Provider FocusJune 2015

UnityPoint Health – Des Moines

Doctor Communication:Quint Studer, former hospital CEO who owns a very successful organization called The Studer Group has co - written a great book called “The HCAHPS Handbook”. In Section Two: “Doctor Communication”, Quint takes three questions on our patient satisfaction survey and divides them into 3 chapters:

1. During this hospital stay, how often did doctors treat you with courtesy and respect? 2. During this hospital stay, how often did doctors listen carefully to you?

We will focus on the third HCAHPS question in this issue:

3. During this hospital stay, how often did doctors explain things in a way you could understand?

To achieve this goal, physicians need to do 3 things:

1. Explain the patient’s diagnosis in really clear simplistic terms.2. Explain medications to the patient in a way that shares the name of the medication, the purpose of the

medication, how long the patient is going to be taking the medication, and what the potential side effects are. 3. Confirm that the information the patient is provided is helpful and that the patient understands it. Ask, “Is there

any more information you need?

…And the tactics that make “ALWAYS” responses more likely=

Tactic 1: Focus on the “E” in AIDET, EXPLANATION. AIDET is an acronym that represents the framework to effective communication with patients. It has been proven to not only improve the patient experience but also impact more clinical outcomes. Patients are more likely to comply with medications and treatment regimens and follow the recommendations of their care providers. They have less anxiety and better comply with the care plans as outlined in their discharge instructions.

AIDET: A = Acknowledge; I = Introduce; D = Duration; E = Explanation: Providing patients with information on treatment, medications, diagnosis, and therapy options. T - Thank you.

Area 1. Diagnosis: The quality of information patients receive and the level of understanding they have regarding their diagnosis and treatment plan can improve adherence to treatment regimen.

Provide diagnosis in a clear order Share the name of the diagnosis Use language the patient understands Let the patient know about diagnostic testing Share the recommendations for treatment

Share the clinical course of the diagnosis Share the information several times Provide written information on the diagnosis Ask the patient if they understand Ask for the patient’s partnership

Show empathy

Area 2. Medications: How and what a physician says to a patient about a medication can heavily impact the probability that the patient will take the medication properly and completely. Not surprisingly, doing this well will also impact the HCAHPS Communication of Medications composite.

Share the name of the medication Share the purpose of the medication Let the patient know the duration of treatment Explain why, if possible let the patient choose Call potential side effects what they are Ask the patient if they understand Create a collaborative environment Give patients a central location for important information, as a folder.

Chikungunya Virus (chic-en-gun-ye) DID YOU KNOW?

This disease is spread by mosquitoes. Four imported cases found in Iowa and many more in our surrounding states. International travel risks are: Parts of Africa, S. Europe, SE. Asia, the Americas and

Islands in the Indian and Pacific Oceans. Chikungunya Virus is now found in the Americas. There have been over 600,000 cases found in the Caribbean and 600 cases in the U.S. in

2014(including both imported and cases locally acquired in Florida).

WHY Should I Be CONCERNED? Chikungunya is transmitted by the same mosquitoes as Dengue Fever and has similar clinical features. Both of these diseases circulate in the same areas and can cause co-infections in the same person. It is important to see your physician and have them evaluate for Dengue Fever if considering Chikungunya. Avoidance of specific meds can improve the outcome of anyone infected with the severe form of Hemorrhagic

(bleeding or clotting issues)Dengue Fever.

WHAT SIGNS AND SYMPTOMS OF DISEASE COULD I SEE? Symptoms usually begin 3-7 days after being bitten by an infected mosquito. Common symptoms are fever and severe joint pain, often in the hands and feet. Other findings may include headache, muscle pain, joint swelling, or rash.

You should feel better within a week, most people do. Some people develop longer-term joint pain that can last weeks to months.

People at increased risk for severe disease include newborns exposed during delivery, adults (>65 years), and people with high blood pressure, diabetes, or heart disease.

ARE TREATMENTS AVAILABLE TO HELP MANAGE MY SYMPTOMS OF CHIKUNGUNYA?

Treatment is symptomatic. No specific antiviral treatment exists for Chikungunya. You may need help in maintaining good hydration an circulatory status and providing supportive care. Your physician may evaluate for other serious conditions (e.g., Dengue, Malaria, and bacterial infections) and

treat or manage appropriately. Acetaminophen has shown helpful for fever and pain. Avoid aspirin and NSAID if your physician is considering a

possibility of positive Dengue Fever due to increased risk of bleeding. Information on Chikungunya and Dengue diseases is available at www.cdc.gov

Welcome to New Physicians and Providers

Matthew Webster, DO, Urgent Care at Ankeny

Matthew completed his undergraduate education at Central College, his graduate degree at Iowa State University and his medical degree at Des Moines University. He is board certified by the American Board of Family Medicine and the American Board of Addiction Medicine.

