Transcript Slide 1

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
Chris Tredent RN, BSN
Chris Sydenstricker RN, BSN, MBA, CPHQ Director of Quality
Senior Quality Nurse
Geneva and Conneaut
UHCMC
Rita Szymczak RN
Michelle Borisa
Senior Clinical Application Analyst
IT Clinical Application Analyst
UHCare Ambulatory EMR Project
Electronic Medical Record
University Hospitals
University Hospitals
Lynn Lebit Hardacre, Esq.
Associate General Counsel
University Hospitals
Objectives
• Review 2011 Medicine Quality Summit
recommendations and update action plans
• Identify communication gaps in
-quality,
- patient safety
- patient satisfaction
• Identify communication breakdown and
potential solutions
• Identify improvements to system wide
communication
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Proposed action items from 2011 Medicine
Quality Summit
• E-Mail choice of communication and utilized
by all
• Inpatient-outpatient handoff
-admission standards
-discharge standards
• Discharge summaries completed time of
discharge
• EMR integration
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Critical & Sentinel Events
Documentation and/or Communication Issues
2012 Critical & Sentinel Events (as of 9/24)
Incident Types with Documentation and/or Communication Issues
8
7
6
3
CE/SE
5
4
3
5
2
4
1
1
1
0
Treatment
Surgery
Other Issues
Medication Error
Communication and/or Documention Issues
The 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.
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Paid Claims
Losses by Negligence Category
Paid Claims By Negligence
UH Wholly-Owned Hospitals
CY 2004-2012 as of 8/31
8%
Delay/Fail to Dx/Mis-dx/Fail to Treat - 50
26%
12%
Delivery Comp (Maternal/Fetal) - 19
Post-Op/Procedure/Surg Comp - 64
Fail to Prevent/Adv Reaction - 43
Medication Error - 15
Combined - 196
12%
23%
Total Paid Claims - 387
19%
*Combined includes the following negligence categories: falls, test/study misinterpretation/lab error, retained foreign body, lost
property, other, and unknown
Note: Chart does not include Extended Care Campus, St. Michael, and Laurelwood claims
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COMMUNICATION
• Activity of conveying meaningful information
• Requires sender, message, and intended
recipient
• Receiver need not be present or aware of
senders intent to communicate at time of
communication
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COMMUNICATION
• Communication game---determine how
accurate intelligent health care providers can
“communicate” defined data or information
bites to one another
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MEDICAL COMMUNICATION
Three Domains
• Communication with patient/family
• Communication about patient
• Communication about health and disease with
community
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COMMUNICATION
Three components
• Accurate original information
• Transmission
• Reception
LACK OF ANY OF THE 3 = FAILURE
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COMMUNICATION
CASE DISCUSSIONS
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Case example : Discharge Communication
• M.C. 72 year WM presents to Geneva ER with increased leg
swelling and shortness of breath
• ER diagnosis new onset congestive heart failure. Patient
transferred to UHCMC as Geneva has no beds
• Admitted to general medical service; echo consistent with
diastolic dysfunction.
• Furosemide (Hctz stopped) and calcium channel blocker are
added to medical regimen
• Discharged on hospital day 4 to follow up with PCP
• One week after discharge develops maculopapular rash on
lower extremities and wife calls PCP
• PCP, UHMP physician, did not know patient was in hospital and
was not aware of changes in patient’s 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.
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Case 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.
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Case example : Patient Noncompliance
• PB 72 y/o WM presented with cough for 4 weeks,
SOB, fever 102 and yellow sputum
• Left infiltrate on CXR and Augmentin 875 mg twice
daily prescribed
• Patient told to phone report MD in 1 week and f/u in
office in 4 weeks for repeat CXR
• Presented 8 months later cough of 2 months, chest
pain, SOB, wt. loss and fatigue. He acknowledged
he did not follow-up as directed
• CXR large mass in left lung, biopsy revealed lung
cancer
• He died 8 wks. later
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Case 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 up
• Patient called office next day( Friday) wrist pain told
no openings. He would be squeezed in following
Friday
• Presented to physician with swollen septic phlebitis
of arm and INR too high to quantitate
• Readmission
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Case example : Consult Communication
• P.R 52 year old woman referred to ID clinic
for fatigue and question of Lyme disease
• Had extensive workup by primary care
physician and has seen Rheumatology and
Neurology prior Infectious Disease referral
• Arrives in ID clinic without records from prior
treating physicians
• ID Clinic MD is frustrated and lets patient
know this always happens
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Case example : Patient Privacy
• JM 52 y/o WM corporate CEO of Fortune 500
Co. He was admitted to UH for altered
mental status and headache. He’s 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
neoplasm
• You decided to sell your stock holdings
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Case 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 he’s 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
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Case 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 paged
• Nurse 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.
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Case example: inappropriate communication
• 30 yo JG presented to out patient facility with
UTI symptoms
• Placed in exam room told MD will be in soon
• Hears clinical staff including MD discussing
sexually activity from night before
• Patient outraged and leaves office
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Communication Game
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COMMUNICATION NEXT STEP
Your concerns and suggestions are
valuable, how do WE move
process forward?
How do WE implement change?
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Thank You.
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Consultant
• Respond to consult addressing specific
questions asked
• Respond in timely manor
• Respond as specifically as possible
• Assessment and plan first-----data chart
review last
• Emergency transfer of information requires
direct communication
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Requester
• Talk or write to consultant to guide consultant
• Be as specific as possible with questions
• Ensure timeliness by finding availability of
consultant
• Continue dialogues of communication until
concerns and questions addressed
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CONCLUSIONS
• E-Mail RECOMMENDED means of all
communication at present – sent and read in
timely fashion
• Critical or Emergent information requires
direct communication :phone /pager
• Professionalism in communication
• Discharge summary completed and sent
within 24 hrs of discharge
• EMR INTEGRATION and IT
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