A Communication Toolkit Increased Quality of Care for Long-term Care (LTC) Residents at a Dental Surgical Center

Long-term care (LTC) residents have complex medical histories and decreased access to dental care, which leads to unmet dental needs and poor health outcomes. This complex and underserved population often requires general anesthesia for dental care. Also, limited communication between LTC and treating facilities frequently leads to missed opportunities to provide dental care. Local Problem: For a small surgical center and one dental provider, poor communication between LTC facilities and the surgical center led to preventable case cancellations due to improper anesthesia preparation. LTC resident case cancellations are costly, and delays dental care for the resident. Methods: This quality improvement project aimed to decrease case cancellations by improving communication processes during a 4-week pilot project. Pre-intervention case cancellation rates were calculated using a retrospective 12-month chart review to determine preventable and nonpreventable cases. Communication barriers were identified between the surgical center, dental office, and LTC facilities. A communication toolkit was developed and implemented to address communication barriers. All users were individually educated on how to use the toolkit. Post-intervention, case cancellation rates were calculated and categorized into "preventable" and "not preventable." Post-intervention interviews were conducted to determine the feasibility, usability, and satisfaction of the toolkit for the surgical center, the LTC facilities, and the dentist. Interventions: The communication toolkit included a preoperative patient assessment form and processes, a medication reconciliation form, an updated patient history and anesthesia record, an updated postoperative order and discharge instructions, a communication handoff and preoperative order form, a postoperative communication handoff form, and a nothing by mouth sign for facility use. Results: Pre- and post-cancellation rates showed no changes post-intervention and a higher percentage of preventable case cancellations post-intervention. Overall feasibility, usability, and satisfaction of the toolkit were high across all users, with increased communication between the surgical center and the LTC facilities. Conclusion: Although there was no change in cancellation rates, and most cases were preventable, the project was deemed successful, with high satisfaction with the toolkit use and increased perception of communication between the surgical center and the LTC facilities. The plan is to modify the toolkit as per feedback, continue its use, and refine the processes as needed. Further implementation will occur in all LTC facilities and for all adult patients seen at the surgical center. Additional fine-tuning will increase efficiency processes and expand services to more clients needing dental surgical care.

1 Implementing a Quality Improvement Toolkit to Increase Communication Between a Dental Surgical Center and Long-Term Care Facilities to Improve Patient Outcomes Catherine A. Bowman, Adam Marberger, Teresa Garrett College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III 4-15-2024 2 Abstract Background: Long-term care (LTC) residents have complex medical histories and decreased access to dental care, which leads to unmet dental needs and poor health outcomes. This complex and underserved population often requires general anesthesia for dental care. Also, limited communication between LTC and treating facilities frequently leads to missed opportunities to provide dental care. Local Problem: For a small surgical center and one dental provider, poor communication between LTC facilities and the surgical center led to preventable case cancellations due to improper anesthesia preparation. LTC resident case cancellations are costly, and delays dental care for the resident. Methods: This quality improvement project aimed to decrease case cancellations by improving communication processes during a 4-week pilot project. Pre-intervention case cancellation rates were calculated using a retrospective 12-month chart review to determine preventable and nonpreventable cases. Communication barriers were identified between the surgical center, dental office, and LTC facilities. A communication toolkit was developed and implemented to address communication barriers. All users were individually educated on how to use the toolkit. Post-intervention, case cancellation rates were calculated and categorized into "preventable" and "not preventable." Post-intervention interviews were conducted to determine the feasibility, usability, and satisfaction of the toolkit for the surgical center, the LTC facilities, and the dentist. Interventions: The communication toolkit included a preoperative patient assessment form and processes, a medication reconciliation form, an updated patient history and anesthesia record, an updated postoperative order and discharge instructions, a communication handoff and 3 preoperative order form, a postoperative communication handoff form, and a nothing by mouth sign for facility use. Results: Pre- and post-cancellation rates showed no changes post-intervention and a higher percentage of preventable case cancellations post-intervention. Overall feasibility, usability, and satisfaction of the toolkit were high across all users, with increased communication between the surgical center and the LTC