Meeting the Challenge for Safer Handovers in Long-Term Care
Patient Safety Culture Teleconference Series
This series presented the skills required to ensure that critical conversations are clear and effective. Learn how to promote organizational learning, as well as how to standardize and sustain best practices for resident care.
Session 1:
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The overwhelming majority of adverse events in resident care involve communication failures. SBAR (Situation-Background-Assessment-Recommendation) is a structured way to communicate more effectively during handovers—or anytime caregivers need to share information and collaborate. You will learn the nuts and bolts of SBAR and how to address common challenges when implementing this practice. Attendees will receive practical training materials for use at their facility. ObjectivesAfter attending the presentation, participants will be able to: Learn—Learn when and how to use SBAR Benefit—Describe how SBAR can improve communication and teamwork Action—Plan to conduct a SBAR test of change at your facility |
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Session 2:
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When a resident is transferred between levels of care, they are at higher risk for adverse events. Some studies have suggested that up to 40% of acute care transfers from long-term care settings could be preventable. During the call, we will discuss WHAT key pieces of information to send and HOW to send it (e.g., standardized froms, SBAR, warm handovers, checklists) to make this transition safer for the resident. In addition to standardizing internal processes, we will discuss ways to partner with your acute care provider to work together to create a more systematic and effective transfer process. ObjectivesAfter attending the presentation, participants will be able to: Learn—Learn how to use a standardized transfer form, checklist, and critical communication process for a smoother acute care transfer Benefit—Describe why transfers are a dangerous time for your resident and how to reduce the risks Action—Audit one acute care transfer and determine which element of your current process you will change to reduce risk for the residents |
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Session 3:
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In addition to being dangerous to patients, hospital readmissions are costly. A 2009 study published in the New England Journal of Medicine found that unplanned readmissions cost Medicare $17.4 billion annually. The Obama Administration has identified readmissions as a potential source of savings, including reducing payments to hospitals with high numbers of patients who are readmitted. Join us for a walk through clinical and communication tools to help guide the reporting, assessment, and management of changes in resident status that commonly result in hospital transfers from nursing homes. ObjectivesAfter attending the presentation, participants will be able to: Learn—Learn about early warning systems and clinical tools to guide assessment and management of common changes in resident status Benefit—Describe how standardized processes can assure more effective and timely assessments and coordination of care Action—Conduct leadership walking rounds to learn about your system |
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Session 4:
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In every aspect of our daily interaction with residents and family members, as well as with our co-workers, we are teaching or sharing information. Low health literacy can be a substantial barrier to this information-sharing. Join us in shifting provider communication styles to become patient-centered and shame-free—and decrease the potential for errors. ObjectivesAfter attending the presentation, participants will be able to: Learn—Learn about barriers to patient understanding of medical information; improve communication between providers and patients Benefit—Understand the importance of health literacy; identify gaps in understanding; gain techniques to reduce gaps Action—Practice the techniques with others in your setting |
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Session 5:
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During this call we will discuss basic principles of human factors and how we manage systems. Hiring competent people has only given us a relatively low level of reliability and safety in our healthcare system. We will learn the "5 whys" method, and discuss David Marx’s model for event investigation using “Just Culture” principles. By learning about the other factors contributing to our outcomes, we can better determine which organizational practices and processes we could modify or put in place to improve reliability and safety. ObjectivesAfter attending the presentation, participants will be able to: Learn—Learn principles to address human factors in systematic improvement Benefit—Describe at least five factors outside of clinical knowledge and skills that lead to failure to provide the right care reliably for every resident every time Action—Identify one process with low reliability where training is not or has not been an effective intervention and determine which other factors are affecting reliability |
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Session 6:
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Sustainability is when a newly implemented process “sticks.” The new ways of working and improved outcomes become the norm. They do not return to the old process. Making system improvements requires a significant investment of time, financial resource, and leadership effort. Yet, up to 70% of all organizational changes fail to survive. Join us to learn more about how leaders at all levels can help assure system improvements “stick.” ObjectivesAfter attending the presentation, participants will be able to: Learn—Learn a practical leadership model for driving change Benefit—Assure that your system improvements are sustained Action—Identify one of your management practices that affects sustainability |
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