1. INTERACT Boot Camp Communication Tools
August 2013

2. Welcome Back
Introduce yourselves and share what you learned from reviewing your readmission data.

3. NC ACE: INTERACT BOOT CAMP
Year long commitment to work on perfecting your Performance Improvement Project
Boot Camp
Communication Tools
Decision Support Tools
Advanced Care Planning
You are Here
Building your QI Program
Nov.
Jan.
PDSA,
Monitor Data,
Spread
Monitor
Data,
Outcomes Congress
April

4. Rolling out
communication
tools
INTERACT as QI program
INTERACT Champion
is part of the
QAPI Committee
Focus on data,
PDSA cycles

5. Where are you in the INTERACT implementation process?
Polling Question
Where are you in the INTERACT implementation process?
Have not started yet
Created plan to implement INTERACT with leadership
Started using INTERACT implementation checklist
Reviewed last 3 months of readmissions
Completing QI summary monthly
Using Hospitalization Rate Tracking Tool

6. Open Discussion
Share success, challenges, barriers, or solutions you have encountered in the last 3 months of your INTERACT work.

7. A Closer Look at Data
Interact2.net

8. Demo of INTERACT Tracking Tool

9. Tips for Hardwiring your Data
Look at your process
and outcome measures
Have Admissions enter the resident info daily
Review every morning during standup
Run monthly reports and share with leadership and staff
Discuss readmissions
Findings from QI Review Tool
Share monthly findings from Summary Tool

10. Polling Question
What is the most common driver of readmission based on your QI Summary?
Delay in identifying change in condition
Lack of evaluation before calling physician
Physician insistence on transfer
Resident family expectations
Communication problems between nurses, or between nurses and primary care clinicians
Services needed are not available
Delay in advanced care planning
Other

11. Actions for Next 3 Months
Ongoing monitoring of data
Prioritize areas for improvement
Develop your SMART goal
Assess your plan of action and make adjustments

12. Staff Education/Communication
Share your data at staff meeting:
Post your timeline on bulletin boards.
Have staff share “Bright Ideas” on implementation.
Discuss rollout at staff meeting.
Select key staff to be champions.
Begin on one unit and spread.

13. INTERACT Program Components
Putting the Tools to Work in Everyday Practice
Communication Tools
Decision Support Tools
Advanced Care Planning Tools
QI Tools

14. What This Session Will Cover
Review use of STOP and WATCH and SBAR
Implementation strategies
Common barriers and lessons learned
Problem solving for success 14

15. Communication Tools
Communication Tools

16. Polling Question
Who has been trained and is now completing the STOP and WATCH tool on a regular basis in your facility?
CNAs and nurses
All non-nursing staff with direct resident contact
Family and close friends with regular direct contact
1 and 2
All of the above

17. STOP and WATCH Seems different Talks or communicates less
Communication Tools
STOP and WATCH
Seems different
Not their usual self? Change in personality or behavior?
Talks or communicates less
Quieter? Drowsier? Confused? Change in speech?
Overall needs more help
Needs more assistance? Changes in gait, transfer or balance?
Participated in activities less
Withdrawn? Decline in ADLs? Change in normal routine?
Pain level increased 17

18. AND Ate less than usual (Not because of dislike of food)
No bowel movement in 3 days or diarrhea
Drank less than usual 18

19. WATCH Weight gain or loss Agitated or nervous
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, or toileting more than usual 19

20. Part of Daily Routine Keep the pocket card with you at all times.
Make it a part of your normal routine.
Complete the Stop and Watch form during your shift
before you leave.
Give the Stop and Watch form to the nurse taking care
of resident. 20

21. Implementation Where will forms be located?
Which nurse will direct care staff give the tool to?
How will the nurse receiving the tool respond back to
the person giving it?
4. How will the nurse document resident follow-up and
actions taken?
Where will the forms go after follow-up is complete?
Does it need to be electronic? 21

22. Common Barriers to Communicating Early Changes in Residents
Unit nurses are busy
giving medications,
taking physician
orders, and admitting
new residents
CNAs are very busy
giving direct care
Stop and Watch
can help
close the gap! 22

23. Common Barriers
Why can’t I just tell the nurse? I don’t want to write it.
Too many forms and too much paper.
Not sure where to keep them.
Not all units are consistent.
Staff are not always compliant.
Need other languages.
Hard to get all nurses on board.

24. Ways to Monitor and Improve Use
Clinical champion and/or DON
Monitor
Who completes tool?
Who the tool is reported to?
Action taken by the nurse
Documentation
Final outcome
Computerized summary or paper flow
Daily, weekly, monthly

25. Suggestions from the Field
Print on carbon paper.
Keep forms handy, near linen room and time clock.
Duplicate copy goes to DON who follows up with nurse.
Fine tune it to facility needs.
Make CNAs more aware.
Incorporate into EHR.
Emphasize benefit of written proof that CNA reported change.

