Changing the Clinical Question from ‘Can I?’ to ‘How Can I?’

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It’s always easy to discuss how things should be. We start sentences with:

“It’d be great if…”

“Ideally…”

“In a perfect world…”

But typically, when we discuss ideals, we quickly follow up with:

“But that’s not realistic.”

“Too bad that can’t actually happen.”

“Wish it could really be that way.”

When it comes to clinical practice, I think we default to the latter group of statements far too often. We significantly limit what we believe is actually possible, because the things we know are good in theory are just too hard to apply in the “real world.” It’s easy to sit through a graduate class or a continuing education session, but it’s another thing entirely to apply that information day-to-day in the therapy room. Think about some examples:

We learn about the importance of evidence-based practice, but “realistically,” there is not a vast amount of high-quality evidence for many of our practices in this relatively young field.

We discuss the necessity of being sensitive to culturally and linguistically diverse populations, but “realistically,” we can never learn to speak every language or understand every culture.

We understand that the Code of Ethics exists for the purpose of maintaining best practices, but “realistically,” ethical dilemmas are not always so black-and-white.

So what’s the point then? Why do we have standards that we can’t live up to in practice? Why are we taught things that we are doubtful we can ever actually apply?

That, right there, is the problem. It’s the question we’re asking. We look at a client or a situation, and we ask, “Can I do this?”

“Can I find any evidence to guide my clinical decisions with this unique and difficult case?”

“Can I effectively treat this client whose language I do not speak?

“Can I maintain my personal and professional ethical codes when a ‘sticky situation’ arises?”

The problem with these questions is that from the moment we decide to become speech-language pathologists, we have already answered all of them. In accepting the responsibilities that come with being a part of this field, we have already said a huge, resounding “Yes” to every ‘Can I?’ question. No matter how challenging the situation may be, yes, we can do it, because we must.

One of my professors recently challenged our class to change the question. When faced with difficult situations that make us uneasy, or cause us to doubt what we can handle, we have to start thinking of it differently. Instead of asking, “Can I do this?” we should ask, How will I do this?”

 How will I follow the levels-of-evidence hierarchy in order to implement EBP, even when the current existing evidence base is not extremely strong in this particular area?”

How will I be creative and use resources to effectively treat this client whose language I do not speak?”

How will I ensure that I maintain my personal and professional ethical codes and engage in best practices, even when a ‘sticky situation’ arises?”

 How will I do this?”

 Many people are familiar with the famous quote from Spider Man, “With great power comes great responsibility.” While a few ‘Cs’ behind your name may not seem like power to most of the world, as members of this field, we know differently. SLPs have the power to help others, facilitate communication, and cause change, and I would say that is great power. We have been given the power, and therefore we have accepted the responsibility. We have said, “Yes,” to every tricky situation and every obstacle, whatever it may be, no matter how challenging. We have said “Yes,” because it is our responsibility to do so, based on the power we have been given. We can, because we must.

The next time you are faced with a tough case and are tempted to ask, “Can I do this?,” remember that you have already answered yourself. Can you do this? Yes, you can, because you must.

So, start asking yourself and others something different. Start changing the question. Start asking, “How?”
Kelsey Roberts is a student in the master’s speech-language pathology program at Abilene Christian University in Abilene, Texas.

Audiologists, You Know the Science of Hearing but Do You Know the Art of Listening? 

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As audiologists, we learn about anatomy, physiology, psychoacoustics, pathologies, technologies, and interventions. We are experts in assessing hearing sensitivity, diagnosing hearing loss, and providing audiological (re)habilitation with technologies and counseling.

Here’s a question, though: Are we experts in listening? To be an effective listener, you need to focus on the meaning of what you hear and take in to gain understanding. Have you ever taking a listening test? Have you ever given your patient a listening test?

There are many types of listening styles, and there’s also depth of listening. In reviewing the literature, I identified 27 different styles of listening and six depths of listening. I believe we use different listening styles and depths of listening based on what is happening in the moment. So, I am a client, I may, during a hearing test, be a discriminative, deep listener. Or if I am the patient learning about the new hearing aids you just fitted for me, I may be a content, full listener.

These are the four most common types of listeners.

People-oriented (empathic) listeners, who:

  • Build relationships and interpersonal connections
  • Search for common areas of interest
  • Tune into the speaker’s emotions, body language and prosody of speech
  • Ask, “Tell me all about it – what happened?”

Action-oriented (evaluative) listeners, who:

  • Prefer information that is well organized, brief and error-free.
  • Will digress when a speaker goes off on a tangent.
  • Evaluate information heard and do not take things at face value.
  • Ask, “What am I supposed to do with all this information?”

Content-oriented listeners, who:

  • Enjoy listening to complex, detailed information.
  • Ask questions to test speakers (are they credible?).
  • Focus on issues and if information is credible.
  • Ask, “Is that so?”

Time-oriented listeners, who:

  • Love “to do” lists.
  • Are overbooked, so they want messages delivered quickly and briefly.
  • Enjoy the role of keeping people on task during the meetings (the time keeper).
  • Ask, “And, what’s your point?”

