I liked what she wrote about communication differences (p.20):

Whereas nurses may focus more on the person and patient knowledge bases, physicians may concentrate on the case knowledge….Although all three aspects may be important when considering the patient’s plan of care, the person considering one set of knowledge may not think the other set of knowledge is as important….Although the physician and the nurse may focus on different aspects, their ability to collaborate for the benefit of the patient should not be affected.

She recommended using the situation, background, assessment, recommendation (SBAR) format to standardize information transfer (p.17).

Ms. Stukenberg’s analysis of the role that physicians and nurses can play regarding financial issues also intrigued me (p.36-37).  For example, reimbursement can nearly double if pneumonia and a urinary tract infection (UTI) that was present on admission cause a major complication in an elderly patient.  Clinical scenarios (p. 107-110) illustrate the importance of physicians and nurses working together, for example when a nurse notes cloudy, foul-smelling urine on admission, contacts the physician to order a urine culture, and when it comes back positive, the clinical documentation specialist makes certain that the chart notes support that the UTI was present on admission.  If not documented properly, payers may conclude that a UTI represents a hospital-acquired condition that they do not need to reimburse.

Ms. Stukenberg wrote that clinical documentation improvement programs are in their infancy and represent a source of competitive advantage for hospitals that are willing to invest in improving documentation and care processes.  Success depends on:

• Hiring the right staff, who are clinically knowledgeable, understand coding and the impact of proper documentation on finances, and know how to communicate with coders, case managers, nurses, and physicians
• Providing the right tools, using a computer program to review charts in real time and match physician documentation with diagnostics (coders can only code off physician documentation)
• Assuring administrative support, especially senior hospital leaders who understand complexity, see the value of their investment, and support the documentation specialists’ credibility when physicians or nurses challenge new processes
• Having a trusted physician advisor who is well-respected clinically, able to explain coding to physician peers on a strategic level, and be a liason when needed to weigh in on important issues
• Educating coding personnel, clinical documentation specialists, nurses and physicians on an ongoing basis
• Monitoring case mix, length of stay, complication co-morbidity(CC), major complication comorbidity (MCC) capture rates,  reimbursement, and effect of documentation on hospital finances 
• Implementing systems to prevent people from reverting to previous habits once their training period ends

 Implications in an era of healthcare reform

I interviewed Ms. Stukenberg by telephone and learned of a number of benefits of investing in improved clinical processes:

• RAC (recovery audit contractors): Being proactive regarding documentation criteria for admission avoids the need to payback money already spent on patient care
• Improving transitions of care: As I wrote in Collaborative Handoffs, approximately 80% of readmissions within 30 days of discharge are preventable
  Reconciling medications, calling  patients within 48 hours of discharge to make sure that they are taking medications as ordered and have scheduled outpatient appointments with their caregivers, monitoring weight of patients with heart failure, and including family caregivers and community providers in predicting home-going needs are all tasks that clinical specialists can facilitate
• ICD10 implementation: By 2013, providers will need to use a more detailed coding system; it is not too early to develop systems that facilitate adoption of the new standard
• Public reporting: in an age of increased transparency and scrutiny, doing processes correctly the first time can improve clinical and financial outcomes and build an organization’s credibility and brand recognition
• Building a culture of collaboration: As I wrote in Collaborative Culture, a culture built by healthcare professionals from the ground up (rather than imposed from above or by outside regulatory agencies) helps to sustain improved clinical processes.

Readers who would like to communicate directly with Ms. Stukenberg can reach her at MCRN@AEROINC.NET.  Her book is also available through www.crcpress.com.

This 113-page book is loaded with practical strategies for improving healthcare collaboration and clinical and financial outcomes.  I believe that it is a must-read for middle-level and senior healthcare leaders in this era of healthcare reform.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure: I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.

©2012 Healthcare Collaboration. All Rights Reserved.

Successful Collaboration in Healthcare: Review of Colleen Stukenberg’s New Book is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations

Something called out to me about Confident Voices: The Nurses’ Guide to Improving Communication and Creating Positive Workplaces, written by Beth Boynton and edited by Bonnie Kerrick:

• In Collaborative Insight, I saluted the nurses who helped me improve my bedside manner and my communication skills; although I may not have been as forthcoming as I would have liked to be upon receiving their feedback, in retrospect, how nice it is to know that they considered me trainable
• I think that many of us career-focused physicians come late to value relationships and teamwork in facilitating a practice environment in which we enjoy coming into work
• My wife is a nurse, who shares with me her workplace challenges occasionally

I admit that I found stories in this book, like certain medicines, difficult to swallow but (in the long run) beneficial:

• A nurse, finishing her first year of training, confessed that she was finally used to being yelled at (p.122)
• Connie, an experienced ED nurse in a new hospital was chewed out by a physician for not telling him about laboratory values soon enough in a patient whom Connie suspected of having internal bleeding (p.142); the nurse who relieved Connie for lunch dismissed the issue with a shrug, saying that the values had come back just a minute ago; Connie’s nursing colleague dismissed the situation with a comment that everyone has to earn their stripes; her nursing supervisor told her not to be so sensitive; a nurse reviewer recalled the catch phrase in the 1980′s that “nurses eat their young”

I entitled my post Collaborative Naivete because I felt unaware of the interpersonal difficulties that existed among nurses.  In reality, I was aware but did not want to acknowledge my awareness because resolving conflicts is a subject in which I had no formal training during medical school, residency, or fellowship.  Only within the last decade, have I come to realize that conflict is inevitable in times of disruptive change and that acknowledging it can bring about more robust solutions than pretending that conflict does not exist, the principal theme of my second book, Collaborate for Success!

I recommend Confident Voices: The Nurses’ Guide to Improving Communication and Creating Positive Workplaces not only because it is good medicine but also because it has practical guidelines to help us improve the practice environment where we work. For example (p.128-130), giving and receiving feedback:

• Check to see if your feedback is desired
• Use specific events rather than hot-button words that judge or exaggerate (like always or never)
• Focus on behavior rather than personality
• Ask the person for his or her opinion
• Listen actively, validate the other person’s input, and thank the person
• Reflect upon the feedback to create greater self-awareness

Although it disturbed me to learn that the ED nurse ended up leaving her job, I was happy to learn that she pursued graduate study and found a nurse-manager position in another ED that had a zero-tolerance policy for workplace bullying, which included training for all staff, including senior management.

Approximately two decades ago, my wife encountered similar feelings of resistance as a CCU nurse when we moved from Boston to New York.  Had I read or been exposed to a resource like Confident Voices, I could have been more supportive and nurturing rather than telling her that she was experiencing growth pains. 

What do you think?

• Have you experienced workplace bullying or do you know someone else who did
• What does it do to people’s confidence and judgment to experience bullying
• What are the implications for patient care if we continue to ignore workplace abuse

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have a material connection because I received a review copy of this book.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Naivete: Post 83 is an original post from Kenneth Cohn on Healthcare Collaboration - Improving Physician-Hospital Relations