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Sydney Edlund

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OPSC Staff Notes

[Additional information about field, if necessary]

Page Properties
hiddentrue

Field Label

[Text of the question that appears onscreen in the online system, if applicable. If field does not appear in onscreen, put “n/a”.]

Field Name

[Field Name or Attribute Name as it appears in the database]

Question ID

[Unique id for each question, directing to Question Master Table.]

Field Location

[Section of the form in which field is found]

Default

[Default answer value, if applicable. (warning) Remove this row if there is no default answer.]

Use Assumptions

[What triggers this field, if anything? Does it trigger other fields, like an “other text” field? If staff only, put “staff only.” If none or extract only, put “n/a”. ]

Required

[Is this field required for submission? (tick) Yes, (error) No, n/a. Include any rules applied to the field before submission is allowed.]

Setting

[Which reporting programs use this field]

Data Type

[Format in which data is stored in database, i.e. character, number, date/time, etc.]

Old Field Name

[Field name from pre-PSRP database]

AHRQ Mapping

[Data element to which PSRP field maps]

Page Properties
hiddentrue

Field Label

Communication factors

Field Name

cf_comm_f

Question ID

Q049

Field Location

Contributing factors

Use Assumptions

Only appears if {cf_comm}=1 (yes)

If {cf_comm}=1 (yes), {cf_comm_f} ≠null

If {cf_comm}=2 (no), {cf_comm_f} must=null

Required

(error)

Setting

ASC, Hospital, Nursing Facility, Pharmacy

Data Type

Character

Old Field Name

Hospitals: [evnt_desc_anlys_chk_box].Contrib_factor_code=A

[evnt_desc_anlys_chk_box].Factor

ASC Among team members -> Among interdisciplinary teams

ASC Between center personnel & patient/family -> Miscommunication

AHRQ Mapping

DE102, DE105, DE96

OPSC Staff Notes

This was part of a more complex table structure in the old form.

Factors 1-9 should appear under the subheader “Healthcare team member factors.” Factors 10-13 should appear under the subheader “Patient/family factors.”

There are dummy contributing factors for this category because the old data does not map well to the new data. They have answer IDs, codes and values, but should not appear on the form. They are cataloged here.

Answer ID

Answer Code

Answer Value

AHRQ

A0532

18

Among hospital personnel

n/a

A0533

19

Available information

n/a

Change History

Jan 2016: added “Patient did not use call light”, “Resident /patient did not use call light”, “Patient unable to communicate”, “Resident/patient unable to communicate” and “Between staff and patient”. Creating a space for common “other” responses.

March 2013: added “Understanding discharge instructions/plan” for ASCs. Clear, unmet need in “other category.”

May 2013: added “Understanding discharge instructions/plan” for hospitals because “why not?”

Response Codes

Answer ID

Answer Code

Answer Value

A

H

N

P

Axxxx

xx

[Answer text as it appears on screen]

(tick)

(tick)

(tick)

(tick)

Description

[Brief description of what this field is collecting]

On-Screen Instructions

[Prompt text as it appears in the user interface. If none, put “n/a.” If field does not appear on-screen delete this header.]

Field Type

[Type of field, i.e. date/time, text, dropdown (single select), radio button (single select), checkbox (multiselect), true/false, yes/no, etc.]

Maximum Length: [Maximum length of response, if applicable. (warning) Remove this header if the field is not a text field.]

Minimum Value: [Lowest value a number field will accept. (warning) Remove this header if the field is not a number field.]

Maximum Value: [Highest value a number field will accept. (warning) Remove this header if the field is not a number field.]

...

[OPTION ONE: Very many answer options with a lot of content]

...

