# Presentation: 435903

## 248 “I’m covering...What do I do now”

- Divya Shroff, MD
- Peter Woodbridge, MD
- Tom Russell, MSN, HSSMel Sharer (contributing author)

## Things to Remember

- Questions will be answered at the end of the 3 speakers’ talks
- 3 x 5 cards are available around the room
- Please jot down questions for the end
- All talks will be available on the Web after the lecture is over

## “Handoffs”  Medicine’s newest buzzword

- Divya Shroff, MD
- Senior Hospitalist
- Washington DC VAMC

## Creative Handoffs outside and inside of Medicine

- NASCAR pit crews
- Formula One Ferrari Team “lollipop man” – Britain’s largest Children’s Hospital
- Nuclear Submarine handoff system – Kaiser Permanente of California
- NASA
- Canadian nuclear power plants
- Aviation industry - Air traffic control/ cockpit and ground crews
- Relay races – “pass the baton” at Trinity Medical Center in Rock Island, IL
- “Telephone game”
- “Ticket to Ride” – key ?s asked between department transfers
- “Just go NUTS” – Name, Unique issues, Tubes, Safety

**Notes:**
Speech patterns/variability / multitasking/focus /hierarchy/ tension

## Why is Handoff important?	

- Reduce likelihood of medical errors and misinformation
- Prevent lost or missing clinical information
- Maintain a high level of medical care
- Increase efficiency/flow
- Decrease cost of multiple tests/length of stay
- Key issue for across all levels of medicine - MDs/RNs/Clerks
- Nursing shortage; therefore, temporary staff
- House staff shift guidelines
- Larger surgical teams due to advanced technology

**Notes:**
Per recent IOM report, 44000-98000/yr die in US hospitals because of errors
Australian study of 28 hospitals found communication errors leading cause of adverse events (2x more than clinical inadequacy)
2005 study found 70% of preventable hospital mishaps occurred because of communication problems
Two of three RCAs list communication problems as a  cause of the adverse event. 

## Barriers that lead to need for Standardized Handoff

- In today’s climate of short hospital stays and complex patients, need for timely and effective communication
- Work hour limits for residents lead to increased number of patient handoffs and potential for communication breakdown
- Decrease in continuity of care/miscommunication/increase in cross-coverage
- Missing information in a non-standardized system
- High variability –
- ex) Code status/allergies missing in 80% of recent studies

**Notes:**
Increase use of hospitalists/ multiple docs with one patient /nursing shortage

## What does a handoff need to address?

- Standardized
- Written and Oral patient summaries
- Communicate in effective and efficient manner during sign-out
- Demonstrate “read-back” skills when communicating
- Evaluate all up to date medications
- Anticipating what may go wrong with patient after a transition in care occurs

**Notes:**
3. (create a solid foundation)

## Key points to remember

**The physical setting** – confidential/ quiet/ minimal distractions
**The social setting** – comfortable along all levels of hierarchy
**Language barriers** – avoid colloquialisms/ only accepted abbreviations
**Medium of communication** –  * face to face vs. phone vs. email / * written vs. oral
**Time / convenience issues** – standardized system will increase efficiency
**Education issues** – formal curriculum to demonstrate effective handoffs
- Ref: _Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs_, *Academic Medicine*, Dec 2005

**Notes:**
Emphasize with voice/tone/facial expressions which influences a reaction / at the bedside if needed
Avoid copying/pasting – making sure updated

## What should be in a successful handoff?

**Team Identifiers** - Staff names, phone numbers, covering staff contact info, distinctive team name/color
**Appropriate patient identifier **-** **2 forms of identification
- 1-2 sentence of **patient presentation**
**Active problem list** - pertinent past medical history
**Medications **– all active listed
**Allergies**
**Access **- Venous / Arterial Access and what to do if changes
**Code status**
**Pertinent labs**
**Concerns** over next 18-24 hours and what to do in those situations (problem vs. system based)
- Long term plans / family questions that could arise if indicated
- Psychological concerns
- Ref: _Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs_, *Academic Medicine*, Dec 2005