If you are a people-oriented listener and your patient is a time-oriented listener, then your patient may feel that you are intrusive and not respecting their time. If you are a content-oriented listener, then be careful not to “throw the baby out with the bathwater”: When taking a patient’s history, you don’t want to ignore what could be key information because you believe there’s a lack of sufficient evidence.

And those audiologists who are action-oriented listeners may need to watch that they aren’t perceived as inpatient and not caring. Knowing your listening style can help you better understand how to adapt to various listening situations. Knowing your patient’s listening style will help you with how to deliver quality care!

There are multiple tests available to assess your dominant listening style.  Here are a few that I have used:

In establishing relationships with your patients, the importance is not so much in what you say as how you listen. Knowing hearing thresholds is only part of the evaluation. Listening to what your patient shares with you will drive your overall outcomes in patient care.

Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.

Ensuring a Warm Send-Off for Your Clients

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Those of us working in hospital settings hear about discharges all day long. And we track everything about them: monthly rates, handovers, discharge summaries, patient’s perceptions of them.

In the outpatient world, discharges are just as important. When the patient leaves your office, do they know what they need to do next?

No matter the setting, we health care providers have a responsibility to ensure safety and efficiency when discharging a patient from care.

What happens when discharge isn’t done well? Patients experience adverse events due to delayed or absent communication, inaccuracies in information exchange, or ineffective planning or coordination of care between providers, as found recently in a study by Gijs Hesselink and his colleagues. In fact, at least 20 percent of patients report adverse events following discharge, and least half of these adverse events could have been prevented.

So what is your discharge or “thank you, goodbye” practice?  Here are five take-aways to consider:

  • Write it down!  Discharge instructions should be written down for patient understanding, not for compliance and insurance companies.  Don’t worry about saving the trees, give the patient the recommendations/plan of care in writing.  And, if you have it available, the patient should be able to review them at any time on your secure, web-based patient portal that you have available.
  • Share your instructions/plan of care with the patient’s medical home, therapists, and those that need to know!  Handoffs are one of the biggest problems in patient care that leads to adverse events.
  • Check for comprehension!  Having the patient repeat back what they heard is essential.  Using techniques like “Teach Back” or motivational interviewing are great ways to check for comprehension.
  • Make the discharge follow-up phone callMultiple studies show that if a simple phone call is made within 48 hours of the patient being seen or discharged from the hospital, it is a win-win for everyone involved. For outpatients, not only will you keep that person as a patient, but you will get more referrals due to having a happy customer. For hospitals, research shows reduced readmission rates and significant cost savings.
  • Own the discharge process.  When the patient leaves your practice/hospital, everyone who directly and indirectly touched that patient needs to own the process.  Does the patient know when to return?  Does the patient know who to contact if they have problems?  Will the patient tell a friend about the great experience they had?

Are you already doing these five simple things to keep patients safe?  If not, consider one of these for your next Plan-Do-Study-Act (PDSA).

For additional information about discharge planning, visit leancare.wordpress.com.

Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. This post was adapted from her blog leanhcare.

 

Audiologists: Are Your e-Records Putting You At Risk for an Audit?

EHR imageMedicare is encouraging the implementation and use of electronic health records, but the way some practitioners fill out these records is under scrutiny. The U.S. Department of Health and Human Services Office of Inspector General has made cloning (inappropriate use of the copy-paste feature) and over-documentation areas of high priority for 2014.

OIG has recommended that the Centers for Medicare and Medicaid Services  evaluate EHRs for fraud vulnerabilities. If fraud is suspected, practices will be subject to fines and penalties. It is essential that audiologists use EHRs effectively and not take too many shortcuts. As we transition from paper charts to EHRs, here are a few things to know.

1.) Review all entries in your note. Avoid repeating past information.
According to CMS 1995 and 1997 documentation guidelines, “A review of systems and/or a past medical, family, and social history obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician [audiologist] reviewed and updated the previous information.” In other words, in your note, refer to a previous note that has the comprehensive history. For example, you could write, “See note dated 1/1/2014 for a comprehensive history of patient X,” and update the present concerns/reason for the visit.

2.) Make sure all your diagnoses listed are relevant for that patient’s visit.
Many EHR systems allow the copying of all diagnoses listed in the problem list, even those that have been resolved or aren’t the reason for that day’s patient visit. Be sure to only list the diagnoses that are relevant for the reason the patient is seeing you. For audiologists, the first diagnoses code should be your treating diagnosis followed by the relevant medical diagnoses. Sometimes the treating and the medical diagnoses are the same and there is only one listed.

3.) Make sure your note is individualized for that patient’s encounter.
Many EHR systems also allow you to clone a previous note. Use extreme caution with this feature. Auditors are looking for patterns in documentation. If all your notes look essentially the same across time and across the patients you serve, then they will cite you for not providing individualized care. Review every item in your note to make sure they are relevant for that patient’s visit that day.

