


Communication

Denise Gribbin, MD • Josh Hagedorn

Psychiatric Leadership Program
 Context: Integrated Care
“ Many of the deficiencies in
U.S. health care are
reflections of the disjointed
and poorly coordinated care
that patients receive as they
move across settings and
among providers…failures of
communication”*
* Fisher ES, Staiger DO, Bynum JPW, and Gottlieb DJ. (2007) Creating
Accountable Care Organizations: The Extended Hospital Medical Staff. Health
Affairs, 26(1): w44-w57.
 Metabolic Monitoring
Consensus guidelines exist for
metabolic monitoring of
patients taking second
generation antipsychotics (SGAs)
And yet…
conformance to these guidelines
remains poor across the nation.

Morrato EH; Druss B; Hartung DM; Valuck RJ; Allen R; Campagna E; Newcomer
JW. (2010) Metabolic Testing Rates in 3 State Medicaid Programs After FDA
Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic
Drugs. Archives of General Psychiatry. 67(1):17-24.
  SGA Monitoring: Baseline Data*
• None of the 6 agencies reviewed had all four indicators
reported in 75% or more of the records reviewed.
• >75% of patients had BP recorded during past year. Of
them, 12% had elevated blood pressure.
• 75% were screened for family history of diabetes in past
year. Of them, 31% reported family history.
• <50% had fasting blood glucose level reported. Of those
that did, 16% had abnormally high results.
• Almost 75% of patients had Body Mass Index (BMI)
reported. Of them, over 80% were overweight or obese.
• <40% of the patients had blood lipid profile recorded.
100%
% of patients with recorded indicators

Agency 1
75% Agency 2 * This data was collected as
part of a project conducted
Agency 3
by network180 in conjunction
50% Agency 4
with Health Management
Agency 5 Associates to plan for
25% Agency 6 integrated care.
OVERALL

0%
BP Recorded BMI Recorded FBS Recorded Lipids Recorded
 Purpose
The goal of our project is to
propose:
 a simple, broad-based framework
 to standardize communication
 regarding essential elements of
treatment, referral &
documentation
 across multiple healthcare
providers.
 Hypothesis
We hypothesize that adherence to
process guidelines for communication
will result in:
 Increased frequency of
communications among providers.
 Greater focus and relevance in the
content of communication.
 Increased adherence to metabolic
monitoring guidelines (the inter-
provider communication process
being examined)
 Stages
The stages of activities
planned to accomplish this
project include the following:
 Communication Survey
 Focus Group
 Implementation Group
 “Is our communication sufficient to meet standards of care?”

100% 100%

90% 90%

80% 80%

70% 70%

60% 60%

50% 50%

40% 40%
Not sufficient

30% 30% Partially sufficient

20% Nearly sufficient

20%
Sufficient
10% 10%

0% 0% Case Manager

Nurse
Administrator

Other (below)

Psychiatrist

Therapist
Nurse Practitioner

Other Specialty Physician

Physician Assistant
 “What is most important to communicate?”

Medical History
Med List
Tx Plan
Active Problem List
Psych/Social History
Labs/Tests
Demographics
List of Providers
Other
3.67 3.67 3.85 4.04 4.54 4.97 5.90 5.95 7.64
* Lower is closer to #1 ranking
 “How frequently does communication happen?”

Direction Type Admin Providers Minimum Maximum

Nurse Practnr Administrator
Emergency 3.18 2.83
(2.30) (3.18)
Receive
Psychiatrist Case Manager
Routine 3.14 2.93
(2.17) (3.21)
Nurse Practnr Case Manager
Emergency 3.46 3.11
(2.20) (3.55)
Send
Physician's Case Manager
Routine 3.28 3.37
Assistant (2.83) (3.67)
Scale:
5 =Almost always
4 =Often
3 =Sometimes
2 =Rarely
1 =Almost never
 “Are there barriers to communication? What?”

No
27%

Yes
73%

* Word cloud of open responses to question.

 Why Checklists?

Our science makes mazes

Too knotted to navigate.
Proceed, check by check.

* Japanese/English haiku paraphrase/translation

of Atul Gawande’s Checklist Manifesto.
 Systematizing

* from Shannon, CE (1948) “A Mathematical Theory of Communication.”

The Bell System Technical Journal. 27: 379–423, 623–656.
 Mapping the Process
Implementation teams mapped
current process for metabolic
monitoring of 2nd generation
antipsychotics, marking handoffs.
 Mapping Networks

*Cacioppo, et al.(2009)"Alone in the Crowd: The Structure and Spread of Loneliness in a

Large Social Network" Journal of Personality and Social Psychology 97(6): 977-991.
 Form
  Feedback: Usefulness

“The Checklist was much easier to use

and read, it provided a better
understanding for others reading the
checklist as well.”