## Paper

_**Pros**_
- Easy/Known
- Handwritten/Typed

_**Cons**_
- Security issues
- Handwriting issues
- Variability
- Not being “green” – waste paper/cut trees
- Fills pockets
- Consistency/Accuracy
- Lack of Verbal

## Index Cards

_**Pros**_
- Traditional
- Easily transportable

_**Cons**_
- Security issues
- Handwriting issues
- Variability
- Consistency/Accuracy

## Excel/Word Documents

_**Pros**_
- Legible
- Can be concise
- Potential for uniformity
- Time Saving

_**Cons**_
- Security
- Email/USB access
- Variability
- Not being “green”
- Fills pockets
- Consistency/Accuracy
- Copying/Pasting
- Lack of verbal

## Verbal

_**Pros**_
- Face to Face
- Emphasis on verbal and non-verbal cues
- Emergency Usage

_**Cons**_
- No documentation
- Miscommunication
- Chaotic
- “Taping”- removes face to face

## Email

_**Pros**_
- Legible
- At any time or place

_**Cons**_
- Security
- Lack of verbal
- Consistency/Accuracy
- Copying/pasting
- Variability

## CAIRO

_**Pros**_
- Uniformity
- Built within VA
- Works with CPRS
- Med reconciliation
- Legible
- Forces updates
- Site/service tailored
- Time saving
- Paperless in future

_**Cons**_
- Not “green”, but has potential
- Security
- Fills pockets
- Lack of verbal
**Class 3, not Class 1**

**Notes:**
Innoventions – m/w 6:30
Class 3 – homegrown
Class 1 - nationwide

## Everyone’s talking about handoffs...

- VHA National Findings and Recommendation For Improving Patient Handoffs
- 2007 National Patient Safety Goals
- 2007 Joint Commission Frequently Cited Standards
- VHA FIX/Flow Effort
- “**SBAR**” - **S**ituation/ **B**ackground/ **A**ssessment/ **R**ecommendation

## VHA National Findings and Recommendation For Improving Patient Handoffs

- Goal – Improve the quality and safety of handoff process
- Objective – Meet the requirements of JCAHO National Patient safety goal 2E:
- Implement a standardized approach to “handoff” communications including an opportunity to ask and respond to questions
**Standardization** of shift-change processes necessitates a written summary and/or flowchart of the standardized handoffs processes.
**Physician to Physician** – a special-purpose written report or “sign out”, checklist or other aids may be needed to **standardize** the quality and sort of pertinent patient information communicated from shift-to-shift

## 2007 National Patient Safety Goals

- Improve the effectiveness of communication among caregivers (2)
- Requirement 2E– implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions
**Rationale** – the primary objective of a “hand-off” is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes.  The information communicated during a hand off must be accurate in order to meet patient safety goals

**Notes:**
Rationale

## Implementation Expectations for Requirement 2E

- The organization’s process for effective “hand off” communication includes: Interactive communications allowing for the opportunity for questioning between the giver and receiver of patient information
- The organization’s processes for effective “hand off” communication includes: Up-to-date information regarding the patient’s care, treatment and services, condition and any recent or anticipated changes

**Notes:**
ALL

## 2007 National Patient Safety GoalsCont. 

- Accurately and completely reconcile medications across the continuum of care (8)
- A process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization (8A)
- A complete list of the patient’s medications is **communicated **to the next provider of service when a patient is referred or **transferred** to another **setting, service, practitioner, or level of care** within or outside of the organization.  (8B)

## 2007 Joint Commission Frequently Cited Standards

- Req. 8A
- Patients are most at risk during transitions in care (**hand-offs**) across settings, services, providers, or levels of care.  The **development, reconciliation and communication** of an accurate medication list throughout the continuum of care is essential in the reduction of transition-related adverse drug events.
- Implementation: The medications ordered for, administered to, or dispensed to the patient while under the care of the organization are compared to those on the list and any discrepancies are resolved

## 2007 Joint Commission Frequently Cited Standards

- Req. 8B
- The patient’s accurate medication reconciliation list (complete with medications prescribed by the first provider of service) is communicated to the next provider of service, whether it be within or outside of the organization
- The next provider of service checks the medication reconciliation list again to make sure it is accurate and in concert with any new medications to be ordered/prescribed.

