Communication between hospitalists and nurses can lead to frustration on both sides when it is fragmented, incomplete and complicates patient care. As part of a year long LEAN project at our institution to improve multiple facets of the hospital medicine program, we decided to spend time on improving hospitalist and nursing communication. In particular, we focused attention on patient care in the evening and overnight hours, when they were often being cared for by physicians who were unfamiliar with their hospital course.
Develop and implement a standardized process to improve communication/coordination of care between hospitalists and nurses.
Using lean methodology we examined our current state of off hour communication between nursing and hospitalists. Observation of initial state revealed lack of standardization both from physician to nurse and nurse to physician communication. This resulted in frequent interruptions to work flow on each side, decreased efficiency and potential delays/omissions in patient care. We also found evidence of disparate work flows leading to unmet expectations for both groups. The nurses were unaware of decreased hospitalist staffing ratios at night and the hospitalists often found it difficult to prioritize multiple web pages that they would receive in off hours. Critical pages were being lost in trivial pages leading to patient safety issues. In addition, the hospitalists were often inundated with calls for routine issues at night. The nurses did not have any standard format to page the hospitalists. We identified our target state (satisfied nurses and doctors in regard to cross cover) and did a rapid improvement event designed to reach that state. The results of this rapid improvement event led to (A) paging guidelines ideal page should start with a paging priority qualifier (five options rapid response team, urgent, call, orders or FYI) and also always include the following unit name, name of nurse, phone number, patient name, and description of patient problem. In addition, expectation of hospitalist responses to these pages was qualified with an expected action and call back time (B) hospitalists and nurses were educated about each other’s workflow (steps taken orienting each new hire, newsletter). (C) Piloted use of mobile device for nurses to decrease amount of time hospitalists spent holding when returning a page. (D) identified the common reasons for pages (pain medications, bowel regimen, diet orders, cough syrup etc.) and developed “Just in case” orders in EMR to reduce number of pages. (E) Made it easier for nurses to identify who to page, when to page (can it wait until physician shows up on the floor to round) and how to page.
Having a standardized process of paging improves coordination of care between hospitalists and nurses, improves communication, improves efficiency on both sides.
Table 1Result of intervention on pilot floors
|Before intervention||After intervention|
|% of complete pages (at end of week 12)||0||75|
|Feedback Re:Communication from hospitalists (% rated as excellent)||20||33|
|Feedback Re:Communication from nurses(% rated as excellent)||3||16|
To cite this abstract:Seiler A, Bryson C, Paadam J, McLean P, Sittig R. Rn and Md Communication: A Lean Performance Improvement Project at Baystate Medical Center. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97702. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/rn-and-md-communication-a-lean-performance-improvement-project-at-baystate-medical-center/. Accessed September 19, 2019.