement Improves multiple aspects of hospital performance Overall improvements in quality and safety Patients and families as allies in safe medication use, infection control initiatives, observing care processes, reporting complications Reduction in preventable readmissions Improved patient outcomes Emotional health, symptom resolution, pain control, physiologic measures Improved CAHPS® Hospital Survey scores Patient-provider communication, pain management, medications, provision of discharge information For more specific information, refer to the handout “How Patient and Family Engagement Benefits Your Hospital.” AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get Started Guide to Patient and Family Engagement

Benefits of Patient and Family Engagement Better response to the Joint Commission standards or other accreditation Improved financial performance Decreased litigation and malpractice claims Lower costs per case due to complications Improved patient flow Less waste associated with higher call volume, repetitive patient education efforts, diagnostic tests Enhanced market share and competitiveness Establishment of brand identify around patient and family engagement Increased employee satisfaction and retention For more specific information, refer to the handout “How Patient and Family Engagement Benefits Your Hospital.” AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get Started Guide to Patient and Family Engagement

Critical Care Family Navigator Establish and maintain a feeling of warmth, goodwill and trust between the staff and the family Establish expectations early in the ICU admission Prevent misunderstandings and conflict, service recovery as needed Convey a receptive, professional attitude towards families as partners in care Support the family at point of need

What is Patient and Family Engagement? Tool provided: AHRQ Patient Engagement Toolkit Patient and family engagement: Creates an environment where patients, families, clinicians, and hospital staff work together as partners to improve the quality and safety of hospital care Involves working with patients and family members as: Members of the health care team Advisors at the organizational level Patient and family engagement is an area of increasing importance for hospitals. The ultimate goal of patient and family engagement is to create a set of conditions where patients, family members, clinicians, and hospital staff are all working together – as partners – to improve the quality and safety of care. On one level, patient and family engagement means providing day-to-day care experiences that engage patients and family members as members of the health care team. For example, in our hospital, we provide opportunities for patients and family members to be involved in their care by: [Modify the examples below to indicate how your hospital provides opportunities for partnership and engagement during the hospital stay] Making sure that we invite patients and family members to partner with their health care team throughout their stay. Conducting nurse change of shift report at the bedside, where patients and families can participate. Involving patients and families in discharge planning and plans for safe care at home. Patient and family engagement also means that patients and family members are involved beyond their own care as organizational partners, or advisors – for example, working together with staff, clinicians, and leaders to improve policies, processes, programs, facility design, and education for hospital staff, clinicians and trainees in the health professions. Patient and family engagement is not a new initiative. It is part of what we are already doing to improve quality and safety! AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get Started Guide to Patient and Family Engagement

Much of Hospital Communication is One-Way Flow of communication is “one-way” from communicator to receiver. (think discharge instructions) Advantages Fast Appears neat and quick Disadvantages Knowledge is imposed Learning is authoritative No feedback Little influence on human behavior

Barriers to Communication Physical/environmental barriers Personal barriers Physiological (Illness/Disease) Psychological barriers (Mental) Cultural barriers Personal Experiences TIME (think discharge instructions) Language/Literacy

Factors Influencing Communication: Perceptions Values Emotions Culture Knowledge Role and relationships Environment Gender Personality #lovemynurse

Engagement is Truly Two-Way Both sender and receiver take part. The process of learning is active , open and honest. Patient’s needs, values and preferences are center Promotes mutual understanding Values diversity, creativity and empowerment ACTIVE LISTENING RESPECT Influences human behavior