A0451

1

Across units

(tick)

(tick)

(tick)

A0452

2

Among interdisciplinary teams

(tick)

(tick)

(tick)

A1114

14

Among pharmacy staff

(tick)

A1115

15

Between manager or pharmacist and staff

(tick)

A0453

3

Between providers and staff

(tick)

(tick)

A0454

4

Between supervisor and staff

(tick)

(tick)

(tick)

A0455

5

Handoffs, handovers or shift reports

(tick)

(tick)

(tick)

A0456

6

Hard to read fax or handwriting

(tick)

(tick)

(tick)

(tick)

A1262

20

Unclear prescription

(tick)

A0457

7

Within units

(tick)

(tick)

(tick)

A0458

8

With other organizations or outside providers

(tick)

(tick)

(tick)

A1116

16

With prescribing provider or other outside organizations

(tick)

A0459

9

Other  (please describe)

(tick)

(tick)

(tick)

(tick)

A0460

10

Culture

(tick)

(tick)

(tick)

(tick)

A0461

11

Language

(tick)

(tick)

(tick)

(tick)

A1117

17

Between staff and patient

(tick)

A0462

12

Miscommunication

(tick)

(tick)

(tick)

A1263

19

Misinterpreted directions

(tick)

A2637

21

Patient did not use call light

(tick)

(tick)

A2639

23

Patient/resident did not use call light

(tick)

A2638

22

Patient unable to communicate

(tick)

(tick)

A2640

24

Patient/resident unable to communicate

(tick)

A1151

18

Understanding discharge instructions or plan

(tick)

(tick)

A0463

13

Other (please describe)

(tick)

(tick)

(tick)

(tick)

Excerpt
hiddentrue

ASC Communication Factors

Healthcare Team Member Factors

Patient and Family Factors

Across units

Culture

Among interdisciplinary teams

Language

Between providers and staff

Miscommunication

Between supervisor and staff

Patient did not use call light

Handoffs, handovers or shift reports

Patient unable to communicate

Hard to read fax or handwriting

Understanding discharge instructions or plan

Within units

Other (please describe)

With other organizations or outside providers

Other (please describe)

Description

Determination of which contributing factor(s) related to communication are known.

On-Screen Instructions

Check all that apply.

Field Type

Checkbox (multiselect)

Anchor
Top
Top
Responses

Table of Contents
minLevel1
maxLevel23
excludeDescription|On-Screen Instructions|Field Type|Responses|Response Codes|OPSC Staff Notes|History|Additional Guidance|Additional Support
typeflat
separatorpipe
printablefalse

Healthcare Team Member Factors

...

Anchor

...

acrossUnits
acrossUnits
Across units

Expand
titleDefinition

Ineffective communication between representatives of different units or departments in a facility contributed to the event.

Includes

  • One or more units within a facility

  • Misinterpreted communication

  • Incomplete, not timely, or inaccurate communication

Excludes

  • Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams")

  • Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

  • Communication between units at different facilities in the same healthcare system (select “With other organizations or outside providers”)

Return to top

Anchor
amongTeams
amongTeams
Among interdisciplinary teams

Expand
titleDefinition

Ineffective communication among any group of healthcare professionals from diverse fields who work to coordinate the care of a patient in a facility contributed to the event.

Includes

  • Healthcare professionals in different disciplines working within a designated team or service (e.g., Rapid Response, Code Blue, Infection Prevention)

Excludes

  • Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”);

  • Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

Return to top

Anchor
btwnProvStaff
btwnProvStaff
Between providers and staff

[OPTION FOUR: a very short list]

[Just list the available answer options without the answerID and answerCode. Example page: Was a briefing conducted prior to the induction of anesthesia?]

  • Answer option 1

  • Answer option 2

  • Answer option 3

Additional Guidance

...

[In Option 2, this is where one would put a “related content” content by label macro.]

Info

Additional Support

Which event type should I select?

History

...

Start Date

...

Spring 2012

...

End Date

...

n/a

...

Change History

...

Each answer option gets an anchor and a heading 2. It also gets an expand macro with the title “definition.” Inclusions and exclusions go in the expand macro, below which should be a link to the “top” anchor to take the user back to the responses table of content. Example page: https://oregonpsc.atlassian.net/wiki/pages/resumedraft.action?draftId=2087354595

Includes

Excludes

Expand
titleDefinition

[If the answer option triggers additional question, add a content by label macro to display all pages that share the form_field label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. Macro should have title “Related Content.”]

