Implementing Teach-back in a Critical Access Hospital: Updating the EMR
by Keri McDermott | Dec 3, 2018 | Care Coordination, Featured, Great Plains QIN, Hospitals, Success Story
Great Plains QIN facilitated a WebEx on Teach-Back in late October to demonstrate the use of teach-back to support patients and families throughout the healthcare journey.
The teach-back method, also called the "show-me" method, is a communication confirmation method used by healthcare providers to confirm whether a patient understands what is being explained to them. If a patient understands, they are able to "teach-back" the information accurately.
During the call, attendees offered examples of how they are incorporating teach-back and the benefits and impact of use. Kathy Corbett, RN, MSN, CPHQ, NEA-BC is the Director of Quality Programs at Memorial Health Care Systems in Seward, Nebraska. Corbett offered several examples of how the team at Memorial Hospital set out to improve patient care through teach-back implementation during the discharge process.
Following the WebEx, we followed up with Corbett to learn more.
Following a patient event, a discharge planning review was implemented at Memorial Health Care so we could seek opportunities to prevent future occurrences. The review demonstrated that only 36 percent of discharge plans were being documented in a timely or thorough manner for patient diagnosis. It was also noted that Teach-back language had not been included in the EMR for nursing documentation of education. The documentation for teaching was in two areas of the EMR which may have been a causal factor for the low rate during the initial review. We recognized that a change was needed to update the Electronic Medical Record (EMR) to meet documentation best standards of practice and regulations and to improve discharge planning.
We developed a team who made incremental changes in the EMR using the PDSA method and tested the changes with nursing staff. The team then eliminated the two places to document by combining DC Planning & Education into one section of the EMR. The Teach-back language (repeated back, demonstrated, etc.) was added to the DC Planning/Education so staff could document the type of teaching used when educating patients.
The initial goal [Aim Statement] was to utilize teach-back for patient education and documentation in the updated EMR discharge planning/education module on topics relevant to patients. The goal was for this to occur 85 percent of the time; a date was also identified.
Our theory was that using Teach-back with educating patients would provide us with knowledge of whether patients understood what we were teaching so they could be safely discharged. Secondarily, updates to the EMR will be accepted by nursing staff as it will eliminate duplication, be easy to use, meet practice standards, provide triggers and reminders for documentation and improve documentation in the medical record. It also allowed for the ability to audit and track improvements in use of Teach-back. Leadership set out to identify evidence-based research on teach-back. The Merck Teach-back Techniques handbook was utilized as well as resources from the Institute for Healthcare Improvement (IHI). Education on Teach-back was provided at a nursing meeting, along with a pre-test.
The EMR was reviewed, tested and updated. Information was shared with nursing staff to seek feedback and obtain buy-in. Throughout the process the team continued to evaluate the changes and the team
continued to seek feedback on whether changes were positive, removed unnecessary steps and were pertinent to improving discharge planning and workflow. The changes were adopted and we are still in the auditing and sustainment process to ensure the new practice is embedded.
"People are more willing to change if they know the why, where, how, the when and the what. This is why the AIM Statement is vital. It provides the key information and adds the sense of urgency with a timeline. Teach-back was introduced with the intent to provide the patient with information, tools, and resources to care safely for themselves upon discharge from the acute setting. Corbett believes "Any change should be looked at from the perspective of all parties involved so creating a good workflow for staff was vital." Feedback from nursing staff on the EMR changes were positive. The Teach-back standard was already being used by Social Services and Therapy departments which reinforced the use of the standard for educating patients.
Corbett shared one of the struggles was limiting the project to small tests of change. Once they were aware of the problem and performed the internal audits, there were other areas that could be addressed, but the team needed to stay true to the AIM, which was to improve the Electronic Medical Record to meet regulations and set the foundation for communicating best practices, regulations and documentation improvement.
The Memorial Hospital Team noted the following successes:
Documentation of the discharge plan, within 24-hours of admission, is currently at 93 percent.
Documenting using teach-back is up to 51 percent and will continue to improve.
The final measure is to look for consistency of documentation of using teach-back throughout the patient stay on the key topic identified from the discharge plan.
Building relationships and collaboration with owners of the process is key. Corbett shared it is wise to pick team members who can help sell the idea; those that are innovators and early adopters. It is also important to get front line staff on board as active participants.
The team at Memorial Hospital just implemented a nurse audit tool to review the patient education documentation to re-measure our progress and enhance education of the staff in the use of Teach-back and where to document. The changes made will continue to be monitored through observation, rounding, and audits and the use of teach-back will continue to be reinforced. This effort was implemented on two areas in our rural hospital and will be spread to the OB, surgery and outpatient nursing center.