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Department: Performance Potential

Checklist for a successful clinical communication overhaul

Mills, Julie MBA, RNC-OB, C-EFM

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Nursing Management (Springhouse): January 2021 - Volume 52 - Issue 1 - p 10-13
doi: 10.1097/01.NUMA.0000724932.19396.52
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Effective communication is paramount to a patient's healthcare experience, but the average patient probably doesn't realize the extent to which nurses shoulder the communication load.1 Throughout the course of a shift, nurses have to use their expertise, as well as the tools at their disposal, to find and convey countless points of critical information across a vast and complex care team. Ideally, these tools would be universally helpful, but many communication methods are slow, inaccurate, or both. Traditionally, nurses have used on-call services and pagers to determine who's available and who should be responsible for a callback, and these inefficient means of communication increase their workload exponentially.2 As a result, although the average nurse completes a remarkable 72.3 tasks every hour, less than 20% of his or her time is spent on direct care—the most important part of the patient experience.3

Nurse leaders are acutely aware of these challenges, leveraging mobile technology to help fill communication gaps.4 In search of communication systems that are an evolution from secure messaging platforms focused mainly on Health Insurance Portability and Accountability Act (HIPAA)-compliant texting, nurse leaders are finding solutions that integrate with the clinical systems required to enhance communication workflows for physicians, nurses, and other care team members from a smartphone or desktop application. These platforms are known as clinical communication and collaboration (CC&C) platforms, which are being integrated with increasing regularity to ease the burden of nonclinical tasks, save time for nurses, and enable more focused and efficient delivery of care. However, the process of successfully selecting, implementing, and integrating this technology isn't always quick or easy for today's hospitals.

Nursing leadership teams currently charting this path have the benefit of learning from those who've already moved on from more rudimentary solutions. Two such innovators were interviewed from the clinical front lines to offer advice and recommendations to help promote successful implementation and adoption of mobile-enabled communication. Cheyana Fischer started her career as a clinical nurse, then becoming the charge nurse, and later the vice president of nursing before assuming her current role as hospital administrator for Central Florida's Health First.5 Paul Coyne is an adult-gerontology NP with a subspecialty in palliative care who, while completing his doctorate, was hired to manage a team of data scientists to help fulfill the clinical need for analytic solutions. He now serves as assistant vice president, clinical practice and chief nursing informatics officer at Hospital for Special Surgery (HSS) in New York, N.Y.6 Together, they present the eight tasks that matter during a clinical communication overhaul.

Task 1: Understand the problem in two languages

The first step of a successful CC&C system implementation is getting your organization's technologists and clinicians on the same page. According to Coyne, sometimes the information technology (IT) team drives a project and makes decisions free of clinical input, and sometimes the reverse happens. To say the least, the two sides often speak different languages. For example, if the IT team is talking to a vendor about a nursing solution, they may not understand the clinical workflows that should direct decision-making. On the other hand, if a vendor states that they can't integrate a particular application programming interface, the IT team will understand in a way their clinical counterparts may not. Because much gets lost in translation, interpretation between the clinical and IT languages is important from the start.

Starting at the beginning of the process, best practice is to create a multidisciplinary decision-making team, including representatives from the following areas:

  • Clinical is the first at the table, with responsibility for identifying the true clinical need for a CC&C solution.
  • IT should be involved every step of the way to translate business needs into technical requirements.
  • Analytics/informatics helps bridge knowledge gaps while reaping long-term data insights from the solution.

Because nurses are the central figures moving communication among care teams, it's critical for them to play a key role in the early stages of discussion and planning and that this participation continues through selection and rollout. When utilizing shared decision-making and shared governance structures for decisions related to product and technology adoption, it's important to ask which clinical nurses and staff members should be invited to the table.

Task 2: Calculate the financial impact

To round out the perspectives represented by your multidisciplinary team, the finance team should have a seat at the decision-making table. Understandably, cost is almost always among the top five concerns when CC&C solutions are being vetted, so it's critical to ensure that the costs for software, hardware, and integration are forecast correctly.