## 2007 National Patient Safety Goals

- Many sentinel events can be avoided
- Look-alike, sound-alike
- Delay in treatments
- Dangerous abbreviations
- Medication reconciliation
**All above are addressed by Handoffs**

## VHA and Handoffs

- 2e: Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions. (All Settings)
- Why?  To improve transfer of patient information and improve overall patient care and patient safety.
**Most RCAs** cite **communications** as a contributing factor.  This addresses a subset of situations where communications lapses can be especially hazardous.
**VACO Status** – National VHA Workgroup established, recommendations prepared, pilot test(s) starting for locally developed electronic template(s), no current plan for a VHA Directive.

**Notes:**
2/3 of all RCAs identify specific communication issues as one of the causes of the particular adverse event under review.

## VACO/NCPS Recommendations

- Standardizing requires something in writing
- Flowcharts, tables, or text describing shift-change handoffs for nurses, physicians, and physicians-in-training (if present)
**Standardizing does not mean it needs to be same VA-wide, VISN-wide, or VAMC-wide, but processes should be consistent at the unit-level**
- Methods and tools for interfacility transfers
- Processes and tools for transporting patients from one area to another within a facility (unit to radiology, unit to ICU, etc.)
- Inform staff on methods to get questions answered across shift changes, even if seemingly obvious

## A standardized approach should identify :-

- The “hand-off” situations that it applies to
- Who is, or should be, involved in the communication
- What information should be communicated
- Diagnoses and current condition of the patient
- Recent changes in condition or treatment
- Anticipated changes in condition or treatment
- What to watch for in the next interval of care
- Opportunities to ask and respond to questions
- When to use certain techniques (repeat-back; SBAR)
- What print or electronic information should be available

## Take Home Points

- Handoffs are the future
- Patient safety
- JCAHO/NCPS/VHA/FIX
- Handoffs do not replace your chart
- Handoffs emphasize communication
- Need standardization/ consistency/ accuracy/ secure process

## References

- Wall Street Journal, Tuesday, Nov 14, 2006 “ A Hospital Races to Learn Lessons of a Ferrari Pit Stop”
- Academic Medicine, Vol. 80, No.12/Dec 2005, “Lost in Translation: Challenges and Opportunities in Physician-to-Physician”, Sollet, DJ; Norvell, JM; Rutan, GH; Frankel, RM
- The Hospitalist, March 2007 “Hospitalists and Handoffs”

## Electronic Hand-Offs Tool Consideration

- Peter Woodbridge, MD

## Why Handoffs?

- CPRSPatient,One
- Admitted for pleural effusion
- IR determined that patient appropriate for bedside tap
- Change in bed teams before thoracentesis
- No formal hand-off (or time-out)
- Thoracentesis on wrong side

- CPRSPatient,Two
- Admitted for CT guided FNA of lung mass
- Transferred to floor where developed SOB and tachypnea
- Returned to Radiology
- Survey film
- Tech marks without noticing patient has been “flipped” for thoracentesis
- No formal hand-off (or time-out)
- Chest tube inserted on wrong side

## “To err is human”

- The Challenge:
- Design to prevent errors

- “Good” (10-1)
- Vigilance
- Common equipment
- Personal check lists
- Working harder next time
- Education
- Awareness
- Compliance feedback
- Standard order sets

- “Great” (10-2)
- Standardized Work
- Decision aids
- Reminders
- Desired action = default
- Opt-out versus opt-in
- Automate scheduling of tasks
- Forcing functions
- Redundancy

## Why Handoffs?

- 44,000 – 98,000 deaths annually due to medical errors (IOM)
- 2/3 of medical errors due to communications errors (JCAHO)
- Many communications errors happen at handoff
- Most handoffs are haphazard (Volp)
- As a result, JCAHO now requires standardized handoffs

## Why Handoffs?

## “Build it and they may not come”

- Computerized handoff tools provide a means for “standardized” handoffs but will staff use it?
- Delicate balance
- Perceived value vs. perceived effort
- Completeness vs. brevity

## Aim #1: Evaluate information transferred using handoff tool

- Well accepted by medicine residents
- 96% of all handoffs
- 70% contained the automatically pulled progress note
- Significant omissions
- Provider name and pager number
- Allergies
- Code status
- Handoff notes with automatically pulled progress notes had higher inclusion of all coded information.