Matthew’s clinical interests include urgent care. When he isn’t at the clinic, you will be able to find him golfing, mountain biking and skiing.

Erica Parrish, ARNP, Virtual Care, Urgent Care at Ankeny

Erica completed her undergraduate education at Mount Mercy College, Cedar Rapids, IA and her medical degree at the University of Iowa. She is board certified by the American Academy of Nurse Practitioners

Erica’s clinical interests include preventative medicine, women’s health, chronic disease management, emergency medicine and telemedicine.

Blake Williams, ARNP, Center for Liver Disease

Blake completed her undergraduate education at Grand View University and her medical degree at Maryville University, St. Louis. She is board certified by the American Association of Nurse Practitioners.

Blake’s clinical interests include liver disease. When she isn’t at the clinic, you will be able to find her spending time with family.

Cynthia Kildare, ARNP, Virtual Care, Urgent Care at Ankeny

Cynthia completed her undergraduate education at Creighton University and her graduate degree at the University of Nebraska Medical Center, Nebraska. She is board certified by the American Academy of Nurse Practitioners.

Cynthia’s clinical interests health promotion/disease prevention and urgent care treatments. When she isn’t at the clinic, you will be able to find her writing, art, bicycling.

Leenhapong Navaravong, MD, Cardiology at Methodist

Dr. Leen completed his medical degree at Siriraj Hospital, Mahidol University, Bangkok Thailand. He is board certified by American Board of Internal Medicine in Internal Medicine, Cardiovascular Disease and Clinical Cardiac Electrophysiology.

Dr. Leen’s clinical interests include cardiac arrhythmia, palpitations, syncope and cardiomyopathy. When he isn’t at the clinic, you will be able to find him running and hiking.

Catherine (Kate) Wallace, ARNP, OB/GYN at Penn Avenue

Kate completed her undergraduate education at Central College before earning her BSN from Grand View University. She then completed her medical degree at University of Kansas Medical Center. She is board certified by the American Nurses Credentialing Center.

Kate’s clinical interests include obstetrics and women’s health. When she isn’t at the clinic, you will be able to find her running, biking and at her kids’ activities.

Sara Fleecs, ARNP, Family Medicine at Greene County

Sara completed her undergraduate education at Grand View University before earning her graduate degree from Briar Cliff University.

She is board certified as an Advanced Registered Nurse Practitioner. Prior to her position at Greene County, Sara served as a provider at UnityPoint Clinic – Family Medicine – Fort Dodge.

Kelly Gann, PA-C, La Clinica de la Esperanza

Kelly completed her undergraduate education at Metro State College of Denver and her medical degree at University of Colorado Anschutz Medical Campus. She is board certified by the National Commission on Certification of Physician Assistants (NCCPA).

Kelly’s clinical interests include child, adolescent, and women’s health and family medicine. When she isn’t at the clinic, you will be able to find her reading, cooking, hiking, camping and traveling.

Quality in Motion: Plain Language Emergency Notifications By Scott Draper, Risk Manager, Safety Officer, & Environmental Risk Management

Beginning late March, UnityPoint Health – Des Moines began the process of transition-ing from color emergency codes to plain language codes.  This initiative was part of a larger Iowa Hospital Association recommendation, with many Iowa hospitals participat-ing.  Nationally, these transitions have been occurring for the past couple of years.

Why are we moving from coded to plain language?There is a large disparity among emergency codes currently used in hospitals.  Based on the science of patient safety, variation can be a contributing factor leading to adverse events.  The decision to adopt plain language is based on literature, research, and the desire to promote transparency and safety.  This initiative also aligns with Federal initiatives to adopt plain language standards.

Why is plain language important?Clear, plain straightforward language is the best tool to communicate what you want people to do and how they are to do it.  There is no need to remember codes.  Less time is needed to find and understand the information.  The adoption of plain language promotes transparency, increases safety, and aligns with national initiatives.

Does the use of plain language create additional fear among patients and visitors?This is a legitimate question to ask and one that our internal development team discuss-ed at length.  Consumer research found that a majority of patients would rather know what is going on.  We already do this with Tornado Watches and Warnings.  By providing patients and visitors with plain language communication, anxiety is reduced and they are better equipped to take necessary action and assist us in our own efforts to maintain safety.