Guide to Patient and Family Engagement Includes four strategies to support engagement: Working with Patients and Families as Advisors Working with Patients and Families at the Bedside: Communicating to Improve Quality Working with Patients and Families at the Bedside: Nurse Bedside Shift Report Working with Patients and Families at the Bedside: Care Transitions from Hospital to Home: IDEAL Discharge Planning Tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety Includes strategies that reflect critical opportunities for patient and family engagement Addresses real-world challenges Contains detailed implementation guidance Includes tools for hospital leaders, managers, clinicians, patients, and families. The Guide contains four specific strategies that represent critical opportunities for hospitals to improve patient and family engagement. Each strategy includes a detailed implementation handbook and a set of tools (brochures, training presentations, materials) that hospitals can use to support implementation. Strategy 1: Working With Patients and Families as Advisors contains tools to help hospitals begin to work with patients and family members as organizational-level advisors, providing a mechanism for involving patients and family members in policymaking; facility design; and the planning, delivery, and evaluation of care. Strategy 2: Working With Patients and Families at the Bedside: Communicating to Improve Quality contains tools to improve communication between patients, family members, and clinicians from the point of admission, including giving patients a clearer understanding of how to ask questions, who to go to for information or help, and how to participate in their care. Strategy 3: Working With Patients and Families at the Bedside: Nurse Bedside Shift Report contains tools to support the safe handoff of care between nurses by involving the patient and family in the change of shift report for nurses. Strategy 4: Working With Patients and Families at the Bedside: IDEAL Discharge Planning contains tools engage patients and family members in the transition from hospital to home, with the goal of reducing medication errors and preventable readmissions. AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get Started Guide to Patient and Family Engagement

Patient Centered Care Delivery Model Hourly Rounding® Use opening Key words: Round Perform scheduled tasks Perform 3P’s Additional Comfort measures Environmental assessment of room Closing Key words Tell when you will return Log the round Bedside Shift Report AIDET® introduction Communication of current state and plan of care Teach back reinforcement of important patient care information such as drug side effects Nursing and Patient Care Excellence Individualized Patient Care Ask what 2-3 things will ensure excellent care Write on board Used by all members of the care team Ask each shift to reinforce listening Post visit calls 1. Questions designed to assess patients progress at home 2. Listening with more than your ears Reference: Studer Group Patient Care Model

The BASIC Best Practices are Rooted in Communication Tell the Patient/Family What you want them to know by using key words, signs, sounds, or behaviors Validate Understanding with staff Can explain why key words are important Demonstrate competency in communication Validate understanding with patients and families Use key words Teach-back to validate comprehension Individualized Care - Care/White/Communication Boards Nurse leader rounding on patients Hourly Rounding Bedside handover Discharge process including post visit calls

Often Missing Key Piece - Validation Nurse Leader Rounds – focused on communication and validating that our best practices are in place. Are we having the impact we expect from the patient and families perspective? Shoulder-to-shoulder direct observation and immediate feedback to staff on implemented best practices. Are we coaching behaviors? Whiteboard and Hourly Rounding® log checks – Have we fulfilled the promise? Skill labs – Do you know with certainty the skills your staff demonstrate? Are you and your staff doing these things every patient, everyday – Always?

Often Missing Key Piece - Validation

Top Performers Use Key Words During this hospital stay: How often did the nurses treat you with courtesy and respect? How often did nurses listen carefully to you? How often did nurses explain things in a way you could understand Staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications.

How Do They Know? We tell them… “Do you mind if I sit while I explain the test you are going to have today?” “ Mr. Jones, as I was listening to your wife, she has many questions about your new medication…” “I was listening to you speak about your pain and it occurred to me that we could try….” “I want to make sure I am listening to you so do you mind if I turn the TV off while we talk about your care?” “I have to document in this electronic record but just know that while I may look away from you, I am listening to you.” “Kathy does a great job explaining medicine side effects, can you tell me one of the side effects she taught you today?”

Hardwire AIDET® and Key Words at Key Times Narrate the care – be more verbal in our approach with patients and families Watch body language and avoid silent assessments Do you really accomplish the objectives of AIDET® Acknowledge/thank – courtesy and respect Introduction – instill confidence Duration/Explanation – reduce anxiety

Acknowledge A Acknowledge Key message: You are important Eye Contact Shake hands Acknowledge everyone in the room Sit 91% of patients want to be addressed by name and 78% of patients wanted their physician to shake hands YET physicians use the patients’ name less than 50% of the time. * Annals of Internal Medicine * Mayo Clinic Proceedings Because greetings are one way to ensure proper identification of patients, they may well be considered a fundamental component of patient safety.” It is also very rare for physicians to knock and ask permission to enter the room. This is a definite sign of respect which is one of the core questions on the HCAHPS survey. Less than 50% of physicians used the patients name – yet 91% of patients want to be addressed by name. Now if they wash their hands before and after entering the room, 78% of patients want their physician to shake their hand. This is another sign of respect.