- Courtesy: Flanagan, Patterson, Frankel, Doebbeling

## Aim #1: Evaluate information transferred using handoff tool

- Percent computerized handoffs containing information (n = 1216)

- Courtesy: Flanagan, Patterson, Frankel, Doebbeling

## Aim #2: Refine the handoff tool

- Although residents highly satisfied with computerized handoff tool,
- 48% indicated either an unanticipated patient event or an event that required additional information
- Many indicated the need to have a face-to-face conversation about patients when receiving the computerized handoff
- Most indicated a preference toward receiving a list of anticipated problems and recommendations for treatment if these do occur in addition to the automatically generated progress note

- Courtesy: Flanagan, Patterson, Frankel, Doebbeling

## Aim #2: Refine the handoff tool

- Handoff tool features that help residents deliver effective patient care:
- Current medication list
- Assessment/plan
- Patient identification
- Portability
- Anticipate problems (“if-then”)
- Easy and fast
- Code status

- Courtesy: Flanagan, Patterson, Frankel, Doebbeling

## Aim #2: Refine the handoff tool

- Suggested refinements to handoff tool:
- Assessment/plan not always included
- Code status not always included
- Lengthy (cumbersome to carry)
- Include location or divide lists by location

- Courtesy: Flanagan, Patterson, Frankel, Doebbeling

## Aim #3: Describe barriers and facilitators to implementing the handoff tool

- Assessment/Plan extraction did not work
- Errors extracting medication lists for the handoff
- Several reported that the system was not available sometimes
- Residents found the print outs too cumbersome to carry
- Residents wanted a “to do” list
- If the paper form was lost it could not be retrieved (in the computer system) by the cross-cover resident

- Courtesy: Flanagan, Patterson, Frankel, Doebbeling

**Notes:**
would not allow printing, which created more work for the residents as they had to create (cut and paste) their own handoff form in a separate word processing document

## Hand-Offs and Patient Flow

## 2006 VA  Inpatient Efficiency Analysis

- Longitudinal study of 2001-2006 VA inpatient stays
- Acute medical, surgical, psychiatric, and substance abuse inpatient stays
- Includes both VA and purchased care
- Results available by facility and VISN
- Examines the interrelation of quality and efficiency
*Emphasis on potentially avoidable complications and adverse events that impact length of stay*
- Compares each VAMC to
- VA best-practice benchmarks
- Medicare best-practice benchmarks

- Courtesy: Barbara Manning

## Methodology – Benchmarking

- Length of stay (LOS) for each VA inpatient stay compared to a national “*well-managed benchmark”* using:
- All Patient Refined Diagnosis Related Groups (APR-DRG) Version 20* grouper to adjust for the severity of illness and resource intensity
- Other statistically significant variables, including diagnoses, procedures, admission source, discharge disposition, age, gender
- Above variables account for 80-90 percent of variation in LOS
- Actual LOS for _each_ VA admission compared to its unique benchmark LOS to identify “*potentially avoidable inpatient days*”

- *All copyrights in and to APR-DRGs are owned by 3M.  All rights reserved.

- Courtesy: Barbara Manning

**Notes:**
Analysis uses 95% of VA and Medicare inpatient stays
National benchmark: well-managed care does not vary geographically
APR-DRG V20 and others explain 80-90% of the variation in LOS
Hospitals not reimbursed under the Prospective Payment System tend to undercode, while those that are may over-code or upcode.