What does this look/sound like?In late March, 2015, the existing Code Silver (missing adult) and Code Purple (missing child) converted to plain language.  It is important to note that your response to these situations has not changed unless otherwise instructed.Instead of “Code Silver” or “Code Purple”, you now hear “Missing adult” or “Missing child”, last seen (location) followed by a physical description if known.  Instructions are provided to call 241-7777 if located.  You are instructed to search your work areas.

What about other codes?Additional codes will transition to plain language throughout 2015.  At this time, following language is planned. See Table 1 on the next page.

Quote of the Month“Too much respect for problems kills our faith in possibilities.”

-Unknown

Inside this Issue

1. Plain Language Emergency

Notifications

2. ISO Audits Completed at

UPDM During 2014

3. What’s the Deal with CRE?

4. RL Solutions Monthly

Featured Forms

5. My Nurse Didn’t Know

About My Status Post-Op

Emergency Plain Language

Red Fire Fire Alarm + location + action required

Green Aggressive Behavior Safety assistance requested + location + action required

White Decontamination Decontamination team needed + location

Bro Utility Outage Electrical/Water/Sewer outage + location + action required

Blue Adult or Pediatric Medical Emergency

Adult/Pediatric medical emergency + location

Pink Neonatal Medical Emergency Neonatal medical emergency + location

Tornado/high wind

Tornado/high wind watch or warning

Already plain language

Wait! I don’t see Code Black and Code Yellow on this list!

Code Black (bomb threat) and Code Yellow (hostile threat) will remain coded.

Code black response involves staff only, with no need for patients or visitors to take action. In fact, we do not want them taking action in an actual bomb threat for a variety of safety reasons.

Code Yellow (hostile threat) is reserved for those very serious situations where there is an immediate threat on campus, such as an active shooter. In these cases, every attempt will be made to provide you with accurate, timely information as we know it. By keeping the Code Yellow option, we have more opportunities for future drilling without unduly alarming patients and visitors.

What if I have additional questions or concerns?

We realize that this transition may prompt additional concerns or questions.  Please do not hesitate to contact Scott Draper at 515-241-8377 or send an e-mail

Directions in Quality: ISO Audits Completed at UPHDM During 2014

By Jan Freese, Accreditation Specialist

DNV-accredited hospitals are required to do internal audits of key processes defined by the hospitals. Here are the results from 2014 ISO audits at UPH-DM.

Key Process & Campus Noteworthy efforts Corrective action needed/Opportunity for improvement

Lock-out/Tag-out (LOTO) = control of hazardous energy-IMMC, ILH

Documentation of LOTO was very good. LOTO tag & logss are readily available &

used LOTO training is provided by 3 trainers:

Ivan Wooster, John Green, & Tim Neal Applicable departments use a Hiring for

Success checklist, NetLearning modules & extensive training for new hires

Contractors LOTO requirements are included in bid packets.

New LOTO procedure for chiller & air handling unit was written & approved 1/22/2015.

Clinical Engineering started using the Facilities log for LOTO.

Pre-op histories and physicals (H&Ps) for outpatient surgery- IMMC

Surgery registration board & scheduling board are synchronized by updates from scheduling desk, so families can be informed via a pager where patient is in the surgical process.

There are multiple checks for H&Ps during the intake process 3 days prior to scheduled surgeries

Some interval H&P notes are not charted prior to patient’s arrival at hospital.

Scheduling icons have to be manually turned off by surgical RN

Since enforcement of H&P policy, some surgical cases are still missing H&P and/or interval note.

Process gap was identified between Pre-op and O.R. about who is responsible for follow-up on day of surgery

Advance Directives (A.D.)- ILH & IMMC

Good documentation on surgical patients Daily parameters report at nurses’ station is

color-coded to quickly identify status of patient’s advance directives

Confusing wording on Survey Monkey tool was reworded for clarity

Nursing Standards & Practice Committee & Documentation Standards Committee will review documentation expectations in policy #004 to assure consistency with Epic & staff workflow.

Staff need to document attempts to obtain AD by second business day

Nursing Care Plans – ILH & IMMC

New employees work with preceptors on care plan elements, using focused follow-up on charting in Epic.

Care plans were updated when patient condition changed.

Care plan family conference is done within 72 hours after rehab admission.

99% of care plans initiated within 24 hours of admission

Continue auditing on specific nursing units for more improvement: Need to document in Epic that care plan was reviewed/updated with RN change

Continue auditing for more improvement on specific nursing units. Include pre-existing conditions and comorbid conditions that are being treated

Need additional detailed care plan training for staff. Request additional choices on some Epic

templates (eg. Ortho) if template can be changed

Infection Prevention: What’s the Deal with CRE?