facilities. Conclusion: Although there was no change in cancellation rates, and most cases were preventable, the project was deemed successful, with high satisfaction with the toolkit use and increased perception of communication between the surgical center and the LTC facilities. The plan is to modify the toolkit as per feedback, continue its use, and refine the processes as needed. Further implementation will occur in all LTC facilities and for all adult patients seen at the surgical center. Additional fine-tuning will increase efficiency processes and expand services to more clients needing dental surgical care. Keywords: quality improvement, long-term care facilities, communication, handoff, surgical case cancellation, dental surgery 4 Implementing a Quality Improvement Toolkit to Increase Communication Between a Dental Surgical Center and Long-Term Care Facilities to Improve Patient Outcomes Problem Description Long-term care (LTC) residents have several physical, mental, and social factors that lead to poor dental health, decreased access to care, and unmet dental needs. Additionally, substantial evidence connects poor oral health with cardiovascular disease, diabetes, and acquired pneumonia in LTC residents (Lemaster, 2013; Walgama et al., 2018; Yoon & Steele, 2012). Subsequently, LTC residents often require general anesthesia to address their complex dental issues (Walgama et al., 2018). Care coordination between the originating dentist, LTC facility, and surgical center is needed to ensure LTC residents are appropriately prepared for general anesthesia. Cancellation of scheduled surgeries is costly, can cause patient anxiety, and is largely preventable with appropriate preoperative assessment (Talalwah & McIltrot, 2019). When LTC facility residents transfer for treatment at a hospital or other facility, better communication between facilities improves patient outcomes (Griffiths et al., 2014). Poor communication between LTC care facilities and a dental surgical center led to frequent cancellations. It delayed dental care due to improper preparation for general anesthesia and incomplete assessment of patient conditions. A Utah-based surgical center, primarily a pediatric dental surgical center supporting dental procedures, works with a local dentist to facilitate procedures for residents of LTC facilities. Occasionally, improper preoperative preparation causes dental case cancellations. The assumption is that the failure to comply with preoperative preparation is due to a communication breakdown between the LTC facilities and the process of entering preoperative orders from the 5 dentist and surgical center. These communication breakdowns needed to be identified and adequately addressed. Also, no official handoff tool transfers with the patient to the surgical center, providing specific nothing by mouth (NPO) status or information regarding medications. Knowing this information affects anesthesia, and if not obtained quickly or reliably, the patient is at increased risk of adverse outcomes or case cancellation due to unknown NPO status. Patient conditions that can affect anesthesia and safe care at the surgical center, such as transfer status or weight, which can affect access to the patient while in the operating room, were not assessed before patient arrival. This lack of communication increased the risk of poor patient outcomes or case cancellation due to the inability to accommodate these conditions. Typically, the preprocedural assessment was performed on the day of the surgery at the surgical center just before beginning the case. The LTC facility provides the patient history and medication list, usually faxed to the surgical center a few days before, or it arrives with the patient upon admission for the procedure. If a nurse assessed this information before the patient arrived, more preparation to accommodate any extenuating needs could lead to better care management and outcomes. Poor communication and improper preoperative assessment lead to case cancellation, poor patient outcomes, and decreased access to dental care. Available Knowledge Surgical case cancellations happen for several reasons, and one cannot generalize the basis for cancellations into one communal category. The most frequently reported top reason varies between hospital or resource availability (staffing, scheduling, ICU bed availability) versus patent-related causes (self-cancellation, inadequate preoperative workup, following preoperative guidelines). However, most case cancellations are preventable (Altun et al., 2020; 6 Askari et al., 2020; Dawson et al., 2019; Koushan et al., 2021; Talalwah et al., 2019; Talalwah & McIltrot, 2019). From a quality improvement perspective, each facility must identify its top causes for case cancellations and tailor their intervention depending on its specific problem (Altun et al., 2020; Askari et al., 2020; Dawson et al., 2019; Koushan et al., 2021; Talalwah & McIltrot, 2019). A standard recommendation to decrease case cancellations is to perform a nurse-led preoperative assessment several days before the case (Dowd et al., 2023; Talalwah et al., 2019; Talalwah & McIltrot, 2019; Umeno et al., 2022: Prasad et al., 2022). The preoperative assessment provides an opportunity for proper patient education and increases patient adherence to instructions (Altun et al., 2020; Askari et al., 2020; Koushan et al., 2021; Talalwah et al., 2019; Talalwah & McIltrot, 2019; Prasad et al., 2022). Other essential