Engaging patients through the use of Teachback
Each year, staff at Health Quality Ontario read the Quality Improvement Plans (QIPs) submitted by Ontario hospitals, primary care organizations, long-term care homes, and local health integration networks (which administer home care). We identified some stand-out examples from the 2017/18 QIPs showing how organizations have engaged patients or residents and their families and caregivers, and reached out to the people involved to find out more about their experiences.
Here, we spoke with Amanda Kaczmarek, CAT(C), Director of Risk Management and Patient Relations, and Rebecca Ross, Chief Nursing Officer at Red Lake Margaret Cochenour Memorial Hospital, to discuss the lessons they have learned from their experience engaging patients, caregivers, and families.
What was the problem you were trying to solve?
It all started with the data. Reviewing the results of our patient satisfaction surveys, we noticed that patients commonly said that they didn’t always understand the information provided to them before going home. By focusing on a technique called “teachback” we hoped that we might reduce unnecessary returns to the emergency department related to poor understanding of when to return the ER, common signs and symptoms of their diagnosis, as well as the follow up from their stay.
The teachback method ensures that staff like nurses could be confident that the instructions were heard and understood. If the patient didn't understand, the nurses could fit it right then. In addition, this approach fosters a culture where patients can feel free to ask questions. This is particularly important in a small location, as we are the only hospital available to most people and because of that, patient may have been concerned about asking questions, in case they may not receive the same level of treatment.
Who was involved?
There was a large team involved, including our senior leadership team, CEO, Chief Nursing Officer (Rebecca), nurses, the patient and family advisory committee, the quality committee, and the risk manager (Amanda).
How were patients involved in this work?
Patients were involved through the survey; in addition, patient advisors participating in our patient and family advisory committee helped us discover the root cause of a problem we were having as we audited teachback. In spite of extensive training in teachback, we kept getting low scores when we conducted audits. We wondered why the staff wasn’t implementing teachback. When we brought this observation to the patient and family advisory committee, a patient on our improvement team observed that he thought that the staff were using teachback but weren’t tracking it in the clinical notes and on the discharge instruction sheet.
What improvement work did you do?
We fixed the documentation problem in a couple of ways. We returned to the nurses and highlighted the importance of tracking that teachback was done. We also added a checkbox to the discharge summary already in use. Patient advisors also told us they were confused about the terminology around “teachback”, so we used posters and signs on the wall behind the stretcher, saying “Ask me about teachback” to prompt patients to ask. We added red stickers to the discharge summary as a trigger for nursing to remember to check the box indicating Teachback was done. We then audited the charts. These multiple efforts resulted in improvement. The audit scores improved from 40% of discharge summaries including the completed checkbox to 80% by the end of quarter three.
What were your successes?
Teachback is now built into our overall discharge process; patients had said that when they went home, they did not remember what to do with the discharge information; now it is written down, and they receive a copy of the discharge sheet to help them remember the instructions.
Implementing teachback did improve patient satisfaction scores but did not improve the ED Length of stay, however reasons that patients did return were not related to a lack of information but for health reasons. The emergency department length of stay indicator score remains stable. We are a small hospital and we don’t have a physician all the time in the emergency department, nor do we have CT scanners, so all these factors contribute to emergency department length of stay.
What were your lessons learned?
- If you have exhausted all the options of how to move an initiative forward, maybe the problem or solution isn’t what you think it is. For instance, nurses were actually implementing teachback, but were not charting it.
- Involve many different types of people; for instance, the advice from our patient and family advisory committee was pivotal in identifying this problem and solving it. It’s important to see the problem from the patient perspective, and have them tell us what they need to make it work.
- Don’t quit!
What do you think others could learn and start implementing quickly?
- Adding the teachback checkbox to the discharge summary was a great help. Staff are already trained to use the discharge summary.
- Communicate about teachback, discuss it frequently, and keep bringing it back to the staff’s attention.
- The CEO and senior leadership team are involved in many of our initiatives, and this really helps the staff get on board.
You may also be interested in:
Quorum’s Indicators & Change Ideas page. Find more information on QIP indicators and related change ideas.