Exhibit D10-1A works through an example DRG to show methodology

## Definition of Well-Managed Benchmarks

- LOS by a well-run delivery system *with the appropriate infrastructure*, where:
- Observable evidence-based best practices are used to achieve the lowest utilization possible *without adversely affecting quality of care*
- System is *not a tightly managed* delivery system that compromises quality for efficiency (e.g., denies services)

- Courtesy: Barbara Manning

## Who Achieves Best Practice Benchmarks?

- Measure –
- Number of benchmarks (fewest potentially avoidable inpatient days of care by DRG)
- More is better
- 570 APR-DRG
- VISNs achieve between 4 and 130 benchmarks
- Top Medicare hospitals achieve between 68 and 143 benchmarks
- VA best-practice benchmarks
- VISNs 18, 19, 20, and 23
- Medicare best-practice benchmarks
- Well-known, well-respected hospitals

- Courtesy: Barbara Manning

## Hospitals Achieving Well-Managed Benchmarks*

- *Using Milliman Efficiency Analysis*

- Courtesy: Barbara Manning

**Notes:**
570 is the total number of models that Milliman developed for Medicare; one for each severity-adjusted APR-DRG
Represents the number of times a facility appears as a most efficient practice
VA is affiliated with all medical schools but Sarasota and Mayo Clinic

## VA Best Practice* – VISN and Facility Level

- *Based on Medicare Best Practice Benchmarks

- Courtesy: Barbara Manning

**Notes:**
VISN
Med	19, 20
Surg	23
Psy	8
SA	23

Facility
Med	Salt Lake City, 3,196 Cases
Surg	Salt Lake City and Sacramento 1,569 and 637
Psych	Baltimore, 396
SA	Sierra Nevada, 351

## Potentially Avoidable Inpatient DaysBased on Medicare Best Practice Benchmarks

- Courtesy: Barbara Manning

## How Do Hospitals Achieve theWell-Managed Benchmarks?

- Minimize potentially avoidable complications that add to LOS such as:
- Infections
- Electrolyte problems
- Medical mishaps
- Case management & disease management
- Flow management
- Active discharge planning

- Use evidence-based clinical best practice guidelines
- Pre- and post-surgery antibiotic use
- Providing aspirin on admission for heart attack patients
- Implementing utilization management programs

- Courtesy: Barbara Manning

**Notes:**
Best observed practices – combination of clinical, quality of care practices and management practices

## FIX Collaborative Goal

## The VA FIX Collaborative

- Apply systems redesign principles to achieve well-managed benchmarks
- Reduce avoidable LOS while maintaining or improving quality
- Reduce inter-facility variability
- Focus
- Improve inpatient flow
- 	“Physiology, not inefficiency, should determine LOS”
- Use utilization management to ensure patient in most appropriate bed
- Reduce medical mishaps and avoidable complications

## The FIX Collaborative

- Five regional collaboratives
- Modeled after the ACA Collaboratives
- Multiple learning sessions
- Learn system redesign principles
- Apply to constraints
- Performance monitors and measures

## The IP Flow Challenge

## Slide 54

## Discharge Model

## The Role of CPRS / VistA in Reducing Avoidable LOS 

- Improve flow
- New tools under-development:
- ED Bed Board
- IP Bed Board
- Utilization management
- Integrate UM tools
- Reduce mishaps and medical complications
- Clinical alerts
- BCMA
- Handoffs

## Tom Russell MSN, HSSMel Sharer

- James E. VanZandt VAMC
- Altoona, Pa

- I’m Covering...What Do I Do Now
- or
- “What do I have to keep track of  Communication”

## What is “Hand-off Communication”

- Method of providing information to others that are taking over for the care of patients.
- Provides clear delineation of “who is responsible for the whom, what, where and why” between now and the next provider.
- Promotes a “Team approach” to the care of patients.
- Increases the patient sense of “comfort” by feeling that everyone is “onboard” with the plan of care.

## WHO ARE THE MEMBERS OF THE TEAM POTENTIALLY INVOLVED IN “HAND-OFF COMMUNICATION

**Team**:   Two or More People trained and organized for achieving a given purpose (Webster)
**Where Does It Occur:**   Anywhere there are patients,  there are teams and the need to communicate.
**What is the Content**:  Content usually involves those “key” items/elements that  are mostly important to the care of the patient.
**How Does the Hand-Off Communication Occur**:
**Verbal Review** (usually a face to face interaction or telephone call)
**Written Documentation** (report sheets, telephone message pads, faxes)
**Electronic Documentation** (CPRS, emails, communication reports)

## The Issue

- What is the most timely, effective, comprehensive and secure method or process that can be instituted to communicate the care and surveillance of patient needs.