aspects of the preoperative assessment include sufficient nursing staff education on preoperative procedural processes (Dowd et al., 2023) and utilization of set preadmission protocols (Talalwah & McIltrot, 2019). Communication breakdown leads to decreased quality of care, especially when residents in a LTC facility transfer to another facility for treatment or care (Kruse et al., 2018; Aird et al., 2022). The lack of electronic medical record (EMR) interoperability deters this transfer of information (Kruse et al., 2018; Aird et al., 2022). Staff education on processes and procedures when communicating between facilities is also vital to successful patient handoff and information transfer (Testa et al., 2020; Baluyot et al., 2022; Farrell et al., 2022; Aird et al., 2022). Thus, using available electronic records and providing efficient staff education may increase communication. Another essential aspect of successful patient handoff is positive collaborative relationships between communicating facilities (Testa et al., 2020; Farrell et al., 2022; Cross et 7 al., 2023) and handoff communication tools (Testa et al., 2020; Baluyot et al., 2022; Leonardsen et al., 2019). Testa et al. (2020) describe successful care coordination models focusing on increasing communication between facilities with a designated person of contact and a communication checkoff list. Farrell et al. (2022) reinforce that higher staff confidence in their communication skills leads to better communication and patient outcomes. Cross et al. (2023) correlate a strong relationship between perceptions of efficient information sharing and highquality indications for care transitions. Baluyot, McNeill, and Wiers (2022) encourage a standardized communication tool to address patients’ immediate needs upon transfer of care. These elements suggest building solid relationships and partnerships with LTC facilities and developing standardized communication tools to increase staff confidence in communication. Better communication and transition of care will result in better patient outcomes. Rationale The Iowa Model was chosen to guide this Quality Improvement (QI) project because it provided an easy-to-follow framework leading to evidence-based decision-making and practice change (Brown, 2014). The Iowa Model involved a seven-step process of identifying a problem, forming a team, gathering evidence, synthesizing evidence, piloting a change, implementing organizational change, and dissemination (Brown, 2014). The first step Brown (2014) suggested in the model is identifying a problem. Staff at the surgical center raised concern over the recurring cancellations and noncompliance with preoperative orders from LTC residents. Also, there was a lack of adequate preoperative assessment information being conveyed to the surgical center to prepare for safe care in the operating room. These problems were a top priority for the surgical center and the providing dentist because cancellations are costly. Safe care can be compromised if not handled appropriately, delaying necessary dental care. The surgical center 8 acknowledged these problems as a top priority, which led to the formation of a team, the critical appraisal of the relevant evidence, and the synthesis of evidence into a practice change (Brown, 2014). The next step in the Iowa Model was deciding if sufficient research and evidence supported a practice change (Brown, 2014). The culminating evidence supported the idea that implementing a preoperative assessment process days before the procedure and developing a communication toolkit would increase preoperative order compliance and improve care coordination. In addition, the toolkit would mitigate unknown patient conditions that may affect anesthesia care and decrease preventable case cancellations. The interventions to achieve these goals required the identification of the causes for case cancellations for LTC residents in the past twelve months and areas for communication breakdown with current scheduling processes. Next, a communication toolkit and nurse-led preoperative assessment procedures and protocols needed development (Aird et al., 2022; Altun et al., 2020; Askari et al., 2020; Baluyot et al., 2022; Cross et al., 2023; Dawson et al., 2019; Dowd et al., 2023; Farrell et al., 2022; Koushan et al., 2021; Kruse et al., 2018; Leonardsen et al., 2019; Prasad et al., 2022; Talalwah et al., 2019; Talalwah & McIltrot, 2019; Testa et al., 2020; Umeno et al., 2022). With sufficient evidence and research supporting a practice change, the next step was implementing a pilot program using these interventions (Brown, 2014). With one surgical center servicing several LTC facilities in the Salt Lake area, the Iowa Model guided this project to pilot the interventions first in ten LTC facilities before implementing it in all facilities (Brown, 2014). During this step, initial visits were made to the LTC facilities and followed up as needed during the project. Surgical center staff was contacted on each of the scheduled case days to assess 9 staff’s perceptions of usability, feasibility, and satisfaction. Feedback guided the continual modification and adaptation of these interventions based on staff comments and experience. Any process changes were made during this implementation stage before applying them to additional LTC facilities (Brown, 2014). These interventions were deemed successful, which allowed the next step of implementation in more LTC facilities with continual