4.) All notes should be signed by the licensed professional, correctly dated for when the services were rendered, and the time associated with the visit.
Lawyers, auditors and accreditation organizations look when the notes are completed. All notes should be started on the day services were rendered and finished within 24 hours. The note should have not only the signature of the provider but the time and date on the note. If your notes are not completed in a timely manner, then be prepared to answer, “What are you trying to hide?” or, “How many patients did you see that day? How could you remember what to write if you did your note a week later?” Any notes that are placed in the medical chart greater than 24 hours after the patient was seen is subject to concern.

5.) Avoid saving the note on the wrong date—a common mistake when a professional does not complete documentation on the day of service.
Two things to know:

  • If the note is not there on the day of service, then the patient was not seen.
  • If you dropped charges on a day of services that the patient did not have an appointment and was not seen, then this is considered fraudulent billing and you could be subject to not only losing your license to practice but also significant fines. If this happens, amend the note immediately to the correct day of service! To prevent this from happening, try to incorporate your documentation during the day or at “bedside” when you are with the patient.

6.) Develop a policy on the use of cloning, the copy-paste feature, and over-documentation in EHR technology. CMS has been charged with reviewing your policy if your site is selected for audit. OIG reported that only a third of practices audited had a policy. Be prepared!

Documentation should not be considered additional work but an extension to your patient care activities. Finally, remember our ultimate goal is to provide the best possible care that is timely and based on evidence-based practices. Having timely and accurate information in your note, and nothing else, will help provide the best possible care to your patients. The consequences are too serious to do anything less.

For additional information about documentation, visit leancare.wordpress.com.

Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.

 

 

Learning to Hear: Finally, the Technology

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Hearing aids have improved by leaps and bounds over the past decade. The advanced signal processing and wireless connectivity options absolutely boggle the mind. As an audiologist, I’m constantly amazed at what today’s hearing aids are capable of doing for patients. I’m equally amazed at what my patients expect the hearing aids to be capable of doing for them; yet can we blame them? They are bombarded by newspaper advertisements and mailers boasting the incredible benefits of modern hearing aids. They don’t understand what all is (or should be) included in bundled pricing, so they figure that a $X,000 pair of hearing aids should fix their hearing problems and more. I believe these inflated expectations, coupled with a lack of comprehensive patient education during the rehabilitative process, explain why patient satisfaction and market penetration are not increasing at the same rate as the technological advancements in amplification.

So how do we address these issues? The answer always goes back to the root of our profession. As audiologic rehabilitation specialists, our job is to equip our patients with tools and strategies necessary to function successfully in the world, despite their hearing loss. Patients must understand that hearing aids are only one piece of the puzzle when it comes to successful communication. In fact, there are five essential keys to communication success:

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In previous blogs we’ve discussed listener strategies, speaker strategies, and environmental modifications as critical parts of the communication puzzle. During the aural rehabilitation process, I deliberately present those pieces before I discuss technology options. Listener strategies empower the patient to take responsibility for their hearing loss. Speaker strategies engage the communication partners to be involved. Environmental modifications make the patient and their communication partners aware of their surroundings and empower them to actively create the best possible listening situations.

When we’re finally ready to present technology options, there are two important points to keep in mind. First, we need to be sure we are presenting options. I don’t mean options in terms of different hearing aid manufacturers. I mean options in terms of ALL the technology options appropriate for the patient, based on his or her specific listening challenges. I present the options as a continuum, with inexpensive assistive listening devices and personal sound amplifiers on one end, and high end hearing aids with wireless accessories on the other end. Obviously there are many technological options in between. Second, it is critical that the technology options are presented in conjunction with the other strategies discussed. Patients must understand that technology must be combined with speaker and listener strategies and environmental modifications. The speaker, listener, environment, and technology keys are equally important when it comes to ensuring a successful communication exchange.

The fifth key to communication success is practice. Patients can learn all the communication strategies in the world, but they won’t help a bit if they don’t actually use them. The same goes for technology. Patients can buy the most advanced digital hearing aids available, but they are just a waste of money if they refuse to wear them in all of their challenging listening situations. As rehabilitation specialists, we are responsible for motivating our patients to practice and use all that they’ve learned. We must find ways to hold them accountable and create a follow-up plan that ensures long-term success.

Patients with hearing loss have many options when it comes to pursuing technology. As audiologists, it is our responsibility to make them see the “big picture” and implement a comprehensive plan that addresses all pieces of the communication puzzle. I truly believe that patient satisfaction and market penetration rates will only increase when we return to our roots and make patient education the focus of our rehabilitation efforts.

 

Dr. Dusty Ann Jessen, AuDis a practicing audiologist in a busy ENT clinic in Littleton, Colo. She is the founder of Cut to the Chase Communication, LLC, a company dedicated to providing “fun, easy, and effective” counseling tools for busy hearing care professionals. She is also the author of Frustrated by Hearing Loss? 5 Keys to Communication Success. Dr. Jessen can be contacted at info@CutToTheChaseCommunication.com.