Can improving communications among clinicians potentially enhance patient safety, while at the same time dramatically improving clinician satisfaction? The answer to both of those questions is a resounding “yes,” according to clinician and operational leaders at the Hospital for Special Surgery (HSS) in New York.
The 214-bed hospital, whose main campus is located on Manhattan’s Upper East Side, is widely respected, and in 2017 was ranked by U.S. News & World Report as the number-one hospital in the United for orthopedics, and the number-three hospital for rheumatology. The nation’s oldest orthopedic hospital, it was founded in 1863, and attracts patients from all 50 U.S. states and more than 100 foreign countries.
HSS is also, not surprisingly, a very complex organization to run, with surgeons and other clinicians constantly involved in very complicated interpersonal communications.
It is in that context that HSS leaders, including Peter Grimaldi, MS, PA-c, assistant vice president and a practicing physician assistant at the hospital, and Nick Wirth, the hospital’s director of operational excellence, presented on the topic “Standardizing Clinical Communication Improves Patient-Centric Care Coordination and Collaboration,” on March 8 at the Venetian Sands Convention in Las Vegas, during HIMSS18, the annual HIMSS Conference, sponsored by the Chicago-based HIMSS (Healthcare Information & Management Systems Society).
Just before they presented at HIMSS18, Grimaldi and Wirth spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the initiative that they’ve been leading at the Hospital for Special Surgery around improving clinician communications within the organization. As part of that initiative, their team at HSS has been partnering with the Knoxville, Tennessee-based PerfectServe, to implement and optimize telecommunications technology, in order to support HSS’ physician-led journey to standardize clinical communication across its enterprise network, an initiative that has included addressing postoperative care’s extraordinary volume of e-conversations traversing multiple units to create a higher level of patient safety. There are now 3,400 total users on the platform that’s gone live, including 1,300 mobile users, and 700 prescribers. Below are excerpts from that interview.
Can you share with me the origin of this initiative?
Nick Wirth: At the end of 2013, our surgeons spoke with us about the faultiness of their answering services. They were using six to eight answering services across their practices, and none was ideal. So we started looking at this from the outpatient side, knowing we would want to expand this to the inpatient side. So we started out with our physician practices.
Peter Grimaldi: This was a natural extension of a lot of work we’ve been doing around communication. We have the largest orthopedic residency program in the US at HSS, and nine different subspecialty fellowships, and we have 102 PAs under my organization, the frontline staff—and an additional 70 who are private who work for individual surgeons, but who are part of the para team in many ways. With that large a staff, and with the decreasing lengths of stay of patients we’re treating, we really had to improve our communication processes. To evolve away from our dated pager system was an extension of what we were trying to do.
Surgeons and other clinicians are demanding as consumers of technology, correct?
Wirth: Yes, and quite a few physicians and residents and fellows told us at the time, “We’re in 2016 [at the time], but we’re still using a paging system from the last century! And while everyone’s moving to texting, why haven’t we improved this yet?”
Tell me about the building-block steps in this telecom initiative?
Wirth: In 2016, we were implementing an EHR [electronic health record] across the organization, so in February 2016, we decided to implement a new system across the practices that could also be implemented at the hospital, to bring inpatient and outpatient communications together. We knew we had to get through the EHR implementation first. That started our timeline, beginning in February 2016, and extending throughout that year. And then once we got through that implementation, we set up a steering committee focused on communications. It was a large committee that was multispecialty—we had representation across all the different clinical departments involved in direct patient care. So probably 20 people on the committee.
Grimaldi: Yes, between the clinical departments, IT, operational excellence, some of senior executives, more than 20.
And what building-block steps were involved, in practice?
Grimaldi: One guiding principle was that of bringing outpatient and inpatient communications into one platform. The second principle was to centralize all call schedules and coverage assignments in the organization into that platform. You’ve heard that there can be a million different clinical departments with different on-call procedures. We said all calls should go through this platform, so that there’s one source of truth. And the third part is, with that standardization, we also developed a standardization of policy on communications across the organization.
When did you go live with the vendor solution?
Wirth: In 2016, we implemented it, at first, just in the physician practice. In September 2016, we introduced it to the hospitalist group as an inpatient pilot for inpatient communications. The full hospital rollout started in April 2017, where we brought all direct caregivers onto the platform; later, everyone in the organization, including direct patient caregivers—our prescribers, our rehab therapists, and our nursing team; and then with everyone else, in June 2017. And we had the pager system still backing us up as we implemented.