monitoring and analysis of processes and outcomes (Brown, 2014). Lastly, Brown (2014) reported that the final step in the Iowa model is dissemination. The results of this project were disseminated to the QI community through a conference poster. Specific Aims This Doctor of Nursing (DNP) Quality Improvement (QI) project aims to implement a nurse-lead preoperative assessment process and communication toolkit to increase preoperative compliance and care coordination, decrease case cancellations, and improve timely access to dental care. Methods Context This DNP quality improvement project occurred at a small surgical center in Murray, Utah, where a private dentist provided dental care for patients from ten LTC facilities in urban and suburban Salt Lake City, Utah. Participants included the dentist, five surgical center nurses, and six anesthesia providers. LTC facility participants included unit nurse managers, directors of nursing, social workers, and transportation coordinators. The population included adult residents at all ten LTC facilities who were generally over 18, had chronic or poor health conditions, and used Medicaid as the primary payment source for dental procedures. Exclusion criteria included patients from other non-nursing facilities, private pay, or living in a private residence. 10 Interventions During the first phase of this project, a retrospective chart review of patients seen at the surgical center for the last 12 months was collected from the EMR between January 2023 and December 2023. Data was collected on all patients scheduled to see the dentist, separated into LTC residents and then into which facility they resided. Reason for case cancellations were noted for all LTC care facility patients and divided into Preventable and Not Preventable categories. Only results from LTC care facilities were compared post-intervention. In Phase 2, communication processes between the LTC facilities and the surgical center were evaluated. LTC staff participants, the surgical center scheduler and office coordinator, and the dentist were all interviewed regarding the processes for scheduling a case at the surgical center. A process flowsheet (Appendix A) was created to show the processes and potential communication breakdowns at the LTC facilities, the surgical center, and during scheduling. Phase 3 involved developing a communication toolkit. The toolkit consisted of a preoperative patient assessment form and processes, Appendix B. A medication reconciliation form, Appendix C. An updated patient history and anesthesia record, Appendix D. An updated postoperative order and discharge instructions, Appendix E. A communication handoff and preoperative order form, Appendix F. A postoperative communication handoff form, Appendix G. An NPO sign for facility use, Appendix H. The QI team reviewed and approved these forms and tools. One-on-one education was provided to all surgical center staff and contacts at the LTC facilities. The fourth phase was implementing the nurse preoperative assessment at least one day before the scheduled procedure and implementing the communication toolkit. Participant check- 11 ins were performed at the surgical center on all scheduled case days and as needed with the LTC facilities for feedback on the processes and toolkit utilization. The final phase included an evaluation of the project one month after initiation. The process for the preoperative assessment and the communication toolkit were evaluated for useability, feasibility, and satisfaction through semi-structured interviews with all available participating staff at the surgical center and LTC facilities. Case cancellation causes were documented, and case cancellation rates were calculated and compared to preoperative rates. A cost analysis was performed and included in an executive summary (Appendix I) presented to the QI team to evaluate the next steps. Study of the Interventions Descriptive statistics and content analysis were used during a retrospective chart review to calculate case cancellation rates and identify causes for cancellations. Post-intervention interviews were collected one month after implementation on all available participating surgical center staff, LTC care facility staff, and the dentist. Common themes were coded and extracted to determine the usability and effectiveness of the interventions and perceptions of communication processes before and after implementation. In addition, perceptions of care coordination, transition of care between facilities, and satisfaction with the interventions were also identified. Staff check-ins were performed on all ten scheduled case days at the surgical center, initially and as needed with LTC facilities, and every two weeks with the QI team. Feedback was documented, and changes to the processes and toolkit were made as required. Case cancellation rates and causes were collected, analyzed, and compared to pre-intervention rates. A cost analysis was also conducted on potential opportunity revenue loss for pre- and post-intervention 12 data. Basic demographic information was collected from all participants interviewed, and all patients in the population included in the project. The expected outcomes included a decreased case cancellation rate, an increased perception of communication processes and care transition, and positive support of the new interventions. Personal interviews and discussions with staff were also documented, along with suggestions and feedback each week