Recently I taught a 5 hour preconference legal workshop at the annual meeting of the Academy of Medical Surgical Nurses. One of the poster sessions caught my eye. Staff of Sutter Roseville Medical Center in Roseville, California, embarked on bedside report as a way of improving patient satisfaction. They used a Plan Do Study Act method to implement the change. Some of the key points that helped to drive the change were:

Plan: Identified best practices through interviews and literature searches, created a standardized handoff report, and defined accountability and measures for success including audits and integration into performance evaluation.

Do: Distributed an education module. On the go-live day, supplied new kardexes and handoff report forms.

Study: Placed flip charts in staff lunges for feedback, did spot audits on the handoff report forms, and monitored patient satisfaction scores weekly.

Act: Refined roles of other staff members, such as nursing assistants, shift coordinators and float RNs.

The bedside report system had benefits for both patients and staff.

Patients felt reassured that the staff worked together as a team. This reduces patient anxiety. Patients had a shorter wait for attention during change of shift and used their call lights less often during that time. Patients and families were more involved in care, and the risk of injury at change of shift went down. Patient satisfaction scores rose.

Nurses also obtained benefits from this system. It helped them immediately prioritize the patient’s needs, because all patients were seen. It promoted accountability between shifts – no blaming the other shift for work not done. It provided an opportunity for teaching and mentoring through demonstration equipment, performing assessments, and sharing information related to specific patient needs. It assisted the nurse to be better prepared to answer questions from physicians shortly after change of shift because the nurse saw each patient earlier in the shift.

Bedside repor sounds like a terrific way to reduce medical errors, and is increasingly being implemented by other hospitals.

Bonus: Solve issues before arguments erupt.

Today’s featured blogger is Dan Rockwell. Dan writes the popular Leadership Freak blog. You can follow Dan on Twitter, connect on LinkedIn, like his page on Facebook, or circle him on Google+. This post originally appeared on the Leadership Blog as “25 Ways to End Arguments.” and was replicated from BudtoBoss.

For those of you not familiar with Candid Camera, this was a TV show that involved cameras that captured the behavior of unsuspecting people. They were set up in a situation, and then filmed. This snippet from Candid Camera reminds me of how group behavior affects us. In this segment, we watch what happens when an unsuspecting man gets into the elevator.

It makes me think of how jurors react when debating the merits of a claim. Does a strong group member sway the others? What kind of pressure is brought to bear on a person who is holding out and preventing the jurors from reaching unanimous verdict? Focus groups can be fascinating as you watch how group dynamics affect group decision making.

In some states attorneys are allowed to ask the jurors to discuss their verdict, but in other states, such discussions are forbidden.

How do you react to group pressure? Could you have withstood the pressure this man felt in the elevator? Write a comment.

• If you’re astute at reading body language during a negotiation, you can pick up on nonverbal signals and detect a liar’s lie before he gets too deeply into it. In so doing, you will decrease the probability of being deceived.

• People lie because they’re seeking something they need at the time of the lie. In a negotiation, if you understand the need, you’ll understand the source of the lie. To assess the genuineness of disgust in your negotiation, note what has led to the display of the emotion and observe the signs that highlight the genuine emotion displayed through disgust.

• Consider mirroring negativity to stake out a position indicating you’re as repulsed as the other negotiator. Do so with caution, so as not to get into a one-upmanship with the other negotiator.

• Negativity begins in your mind, when negotiating, as in all phases of life. Give thought to the benefits of negative situations. You may surprise yourself by uncovering a diamond that first appeared to be coal.

• Display an even disposition when you negotiate and you’re beset by negativity. Don’t bemoan negativity to the degree that you allow it to take you off track. Never let them see you sweat.

• You reach major milestones by achieving small gains. Be persistent in your attempts to achieve the goal of your negotiation and don’t be dismayed by negativity.

• Stop anytime you encounter a negotiation situation that doesn’t appeal to you. Ask the other negotiator if he meant to take the position that made you anxious. If he says, “No”, you’ve defused the situation. If he maintains the point that created the anxiety, be prepared to take appropriate actions to thwart his position.

• Depending upon the negotiation characteristics of the other person, you may consider appealing to his sense of fairness. Be sure the other negotiator perceives fairness as a worthwhile value to possess, otherwise, this ploy will be ineffective.

• Choose with whom you negotiate and seek those who negotiate in a similar style as you to gain an advantage prior to entering into a negotiation, when possible.

• When you hear the word “manipulate”, remember there could be good implied. You enhance her life if you manipulate someone for her good.

