Initiatives

Build reliability into the system

• General comments:
• JCAHO “read back” complements our initiative
• Dovetail efforts to improve communication process with efforts to meet “read back” requirements
• Use preformatted text for “read back”:
• Called to First Name, Last Name (receiver)
• Critical test and test value
• Read back noted
• Date/Time
• First name, last name (sender)
• Build policies on the communication of critical tests results for each department that are as similar as possible to policies from other departments; standardize language on key processes for the reader
• Build teamwork with unit staff and across departments to assure that time targets are met for communication and acknowledgement
• Keep focus on the patient; documenting the handoff is a necessary first step in the process
• Some implementation strategies teams have found helpful in all practice areas are:
• Standardized language whenever possible:
• Written
• Build templates to have alpha numeric beepers to read “Critical Result, call XXXXX”
• Build templates for documentation (see documentation section below)
• Verbal
• Start all communications with “I am calling with a critical result/interpretation”; this prompts the receiver about intended action and highlights the priority of this event; engage call center in this process
• Standardize the “read back” script for both senders and receivers
• Use template for sending and receiving critical patient information (SBAR technique) for nursing and medicine responding to a critical test finding
• Identify all outliers (delayed or missed test results) that you have identified in your system; what contributed to communication failures?
• Log books/tracking tools help build real-time reliability; include:
• Name, test time, location, abnormality, reader, time MD paged, time ordering provider notified, and action taken
• Log books can serve as time-tracking system so RN knows when to activate “fail-safe”
• Lab can play the role of time keeper by keeping a log of the interaction; often a critical result was sent “stat” so the ordering provider is still around and awaiting the page of the results
• Implementation tips about acknowledgement
• Acknowledgment assures the handoff to the responsible provider is complete;
• Build processes to verify that all critical values have been acknowledged:
• Assign “owner” for tracking system, monitor at regular intervals to ensure reliability; print daily report of all critical values with check for notification
• Follow verbal notification with a paper copy to the unit; unit secretary can log report, track and confirm acknowledgement
• Identify a “timekeeper” responsible for tracking communication process; this person keeps track of the notification process and can activate the fail-safe process when necessary
• Audit real-time notification information periodically; correct deficiencies immediately
• Periodically audit your process starting with the identification of a critical test and ending with documentation of a decision for the patient based on the interpretation of that result from the responsible provider; appropriate end points can be found in an order; the clinical note, progress note, or flow sheets
• Some innovations in documentation:
• There is value in only writing the critical value report once
• Use permanent “sticky notes” to record critical test results that can later be placed in the patients’ chart to become part of the medical record
• Use stamps or preprinted forms to prompt correct documentation; (patient name, critical value, name of MD called, date/time, call back time, clinical action, who took call with credentials); include in the medical record; this supports efficiency of record review
• Use existing sheets for recording telephone orders and add critical test results to this sheet to simplify recording, include test, value, data and time called and description of clinical action that was required
• Use stamps or preprinted forms with most test types to limit the amount of handwriting; make revisions to the form over time
• Utilize/adapt bedside flow sheets to include templated documentation cues for who, what, and why
• Implementing a “fail-safe” system
• Keep the chain of command short, no more than three steps
• Fail-safe should be at the attending or chief level
• Use every instance of having to activate “fail-safe” as a learning opportunity; where did the system break down?
• Set clear time parameter for when “fail safe” should be activated; clearly identify name of and contact information for designated “fail-safe” provider
• Simulate activating the “fail-safe” plan at different times during the day
• Activating the “fail-safe” system, even once, can accelerate improvement
• Provide capacity to work against the authority gradient
• Generate a variance report every time the fail-safe is activated; require a meeting with the medical director
• Implementation tips for using protocols and decision rules
• Build or strengthen mutually agreed upon standing protocols or clear decision rules for directing clinical action by the RN, when responding to a critical value; these rules and expected clinical action must be interpreted by all physician groups and both experienced and new staff nurses in the same way