and post-intervention. Measures During the implementation phase, staff were interviewed each case day at the surgical center on what was working and what was not, as well as any suggestions for improvement; see Appendix J. Patient charts were reviewed for toolkit use and completed preoperative assessments. Feedback was documented, and changes were implemented as needed. Semi-structured interview questions were developed specifically for this project, reviewed by the project chair, and conducted by the author, Appendix K. Post-intervention, surgical center participants answered questions regarding communication processes, patient handoff, preoperative nurse assessments, quality of care provided, and any barriers affecting these processes. Staff responded to questions regarding the feasibility and satisfaction of the toolkit and if they felt it increased communication and quality care. They also answered questions on ease of use and how likely they would use it with future patients. LTC facility staff were interviewed post-implementation using a semi-structured interview regarding usability, feasibility, and satisfaction with the toolkit and processes. Feedback and suggestions were documented and analyzed for themes. Analysis 13 Descriptive statistics were used to analyze case cancellation rates. A retrospective chart review was used to identify and describe case cancellation rates and causes for the past 12 months before the interventions. Case cancellation causes were noted and organized into categories and common themes. Central tendency and variability were used to describe patient and participant demographics. Detailed notes were recorded on feedback during check-in meetings and postintervention interviews. Descriptive statistics and content analysis were used to analyze participant feedback and interview results. Words were read word for word, then categorized, organized, and summarized into themes. Ethical Considerations This project did not require University of Utah Institution Review Board oversight as it was deemed a quality improvement project. There were no conflicts of interest in this project. Results The evaluation of this project involved three primary focus areas, including pre- and postcancellation rates and toolkit feasibility, usability, and satisfaction. Overall, satisfaction with the toolkit was high among the users. Pre- and post-cancellation rates showed no changes postintervention. Table 1 displays a retrospective chart review from January 2023 through December 2023 and showed an overall case cancellation rate of 33.3% for 171 scheduled cases with 57 cancellations; 28 (49.1%) cancellations were deemed preventable, and 14 (24.6%) were unknown. Figure 1 provides a visualization of the causes of case cancellations. This quality improvement project was implemented between January 11 and February 9, 2024. During the ten scheduled operating days, the overall case cancellation rate was 33.3% (no change from preintervention) for 30 scheduled cases with ten cancellations; 7 (70%) cancellations were deemed 14 preventable (compared to 49.1% pre-intervention). The top three causes for case cancellation included 4 (40%) for preoperative processes (preventable), 2 (20%) for preop compliance (preventable), and 2 (20%) for patient-caused (not preventable), see Figure 2. Patient demographic information is presented in Table 2. This project required the full utilization of a toolkit by the surgical center's nursing staff. Their participation and feedback impacted the overall success of this project. Anesthesia use was limited to the anesthesia form and the discharge instructions; however, their general input on the processes of the toolkit was invaluable to developing future protocols and recommended changes. All five participating nurses and five of the six participating anesthesia providers were interviewed post-implementation. One anesthesia provider was unavailable for an interview during the post-intervention phase. Demographic information on all staff participants is presented in Table 3. Compliance with toolkit use and adoption is displayed in Table 4, with a high percentage of use among the surgical center staff. Post-intervention interviews showed a high overall satisfaction rate with the toolkit and processes. All staff agreed that the toolkit was feasible and easy to use, and they asked to use it with all adult dental patients in the future. Staff provided input for changes in processes and forms to increase usability, but overall suggestions were minimal. Common themes from staff interviews are displayed in Tables 5, 6, 7, and 8. Interview responses for the surgical center nursing staff, Table 5, include the following top three themes. Preoperative processes helped nurses feel better prepared and increased the perception of the quality of care they provided. The new processes and forms increased communication handoff with LTC facilities. There is an increased satisfaction with documentation that is more relevant to the patient population. The central anesthesia theme that emerged was agreement that current 15 preoperative processes could be improved, and a preoperative assessment could reduce this gap; see Table 6. Both anesthesia and surgical center nursing staff agreed that communication with LTC facilities is one challenging aspect of working with this population at the surgical center. Both groups agreed that the toolkit addresses some of these issues and has improved or will help improve