Introduce I Introduce Name Specialty and what a Hospitalist is “ I am Dr. Beeson, I am a hospitalist, and hospitalists see patients in the hospital only, I am working with your doctor who sees you in the clinic” With the increase in hospitalists, patients don’t know who is taking care of them – this is a critical opportunity for improvement. This is the opportunity to manage up yourself, your role, your team and others that are part of the care team. 75% of patients admitted to the hospital were unable to name a single doctor assigned to their care. *Archives of Internal Medicine

Duration D Duration Key Message: I anticipate your concerns How long will the hospital stay be? How long will the test, procedure, appointment or admission actually take? How long will you be on service? How long before you come back and see the patient? These are more examples for a hospitalist who does not see the patient every day. You can also use duration when discussing how long before the results are back, what the plan for discharge is etc. Try to avoid broad generic terms like “you will be discharged first thing in the AM. Patients’ rating of quality is more predicted by their rating of the quality of communication than technical care. * Annals of Internal Medicine

Explanation E Explanation Listen to the patient’s story – 2 minutes! Clarifying questions Empathy through words and body language Explain the treatment plan Using language that patient and their family can understand with “teach-back” if appropriate 74% of patients are interrupted by physician within 17 seconds of giving their history. *J Gen Int Medicine, 2005

Thank You T Thank You Key Message: I appreciate the opportunity to care for you Closing Key words What other questions can I answer for you? Thank you for your patience in our slight delay today.

Types of Communication: Verbal Language: Chief vehicle of communication. CLEAR & BRIEF The words we use: Abdomen vs Tummy vs Stomach Pacing Timing and relevance Humor Tone Examples of verbal @ SVH Nurse Advisor Intercom/Switchboard Room Service Walkie Talkies Appointments: SVPN Vocera HCAHPS Triage ER Report to Floor Huddles

Types of Communication: Written SIGNS WHITEBOARDS MENUS Emails/Texts Education handouts Medication Bottles Manuals, Orders Policies and Procedures EMR Patient complaints An interaction that makes use of the written word and at times pictures.

Written Communication

Written Communication www.studergroup.com © 2012 Studer Group

Written Communication

Hardwire the Use of Communication Boards These are for the patient, not for the staff Customize them for your facility or care area Focus on the use of the information by the whole care team Gaps in data on the board don’t fulfill the promise to patients and families

Hardwire Use of Patient/Family Tools General Admissions Orthopedic & Bariatric

Hardwire Use of Patient/Family Tools

Hardwire Bedside Shift Handover Transitions in care have potential for medical errors Research shows bedside shift report can improve: Patient safety and quality Improved communication Decrease in hospital-acquired complications Patient experiences of care Time management among and accountability between nurses Decrease in time needed for shift report Decrease in overshift time We are interested in focusing on Strategy 3: Working with Patients and Families at the Bedside: Nurse Bedside Shift Report. Patient safety and quality. Bedside shift report is an opportunity to make sure there is effective communication between patients and families and nursing staff. One study found that more than 70 percent of adverse events are caused by breakdowns in communication among caregivers and between caregivers and patients.1 Studies have shown that bedside shift report improves patient safety and service delivery.2,3 For example, one study showed a decrease in patient falls during change of shift, dropping from one to two patient falls per month to one patient fall in six months.4 Improved communication during shift report can help catch potential medical errors in blood incompatibility, catheter-associated urinary tract infections, and air embolism, all of which are on the Centers for Medicare and Medicaid Services’ (CMS) list of hospital-acquired complications “never events.” Patient experience of care. After implementing bedside shift report, hospitals reported an increase in patient satisfaction scores and improvements in the nurse-patient relationship.5,6 Also, one study noted a sharp decline in the average number of call lights on by the end of shift change.4 Time management and accountability between nurses. After implementing bedside shift report, nurses have reported better ability to prioritize their work or cases during their shift and an overall decrease in staff time.4,6 One study noted a decrease in overshift time by 100 hours in the first two pay periods on a 32-bed general surgical unit.6 In another study on a 34-bed progressive care unit, a 2-month review of overtime data demonstrated an $8,000 reduction directly associated with the decrease in time for shift report.4   [Include hospital specific goals or data] References Sentinel event root cause and trend data. Improving America’s hospitals: the Joint Commission’s annual report on quality and safety; 2007. Available at http://www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf. Accessed July 23, 2010. Athwal P, Fields W, Wagnell E. Standardization of change-of-shift report. J Nurse Care Qual 2009;24(2):143–7. Chaboyer W, McMurray A, Johnson J, et al. Bedside handover: quality improvement strategy to ‘transform care at the bedside.’ J Nurse Care Qual 2009;24(2):136–42. Chaboyer W, McMurray A, Wallis M. Bedside nursing handover: a case study. Int J Nurse Pract 2010;16(1):27–34. Anderson CD, Mangino RR. Nurse shift report: who says you can’t talk in front of the patient? Nurs Adm Q 2006;30(2):112–22.  Kelly M. Change from an office-based to a walk-around handover system. Nurs Times 2005;101(10):34–5.

