Historically, nursing homes and physicians sometimes have been siloed, but that relationship model is no longer sustainable given the pressure on facilities to provide high-quality, resident-centered care, says Susan Purcell, BS, RN, CPHQ, project director at TMF Health Quality Institute, the Austin, Texas-based Medicare Quality Innovation Network-Quality Improvement Organization for Arkansas, Missouri, Oklahoma, Puerto Rico, and Texas.
“The physician is an important part of the care team at nursing homes,” she explains. “You really want to strive to build a relationship so that the physician supports and buys into what you are doing. If the relationship is not working well or it’s defensive or adversarial, your whole work life will be a challenge to get what you need for your residents.”
Here are some communication best practices that directors of nursing services (DNSs) can implement in their facilities with the medical director, attending physicians, and physician extenders:
Meet regularly with the medical director outside the QA process
DNSs and administrators should have very clear lines of communication on a regular basis with their medical director, says Susan Levy, MD, CMD, AGSF, president of Columbia, MD-based AMDA—The Society for Post-Acute and Long-Term Care Medicine. “First, you should be aware of the medical director’s schedule and when they plan on being in the building. Then set up some time during those visits to meet with the medical director for at least half an hour to discuss issues they might have and ongoing projects they are working on.”
This meeting should be separate from routine quality assurance meetings, she suggests. “It’s an opportunity to sit down and do a quick pulse check, giving each other feedback on either concerns or opportunities for improvement.”
Don’t ignore attending physicians
“Having a regular, established time for communication can be very helpful with attending physicians as well,” says Purcell. “You don’t want to just bombard physicians while they are making rounds.”
This sit-down should review facility concerns with resident care, says Purcell. “However, there also needs to be two-way communication. You need to listen and hear concerns from the physician. For example, the physician might say, ‘Your staff are calling me inappropriately in the off hours. I don’t need to get woken up at 2 a.m. for Tylenol’ or ‘Your staff are calling me, and they’re not giving me enough information to make a good decision.’ You need to find out what is off-putting to the physician relationship.”
These types of meetings can help attending physicians feel like they don’t always have to go through the medical director, says Levy. “Of course, if you have difficulties with any practitioner in the building, you can always pull in the medical director to assist you to improve communication or address a specific care issue.”
It’s also important to note that communication with the attending physician/physician extender and communication with the medical director are two separate issues, says Levy. “In many buildings, the medical director is also the attending, so your communication should be a little different based on which role they are fulfilling.”
Don’t communicate only around problems
One common mistake that both DNSs and administrators make is failing to develop a collegial, collaborative relationship with their medical director, as well as attending physicians, says Purcell. “Too often, communication is only around problems. If you develop a relationship that demonstrates you are committed to working together in a team-like fashion to achieve both parties’ goals, you will have much better (1) communication and (2) outcomes. You want to avoid a chaotic ‘you’ve got to solve this problem for me right now’ mode.”
Without a collegial working relationship, attempts to communicate can often be unsuccessful, says Purcell. “For example, one continuing high national priority is reducing inappropriate antipsychotic medications. If you fire off to a doctor ‘I need you to discontinue these meds on these patients,’ you will have two potential problems. First, you might not be giving them enough information to make a good, informed decision. Second, you are putting them on the defensive where their first reaction will be, for example, ‘There’s a reason I prescribed that med. Your staff called me in the middle of the night.’ You need to lay the groundwork that you want to work together with the physician to develop a plan to reduce these medications.”
Act on physician concerns
“Respect and trust often break down when physicians continually get inappropriate communication from staff,” says Purcell. “So when you hear concerns from physicians, you need to put plans in place to ensure your staff are delivering what the physician needs to render the best care to the resident, especially if it’s telephonic information. It is important to assure that all staff communicating with physicians understand how to communicate the appropriate amount of information to make a sound clinical decision.”
