Module 2. Communicating Change in a Resident's Condition

Improving Patient Safety in Long-Term Care Facilities: Training Modules, Instructor Guide

Instructor Guide

Communicating Change in a Resident's Condition is intended for use in training staff in nursing homes and other long-term care facilities. This Instructor's Guide describes how to use the materials in the companion Student Workbook as a teaching session and also how to apply a quality improvement project for the topic of communicating change.

 

Principal Message

The single most important message your audience should come away with is that communicating about changes in a resident's condition is essential and is everyone's responsibility. When procedures for team communication are in place, the number of "adverse events" (negative effects on residents' health) can be reduced. Staff should know how to keep track of and report changes in a resident's condition.

Staff should understand the concept of working in a safe environment. This means that nursing staff can work together as a team and share information openly. It also means they understand that keeping residents safe (not worrying about who might be to blame when things go wrong) is the most important thing. Participants should experience the setting of your teaching as an example of a safe environment, where information is freely shared and concerns are openly reported and supportively addressed.

Return to Contents

 

Principal Audiences

This training is geared towards licensed nurses (RNs/LPNs/LVNs), occupational and physical therapists, nursing assistants, and custodial and activities staff. It is designed to be accessible and relevant to all these care providers. So you can teach your participants all together, mixing the professional roles.

The importance of teaching the different professions together is that it will, in and of itself, likely improve teamwork by allowing each profession to understand the other better. For instance, anecdotal research suggests that nursing assistants feel that licensed nurses rarely read their notes. Learning together presents an opportunity for nursing assistants to understand more about what licensed nurses need to see in a nursing assistant's note, and it allows licensed nurses to understand that it is important to read the notes and to let nursing assistants know that they do so.

Return to Contents

 

Workbook Content Overview

Clinical Content

A change in a resident's condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes including medical complications, transfer to a hospital, or even death.

This module reviews ways for care teams to communicate about changes in a resident's condition, and it offers tools for reporting and following up after the report.

Content by Session

This module is designed for presentation in two sessions. The first session introduces some of the art and science of communication. The second session provides tools of communication and discusses how to use them.

Your teaching goals for the module are to:

  • Ensure that participants understand a safe work environment and buy into that as something they want to be part of at their nursing center.
  • Develop participants' knowledge and skills in communicating resident change.

The module materials can also be used flexibly to fit a range of session lengths. Selecting materials to suit a 30-minute single session, for instance, is quite possible. However, this module is designed to be a 2-hour session.

 

Return to Contents

Objectives of the Session

Objectives are separated into knowledge and corresponding performance objectives. Suggested slides are provided in Appendix 2-A; they can be modified to suit your facility's needs. You can present these at the start of the session and even have them up on a flip chart or screen that stays on the side of the room during the session. Or, you can return to them at the end of the session to give participants a sense that they are following your road map. It is often best to select one, two, or three objectives and leave the others aside. In teaching things that you want participants to really take in and use in practice, often "less is more" people can take in and integrate the new material in a useable way. You can remove unwanted objectives on the slides or highlight the ones on which you will focus.

Knowledge Objectives for Participants

At the completion of this training, all participants should understand:

  • Why communicating changes in a resident's condition is an important safety issue.
  • Why communication lapses are a major risk factor for resident safety.
  • The key principles of effective communication.
  • Typical obstacles to effective communication and how to overcome them.
  • What to communicate about changes in a resident's condition.
  • How to communicate a resident's change in condition using the SBAR (Situation—Background—Assessment—Recommendation) and CUS (Concerned—Uncomfortable—Safety) tools.

Performance Objectives for Participants

At the completion of this training, all participants should be able to:

  • Demonstrate good communication techniques.
  • Use good communication skills.
  • Know how to communicate a change in a resident's condition.
  • Use some simple tools to improve communication.