Filter by label (Content by label)
showLabelsfalse
sorttitle
showSpacefalse
titleRelated Content
cqllabel = "anesthesia" and label = "form_field" and space = currentSpace ( )

[If the answer option is associated with an “faq” item, add a content by label macro to display all pages that share the faq label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. Macro should have title “Additional Support.”]

Filter by label (Content by label)
showLabelsfalse
sorttitle
showSpacefalse
titleAdditional Support
cqllabel = "device_event" and label = "faq" and space = currentSpace ( )

Return to top

[OPTION TWO: several answer options with limited content]

...

[Each answer option gets an anchor and a heading 2. It does not get an expand macro. The definition is unlabeled and goes here, where this text is. Inclusions and exclusions go below it. There is no “top” anchor or “return to top.” Example page: Anesthesia event type ]

Includes

Excludes

[In this version, there is one “Related Content” content by label macro and it goes under “additional guidance, below.]

[OPTION THREE: a very large table]

[If there is an appendix with answer options and definitions, that content goes in the table. Example page: Event Type (Hospitals).]

...

[Item]

...

Definition

...

[Item name in bold]

...

[Description of the item.]

INCLUDES: [inclusions; separate inclusions with semicolons]

EXCLUDES: [exclusions (choose “appropriate answer option” instead); separate exclusions with semicolons (and always tell the user what to do instead)]

[Any “related content” or “additional support” content by label macros would go in the table cell below the inclusions and exclusions. BUT it feels maybe not easy to see or understand what it is?]

Filter by label (Content by label)
showLabelsfalse
sorttitle
showSpacefalse
titleRelated Content
cqllabel = "fall" and label = "form_field" and label = "hospital" and space = currentSpace ( )
Filter by label (Content by label)
showLabelsfalse
sorttitle
showSpacefalse
titleAdditional Support
cqllabel = "fall" and label = "faq" and label = "hospital" and space = currentSpace ( )

...

[Item name in bold]

...

[Description of the item.]

INCLUDES: [inclusions; separate inclusions with semicolons]

EXCLUDES: [exclusions (choose “appropriate answer option” instead); separate exclusions with semicolons (and always tell the user what to do instead)]

[Alternatively, the “related content” or “additional support” could be manually entered in an info panel macro. Easier to see that it’s something different, BUT a lot more manual updating work. ]

Info

Additional Support

Medication Event Types

Ineffective communication between provider and staff in a facility contributed to the event.

Includes

  • Staff does not communicate with provider

  • Provider does not communicate with staff

  • Misinterpreted communication

  • Incomplete, not timely, or inaccurate communication

Excludes

  • Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

  • Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

  • Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Return to top

Anchor
btwnSupStaff
btwnSupStaff
Between supervisor and staff

Expand
titleDefinition

Ineffective communication between supervisor and staff in a facility contributed to the event.

Includes

  • Misinterpreted communication

  • Incomplete, not timely, inaccurate communication

Excludes

  • Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

  • Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Return to top

Anchor
handoffs
handoffs
Handoffs, handovers or shift reports

Expand
titleDefinition

Ineffective communication related to handoffs, handovers or shift reports in a facility or between facilities contributed to the event.

Includes

  • All healthcare professionals

  • Misinterpreted communication

  • Incomplete, not timely, or inaccurate communication

  • Transfers of patients from one facility to another (also select “With other organizations or outside providers”)

Excludes

  • Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

  • Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Return to top

Anchor
hardToRead
hardToRead
Hard to read fax or handwriting

Expand
titleDefinition

Hard to read handwriting or a hard to read fax contributed to the event.

Includes

  • Illegible printing or handwriting

  • Printing too light to read clearly

  • A healthcare professional’s temporary notes to self

Excludes

Return to top

Anchor
withinUnits
withinUnits
Within units

Expand
titleDefinition

Ineffective communication within a unit in a facility contributed to the event.