26. Suggestions from the Field
Monthly drawing for person using most S&W
Bulletin board to recognize CNAs who use it
Nurses need to encourage CNAs to use tool
Automatically goes to nurses’ electronic dashboard.
Embed in new employee orientation and all in-services.
Monthly meeting with CNAs.

27. Use QAPI to Get Started Planning for PDSA
Select one unit. Make 25 copies of Stop and Watch for use.
Laminate a copy for each CNA on the unit so that it fits easily into pocket.
Make blank copies and put within easy access for all direct care staff.
Ask lead CNAs and key nurses to teach all direct care staff and nurses working on the unit how to use the tool.
Your facility’s project champion is responsible for coordinating INTERACT implementation. She or he may ask you to complete specific activities.
Suggested activities include:
Select one unit.
Make 25 copies of the Stop and Watch tool. See the INTERACT website to print a copy. Go to Click on INTERACT Tools, Click on “Early Warning Tool”
Laminate a copy for each CNA on the unit so that it fits easily into a pocket and can be used for easy reference.
Make blank copies and put within easy access for all direct care staff.
Ask lead CNAs and key nurses to teach all frontline staff and nurses working on the unit how to use the tool.
Try using the Stop and Watch for a week. Track its use as suggested. Meet with staff to discuss how it was used, what barriers arose, and ways to improve. How many times a shift was the tool used? How did the nurses respond? Try again for another week and continue to identify areas of success as well as those that need improvement. 27

28. STOP and WATCH PDSA D – Implement on unit S – Data to collect:
Number of times tool is used
Flow of tool use and responses
Staff input about barriers and what is working
A – Huddle with staff
What needs to be modified?
If no modification, then spread to other shifts and then facility wide

29. Polling Question
What type of training has been most helpful in training nurses to use SBAR in your facility?
In-person group training
1:1 training
Online training
Unit-based training
All of the above
Other

30. Polling Question
What percentage of nurses complete the SBAR successfully in your facility?
10% or less
25%
50%
75%
100%

31. Assessment/Appearance Request
Communication Tools
SBAR Tool
Situation
Background
Assessment/Appearance
Request

32. SBAR: More than one purpose
Communication tool
Contact MD/NP
Change of shift report
Morning meeting/huddle/change of status meeting
Documentation tool
Progress note
Transfer note to send to ED
Educational tool
Just in time and scheduled in-service

33. Barriers It is too long. Not all MDs like it.
If you suggest an intervention and it is not done, facility is liable.
Overwhelming for nurses without good clinical assessment skills.
Time and frustration
Nurses are not trained for this.

34. Suggestions from the Field
Education, education, education (nurses and physicians)
Adapt it to facility needs.
Fax it to MD who may fax it back or use telephone order.
Review in weekly nurse meetings.
Changed “request” to “response.”
Instruct MDs and NPs to ask nurse to complete SBAR.
Ask MDs and NPs to show gratitude for improved communication due to SBAR.

35. Suggestions from the Field
Tie use to prevention of hospital transfer and reward staff for successful prevention of transfer.
Supervisor reviews SBAR and goes over it with nurse.
Incorporate into EHR.
Use SBAR in interdisciplinary team resident reviews as the “nurses note.”
Use SBAR as first step in QI Review Tool.

36. Use QAPI to Get Started PDSA
P – Nurse input, current process, eliminate duplication, train staff, involve MD
and NP, design accountability, adjust or modify based on input
D –Begin with smaller group or unit, reinforce in daily huddle, continue to train
as needed, use in team meeting review
S – Data to collect:
Number of times tool is used
Number of times hospital transfer averted
Nurse and physician input
A – What is working? What needs to
be modified? If no modification,
then spread to other shifts or units.

37. Medication Reconciliation
Receive Admission Med from FL2
Nurse completes review
Fax Med List to MD
Fax list to pharmacy
Nurse completes MAR
MD approves list
Meds delivered by pharmacy
Nurse checks meds
Place in med cart
Makes adjustments
Clarify orders
Clarify orders
Verify any discrepancies

38. Where do most of your medication errors occur?
Polling Question
Where do most of your medication errors occur?
Upon admission with FL2
MD clarification
Transcription
Pharmacy review
Pharmacy fill
Administration
Adverse reaction

39. How to Roll Out INTERACT QI Program
QAPI Leadership Team
INTERACT
Med Rec
Tool Implementation

40. Communication with Hospital
What have you accomplished in last 3 months?
Shared Nursing Home Capability List
Met with hospital and discussed readmission
Shared potential goals you could work on
Participating in coalition with other LTC and hospital

41. Call to Action Next 3 months
Work on hardwiring Stop and Watch and SBAR
Monitor process and modify as needed
Review medication errors with nursing and pharmacy
Continue communication with hospital

42. Thank you!
This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-BI-C