Return to Contents

 

Preparing for a Session

1. Assess the Needs of Your Audience

These training materials are meant to be used as a complete package. However, you may tailor them to the needs of participants and current practice at your nursing center. To determine needs, you can use a survey or talk to individuals familiar with the nursing center. Whether you choose to use all or some of the material in the Student Workbook, decide on a focused goal for teaching. It is better for participants to learn and remember a few important pieces of new information than to feel overwhelmed by many new ideas.

Consider the language level that will best suit your audience. If you use technical medical terms, be sure to explain the meaning of the term. If your audience uses English as a second language, speak clearly and not too quickly.

2. Consider Your Teaching Method(s)

Most instructors find that a combination of methods—lecture and interactive—works best. Consider using a selection of these teaching methods:

  • Lecture with slides.
  • Whole group discussion.
  • Break-out group discussion.
  • Case discussion.
  • Role play.

Suggestions for ways to use these are in the "Recommended Teaching Methods" section of this module.

3. Presentation Timing

The suggested timing for each portion of this 2-hour module is:

ActivityTime
Introduction of Instructor, Topic, and Objectives5 minutes
Pre-test5 minutes
Case Discussion10 minutes
Presentation 1, Interactive Lecture20 minutes
Case and "Critical Reflection" Discussion15 minutes
Break5 minutes
Presentation 2, Interactive Lecture18 minutes
Case Discussion and Role Play (2 scenarios)20 minutes
Debrief on Teaching Methods5 minutes
Key Take-Home points5 minutes
Post-test.5 minutes
 Total: 115 minutes

Although this is a 2-hour module, you can teach it in two 1-hour blocks. You can also select material within the module to make a 30-minute or a 45-minute session, or two 30-minute sessions within a 1-hour slot. This flexibility is important, as some nursing centers might not have adequate nursing coverage for a 2-hour session.

4. Suggested Slides

The Student Workbook is not meant to be used as a prepared speech. It assumes that you know the subject and offers material you may want to use. The suggested slides found in Appendix 2-A and the text boxes shown in the Student Workbook are meant to trigger your presentation. You can pick and choose the slides to suit your students and your facility; it would be useful to practice speaking with them.

5. Preparing Your Presentation: Overview of Effective Instruction for Adult Learners

Adult learning involves change—in knowledge, behavior, and skills.

This module aims to help participants improve the way they notice, report, and keep track of changes in a resident's condition.

Adults are usually most motivated to learn when:

  • They see the subject as directly related to their own needs and goals.
  • They see ways for their learning to be applied to their own work settings.
  • They are responsible for their own learning.
  • Their own knowledge and skills are appreciated.
  • "Mistakes" are seen as chances to learn.
  • Practical, hands-on experience is part of the instruction.

Adults take in new information more quickly and remember it better when it relates to their own experience. Structure your session to draw on what participants already know and what they want to learn. Make sure everyone feels that they have something to contribute.

Teaching methods such as interactive lecture, case discussion, and role play help lead adults to make changes on the job. A good way to get your group moving in this direction is to start with a case for discussion. If the case reflects a situation that's familiar to participants, with a problem they want to solve, you'll have a "teachable moment."

Interactive Lecture

With this method you present the material, using questions and answers and slides or other visual aids.

Case Discussion

The case tells a story. It involves situations like those participants face at work. You lead a discussion that brings in what they know and how they might handle the situation. You will want to be sure that different ideas are heard, and see if anyone changes their mind. You will find a sample case in the "Making the Presentation" section that follows.

Role Play

"Learning through acting" gives participants a chance to use what they know and practice something new in a real-world setting. It can help them see a situation from different points of view. It also helps to develop communications skills.

Writing It Down

With all these techniques, it is useful to note participants' ideas and questions—a flip chart works well. This helps keep participants thinking and engaged. You can keep a "parking lot" list of thoughts that may not be on point at the moment, but should be kept in mind when you're summing up the session.

More information on how to teach this material is presented in the "Giving Your Presentation" section.

6. Preparing a Handout for Participants

These training materials are meant to be used as a complete package. However, you should feel free to choose the parts you think are most relevant for your particular audience and nursing center. The slides provided in this Instructor Guide (Appendix 2-A) may be reproduced and provided to participants. For this module, you may also want to distribute the case.