Includes

Excludes

  • Across staff on multiple units (select “Across units”)

  • Communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”)

  • Communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

  • Communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Return to top

Anchor
withOutside
withOutside
With other organizations or outside providers

Expand
titleDefinition

Ineffective communication with other organizations or outside providers contributed to the event.

Includes

  • Different facility or location within the same healthcare system

Excludes

Return to top

Anchor
otherHCTeam
otherHCTeam
Other (please describe)

Expand
titleDefinition

Any other factor related to communication among facility personnel, not included in the list above, which contributed to the event.

Includes

  • Inadequate available information that is not covered by one of the existing factors

Excludes

Return to top

Patient and Family Factors

Anchor
culture
culture
Culture

Expand
titleDefinition

Ineffective communication related to cultural differences between facility personnel and the patient or patient’s family contributed to the event.

Includes

  • Failure to recognize cultural prohibitions and preferences

Excludes

  • Language barriers (select “Language”)

Return to top

Anchor
langauge
langauge
Language

Expand
titleDefinition

A component of language that impacted the communication between patients and facility personnel contributed to the event.

Includes

  • Spoken language

  • American Sign Language (ASL)

  • Pronunciation or accent

  • Lack of or inappropriate translation services

Excludes

Return to top

Anchor
miscommunication
miscommunication
Miscommunication

Expand
titleDefinition

Miscommunication between facility personnel and the patient or patient’s family contributed to the event.

Includes

  • Incorrect information regarding condition, medications, etc., provided to or by patient or patient’s family

Excludes

  • Misunderstood or incorrect discharge instructions (select “Understanding discharge instructions or plan”)

Return to top

Anchor
call_light
call_light
Patient did not use call light

Expand
titleDefinition

Patient does not use call light to communicate needs with staff.

Includes

  • Any reason a patient does not use a call light (e.g., patient cannot remember to use call light, patient desire for privacy or independence, patient does not want to bother staff)

Excludes

  • Call light not available (select “Device , equipment, or supply availability”)

  • Call light not working (select “Device, equipment, or supply Function (e.g., defective, non-working)”)

  • Call light alarms turned off (select ““Device, equipment, or supply Use or selection by healthcare provider or staff” or “Device, equipment, or supply Use by patient”)

  • Patient not provided instruction for using call light (select “Miscommunication”)

Return to top

Anchor
unable
unable
Patient unable to communicate

Expand
titleDefinition

Patient’s physical inability to communicate contributed to the event.

Includes

  • Nonverbal patient

  • Patient unable to communicate due to clinical condition (e.g., ventilated, comatose)

Excludes

  • Patient provides incorrect information or fails to disclose information to care team (select “Miscommunication”)

  • Patient is difficult to understand (select “Miscommunication”)

  • Patient has language barrier (select “Language”)

Return to top

Anchor
DC_instructions
DC_instructions
Understanding discharge instructions or plan

Expand
titleDefinition

Ineffective communication impacting the patient’s understanding of discharge instructions or discharge plan contributed to the event.

Includes

  • Missing, incomplete, or inaccurate information about: medications; next appointment; limitations; indications for provider evaluation of symptoms after discharge from facility

  • Ineffective communication of discharge instructions (either written or verbal)

  • Lack of confirmation of patient understanding)

Excludes

Return to top

Anchor
otherPtFam
otherPtFam
Other (please describe)

Expand
titleDefinition

Any other factor related to communication between facility staff or providers and the patient or patient's family not included in the list above, which contributed to the event.

Includes

Excludes

Return to top

Additional Guidance

Communication factors may be related to any spoken or written communication between anyone in a facility, including, but not limited to, providers, staff, patients, and patient families. Ineffective communication is communication that was inaccurate, incomplete, ambiguous, misunderstood by the recipient, or not timely.

History

Start Date

2006

End Date

n/a

Change History

Spring 2012: PSRP Implementation

March 2013: added “Understanding discharge instructions or plan” for ASCs

May 2013: added “Understanding discharge instructions or plan” for hospitals

January 2016: added “Patient did not use call light” and “Patient unable to communicate”