Addressing HIPAA concerns Health information can be disclosed for: Treatment Health care operations Payment HIPAA acknowledges incidental disclosures may occur Not a HIPAA violation as long as Take reasonable safeguards to protect privacy Disclose only or use the minimum necessary information As nurses, you may be concerned about violating HIPAA, especially when family members are present at shift report or if you have patients in semiprivate rooms. It is important to know that because bedside shift report is part of treatment and normal operations, it does not violate HIPAA. Strategy 3: Nurse Bedside Shift Report (Tool 3) Strategy 3: Nurse Bedside Shift Report Training (Tool 3)

Accelerator – Patient/Family as Advisors Patient and family advisors help us provide care and services based on patient- and family-identified needs rather than our assumptions Patient and family advisors offer Insight on our strengths and areas where changes may be needed Feedback on practices and policies that can help patients and families be active partners in their care Feedback that is timely and gives a fuller picture of the care experience than standard patient and family satisfaction surveys We are interested in focusing on Strategy 1: Working with Patients and Families as Advisors. Working with patient and family advisors can help us improve the quality and safety of care we provide by building a shared agreement around quality and safety priorities. In addition to the improvements in hospital performance already discussed, working with patients and families at an organizational level has benefits [read slide]. Information to Help Hospitals Get Started

Accelerator – Patient/Family As Advisors Formal – Advisory Council Focuses on strategies, priorities, input on decisions Informal – Spontaneity, convenience Waiting rooms, bored families Invite 2 families per unit to have lunch that day with the CNO (planned every other week) Past employees who received care “What rules did you have to break to get care?” “What made you most/least proud of the care?”

Electronic Family Advisors

Accelerators: Every Department, Every Experience

Accelerators - Infrastructure Senior leaders integrate family/patient engagement strategies into culture Serve as role models for engaging in partnerships with patients and family members Provide resources to support initiatives Integrate into personnel policies and practices Align incentives to results Patient and family engagement can be a way to improve quality and safety at our hospital. But, sustained change does not happen without a clear mandate and ongoing support from leadership – you. There are different ways you can show support for patient and family engagement. Note to presenter: For more information, see the handout “Supporting Patient and Family Engagement: Best Practices for Hospital Leaders.” Guide to Patient and Family Engagement

Final thoughts Our hospital is committed to patient and family engagement — everyone plays a critical part Patients and families won’t engage if they believe that you don’t want them to—it is simply too risky for them Your job is to make it safe for them to be involved, not just as patients but as partners in their care How do they know ___ - you tell them How do we know ____ - we ask We would like to end by reiterating how important patient and family engagement is to our hospital. Clinicians and hospital staff play an important role in inviting and support patients and families as full partners in the health care team. By doing this, we can work together as partners to improve care experiences for everyone. Strategy 3: Nurse Bedside Shift Report Training (Tool 3)