7. Learning Settings that Work for this Module

Think ahead about the kind of setting that will be available and will best allow your targeted group to participate in the training. You also should consider work shifts and how your session can fit with in-service training requirements or other options. It helps if your session meets some of the nursing center's requirements for staff training. It is also good to provide refreshments if you can—that tends to increase attendance. Post announcements ahead of time so that people know when and where your session is going to happen. You might have a leader introduce the session to show that it is important.

8. Using Pre- and Post-Tests

Pre- and post-tests provide real-time feedback on how well the training session worked. The pre-test sets a baseline of what participants knew about the topic before the session; this can be compared with the results of the post-test to answer the questions, "What changed from the beginning of the session to the end? Did participants learn what we wanted them to learn?" The tests can be found in Appendix 2-B.

9. Equipment

You will need equipment that allows you to display slides, and also record discussion points and questions from participants. You may use one or more of the following:

  • Slide projector and screen, along with PowerPoint® slides.
  • Flip chart.
  • Overhead projector with transparencies.

Return to Contents

 

Giving Your Presentation

  • Introduce yourself and explain the reason for the training.
  • Hand out the pre-tests. Explain that pre- and post-tests help participants evaluate themselves and help you evaluate the course. Have participants complete the pre-test.
  • Introduce the topic and review session objectives (using slides—go to Appendix 2-A).
  • Present the material.

Return to Contents

 

Recommended Teaching Methods

For this module, a mix of teaching methods may be the best—some interactive lecture, some case discussion, and some role play.

Interactive Lecture

The "stand-up" lecture works well when the topic is something participants care about and when the speaker is engaging. It is best used when a large amount of information needs to be delivered to a silent audience.

In an "interactive lecture" you still speak most of the time and control the subject being addressed, but the audience participates in different ways—asking or answering questions, giving examples from their experience, and/or expressing opinions.

Like a story, any lecture—regardless of length—has a beginning (the introduction), a middle (the body), and an end (the summary). Each of these serves a different purpose.

Introduction: establishes the purpose of the lecture. The overall goals and specific objectives are stated. The introduction should include an overview of the whole lecture. Your aim is to get participants interested and make them aware of expectations for the session.

Body: includes the material needed to meet the objectives stated in the introduction. Your session will be most effective if you:

  • Capture participants' attention in the first few minutes.
  • Involve them in fine-tuning the focus of learning.
  • Plan a change of pace every 8-10 minutes during a lecture.
  • Give participants a chance to reflect.
  • Use visual aids.

Give participants a chance to share experiences.

Summary: includes a recap of the material presented in the body of the lecture. It may also include an opportunity for participants' questions and feedback.

Case Discussion

Most instructors prefer to use the case provided in this module. A clinically experienced instructor who is also a seasoned teacher may also invite participants to contribute relevant cases they have been involved in, while a new instructor may prefer to keep the focus on a familiar case.

Case Study

Mrs. C is 85 years old; she has lived at the Manor Nursing Center for about a year. Lisa and Anne are the nursing assistants on duty on Mrs. C's unit today on the evening shift, and Linda is the licensed nurse. Lisa and Anne know that Mrs. C has recently learned that her daughter, who lives in another State, is seriously ill. After the evening meal, Lisa notices that Mrs. C is not her normal self. Usually talkative, she is suddenly not talking much. She is also limping for an unknown reason, and seems very upset and angry. Lisa tries to talk to Mrs. C but doesn't get much response. When she arrives to help Mrs. C prepare for bed, she finds Mrs. C already asleep on her bed, still in her clothes. When she wakes Mrs. C up to help her change and wash before bed, Mrs. C seems disoriented and says something rude to her.

What needs to be communicated? By and to whom? How? When? Where? How do you know when the communication has worked or not?

In answering these questions, think about specific things that specific people should do: What should Lisa do next? What can Anne do? What can Linda the nurse do? Should Linda call Mrs. C's attending doctor? What should they tell the night shift licensed nurse and nursing assistant when they come on duty?