Addressing physician concerns is a critical piece of the communication puzzle, she points out. “These relationships have to work both ways. You have to work with the physicians as much as you can, and then the physicians will try to work with you. It’s the art of communication and collaboration.” (See some physician/staff communication practices to try at the end of this article.)
Obtain early physician buy-in for communication practice changes
DNSs should avoid implementing any new communication practice without physician input, says Purcell. “You don’t want, for example, to have a new form just start showing up on the fax cold. Let them know what you are thinking, and be willing to collaborate.”
For example, if DNSs want to implement the SBAR Communication Form for RNs and LPNs/LVNs to use to communicate with physicians and physician extenders as part of the INTERACT (Interventions to Reduce Acute Care Transfers) v4 tool set, “of course the first step is to obtain internal approval from your own leadership,” says Purcell. “But you also need to bring the physicians into the process—before you implement the form—and say, ‘We think this is a good tool for improving communication. What do you think? Is this the kind of information you want from us? Is there something missing from this form that you might want?’”
“You do need to include the physicians and physician extenders early on and not as an afterthought any time you roll out a new initiative that will impact them,” agrees Levy. “You can’t just start rolling out programs that will direct your physician communication or provide guidelines to that communication without including your medical director and your attending physicians to make sure that they indeed agree with the process that you are implementing. If they are not on board, you will set yourself up for a lot of frustration because you won’t all be working together from the same place.”
Note: To learn more about SBAR tools and to find other communication resources, see “Communicating Change in a Resident’s Condition” in Improving Patient Safety in Long-term Care Facilities from the Agency for Healthcare Research and Quality. View a video of a SBAR phone call in action at a nursing home here.
Get creative with communication methods
“Sometimes periodic sit-down meetings aren’t possible due to scheduling conflicts,” says Levy. “In those cases, you should be creative in terms of how you communicate. For example, you might do a conference call, asking for 15-20 minutes of people’s time to call in and talk about the rollout of a new initiative. Then you might walk over and do quick check-ins with a physician when they’re in the building.”
Medical directors also can be a communication resource for DNSs, says Levy. “For example, the medical director might send out an e-mail notice to attendings summarizing quality issues that came up during a QA meeting and asking for feedback.”
Strive for staff stability
One significant challenge to strong physician communication is beyond the ability of the DNS to control: turnover in the DNS position, says Purcell. “If doctors are remaining stable and they have to deal with four different DNSs over the course of a year, you can see where that would become frustrating. It takes time to develop these relationships.”
In addition to being sensitive to physicians who have dealt with frequent turnover at the DNS position, DNSs can work to improve the stability of the staff they manage, she says. “The more stability can be shored up, the better the relationship will be because we are all challenged to develop professional relationships with people when those positions change.”
DNSs who don’t keep staffing as stable as possible will “constantly be retraining new staff on how your team approaches dealing with physicians,” points out Purcell. “You don’t want to get into a situation where every time you have a new nurse, the physician says, ‘Here we go again. They called me, and they didn’t give me enough information.’ You have to do that initial training and continual retraining as staff change.” (Find staff stability resources here.)
Staff/physician communication channels: Good practices
DNSs may want to consider implementing the following practices to improve the effectiveness of staff communications with the medical director, attending physicians, consultants, etc.:
• Set standard times for medical director/primary physician to be available for consult regarding non-urgent issues. For example, 7-8 a.m. or 5-7 p.m.
• Ensure access via business or personal cell phone to staff (encouraging staff to call).
• For urgent issues, available to nurses 24/7.
• Use available technology (electronic medical records, video chat).
• Reduce or eliminate medical care by fax. Instead, communicate verbally with primary care physicians/providers.
• Use standardized communication templates or tools such as SBAR (situation/background/ assessment/recommendation) to promote clear, concise information across providers.
Source: Change Package (A Curated Collection of Great Ideas & Practices to Create Lasting Change in Your Nursing Home) March 2015 v2.0, National Nursing Home Quality Care Collaborative
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