Communication and Miscommunication: Say What You Mean and Mean What You Say

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, BSNDirector of QualityGeneva and Conneaut Chris Sydenstricker RN, BSN, MBA, CPHQ Senior Quality Nurse UHCMC Rita Szymczak RN Senior Clinical Application Analyst UHCare Ambulatory EMR Project University Hospitals Michelle Borisa IT Clinical Application Analyst Electronic Medical Record University Hospitals Lynn Lebit Hardacre, Esq. Associate General Counsel University Hospitals

2. 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 University Hospitals

3. 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 University Hospitals

4. Critical & Sentinel EventsDocumentation and/or Communication 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. University Hospitals

5. Paid ClaimsLosses by Negligence Category *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 University Hospitals

6. 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 University Hospitals

7. COMMUNICATION • Communication game---determine how accurate intelligent health care providers can “communicate” defined data or information bites to one another University Hospitals

8. MEDICAL COMMUNICATION Three Domains • Communication with patient/family • Communication about patient • Communication about health and disease with community University Hospitals

9. COMMUNICATION Three components • Accurate original information • Transmission • Reception LACK OF ANY OF THE 3 = FAILURE University Hospitals

10. COMMUNICATION CASE DISCUSSIONS University Hospitals

11. 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. University Hospitals

12. 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. University Hospitals

13. 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 University Hospitals

14. 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 University Hospitals

15. 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 University Hospitals

16. 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 University Hospitals

17. 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 University Hospitals

18. 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. University Hospitals

19. 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 University Hospitals

20. Communication Game University Hospitals

21. COMMUNICATION NEXT STEP Your concerns and suggestions are valuable, how do WE move process forward? How do WE implement change? University Hospitals

22. Thank You. University Hospitals

23. 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 University Hospitals

24. 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 University Hospitals

25. 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 University Hospitals