• Some implementation strategies teams have found helpful for laboratory findings:
• In most hospitals, the lab has best capacity for implementing a time tracking mechanism to know when to go to “fail-safe”
• For busy labs, run follow-up lab report, every 4 hours, to verify that all critical values were called and acknowledged; immediately track any omissions or outstanding results
• Some institutions identified two tiers of lab values for calling; for some values both the RN and MD would be notified; the others values are called just to the nurse with clearly defined protocols in place for clinical action
• If you do not have a tracking tool in place on nursing units; consider doing FMEA if considering continuing to call to RN
• Having laboratory staff engaged in project and in MD notification has benefit of making them part of the “care team” for the patient
• Some implementation strategies teams have found helpful for radiology findings:
• Introduce “risk friendly” language, like CI (called in) in text-searchable field in radiology reports to complete regular audits on your communication system
• Recommend a “minimal set” of clinical information at the point of test entry to aid clinical interpretation, such as clinical history, reason for the imaging test
• Document acknowledgement interaction in the clinical note, the interpretation report, or as an addendum; include the name of the individual notified and the time of notification
• Some dictated summary software allows query of first 120 characters in note; if so, start each dictation of a critical result with a searchable code word for critical findings in first line of dictation; (avoid “red” because often confused with “read” in dictation); this enables later tracking of critical results
• Create template for radiologists dictation to include results, called to, and time to document conversation with receiving provider
• Periodically (monthly) audit, all “positive” results of all cases completed on one day, to be sure compliance is maintained
• Call all positive results at the time the study is being read;
• if contact made immediately, document in official dictated report;
• if contact not made immediately, hold all billing slips aside until contact is made
• Build in a tracking system to learn more about your process and identify opportunities for improvements to communication process
• Some implementation strategies teams have found helpful for cardiology findings:
• Flow chart the process of communication to ordering providers from all cardiology diagnostic centers; learn the similarities and differences in the process for each center; identify best practice; test replicating best practice to a pilot area; then test spreading these ideas to other centers within cardiology
• Learn about reading schedules for Holter monitors, or usual review process for EKG’s
• Test a standardized log book to help data collection; this builds relevancy for cardiologists
• Log should include patient identification, type of abnormality, page time for cardiologist, contact time for ordering provider, and action taken
• Dovetail with other PI projects that have value for the clinical team such as reducing turn around time; provide “real time” tracking of critical results; this project meets the need for a QM indicator for cardiology accreditation
• Review existing processes for turn-around-times for routine cardiology findings; some teams have set targets of assuring a read by a cardiologist within 12 hours for all tests
• For stress testing and cardiac ECHOs, where monitoring is done by the nurses/technicians, assure that a cardiologist is available immediately to urgently read an equivocal or clearly positive test; confirm procedure at beginning of each testing day; review teamwork and communication pattern daily; identify action plan for immediate care of patient if “critical” finding identified
• Build provider notification into flow chart form for stress tests; use protocols for RN to complete ST analysis with clear instructions on when to notify cardiologist
• If patient in CCU, ICU, ER, CICU call positive reading as critical finding with expectation that patient is being monitored 24/7
• Identify ways your system could identify EKG’s that should require expedited review by a cardiologists, e.g. have EKG tech use computer reading to identify readings that should have higher priority for reading; test ways to complete expedited review, e.g. review by trained RN, review by a hospitalist. 

And finally,

1. Follow up on all outliers; you lose valuable data by just looking at the average
2. If critical test results are a very rare event in your institution, try tracking the number of days between failures, defined as when you did not meet your time targets
3. Monitor your processes regularly to assure you are holding the gains
4. Agree on your aim statement, then divide the project into manageable tasks (the three categories for example) and assign small task groups (working teams) to test changes and report back to project team

For more information, contact Paula Griswold at pgriswold@macoalition.org or (781) 272-8000 x152.