• The way you present offers affects the perception of the offer.

Greg Williams is the guest author of this blog post. This material is used with permission from a forthcoming book on negotiation skills. He is the author of the”Negotiate: Afraid ‘Know’ More” and the author of a forthcoming book on negotiation and reading body language, with an emphasis on micro expressions. Reach Greg at GregWilliams@TheMasterNegotiator.com.

• Pay attention to what the other negotiator says, but pay more attention to his body language. Words can be used to manipulate, but the body never lies.

• Practice using head gestures to lead people to agree with you. Do so with friends and observe to what degree they agree with you. By doing so, you’ll gain insight into when to use your head gestures.

• You give others insight into your demeanor when negotiating. Therefore, always be aware of the demeanor you display.

• One can’t accurately brand a single gesture as a lie when reading body language. First, establish a baseline. To establish a baseline, observe the other negotiator’s gestures in a nonthreatening environment.

• Gauge by the body language of the other negotiator the value he may place on your offer.

• You can detect when lies are being told by being attentive when negotiating via the phone. It will usually occur in the form of a different rhythm in the other negotiator’s speech patterns.

• Micro expressions are actions not filtered by the mind. They give clues about the negotiator’s reactions.

• By being able to detect micro expressions, you’ll be able to sense when someone is in support or opposition of your position.

• Always observe the placement of someone’s hands when you negotiate. If you’re not sure of what you’re perceiving, look for a cluster (more than one gesture) of hand signals to give you additional insight.

• Pay close attention to how the other negotiator uses her hands from the moment you enter into an environment in which you’ll be negotiating. You’ll gain insight into what she’s thinking and the direction in which she’d like to take the negotiation.

• Give up a point when the other negotiators hands are open. Be wary when they’re closed. The other negotiator will not be in a giving mood, when his hands are closed. Don’t ask for anything you want that’s important during those times.

Greg Williams is the guest author of this blog post. This material is used with permission from a forthcoming book on negotiation skills. He is the author of the”Negotiate: Afraid ‘Know’ More” and the author of a forthcoming book on negotiation and reading body language, with an emphasis on micro expressions. Reach Greg at GregWilliams@TheMasterNegotiator.com.

• Don’t make “take it or leave it” offers when you have a power position in a negotiation. If you’re in a position of strength, you don’t have to flaunt it.

• It doesn’t cost anything to be nice. That’s especially true when you have a power position in a negotiation. By being magnanimous in such a situation, you create goodwill. If circumstances are reversed one day, you may gain from that goodwill.

• The ranges of emotions experienced in a negotiation are tied directly to how you answer and ask questions. Answer questions with this thought in mind.

• Negotiators experience a wide range of emotions prompted by the questions posed. In order to become a better negotiator, learn to use questions strategically.

• By posing and responding to questions strategically, you decrease the potential for defeat and improve your chances of reaching a successful outcome.

• Always remember that displaying anger can be a game changer when you negotiate. Once the other negotiator realizes that he’s caused you to become angry, he’s changed the game.

• Play it cool when angered during negotiations. As a commercial once said, “Don’t let them see you sweat.” Don’t let your anger show. People can sense anger before it is manifested. At the first moment you realize you’re becoming angry, take a deep breath and let it out slowly. Try not to allow this display to be observed by the other negotiator.

• Always be aware of the need to control your emotions during a negotiation. A loss of control could cause you to think irrationally, and adopt actions that you might otherwise avoid.

• Your emotions will possess more credibility to the degree there’s congruity in your words and emotions.

• You may consider pointing out this observation if the other negotiator’s emotions are not aligned with his body language. Your attempt would be to get him to alter his facade.

• Anger serves the purpose of changing one’s demeanor. In a negotiation, you must maintain mental control of your environment. Don’t allow yourself to be manipulated by the false pretense of anger.

Greg Williams is the guest author of this blog post. This material is used with permission from a forthcoming book on negotiation skills. He is the author of the”Negotiate: Afraid ‘Know’ More” and the author of a forthcoming book on negotiation and reading body language, with an emphasis on micro expressions. Reach Greg at GregWilliams@TheMasterNegotiator.com.

Just answer the question, Doctor.