By Molly Hall, Drake University, SR Student Health Science

CRE stands for a bacteria: Carbapenem (broadspectrum antibiotic) resistant Enterobacteriaceae These bacteria are found in the gut and are resistant to most antibiotics Infections with CRE can be very difficult to treat and can be deadly CRE is typically spread through contact with an infected or colonized person (occurs when a

microorganism is found on or in a person without causing a disease), mainly through contact with stool or wounds

CRE have also been spread through ERCP (endoscopic retrograde cholangio-pancreatography) procedures

An ERCP procedure involves the use of a specialized endoscope called a Duodenoscope. It is inserted into the mouth and down into the intestine in order to

access the biliary (gallbladder and/or bile ducts) or pancreatic ducts

Duodenoscopes are unique from other endoscopes because they contain an “elevator” channel that can change the angle of the scope

This “elevator” channel makes cleaning and reprocessing duodenoscopes a greaterchallenge

Meticulous attention to detail must be followed when cleaning these scopes

At UPHDM we have implemented a multi-step safety plan in response to recent CRE outbreak reports associated with ERCPs:

Patients who are undergoing duodenoscope procedures will be informed that there is a risk of patient-to-patient bacterial transmission as part of the consent process. All staff who reprocess endoscopes undergo regular

competency assessment

In March 2015 all staff involved in reprocessing were re-educated and

demonstrated competency according to manufacturer recommendations

A plan to evaluate effectiveness of our scopes reprocessing is currently underway

No duodenoscope related infections have been identified at UPHDM.

All measures are being implemented to minimize the risk of CRE

or any infection associated with ERCP scopes.

Quality in Motion: RL Solutions Monthly Featured Forms By Janice McCullough, Clinical Quality

Tip of ERCP scope

ERCP cleaning

Keep watching for the Monthly Featured Form in Quality in Action. Each month, you will be provided with information about a specific form in the RL Solutions Event and Feedback program. This month’s forms:

Adaptive Design - Solving Problems & Improving Patient Care: My Nurse Didn’t Know About My Status Post-Op By Nurse Residency Project – Younker 7

Current State: Ideally my nurse would have known my status before returning to Younker 7, but this time nurse was unaware.

PACU nurse gives telephone report to floor nurse. There is no specific format or protocol for what is to be included in telephone report. Typically, the PACU nurse states meds given during procedure, (i.e. fentanyl & versed), the latest set

of vitals, and any new LDA (lines, devices, access). PACU nurse calls patient transport to transfer patient back to floor. Questions Raised:

Is there a standard post-op report that PACU follows? What do PACU nurses typically include in telephone report? Is there a better way to communicate directly from PACU to floor RN? How can we make the transfer from PACU to the floor SAFER for the patient?

Assumption(s):

Floor RNo No narcotics had been administered since report was given from PACU RNo PACU nurse would call floor RN if there had been changes since telephone report

PACU RNo Patient would be stable during transporto Floor RN could see MAR for additional narcotics administered.

Problem Statement: My nurse did not know my current status before I returned to Younker 7.

5 Why’s:

Why: Pain medications that I received in PACU were not communicated to the Younker 7 nurse.

Why: An updated report was not called before my transfer to Younker 7.

Why: No one identified that additional communication was needed.

Why: There is no standard process between the PACU and admitting unit for when to call report or what should be included in report.

Ideal State: Ideally, my nurse would have known my current status before returning to Younker 7.

Changes in patient condition will be identified in PACU before sending to floor after medication administration.

PACU nurse will call the floor nurse to state that multiple IV narcotic doses had been administered prior to transport.

PACU RN and Floor RN will have a clear line of communication for nurse to nurse report. Countermeasures:

Floor nurses went to PACU and spoke with several nurses regarding report process Collaborate with PACU AD team to formulate a list of “must have” items for reporto Patient identification and procedure completed, i.e., endoscopy, colonoscopy, paracentesiso Vital signs: Current vitals & sedation level; during the procedure were there any vital signs that were

abnormalo Medications: Sedative, pain medications, cardiac meds o Fluid gain/loss: how much was removed during a paracentesis?o New LDAs: JP drain, incision, pressure dressing, etc. o ASCOM telephone number for any changes or questions after initial telephone report.

PACU discussed signal at their unit meeting in Decembero Update: Decided that when getting/giving report floor nurse will share with PCU nurse their ASCOM

phone numbers to eliminate going through unit clerk. Outcomes:

ACT the only option is safety

Increase the detail in PACU report to floor nurse Floor nurses encouraged to ASK as many questions as possible concerning any new LDA, change in

status, and patient condition. PACU nurse encouraged to CALL ASCOM phone in order to TALK to floor RN about any additional

meds or changes in condition since original telephone report has been called.

Save The Date: Hawaii41