“The check list did help… giving

more clarity as to the reason for
“I do not believe the checklist
communication and the type of helped…the form was
response I was looking for from confusing.”
the recipient.”
 Feedback: Reception
“…I have received more
responses from PCP's
using the form.”
“We had several PCP offices that stated
they had discharged the client and did
not want to be sent further information.
ED departments were not wanting us to
call or fax information ...”
“A couple of doctor's offices …didn't
respond to my 1st or 2nd request for
communication. I'm not sure that had to
do with the form…maybe the doctors’
lack of communication.”
“PCP offices calling back and asking if
we were asking for additional
information, medical records or
needed a referral.”
 Limitations of Study
• A primary benefit of standardized communication format
would be familiarity, which our study was not broad or
long enough to model.
• We were unable to eliminate all existing formats for
reporting, thus there was still redundancy in the forms
that people were using.
• A truly integrated communication format would require a
shared platform for data exchange (EHR, HIE).
 Lessons Learned

• The complexity of care coordination will increase

proportional to specialization.
• Communication is multi-dimensional and incredibly
complex. Its success depends as much on the
expectations and relationship of communicants as on the
linear process.
• Without clear expectations and a systemic process,
communication induces stress and may be unproductive.
 On the horizon
• Level Design for Coordination of Care
Assessing complexity of comorbidity, fragmentation of
related health care entities and personal capacity.
• Embedded Communication Format in EMRs
Continuity of Care Document (CCD), a specification related
to the HL7 CDA standard.
• Ongoing need to ensure that the right person receives the
right information at the right time and knows how to use it.
 Into the Commons

Repeated communication is
related to people’s ability to
develop accountable,
collaborative relationships and
to successfully manage limited
resources*
* Ostrom E, Walker J, Gardner, R. (1992) “Covenants with and Without a Sword:
Self-Governance Is Possible.” American Political Science Review. 86(2) 410.
Care together.
 Bibliography: Checklist R&D
• Verdaasdonk, et al. (2009) Requirements for the design
and implementation of checklists for surgical processes.
Surgical Endoscopy 23:715–726.
• Lingard, et al. (2005) Getting teams to talk: development
and pilot implementation of a checklist to promote
interprofessional communication in the OR. Qual Saf
Health Care 14:340–346.
• Lingard, et al. (2008) Evaluation of a Preoperative
Checklist and Team Briefing Among Surgeons, Nurses, and
Anesthesiologists to Reduce Failures in Communication.
Arch Surg. 143(1):12-17.
• deVries, et al. (2009) Development and validation of the
SURgical PAtient Safety System (SURPASS) checklist. Qual
Saf Health Care 18:121-126.
• Civil Aviation Authority (2000) CAP 708: Guidance on the
Design, Presentation and Use of Electronic Checklists
• Civil Aviation Authority (2006) CAP 676: Guidance on the
Design, Presentation and Use of Emergency and
Abnormal Checklists
• Hales, et al. (2008) Development of Medical Checklists for
Improved Quality of Patient Care. International Journal for
Quality in Health Care. 20(1):22-30.
 Bibliography: Measurement
• Fletcher et al. (1984) Measuring the continuity and
coordination of medical care in a system involving
multiple providers. Medical Care 22(5):403-11
• Lingard, et al. (2006) A theory‐based instrument to
evaluate team communication in the operating room:
balancing measurement authenticity and reliability. Qual
Saf Health Care 15(6): 422–426.
• Strandberg-Larsen et al. (2009) Measurement of
integrated healthcare delivery: a systematic review of
methods and future research directions. Int J Integr Care.
v.9.
• Foy, et al. (2010) Meta-analysis: Effect of Interactive
Communication Between Collaborating Primary Care
Physicians and Specialists. Annals of Internal Medicine
152:247-258.
• Krivonos PD. (2007) Communication in Aviation Safety:
Lessons Learned and Lessons Required. Presented at the
2007 Regional Seminar of the Australia and New Zealand
Societies of Air Safety Investigators
 Bibliography: Theory
• Shannon, CE (1948) “A Mathematical Theory of
Communication.” The Bell System Technical Journal. 27:
379–423, 623–656.
• Newman, MEJ (2003) “The Structure and Function of
Complex Networks.” Siam Review, 45:2, 167-256.
• Ostrom E, Walker J, Gardner, R. (1992) “Covenants with
and Without a Sword: Self-Governance Is Possible.”
American Political Science Review. 86(2) 410.
• Liu Y, Passino KM. (2000) Swarm intelligence: Literature
overview
• Corman, SR, Kuhn, T., McFee, R. D., & Dooley, K. J. (2002)
Studying complex discursive systems: Centering
resonance analysis of communication. Human
Communication Research, 28, 157-206.
• Holsapple, C. W., Johnson, L. E., & Waldron, V. R. (1996) A
formal model for the study of communication support
systems. Human Communication Research, 22, 422-447.
• Cacioppo J.T., Fowler J.H. and Christakis N.A. (2009)
"Alone in the Crowd: The Structure and Spread of
Loneliness in a Large Social Network," Journal of
Personality and Social Psychology 97(6): 977-991.