When did you finally eliminate your pager system entirely?
Grimaldi: We sunsetted our pagers in June 2017 when everyone came on board.
How has it all worked out?
Grimaldi: From the inpatient point of view, it’s been phenomenal. The trials and tribulations using a traditional analog pager system all those years were many: you’d send a page, there was no feedback loop, no way of knowing whether the page went through; and when you received a page, there was no way to know its level of urgency, which means that you had no way to triage your pages. And we were dealing with an extreme level of volume. No way to prioritize what you were dealing with, in a given moment.
What allows you to triage pages in the new system?
Grimaldi: Oftentimes, the nurse is the one initiating a message to the PAs and doctors; that’s received via your app on your smartphone. You’re alerted, and you can check the message, which often gives you enough detail to address the issue at hand. The nurse can also indicate that a callback is required. So it helps you determine what the issue is and how to address it, and you can also give the nurse a message back and say, OK, I’ll deal with this now, or I need, say, 20 minutes to deal with a patient first.
Wirth: Also, an integration between our EHR and the clinical communications platform has allowed us to have the nurses select the patient involved, so that they can communicate directly with the correct provider; so the message includes not only the patient’s name, but also the medical record number (MRN), the patient identifier.
Grimaldi: Nick makes a really good point. We put in some algorithms with the messaging so that, depending on the issue at hand, or the people involved—some of our clinical services are quite large, and sometimes you’re dealing with a team of three or four PAs, and this allows you to eliminate the middleman, and in March 2017, it was the one PA who was holding the analog pager, who would redirect the page to one of their teammates.
That sounds so last-century!
It does, and that was in 2017!
Do you have any metrics that you can share, related to the enhancements you’ve made?
Wirth: Yes, especially around the nurse-to-provider communication. Since implementing the solution, we’re seeing 10,000 unique communications or conversations between nurses and PAs every month, and across those, the average response time has been 3.3 minutes to acknowledge the message.
I’m sure it was much longer with the pagers.
Wirth: It’s one of those things that we wish we could have measured.
Grimaldi: But without question, the time to acknowledgement has been much, much shorter. And the inability to track this information was a real problem in the past; we didn’t even know, with pages, that the message was received. And with that paging system, there wasn’t a lot of motivation for the paging companies to improve their technology.
[In addition, Grimaldi and Wirth noted in their HIMSS18 presentation that 90 percent of conversations initiated from the PACU (post-anesthesia care unit) and inpatient floors are now read in under 15 minutes, while 98 percent of sepsis alerts are read within five minutes.]
What lessons have you learned overall, and what would your advice be for HIT and telecommunications leaders in other patient care organizations?
Grimaldi: First and foremost, a great takeaway for this is to listen to your frontline staff—issues they were having dealing with volume and prioritization, was critical for us in making the case to executive leadership, per a burning platform, for this. That would be the very first thing that I would call out. I would also say, don’t underestimate the importance of a sound communication policy and setting clear expectations around that policy.
Wirth: And two of the lessons learned, or things I’d want to identify very early in the process, have been around developing an organization-wide device policy. First, we decided to set a BYOD [bring your own device] policy, rather than forcing everyone to use our devices, which would be going against what we were trying to achieve. Second, when you’re moving to a secure mobile platform, you need to make sure you have the foundation set up well. Apple passwords and making sure people were getting onto the secure WiFi of the organization—those little things can really matter.
Is there anything else either of you would like to add?
Wirth: I think one of the things I’d say as well is, to me, the implementation of the medical record and then of the clinical communications platform, really is the foundation that sets your organization up for success. We’ve been able to spinoff so many things, things like emergent notification processes, integration between the EHR and the communications platform—this was the beginning of a lot of cool things we’ll be able to do here.
Grimaldi: And this has allowed us to assess our benchmarks and our staffing; it gives us information that allows us to redesign care models and repurpose staff in an area of need. We can see that a particular service is extremely busy—the messaging volume can signal whether perhaps patient complexity is playing a role—this can help us to rethink care models. And we’re able to identify some perhaps-unexplained phenomena, such as unexpected spikes in messaging in specific clinical areas, or cultural developments that have occurred. We can now address those more effectively.