Once the case has been presented, pause and invite participants to comment.

Questions to get discussion going and draw on prior knowledge might be of the "survey" type:

  • Have any of you ever had to work with a new resident without having been told anything about them?
  • How often would you say this happens in your nursing center?
  • Does your nursing center have rules to follow when you see a change in a resident, such as Mrs. C's sleeping at a time when she's usually up and dressed?
  • Who are you supposed to talk to if you have a concern about a patient?

Questions you could ask to reinforce the knowledge you are sharing might be:

  • When would you use SBAR?
  • When would you use CUS?

You can encourage critical thinking and communication with questions like these:

  • What should each person on the care team know about Mrs. C?
  • When should a member of the team ask for help? Who should it be?
  • When should a report be made about the change in Mrs. C's condition?
  • What kind of report should be made, and who should receive the report?

You might ask participants to brainstorm ideas about ways to communicate that would prevent this situation.

Keep in mind that you are trying to get participants to think in terms of teamwork rather than blame.

Try to get them to talk with each other, not just to you. Have them discuss a topic in pairs or in groups of three. This method makes it easier for a shy person to be heard, as the less shy member of the pair or team can speak up for both or all of them.

If the number of participants is small, case discussion may be led with the whole group. Larger groups may be broken up into smaller ones, with each taking one or two questions and then reporting out to the whole group. You may also wish to divide participants into groups according to what they do (i.e. licensed nurses, nursing assistants, occupational and physical therapists, etc.)

Role Play

This technique has participants take on roles in a clinical interaction. There is no written script, and the "actors" don't have to memorize anything.

There are five parts to this technique.

Set-up: Ask participants about their previous experiences with role play. Explain the goals of this exercise and relate them to the key learning objectives. Make sure everyone is familiar with the overview of the case. Only the "actors," however, will know the details of their roles. It may be helpful to provide the description of the role play to those who are not participating as actors in the role play.

Then go over some guidelines:

  • Anything that comes up is confidential.
  • This is a safe place. Actors should not be afraid to take risks.
  • Feel free to be spontaneous.

Assign the roles: You may have actors play a role similar to the one they have in their actual jobs; or you might encourage them to try out a new one. A licensed nurse, for example, could take the part of a resident, or a nursing assistant could act as a licensed nurse. Involve as many people as possible in the role play. Because role play requires participants to be somewhat emotionally open, they may feel anxious, or they may resist being an actor. Your own positive attitude and a light touch will help. Any participants who are not assigned to a role should be asked to be observers.

Conduct the role play: Participants act out their roles in the "scenarios" you will provide (examples below), based on the case. Try not to interrupt the role play while it is running; just let the interactions flow naturally.

Before each scenario, explain how much time it will take and that it will be followed by discussion. It should take only 2-3 minutes, followed by perhaps 5 minutes of discussion.

Don't let the role play go on for too long—most of the learning happens in the first few minutes. If actors seem too carried away by their roles, remind them to keep it simple.

Scenario 1. Two roles: Pamela and Peter. Peter gets paged while taking a report from Pamela and has to leave to deal with a situation on another floor. Pamela had just begun telling him about Mrs. C. Pamela switches to a rapid SBAR communication so that Peter can act on it before going to the other floor.

Tell the role players to simulate the interaction between the nursing assistant and the licensed nurse, making it clear when the interaction is happening and in what setting (e.g. on the phone as soon as possible, at change of shift etc.). Tell them their goals are to: 1. get all the information across; 2. communicate about the situation in a timely fashion; and 3. be able to push if the message does not seem to be getting across.

Scenario 2. Three roles: Pamela, Paulina, and Angela. Pamela, who has cared for Mrs. C for some time, does not recognize the names Mrs. C mentions when she is awakened. As Pamela passes Angela in the hall, Pamela asks what time Mrs. C got up over the weekend when Angela cared for her. Angela shares that Mrs. C. was not herself over the weekend either and that she told Paulina, the registered nurse, about it then. Together, they decide it's time to use the CUS method.