A: I told you I wasn’t perfect. I attempted to comply with Medicare regs. I was not perfect in my documentation.
Q: Okay. And it was pointed out to you on a number of occasions, was it not?
A: I disagree with the term “number of occasions.” It was pointed out a couple of times that there were gaps in my documentation.
Q: A couple of times means two?
A: Does a couple mean two?
Q: Well, I’m trying to understand your answer. What does it mean to you?
A: It means a few.
Q: Okay. Does that mean – a few, does that mean several?
A: I told you. I don’t remember the exact number.
Q: Okay. I’m not asking you exact numbers. I’m asking you a ballpark. Is it more than ten?
A: It was a few.
Q: How many is a few to you? Bookend that for me.
A: More than two and I don’t know. I never had to define a few before. More than two.
Q: Okay. Is it 100?
A: No, I wouldn’t consider a few a hundred.
Q: Would a few be ten?
A: It depends upon in what context it was in.
Q: This is your answer. You’ve got to tell me the context. How much is a few?
A: I gave you an answer. A few is a few. It is more than two.
Q: More than two?
A: And less than a hundred.
Q: It is less than fifty?
A: Probably less than fifty.
Q: It is less than 25 to you?
A: Once again, that would depend upon the context.
Q: In this context in receiving criticism regarding your documentation, how many times is a few. Is it less than 25?
A: I believe so.
Q: Less than twenty?
A: Based on what I recall, yes.
Q: Okay. Less than 15?
A: Possibly.
Q: Less than ten?
A: I don’t remember specifically. It’s somewhere in that ballpark.
Q: Okay. So a few being more than two and less than a hundred is now more than two and less than 15, is that right?
A: If that makes you happy, yes.
Q: I want to know what your answer is. I don’t want to be happy. I want to know your answer.
A: My answer is a few.
Q: Okay. The best of your recollection right now, speaking to me today, does a few mean more than two and less than 15? Can you be more specific than that?
A: No.

Incomplete documentation can dramatically affect a malpractice case. In the ideal world all pertinent observations and interventions are recorded. But is “If you didn’t chart it you didn’t do it” true? For a variety of reasons, medical records may be incomplete. Emergency situations, such as cardiac arrests, often result in gaps in documentation as patient needs take priority. Ideally the nurse tries to record detailed notes after the emergency is over, but this does not always happen because the nurse must direct attention to the other patients who took a back seat to the crisis. Sketchy documentation complicates the defense of a case and provides the plaintiff’s attorney with an opportunity to advance theories of liability.

Plaintiff’s attorneys may use the phrase, “If you didn’t chart it, you didn’t do it” to convince the jury that essential care was not given. Defense attorneys sometimes attempt to preempt the anticipated attack on the nurse’s credibility or documentation. This can be brought up on direct examination of the nurse during trial by having the nurse testify about the impossibility of recording every detail or observation of the patient. Another useful technique is to have the nurse testify about the nurse’s usual practice which may or may not be recorded in the medical record.

Missing documentation coupled with a poor outcome complicates the defense of cases no matter what strategy is employed, and it provides the plaintiff with an opportunity to successfully argue that care was not rendered. In the case below, the nurses could not prove they contacted the physician, if they did.

The plaintiff, age sixty-three, suffered a back injury and could not to return to work as a nurse. She decided to have an anterior approach lumbar fusion of the spine. This was to include surgery to the spine from the front of the body and then a day or two later, surgery from the back. For the anterior approach the plaintiff’s abdomen was opened and her internal organs were moved in order to get to the spine. After surgery the plaintiff had fluctuating blood pressure and no pulse in the left leg. The nurses noted the lack of pulse in the leg but did nothing about it.

The next morning, when Dr. Brown arrived to perform the second part of the surgery, he discovered her problems and had her rushed for a CT scan which showed internal bleeding in her abdomen and a block¬age of the artery which supplies blood to the left leg. The plaintiff was transferred to another hospital by helicopter, but the surgeons there were unsuccessful in salvaging the leg and an above-knee amputation was performed. The plaintiff had been unaware of the problem with the leg overnight due to being heavily medicated. The plaintiff’s abdomen took four years to heal because the surgical incision wouldn’t fully close due to the swelling of her organs and the internal bleeding. The plaintiff also had infections and required repeated surgeries to repair the damage to her abdomen. The matter settled for $5.25 million. 1.

Good documentation is consistent, concise, chronological, continuing, and reasonable complete. 2.

Cites:
1. Laska, L. (Ed), “Woman suffers lack of pulse in leg after spinal surgery”, Medical Malpractice Verdicts, Settlements, and Experts, January 2010, page 37
2. Legal issues in the care of pressure ulcer patients: Key concepts for healthcare providers, International Expert Wound Care Advisory Panel, 6/22/2009

This blog post was modified from Iyer and Koob, “Nursing Documentation”, in Iyer, Levin, Ashton and Powell, Nursing Malpractice, 4th edition, 2011, available here.