## The Perceived Problem(by those not involved in the direct care of the patient)

- Documentation of by Medical Service Assistants (MSAs) and Patient Service Assistants (PSAs) in the “progress notes” section of the electronic medical record.  The perception that documentation initiated by “team” administrative or non-provider staff was inappropriate.
- The need to establish a method of communicating patient needs without documentation in the medical record.
- Types of communication included:
- 1 on 1 interactions with the patient (ie requests for medications)
- Inquires by outside providers or community resources on patient care issues (home nursing agency, co-practice issues, consultants).

## The Arbitrary Decision

- March 14, 2006 All administrative clinical support staff in Outpatient Services will no longer document in the patient electronic medical record.
- Each team or service will establish a method of documenting the patient concern and/or call the provider if they are available.
- The method for immediate use was to formulate a “paper reporting or Communication Sheets” designed uniquely by each primary care team (HBOC/CBOC, or Specialty area (subspecialty clinics, and behavioral health).
- Handwritten documentation sheets once transcribed and entered by the clinical providers would then be destroyed.

##                 The Impact

- Erased any beginning timeline of care.
- Increased the potential and reality of losing “paper documentation”.
- Provider mailboxes (*checked infrequently)*
- Folders in Chart Racks (*Outside of exam rooms*)
- Hand carried copies (*potential for laying down sheets anywhere in clinic setting).*
- Laying communications of provider desks (*in the potential view of other patients and misplacing communication)*
- Misfiling of documentation in different folders
- HIPAA issues (losing handwritten paper)

## The Revolt

- The Complaints consistently rise to the Office of the Director.
- Outpatient Departments (Specialty Clinic, Primary Care Clinics, Behavioral Health Clinic) began sending numerous written documentation to the “Quadrad” leadership.
- Verbal communication with Director on his “hospital rounds”.
- Increased complaints by patient and staff regarding loss or lack of timely care.

## The Survey of Problem

- The Associate Director assigned Health Information Service staff to review the concerns and interview all outpatient staff.
- Submitted a report to the Associate Director on the findings.

## The Intervention

- The Medical Center Director decides to establish a “Process Action Team” (PAT).
- Delegates responsibility to HSS
- Reports directly to the Director on all actions and progress related to the PAT on a weekly basis.
- The HSS assigned to address the concern in the AD report and to establish an “electronic method that address the patient care needs with the input of outpatient staff.

## The Team

- Involve those **closest** to the issue/problem.
- Equal and diverse representation of the PAT      (bring together the open/radial thought).
** ****3 ** Physicians (CBOC, HBOC)
** ****4**  RNs (CBOC, HBOC, Specialty)
** ****3**  PSA/MSA (CBOC, HBOC, BHC)
** ****1**  Risk Manager
** ****2**  CACs (1 non-voting advisory member)
** ****1**  Union Representative
** ****1**  HIMS Supervisor (non-voting advisory member)
** ****1  **Chairperson (HSS)

## The Plan

- Meeting Times:  Twice per week (Tues/Thurs) from *9:00 – 10:00
- Video Conference Room
- Start sharply at 9:00 – end at 10:00 (providers have clinics- promotes buy-in)
- 6 weeks or meetings (*extended 2 weeks*)
- Spelled out timeline of what is due when
- Chairperson – Keep everyone “on track” and support assignment and reports of members.

## The PAT

- Define the Problem.
- Clarification of the assigned “charge” of the group.
- Review the status of problem (the starting point of the PAT – *avoid the history of who caused the problem unless it is relevant to the solution).*
- Define generalities working to finite “brainstorming” (*use of flip charts is very helpful*).
- Ensure that everyone has input (*this begins with selection of the PAT members).*
- Everyone has a action item (*either as a subgroup or individually).*
- All PAT members takes discussion back to other staff to get valuable input/suggestions ( *after each meeting as a part of their action – responsibilities)*