Tell the role players to simulate the interaction with the following goals: 1. how to decide if there was a change in Mrs. C's condition; 2. how to get Paulina's attention; and 3. have Pamela use CUS with Paulina.

Discuss the role play: Discuss the issues that came up in the role play. Everyone's input should be included. After each scenario is played out, ask the actors: What went well? What did not go well? What would they do differently next time? How did it feel to say____? How did it feel to hear____? Ask observers for their opinions about what the desired outcome was in each situation and how they might have handled the situation differently.

Conclude the role play: Encourage a round of applause as the participants return to "out of role." Summarize the major themes and issues. Consider with the group how to apply the role play to real life clinical situations. Emphasize what was learned during the role play.

Debrief About the Teaching Method

  • Ask participants what methods they think you used. Get their thoughts on what worked and what could be done better.
  • Listen and thank them for their thoughts.

Review Key Take-Home Points

  • Promote a safe environment based on teamwork and thinking about how the system of care works and how it can be improved, rather than thinking about blame.
  • Educate the entire staff about the importance of communicating about changes in a resident's condition.
  • Use appropriate reporting tools.

Post-Test

Thank your participants for attending, and hand out the post-tests. Emphasize how important it is to complete the post-tests because they can get feedback on what they've learned (based on their answers to the pre- and post-tests). Tell participants that you will provide the correct answers and rationales for the tests after they are done.

Be sure to stress that the post-test is anonymous.

Return to Contents

 

Translating the Teaching into Practice

Often, it is difficult to ensure that what is taught in a classroom or in-service learning session is translated into action as part of resident care. Even if the teaching has gone well and the learning was taken in and appreciated, it can be hard to put the new learning into practice. There are many possible barriers. For instance, the system of care may not accommodate the new practice, the culture of care may not accept the change, or the leadership may not be aware of the new learning and so may not make room for it.

Following up after a teaching session with a quality improvement project in which the new learning is put into practice by the whole team can help a lot. Quality improvement projects use a step-by-step approach to improving care by taking a long, hard look at what needs to be done. Participants will be starting out with a small change, watching it, adding to it, and continuing in this fashion until the job is done. It has a whole method to it, and the method is described in the "Quality Improvement" section.

Quality improvement methods often include a teaching step. This module can be the teaching material for that step. If the quality improvement project is to improve the way nursing assistants and licensed nurses detect and communicate changes in a resident's condition, then this module is perfect for the teaching part of the project.

Return to Contents

 

Quality Improvement

Quality improvement (QI) is an approach that may be used by nursing staff and managers to improve quality and safety in patient care. QI's three main components are to:

  • Gain knowledge and skills to understand systems of care and minimize adverse outcomes.
  • Apply methods to identify, measure, and analyze problems with care delivery.
  • Act on the results of data collection and analysis to improve both individual care delivery and systems of care delivery.

QI requires a team approach, involving everyone in thinking about innovation and recognizing that the key to improvement is the people who care for patients. It is not about individual rewards and punishments, but rather it relies on measurement to improve the center's performance as a whole.

At the core of QI is the Plan-Do-Study-Act (PDSA) cycle, based on trial and error over time.

  • Plan: Identify a problem and design a change to address it.
  • Do: Implement a small change.
  • Study: Measure and analyze the effects of the change.
  • Act: Take action based on the results of analysis, such as trying another change, formally implementing a change, or extending implementation more broadly.

When you engage in a QI project you will be using information/data that you have on current practices at your site to develop goals based on both best practices and realistic expectations.

The five phases of the QI process are outlined here.3

1. Project Initiation Phase

Decide on the Area of Work that Needs Improvement

In this example we focus on communication about changes in a resident's condition. Most likely, there already will have been a process at the center to get to this point. Still, it is helpful when starting the project to make sure everyone believes in its importance. Collect data to support your assumption that there is a problem and establish a baseline for measuring improvement.

Form Teams

Leadership teams must include one or a few people with enough institutional authority to help get the resources that the project team needs.