So let me share a few tidbits about branding. Here are a few definitions and some questions to ponder to help you find your direction:

There are three main kinds of branding: corporate branding, individual branding, and personal branding.
A. Corporate branding relates to an organization that offers services and products and uses their company name as the brand name. They wish to create a strong brand identity for recognition and to build brand equity. (Coca-Cola, Disney). This type would apply to a law firm.

B. Individual branding is when you focus on branding individual products versus branding the company that creates those products. This allows for the products themselves to stand on their own (Proctor & Gamble holds Dove, Unilever and Pampers)

C. Personal branding usually relates to having people and their careers marked as a brand. Think Donald Trump. He has created a brand name for himself just by building his career (Trump Towers, Trump Steaks, etc.) Think Gerry Spence.

Now ask yourself some questions to determine which category you wish to fall into:
1. What are your main products and services that you offer?
2. Why was your company founded? OR Why choose that career path?
3. If you had to describe your company/organization/yourself in one word, what would it be? Why?

Asking some of these questions will help you look at the WHY behind what you’re DOING and the impression your brand must leave on your target audience. Stay true to what you are and you will find your million-dollar brand!

Jena is a successful branding expert who is joining Pat Iyer in a webinar on May 25, 2011 at 8 PM Eastern. Details are at www.patiyer.com

Key differences between NH and hospital records

If you have never worked in the long term care environment a glance into the medical chart might be intimidating. Flipping through the records in a nursing home chart will reveal many documents specific to this nursing specialty. Some nurses without long term care experience are very hesitant to review one of these cases due to the lack of understanding the purpose of these industry-specific records. Once you understand where important information is located within these medical records you can use them to support your analysis of the matter.

One of the most mystifying records within a nursing home chart is the Minimum Data Set, most often simply referred to as the MDS. This document is a comprehensive assessment of the resident’s functional abilities, cognitive status, indicators of delirium, fall history, ADL status, diagnoses, wounds, nutritional status, restraint use, continence status, and more. The nursing and therapy notes and other documentation should be reviewed to ensure the information in the MDS is accurate.

The data collected in the MDS is utilized to create a Resident Assessment Protocol, also known as the RAP, which provides the foundation for creation of the resident’s individualized care plan. The MDS triggers any risk potential that should be addressed on the care plan. The staff may override the trigger or decide to proceed and create a plan of care. For example, a RAP may be triggered based on recent weight loss. However, the staff may override the trigger by indicating a recent history of bilateral above the knee amputations, thus justifying the recent weight loss or less than ideal body weight status. The RAP should be reviewed to ensure that all potential risks have been appropriately triggered and addressed in the plan of care.

While the Plan of Care (POC) is not paperwork specific only to long term care, it is a very critical document and must be closely reviewed to ensure every risk unique to that resident has been addressed and that the POC is individualized to the specific needs of that resident. The care plan is a dynamic tool that should be updated as the needs of the resident change. For example, if the resident is at risk for falls and the goal indicates the resident will have no falls with injury within the next 90 days and that resident does indeed fall and sustained injury, the plan of care must be updated. You should expect to see new interventions to prevent falls.

Therapy records are critical to long term care case. When a resident is involved in PT, OT or ST you will find frequent documentation which can be crucial, especially when there are few nursing and physician notes. Therapy notes will usually describe the resident’s functional ability, level of pain, subjective statements, cognitive status, and safety recommendations. Always be sure to review the therapy records thoroughly and compare these assessments to the nursing notes, physician notes, MDS and care plan. Likewise, important information may be found in the social services notes as documentation regarding discharge plans, family concerns, and social history is likely recorded in this section.

Don’t allow your lack of familiarity with long term care records hold you back from an interesting case review. Your knowledge of the records outlined above will provide you the ability to thoroughly understand the residents’ needs and determine whether they were met. This information is just a brief overview of a few of the records. However, part of being successful is self-educating and knowing how to find the information you need. Identifying a long term care nurse that you can call with questions as needed might just provide you with the added confidence needed to say “Yes” when asked to review a nursing home case.

Angie Duke-Haynes, RN is Principal, Legal Nurse Consulting Institute, LLC and co-presenter of an all new webinar on polishing your writing skills. Learn more about record reviews and how to WOW clients by signing up for a webinar how to polish your writing skills. See www.PatIyer.com for details.