As clinical staff, veterinary technicians are often challenged to fill a diverse range of roles in providing care to their patients. We receive extensive training and continuing education to hone our medical skills and may even dabble in methodologies for best interacting with clients and colleagues. In fact, how we navigate our work environment has great potential to improve upon the experience of patients and clients seeking veterinary care. Furthermore, our conscientious application of skills and behavioral tools may actually improve upon patient outcomes, an idea substantiated by a large body of quality improvement literature. The goal of this article is to provide the veterinary technician with tangible improvement tools and skills that may be readily and inexpensively applied in a diverse range of practice settings, rather than a recitation of theory.
Communication: ISBAR and Read-Back
The U.S. Navy developed a communication tool called SBAR (an acronym meaning Situation, Background, Assessment, and Recommendation) that was subsequently utilized for standardized briefings on submarines (Marshall). In recent years, the Institute for Healthcare Improvement suggested SBAR may have some utility in the health care setting. In 2008, SBAR was adapted for use in a hospital setting (and renamed ISBAR -- the I standing for Identify), and subsequently tested in a randomized, controlled study to demonstrate its effectiveness in improving clinical communication (Marshall). Researchers found that in a simulation, ISBAR improved the content and clarity of communication in clinical staff (Marshall). Table 1 provides a veterinary specific adaptation of ISBAR.
|Identify||Identify yourself, including your organization, position, or role if necessary.||“Hello Dr. Jones, you must be the relief vet. My name is Morgan and I’m one of the ICU CVTs here at DoveLewis.”|
|Situation||State your purpose. If the situation is urgent, say so.||“This is urgent. I needed to talk to you about one of our patients, Spot Smith.”|
|Background||Provide a brief narrative of the situation.||“Spot underwent a splenectomy following vehicular trauma. I just measured his blood pressure, which is 60, down from 110. I’m also worried because his mucous membranes color is deteriorating.”|
|Assessment||State what you’re concerned about.||“I’m concerned Spot may be experiencing some postoperative bleeding.”|
|Request||State your request.||“Would you please take a look at Spot while I run a PCV?”|
While this undoubtedly appears overly formal and rigid, bear in mind that you are free to adapt ISBAR to your particular need. If you and your doctor have a well-established relationship, you probably don’t need to identify yourself with every communication. However, don’t overestimate your familiarity with your coworkers. One study in a human hospital found that nurses correctly identified the doctor assigned to a patient only 70 percent of the time, whereas doctors were able to identify a patient’s nurse around 36 percent of the time (O’Leary and Ritter). Obviously, then, it’s not just knowing your coworkers, but communicating clearly about who is responsible for which patient.
Read-back is another tool that you might utilize, especially in critical situations. You’ve undoubtedly encountered it before, although perhaps not in a clinical situation. Chances are the last time you ordered from the drive-up window at Starbucks, the barista read your order back to you to ensure clarity and accuracy. One study in a clinical laboratory found that reading back a verbal order or communication took approximately 13 seconds, and corrected 100 percent of the 29 errors detected within these communications (Barenfanger). Consider utilizing read-back the next time you have a patient in crisis, and a veterinarian calling out verbal orders for medications or other therapies.
Quality Improvement Projects
Look around your hospital. Is there a specific process or system you think your practice could improve on? Spearheading a quality improvement project may improve both your job satisfaction as well as your patient’s hospital experience. Consider, as an example, how you clean your hands between patients. Whether working in an Intensive Care Unit or a vaccination clinic, appropriate and thorough hand hygiene practices have the potential to drastically reduce transmission of infectious agents between patients (Harris, WHO, Gawande). Yet, regardless of the setting and the established benefit of rigorous hand hygiene, compliance with protocols is often underwhelming (Harris). What then best improves compliance rates? The literature suggests that buy-in for such protocols may be championed both by those who have the most control over end use, as well as symbolic leaders within the organization (Harris, Chassin).
Practice management should consider allowing veterinary technicians and assistants to both introduce and advertise safety initiatives around the hospital. In fact, the support of management is vital to removing barriers to effective improvement efforts, so technicians may be well served by obtaining managerial support with a positive and proactive attitude. Underlying these recommendations is the idea that everyone affected by or responsible for implementing an improvement initiative needs to be somehow invested in the project. Empowering clinical staff to change policy may generate the trust, reportage, and process improvement, to build a safety culture within your hospital (Chassin).
On a final note about leadership, Long and colleagues identified the qualities possessed by clinical safety leaders. Among them were strong technical and crisis management skills, honesty, organization, efficiency, vigilance, and team awareness (Long). Our profession should give special attention to the cultivation and maintenance of such qualities in current and future technicians, as strengthening individuals may strengthen the entire practice.
Quality improvement projects are closely tied to the concept of teamwork. Rather than viewing each member of the practice only as an individual expert who plays a temporal role in patient care, approach the patient as a unified, continuous team. One expert in health care quality and safety, Eric Thomas, suggests utilizing comprehensive, generic team training; brief, task-specific team training; and quality improvement projects to build a stronger clinical team.
Error Management Tools
Finally, no discussion of improving the patient experience would be complete without addressing error management. While veterinary medicine has yet to produce a report so alarming as To Err is Human, the report of errors in human medicine created by the Institute of Medicine, it is not hyperbole to say that every single organization providing veterinary care makes mistakes. Rather than furthering a culture of blame, it is important to identify, analyze, and remedy these errors with a system view (Gorini).
Systems theory dictates that to reduce or eliminate errors, one must examine and improve upon the systems and processes that produce these errors (Johnson). This is not to say individual behaviors and mistakes that contribute to errors should not also receive remedial attention (for a more thorough discussion, see Chapter Two of The Improvement Guide by Gerald Langley).
However, Dr. Don Berwick of the Institute for Healthcare Improvement asserts that “every system is perfectly designed to achieve exactly the results that it achieves.” Given such thinking, it is impossible to improve upon errors within a system without changing the system itself. Furthermore, focusing primarily on system improvement reduces the “second victim” effect, whereby an otherwise competent and skilled veterinary technician becomes a second victim (the first being the patient) of an error-prone system (Scott).
The following is a list of effective error reduction strategies that may be utilized by the veterinary technician:
• Utilize good reminders. These reminders should be conspicuous, contiguous, given context, sufficient content, and count the steps in a task. (Reason)
• Examples of good reminders may include notes, post-its, diaries, checklists, or even writing on your hand.
• Periodically update and improve reminders.
• Create error and adverse event logs
• Identify common mistakes. This may be as simple as making a list of all the mistakes (or potential mistakes) identified in one week.
• Utilize mistake-proofing. This may involve mistake prevention, mistake detection, fail-safe mechanisms, or changing the environment that produces the mistake. (Grout)
In conclusion, it has been my goal to provide other veterinary technicians with simple, effective, non-clinical tools that may create a safer, more harmonious patient environment. If you have utilized these tools within your practice, or even something similar, I would encourage you to email feedback regarding their usefulness to me at email@example.com. Questions regarding this article are also encouraged. While we may not have the advantage of comprehensive, veterinary-specific improvement literature, establishing narratives of improvement success may provide sufficient evidence of the benefits of such tools.