Sharing patient information very often takes place over the telephone, from discussions within departments (as when seeking telephone orders), to those between facilities (as when discharge information is exchanged upon transfer), to those with family and friends inquiring about a patient's status. Nurses are continually faced with the need to safeguard their patients' private medical details.
In 1996 President Bill Clinton signed into law the Health Insurance Portability and Accountability Act (HIPAA). This law was designed to protect the security and privacy of patients" health information.1-3
Nursing staff at the University of Texas M.D. Anderson Cancer Center in Houston, one of the three original comprehensive cancer centers in the United States,4 learn about HIPAA during their new employee orientation and are reminded of it during an annual employee education event. Policies addressing confidentiality also are included in our standard code of conduct booklet, which outlines the behaviors expected of employees with regard to patients, fellow employees, and property.
The challenges our nurses face are how to put these policies into action, gain patients' trust, and demonstrate a sincere attempt to maintain the privacy of each patient's health information, while appropriately meeting family needs for information. Through our work in the Transforming Care at the Bedside (TCAB) initiative, we have taken steps to address these challenges.
CONFIDENTIALITY AT A CANCER CENTER
The average length of stay on our thoracic and cardiovascular surgical unit is approximately 6.1 days, and 50% to 60% of our patients aren't area residents; rather, they are from a different city, state, or country. Their family members share with them the emotional burdens of a cancer diagnosis. The geographic separation of patients from family and friends and the shared emotional response to cancer lead to numerous calls to the unit each day.
This unit became involved in the TCAB project in early 2008. At one of the initial TCAB "snorkel" (brainstorming) sessions, the staff discussed the issue of patient confidentiality and privacy when communicating by telephone. They recognized the difficulty of distinguishing between callers and visitors "needing to know" and those "wanting to know" medical information about a patient, as well as the importance of determining who was requesting information.
The unit staff believed that patients should play an active role in deciding what information could be shared and with whom. Staff from the night shift came up with an idea to empower patients by creating a system we call "Ring! Ring!"
HOW RING! RING! WORKS
Upon admission to the unit, patients are given a letter explaining the intentions of Ring! Ring! Initially, staff told each patient a password to share with family members and friends whom she or he wanted to receive information. Within the first two weeks, however, problems with this system became apparent. Some patients and family members forgot the passwords and expressed displeasure when staff wouldn't provide the information, which in turn created frustration among the staff. So we regrouped, abandoned the oral exchange of passwords, and developed the Ring! Ring! card, which is about the size of a business card. The patient chooses a password and writes it on as many Ring! Ring! cards as necessary to distribute to family and friends. The patient can also share the password verbally. A Ring! Ring! card with the password is attached to the patient's Kardex.
The night shift began the rapid-cycle testing. After we started to use the Ring! Ring! cards, the rapid-cycle test of change spread to the day shift. Within a week, it was evident that Ring! Ring! would be a permanent part of the unit's admission process.
Now when a nurse receives a call about a patient's condition, the initial response is "Can you provide the patient's password?" If so, the conversation continues. A caller who cannot relay the password is told that no information about the patient can be shared. A few callers have expressed annoyance with this answer, but the nurses stand firm and explain that they are protecting patients' privacy.
We audited staff compliance—whether staff were explaining the Ring! Ring! process and having each patient complete a card during admission—by counting the Ring! Ring! cards stapled to the Kardex. The initial compliance rate was 20% (an average of 6.4 out of 32 patients). This low compliance rate made it clear that we needed to reinforce the new process. Approximately seven months later, the compliance rate was 90.7% (29 of 32 patients).
The staff attributed this increase in compliance to their management of the entire change process. Whenever a patient made a comment about Ring! Ring!, it was shared with the staff. Although the Ring! Ring! cards weren't consistently available at the beginning, now they are always in the same easily accessible place. But the most important reason for increased compliance was that the staff decided that because this was their idea, it was their responsibility to ensure its success. Now the entire nursing staff—including nursing assistants, clinical nurses, and the associate director—can and do discuss Ring! Ring! with new patients.
Family members have provided positive feedback. Some relatives who work in health care have asked us for information on Ring! Ring! that they can take back to their institutions. Most important, patients have told the staff that they appreciate our commitment to protecting their privacy.
We surveyed staff and patients about Ring! Ring! four weeks after the program began and again three months later (see Figure 1). Patients were asked, "Do you feel Ring! Ring! assisted in protecting your privacy?" On the initial survey, 87.5% said "Yes." The positive response rate increased to 93.7% on the second survey.
In their surveys, staff answered the question, "Do you feel more comfortable providing patient information over the phone since introducing Ring! Ring!?" Experience with being able to confirm that they were speaking to people approved to receive private information increased nurses' comfort levels from a 90% positive response at four weeks to 97% four months into the program. Many staff felt that the increase in patients' positive responses stemmed from the staff's greater comfort with the process, which led them to more clearly explain the program to patients. The staff were surprised by their own efforts, especially since Ring! Ring! added another step to an already in-depth admission process.
The staff have now experienced firsthand the simplicity of rapid-cycle tests of change and the positive outcomes that can result in a short time. Ring! Ring! has been shared in weekly TCAB meetings that are open to all units and all levels of staff. We have also shared the letter and cards with colleagues on other units for them to adapt.