Presenting info doesn’t always = communication
UTMB looks at ways to improve understanding
It’s not enough simply to inform patients of what they need to know about such things as advance directives, hospital bills, and discharge arrangements upon admission to the hospital. The access professional should make sure patients understand the litany that’s being delivered and be aware of any personal baggage carried by either the patient or staff members that might get in the way.
That’s the message Ruth Finkelstein, hospital project manager at the University of Texas Medical Branch (UTMB) in Galveston and a former admitting director, wants access managers to hear. "I want to emphasize the importance of patient assessment, of assessing the patient’s readiness to learn and what the patient’s comprehension needs are," adds Finkelstein, who recently addressed the issue as part of a team at UTMB looking at ways to ensure compliance with the Joint Commission on Accreditation of Healthcare Organiza-tions (JCAHO).
The team was concerned that "just providing the informa- tion" on advance directives, billing for hospital services, and discharge arrangements was only meeting half the objective, she explains. "There was also the need to ensure that the patient had comprehension, or at least memory of the information being presented, and that compliance with the JCAHO guideline could be demonstrated."
The admitter may not realize and the patient may be reluctant to admit, for example, that he or she is hearing impaired. Or the patient may have tuned out the staff member’s instructions because the subject matter is distasteful, Finkelstein points out.
"There may be cultural reasons they don’t want to hear; there may be denial and embarrassment concerning certain issues," she says.
Similarly, some people hide behind a language barrier because they don’t want to establish a rapport with the interviewer, she says. Others might be distracted by the movement around them, or think, "What’s this going to mean?" or "How am I going to make dinner tonight?"
Dementia, for example, can hide itself so well that a person may be able to carry on a coherent 10-minute conversation but have no retention of what was discussed three minutes later, Finkelstein adds.
When dealing with patients from cultures with which they are not familiar, admitters need to be aware of important customs and beliefs, she says. In some religions, for example, it is considered inappropriate for men and women to shake hands under some circumstances; in the Muslim religion, men and women generally maintain a separation of the sexes in public; and some people don’t eat pork or any meat products for religious reasons.
Access personnel also should recognize their own personal prejudices to ensure they don’t interfere with patient communication, Finkelstein suggests.
"If I’m prejudiced against street people, and a homeless man smells of alcohol, I may be put off by that and not realize that I’m hurting that patient’s feelings," she says. "It’s a universal reality that all of us find people we connect with immediately and others we have difficulty speaking with. Admissions people need to be aware of what those parameters are for them, so the supervisor can make sure the situation is handled in the best way."
Checklist, form to facilitate communication
As part of its efforts, the team identified what patients should be told (see list, p. 31), where they should receive the information, and the most common reasons patients don’t remember or understand what they’ve been told, Finkelstein says.
The team developed a quality assurance plan covering these five components:
1. Feedback from patients.
2. Audit conducted by interdisciplinary team to ensure the use and completion of a new hospital policies and patient information (HPPI) form. (See insert for a copy of the form.)
3. Feedback from the hospital information management department to determine the number of patient records with HPPI forms, which are to be collected during record processing and removed from the record at the time of discharge.
4. Increased use of patient satisfaction survey results in the business office and registration areas.
5. Increased bill collections, as a result of patients’ better understanding of their financial responsibility.
One of the reasons for the HPPI form is to document exactly what the patient has been told in case there is a dispute later, Finkelstein says. Copies of the form are given to the patient and the interviewer, and another copy is filed in the patient chart until discharge, when it’s sent to the patient finance department for optical storage.
"Three months later, when the patient says, No one told me I’d have to pay for the telephone,’" the documentation is there to show that he or she was informed of the charge, she says. "Then it becomes a judgment by the administration [as to whether to pursue the issue], but at least the interviewer is covered."
The awareness of patient communication issues she gained while preparing for the JCAHO review is being enhanced further as she delves into a current project going through UTMB’s patient satisfaction surveys and cataloging the comments, Finkelstein says.
"Patients’ perceptions of what they liked and didn’t like have made me very sensitive about how we talk to patients," she says. "We need to be courteous, to remember the patient is in pain or anxious, even if the event is positive, like having a baby.
"We’re going through so many questions, giving so much information, that they’re not comprehending what we’re saying for a variety of reasons."
It’s become clear, Finkelstein says, that the staff’s interpersonal skills can greatly affect a hospital stay. Patients want to be informed and they want staff to be courteous and respectful. "They’re even critiquing whether housekeeping was friendly, whether the person carrying the tray said, How are you?’"
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