For this project, the Director of Nursing, the Quality Improvement Officer, the center's overall Director, or the Chief Operating Officer would potentially be good choices.

Project teams must:

  • Have basic knowledge of the problem.
  • Represent all parts of the process and different levels of the organization.
  • Have at least one member trained in QI.
  • Recognize that good ideas can come from anyone.

The ideal team size is five to nine people. Additional temporary members with special areas of expertise can be invited to particular meetings as needed.

For a communication of changes improvement project, the following project team members are one example of a good team.

  • Registered nurse.
  • Two nursing assistants.
  • Director of nursing.
  • Education director.
  • Geriatrician.

Write an Aim or Mission Statement that is "SMART"

  • Specific.
  • Measurable.
  • Appropriate.
  • Result-oriented.
  • Time-scheduled.

The aim should include a "stretch" goal that may be hard to reach but is achievable, for example: To decrease the rate of resident falls by 50 percent in 12 months.

Consider Appropriate Measures

Examples of measurement (data) include a "process measure" like compliance rates for wearing ID badges with the SBAR or CUS acronym spelled out on the back, or documented nursing notes in the chart on reports of change; or an "outcome measure" like reported use rates for SBAR and for CUS.

To show improvement, you should be able to plot the variable being measured on a run chart (a graph that displays observed data in a time sequence).

2. Identifying the Problem

Identify the Problem
  • The problem and its extent—that is, what are the barriers to and how poor is communication of change now?
  • Changes that can be made that are expected to result in improvement—that is, what might improve communication by overcoming those barriers and how?
  • How the effects of the changes will be measured—that is, select the measures that you will use to assess change over time in communication about changes in a resident's condition.
Plan for Data Collection and Analysis

Tools include process flow charts, brainstorming, cause and effect diagrams, and consumer focus groups. These tools are readily accessible at:http://www.health.nsw.gov.au/resources/quality/cpi_easyguide_pdf.asp.4

3. Intervention Phase

Get Consensus

Get team consensus on priorities and changes most likely to result in improvement and then decide on an intervention.

Remember Culture and Teaching, as well as Protocols

Many interventions focus on what is done; for instance, changing or adding a protocol. These are good, but they often don't work as well as they could unless they are part of changing the culture to appreciate the importance of the new protocol. The best interventions tend to address culture with team meetings and other educational or inspirational materials at the same time that the new protocol is added. Usually, culture change includes implementing and disseminating some core teaching.

Conduct PDSA (Plan, Do, Study, Act) Cycles

The cycle begins with a plan and ends with an action based on learning gained. It should specify who, what, when, and where. The end of each cycle leads directly to the start of the next one.

  • Try a change—for example, provide a new I.D. badge with SBAR and CUS on the back, as well as a 1-hour, online educational session for nurses on a specific ward.
  • Observe consequences by using the selected measures.
  • Learn from consequences—for example, some people used SBAR and the Early Warning Tool, but others did not, and you discover that those who used the tools had taken the online learning and the others had not.
  • Try a change—for example, in-service time is given for all staff to complete the online education. Then run another PDSA cycle.

The way you document observations may be simple, such as counting and recording on a tally sheet, or it may be more complex, using sophisticated tools for data analysis.

If the data do not support the intervention, they may not be appropriate. Look at the data for clues about what to change, and run another PDSA cycle. When you have finally arrived at a sustained change of the kind you intended, that final version of the intervention may be implemented on a larger scale.

4. Implementation and Impact

Implement the Change

When you implement the change it means making the change a permanent part of normal business throughout the unit or setting. It may mean applying the intervention throughout the nursing center, for instance. In this case, it would probably mean ensuring that all nurses and nursing assistants take the online teaching and receive badges with SBAR and CUS written on the back.

Relevant support processes have to be implemented at the same time. For instance, the rollout of education will need to be supported with suitable in-service learning time.

Measure the Impact of the Change

To provide evidence that the intervention resulted in improvement in all places it was implemented, you will need to collect, analyze, and display the data. For example, you might create an annotated run chart showing changes in reported use rates for SBAR and CUS, unit by unit in the whole nursing center, after nursing assistants started using a new form to document changes in a resident's condition. You will be able to choose your measure from the experience you gained in the Intervention Phase (go to item number 3, above).