Another crucial role that finance can play is finding ways that costs will be eliminated by implementing a modern clinical communication tool. For example, make sure your team looks into the amount being spent on line items such as remote call or transcription services. When the budget for a new CC&C solution makes note of existing expenditures that can be phased out after implementation, you may even find that the cost of the new technology is offset by associated savings.

“Justifying the cost of a standalone clinical communication solution can be harder upfront,” says Coyne. “But in our experience, the CC&C platform has grown to touch as many facets of patient care as the EHR, and you can see the trickle-down effect of faster communication cycles with things like decreased length of stay for patients. Deployed the right way, a CC&C system will have myriad benefits down the line that shouldn't be overlooked in initial budget conversations.”

Task 3: Build your requirements with HIPAA at the forefront

Once the team understands the business problem and the scope of the budget, the next step is to consider vendors against a list of requirements. First and foremost is HIPAA compliance, which automatically rules out vendors that won't certify and sign the necessary business associate agreement. In addition to ensuring that the CC&C platform meets HIPAA and Health Information Technology for Economic and Clinical Health Act standards, important security requirements include making sure the solution filters protected health information (PHI) from nonsecure messages sent to email, short message service (SMS) text, or pagers; doesn't cache PHI data on mobile devices; and encrypts data during transmission and in storage.

Once you've narrowed down the list to HIPAA-compliant vendors, it's time to match the remaining solutions against your full list of requirements. Additional requirements your team should consider include:

  • centralized communication that incorporates nurse call, prioritized notifications, and alert and alarm notifications
  • advanced search to connect with individuals across your entire healthcare ecosystem
  • customizable algorithms to compile and maintain workflow rules, call schedules, routing, and contact preferences at both the group and individual levels
  • responsive escalation by defined protocols when a message goes unread
  • integration engine that's source system agnostic with the ability to incorporate the electronic health record (EHR), staff scheduling tools, nurse call, middleware for alerts and alarms, and relational interface system middleware for critical results
  • support for all devices and modalities, such as smartphones, web browsers, landline phones, Voice over Internet Protocol devices, pages, and SMS text
  • auditable message activity by data elements, such as date, time, activity type, and authenticated user
  • analytics engine that automatically documents conversations with detailed tracking reports.

Determine how each of these requirements will work for your organization, and what integration with your EHR will look like in each case. Finally, make sure the vendor you select will give your organization ample time and attention for both short-term implementation needs and long-term support once the solution is live.

Task 4: Recodify time-tested policies

While selecting vendors and building the implementation roadmap, consider how this new communication strategy will impact existing policies. For example, most policies don't support texting in any way. There are also policies that prevent nurses from using mobile phones in front of patients. Of course, these policies need to be amended to support a secure communication platform that not only allows, but also requires nurses to send patient information on a mobile device. When it comes to editing existing policies, nursing leadership should involve both the human resources and quality groups in all discussions.

“Beyond rethinking existing policies, you're also going to have to consider how to educate your staff about CC&C etiquette,” says Fischer. “As humans, we have some basic communication tendencies—such as telling someone ‘thank you’ when they deliver requested information—that seem innocuous but can actually create excess noise in a clinical environment. It seems counterintuitive to avoid everyday pleasantries in a text conversation, but in the course of patient care, brevity is best.”

Task 5: Pilot with an eye toward physician buy-in

A solution that's only used by a fraction of the organization is destined for failure in the long run. Similarly, a tool that hasn't been tested in a real-world environment before go-live isn't well positioned for success. As you implement a CC&C platform, remember that physician buy-in is critical. This tool will ultimately replace processes that have long been essential for nurse-to-physician communication. Much of the groundwork for successful adoption can be laid upfront with input from both IT and clinical staff, but efforts can be solidified during the pilot. As noted by Fischer, the pilot serves as a real-time opportunity to put requirements such as physician communication preferences into practice. Don't invest in a CC&C solution without first seeing how it handles your facility's complex and varied workflows.