## Their Work

- Overall 96% attendance rate of PAT members (*including those on the video conference calls).*
**1****st**** Meeting*** – Organization of Meeting and Brainstorming sessions start.*
**2****nd**** Meeting** – 3 templates were developed (*Primary Care, Spec. Clinic, BHC).*
**3****rd**** Meeting** – Education of “Leadership” and Teams by members of the PAT.
**4****th**** Meeting** – rollout to select areas of outpatient (2* PC teams HBOC/CBOC, Spec. Clinic “North”, select BHC staff – no BHC consultants, with *_*concurrent monitoring*_*)**.*
**5****th**** Meeting*** – *Review of concurrent monitoring and changes to full implementation plan.
**6****th**** Meeting** -modifications to templates, re-education of clinical managers and teams.
**7****th**** Meeting** – Full Implementation (*concurrent monitoring)*
**8****th**** Meeting** – Plan to Present Final Plan and Implementation to Leadership Staff Council of the Hospital.
**Extended 2 weeks** focused on the review of continuing compliance and any further education related to Medical Records issues, MCMs development, and monitoring.

## Slide 72

## Slide 73

## MSA PSA Communication Notes

_**Communication Note**_
- Includes a documentation guide for all MSA PSA documentation
- Template auto displays when title selected
_**Med Request Note**_
- Includes documentation guide for Refills, Renewals, and Outside Meds
- Template auto displays when title selected
_**Letters/Fax/1010m Note**_
- Includes documentation guide for receipt of correspondence
- Template auto displays when title selected

## MSA PSA Communication Note

*Selecting the title will generate the Template. Having several Titles will differentiate the content for high volume notes such as Med Requests, and Correspondence. The Refill and Correspondence guides are also on the main Communication Note.*

## Slide 76

## Slide 77

## Slide 78

## Requests Test Results

*Requests Test Results*

## Referral/Scheduling Request

*Referral/Scheduling Request*

## Request to Discontinue Care 

*Request to Discontinue Care*

## Medication Issue; First, differentiates between VA and Non-VA request

*Medication Issue; First, differentiates between VA and Non-VA request*

## Then Documentation ‘included or not included when the patient brings in the document but scanning is pending but copy of document is attached or hand carried with printed out copy of the attach “communication note”.

*Then Documentation ‘included or not included when the patient brings in the document but scanning is pending but copy of document is attached or hand carried with printed out copy of the attach “communication note”.*

## VA request contains sections for Refill, Renew, & Outside meds

*VA request contains sections for Refill, Renew, & Outside meds*

*Med Listing does not transfer to Note *

## Moved Med listing object below ‘Medication text box’.

## Slide 86

## Warning does NOT transfer to the Note text and is meant for a reminder to forward the Note to the appropriate personnel

***Warning does NOT transfer to the Note text and is meant for a reminder to forward the Note to the appropriate personnel***

## MSA PSA Comm Med Request

*Used for Refills, Renewals and Outside meds only*

## MSA PSA Comm Med Request Note

*Appropriate Note title should be selected for Med Request*

## Initial Prompt requires a VA or Non-VA Request

*Initial Prompt requires a VA or Non-VA Request*

## Allergy information pulled to display on initial selection without additional check box.

*Allergy information pulled to display on initial selection without additional check box.*

## The same prompts are present for ‘Documentation Included’ and ‘Documentation NOT included’.

*The same prompts are present for ‘Documentation Included’ and ‘Documentation NOT included’.*

## Slide 93

## Slide 94

## Warning – Reminder to forward to Appropriate personnel

*Warning – Reminder to forward to Appropriate personnel*

## MSA PSA Comm Fax Letter 1010m

*Used for received correspondence only*

## MSA PSA Comm Fax Letter 1010m

*Appropriate title is selected for correspondence*

## Warning is added to the field to ensure communication is forwarded to appropriate personnel

*Warning is added to the field to ensure communication is forwarded to appropriate personnel*

## The Current Status

*Small VRAH *
*950 – 1000 Electronic Notes per week.  *
*97% Compliance to Independent Medical Records auditing.*
*No formal provider complaints **(most informal complaints are regarding the number of alerts received per day).*
*Most frequent issue, note not visible unless it is signed (reminder at bottom of all communication notes.*
***Staff satisfaction and “buy in” because they knew and worked on a solution.  ***
_***Repeat***_*** volunteering by those participating in the PAT. ***

## Questions??

## Slide 101