5. Sustaining Improvement

The step in QI that fails most often is sustaining the improvement. When the project is done, even if it has been successful, if it is not monitored and no one is assigned to make sure the new standards are kept up, it will probably fade away.

Mechanisms for sustaining change include:

  • Standardization, ensuring that new methods are implemented consistently over time.
  • Documentation of the project from planning through testing, implementation, and followup.
  • Indefinite periodic measurement—for example, of reported SBAR and CUS use rates, and review to ensure that the change becomes routine practice. The measure chosen for this is called a quality indicator, and usually it is easy to establish (for instance, something that is part of the Minimum Data Set or some other set of data that are always collected) and part of what a senior person reviews regularly.
  • Staff training and education, geared to the type of change proposed, the people who will be asked to implement it, and the skill level and work experience of the target group.

Return to Contents

 

Applying QI to Improving Communication of Change in a Resident's Condition

Starting the Improvement Effort

First you will generate and look at relevant data on communicating resident change in your area, probably with some of your lead team members. For instance, you might survey staff about how often they think a significant resident change that gets noticed also gets communicated in an optimal fashion. Then you will ask questions and discuss how this state of affairs stacks up against other institutional priorities. When you have decided that this is the area you want to work on, you will form your teams—you will have a leadership team of one or a few people and a project team of five to nine individuals. The project team will write a mission statement and select measures that the leadership team will review, adjust as needed, and approve.

Next, the project team will decide what problem to address in order to help communicate change. Whatever the intervention, it likely will be essential to enhance the culture of awareness and the importance placed on the topic. That is usually where the teaching module comes in. The project team will decide what area to work in first and what process to change; then the people in that unit will receive the training about the topic area.

The Intervention

In the case of communicating change, the primary intervention may be teaching this module. But it is likely that there will be a counterpart change in standard operations. For instance, daily rounds may add a specific question for every resident: "Did you notice anything new about [resident name]?" Or it may add SBAR to the format used by nursing assistants in their change-of-shift verbal and written reports. Each QI effort may have its own intervention to enhance detection and communication of change.

Including Teaching for Culture Change in the Effort

Finding the right person to teach the module is important. Someone that the participants will look up to and respect for their knowledge of the area is essential. A person who teaches well is also very important and not always easy to find. The person can be a lead nurse or other clinician, a QI officer, or a special guest teacher.

Plan-Do-Study-Act (PDSA) Cycles

When the teaching is done and the new protocol is starting, the project team will have someone assigned to collect and review the data. That person will look at the data, decide what seems to be working and what seems to not be working, adjust the protocol, let the staff know, and try again. The cycle will continue until things seem to be where they should be for a sustained period of time.

Implementation and Impact

Next, the protocol and education will be rolled out throughout the relevant area—say, the whole nursing center. A small number of key measures will be collected that the center can monitor to know how well the implementation worked.

Concluding the Improvement Effort

Finally, a routine measure—such as the rates of documented nursing assistant reports of change, documented communications from nursing assistants to licensed nurses about change, or reported SBAR or CUS use rates—should be chosen as a quality indicator. The leadership team then needs to ensure that the quality indicator is routinely collected and reviewed by a responsible member of the center to ensure that the improvement is sustained over time and, if it falls off over time, that attention to the problem is renewed.


3. For more detailed information on QI and measurement tools, please go to The Patient Safety Education Project (PSEP), Module 9: Methods for Improving Safety, which can be found at http://patientsafetyeducationproject.org.
4. Easy Guide to Clinical Practice Improvement: A Guide for Healthcare Professionals. New South Wales, Australia: New South Wales Department of Health; 2002

Current as of June 2012
Internet Citation: Module 2. Communicating Change in a Resident's Condition: Improving Patient Safety in Long-Term Care Facilities: Training Modules, Instructor Guide. June 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcgdmod2.html