You can create a foundation for physician buy-in early in the process by singling out and including physicians who are vocal about their support for or resistance to the change. Once these individuals are identified, solicit their input during demos and throughout the design of the pilot. Including them in the planning stage encourages their participation as ambassadors for change among their peers as the solution is rolled out.

Task 6: Work through communication workflows

In a world where clinicians are rarely in the same place for long—whether they're in and out of surgery or moving from room to room—connecting with the right care team member in the fastest way can be a complex problem.4 The benefit of conducting a pilot before broad rollout is that your team can take lessons learned from the pilot and use them to make necessary changes to existing workflows. This is important because rules for communication can get cloudy when a CC&C solution is adopted. For example, what standards should your organization set for emergent, urgent, and nonurgent messaging? How should messages sent at night be handled? When these workflows are considered thoughtfully during implementation, the clinical communication tool will help nurses deliver better, more efficient care.

“We've now seen our solution used at the bedside with patients, and it makes them feel more confident that their physician received the timely communication,” says Fischer. “That's a big win.”

Task 7: Make hard decisions on hardware

When it comes to picking the right hardware strategy, there are two main schools of thought. Some solutions can be installed on personal devices as part of a bring your own device (BYOD) program. Alternatively, you can provide work-issued (or shared) devices that don't function outside of the hospital's Wi-Fi network. You may find that a BYOD approach works well for physicians, but not so well for nurses from an inpatient nurse mobility standpoint, which prioritizes rugged devices that can be thoroughly sanitized.

“This is something that every hospital has to decide based on its own EHR software or enterprise mobility management policy,” says Coyne. “There are many factors from both an infrastructure and operational perspective that need to be weighed. The reality is that many organizations haven't deployed smartphones for nurses yet, and while it adds to the scope of the CC&C project, equipping nurses with all the patient information they need right in the palm of their hand allows them to return to the bedside more often. That's a powerful concept.”

Task 8: Create a closed loop for continual improvement

As nurse leaders are well aware, even when a decision is made and a solution implemented, the journey is ongoing because healthcare organizations and technology vendors continue to evolve. For example, a vendor may add new features that overlap with functionality provided by an existing solution. As such, CC&C solutions benefit from a mindset focused on continual improvement and innovation.

“If ever there were a year to demonstrate how important it is to work with responsive technology partners, 2020 is it,” says Coyne. “At HSS, our world was upended by the COVID-19 pandemic in too many ways to count, and we worked closely with our CC&C provider to rapidly build a number of new communication workflows to accommodate our facility's COVID-19 response. Communication takes on heightened importance during a public health crisis, and our CC&C platform was the key to making sure important information was routed to the right people.”

Agile solutions

In the end, it's important to find an innovative technology partner that readily includes customer feedback in software development plans. By ensuring that the product team follows a thoughtful roadmap informed by real-world results, you can align your organization's clinical communication plan across vital time intervals accordingly. With the right partner, you're implementing a valuable solution that will grow and evolve to keep up with the swift pace of technology.

“You can't look at this as a process that ends when implementation is complete,” says Coyne. “Some of our most valuable insights have come from efforts to continue refining communication workflows over the years, and that's why our CC&C platform has blossomed into the kind of vehicle that can facilitate a closed loop on critical lab results in a matter of seconds. I never would've imagined that at the beginning of the project, but now it's just another way we've unlocked value from this technology while improving patient care.”

REFERENCES

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2. Hendrich A, Chow MP, Skierczynski BA, Lu Z. A 36-hospital time and motion study: how do medical-surgical nurses spend their time. Perm J. 2008;12(3):25–34.
3. Westbrook JI, Duffield C, Li L, Creswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals. BMC Health Serv Res. 2011;11:319.
4. Cipriano P, Hamer S. Enabling the ordinary: more time to care. American Nurse. 2013. www.myamericannurse.com/enabling-the-ordinary-more-time-to-care.
5. Fischer C. Phone interview. July 10, 2019.
6. Coyne P. Phone interview. June 14, 2019.
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