"Critical conversations" important in care process

Three key points identified in study

While interventions such as "time-outs" have gained support as important safety tools during procedures, not nearly as much attention has been paid to similar interventions where procedures are not involved. But similar tools are also extremely important in several such situations, argued a group of researchers from the University of California schools of medicine and nursing in San Francisco, who developed a set of interventions they call "critical conversations" for three key points of time during the care process: Admission, changes in clinical condition, and discharge.

"I was working closely with a nurse educator on a broader project, and he and I got into a discussion during a teaching session," recalls Niraj L. Sehgal, MD, MPH, associate professor of Hospital Medicine and Associate Chair for Quality & Safety in the Department of Medicine at the University of California, San Francisco, and lead author of the article, which appeared in the April issue of the Journal of Hospital Medicine1. "He said, 'Why is it that you guys do not talk to every bedside nurse of every patient every day?' The reality is that the dialogue created by that would make it hard to get treatment plans moving. Think, for example, if I had patients on five or six different units and spent 10 minutes talking to every nurse. Even that nurse said they were not sure they'd want us to do that."

However, the conversation continued, in a world where we know teamwork and communication are so important, perhaps we could think about times where face-to-face communication is really needed. "In the surgical setting, the idea of a timeout was mandated during the Universal Protocol; getting everyone on the same page seemed like a logical thing to do," says Sehgal. "So we started to examine what such a tool and the policy and the structure around it would look like."

At the time, the facility was paper-based (it now has an EMR). "We did the study on one of the medical units as part of the broader project," Sehgal explains. "We started with educational efforts, leveraging our existing educational programs to bring the various disciplines together in a conference setting; it also included putting posters up in the unit."

Key items enumerated

Why did they end up focusing on these three junctures? "There has been a lot of focus — quite appropriately — on trying to ensure team members are on the same page at times of procedures," says Sehgal. "When we think of moving patients, the highest-risk times are during discharge, so that was clearly important. Admission also seems obvious, given these are new times and new entries. Then, changing clinical conditions — like unexpected deterioration — organically grew from provider comments. The idea was, it's time to take steps; how do we prioritize, how do we make sure the patient gets what he or she needs? It's a re-set, to make sure you're doing the right things, because the patient is potentially at higher risk."

Part of the challenge with most communication interventions, such as handoffs, is to codify responses during such high-risk times, notes Sehgal. The researchers did just that, by creating a set of topics for each "critical conversation."

So, for example, during admission process the discussion is to focus on the following:

  • Admitting diagnosis;
  • Immediate treatment plan;
  • Medications ordered (particularly those new to a patient to anticipate an adverse event);
  • Priority for completing any admitting orders;
  • Guidelines for physician notification when a change in patient condition occurs.1

For a change in clinical condition, the following is discussed:

  • suspected diagnosis;
  • immediate treatment plan;
  • medications ordered (particularly those new to a patient to anticipate an adverse event);
  • priority for completing any new orders;
  • guidelines for physician notification when a change in patient condition occurs.1

At discharge, the discussion includes:

  • discharge diagnosis;
  • follow-up plans;
  • need for education/training prior to discharge;
  • necessary paperwork completed;
  • anticipated time of discharge.1

It was the staff, says Sehgal, that "really came up with the solutions." He posed a number of questions at the outset of the process "to get them to create the talking points — to let them raise the key issues." So, for example, he asked them what they talk about when a patient is admitted, how often they found they had all the information they needed, and how easy it was to prioritize steps to be taken.

Challenges, lessons, and best practices

Interventions like these are not without their challenges, notes Sehgal. "One challenge is how to really enforce it — how to really measure a good communication intervention," he shares. "You can, of course, measure if it happened or not."

In order to better measure the intervention, he continues, teams were interviewed two days after being on call and asked if they had direct conversations. "We followed that up with educational conversations with nurses about how things were going, and if they found that doctors were contacting them more at those three junctures," says Sehgal.

Another challenge, it seems, was unavoidable, given the march of technology. "If you walked up to a medical unit at two in the afternoon four years ago before the electronic medical record, people of all disciplines would have been running around the unit mainly because they all had to find a chart," Sehgal observes. "This created informal communications because they were all in the same space. Now, if you walk up to a medical unit at two it often looks like a ghost town; doctors are three or four floors away in the charting lounge, and nurses are also at computers. It has had an unintended consequence of removing times for informal communication."

How can you meet this new challenge? "With the arrival of so many computer tools, you must figure out how it will fit into the EMR, and in general how to create a cohesive message of how we communicate," says Sehgal.

"You can argue it's even more reason to get this embedded in the culture," he continues. This, he says, flows from education and from embedding the intervention into the care process. "Buy-in comes from seeing it work," he asserts.

One of the lessons he learned, Sehgal says, is that such an intervention should be part of a broader program of improving teamwork and communication. "There are so many different interventions on different units," he declares. "One thing we like to do is marry them together in ways to make it more cohesive, so every provider does not think he's being asked to do so many things in silo."

One best practice cited by the authors is capturing stories of success. "Stories are equally important to data," Sehgal asserts.

Demonstrating effectiveness is both a challenge and a best practice, he continues. "It's not that different from many communication interventions — how frequently it occurs, and whether people are adhering to it, and, like in timeouts, whether it is affecting clinical outcomes," says Sehgal. "This is very challenging to demonstrate.

"The main lesson we learned is that the frontline providers are not only the best folks to identify where the gaps in care are, but without question the best to come up with solutions," Sehgal continues. "The more you can get them involved, the more you really allow them to be part of making change. This undertaking is not successful if it's a top-down intervention."

[For more information, contact Niraj L. Sehgal, MD, MPH, Associate Professor of Hospital Medicine and Associate Chair for Quality & Safety in the Department of Medicine at the University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA 94143. Phone: (415) 476-0723. Fax: (415) 476-2818. E-mail: nirajs@medicine.ucsf.edu.]


  1. Sehgal NL, Fox M, Sharpe BA, Vidyarthi AR, Blegen M, Wachter RM. Critical conversations: A call for a nonprocedural "time out." J Hosp Med 2011;6:157-162.