communication with LTC facilities. Staff from eight of the ten participating LTC facilities provided feedback. Table 7 provides common themes from facility interviews. Overall, LTC facility adoption with the handoff communication tool was 61.9%, Table 4. Even with lower adoption, LTC facility staff liked the toolkit and processes, thought they were helpful, and increased communication, and they would like to continue the use. Finally, the dentist was interviewed regarding the toolkit, Table 8. He was not a process user but an end user. The dentist’s responses were consolidated into two major themes. First, he was satisfied with the overall outcomes of the project and the efforts to make his job easier and get more patients seen. However, he was concerned about adding more paperwork to the process, which led to a theme of condensing paperwork. He was chiefly concerned with the preoperative paperwork (not addressed in this project), which increased the workload of the LTC facility staff. He didn’t want to add more paper to the postoperative phase with the toolkit and processes. However, he wants to see these processes continue and is willing to work with the QI team to improve them. Discussion Summary This project aimed to improve communication processes to decrease case cancellation rates and increase patient access to dental care. Although there was no change in cancellation rates pre- and post-intervention, the overall satisfaction with the toolkit among all users deemed 16 this project successful. Using the Iowa model, this project was implemented for ten LTC facilities and twenty-seven patients seen by the dentist. This project improved communication handoff processes, identified preventable case cancellation causes, and increased participants' perception of the quality of care they provided. With further refinement and implementation, communication will continue to improve, case cancellations will decrease, and more patients will receive the dental care they need. Interpretation Preventable Case Cancellations Many variables contribute to case cancellations, and this project focused on increasing communication processes to reduce preventable case cancellations. This project had a common thread that coincided with the literature: a high percentage of case cancellations are preventable (Altun et al., 2020; Askari et al., 2020; Dawson et al., 2019; Koushan et al., 2021; Talalwah et al., 2019; Talalwah & McIltrot, 2019). Surprisingly, preoperative processes and not NPO status (preoperative compliance) were the top reasons for preventable case cancellation. The literature suggests interventions need tailoring depending on cancellation reasons (Altun et al., 2020; Askari et al., 2020; Dawson et al., 2019; Koushan et al., 2021; Talalwah & McIltrot, 2019). This project did not focus on preoperative processes, but future projects will. Preoperative Assessment Preoperative nurse assessments are highly recommended to decrease preventable case cancellations (Dowd et al., 2023; Talalwah et al., 2019; Talalwah & McIltrot, 2019; Umeno et al., 2022; Prasad et al., 2022). Part of the success of the assessment is preoperative compliance education (Altun et al., 2020; Askari et al., 2020; Koushan et al., 2021; Talalwah et al., 2019; Talalwah & McIltrot, 2019; Prasad et al., 2022). For this project, the LTC resident's preoperative 17 compliance responsibility resided in the facility, not with the patient. The preoperative assessment was initially implemented as part of the toolkit to better prepare for patients with complicated health needs. The surgical center nursing staff expressed high satisfaction with the preoperative assessment because they communicated directly with LTC staff. A common misconception was that the LTC resident had an appointment at a dentist's office. This new process made the LTC facility staff aware of the general anesthesia procedure and the need for NPO orders. Surgical center staff felt this direct communication with staff would help support NPO compliance at the facility. Preoperative assessments were planned to be completed at least one day before the dentist’s scheduled procedure days. Still, it was not feasible for the surgical center nurse to care for patients and call LTC facilities for assessments for the next planned procedure day. The author of this paper and a nurse at the surgical center were present during all scheduled case days and completed many of the preoperative assessments. All nursing staff participated in the preoperative assessment processes during the project. Future feasibility will involve a designated nurse focused primarily on preoperative assessments. The preoperative assessment may not have influenced the case cancellation rates, but the overall high satisfaction with processes supports their continued use. One central theme from the surgical center nurse interviews was that these processes helped nurses provide higher-quality care because they felt better prepared and knew what to expect. Talalwah and McIltrot (2019) suggested that part of the preoperative assessment should include preadmission protocols. This project initially hoped to develop specific preoperative standing protocols, but time constraints prevented this from occurring before the project began. 18 Information collected from this project will support the development of such protocols in the future. Communication with LTC Facilities All surgical center staff shared experiences (pre- and post-intervention) where communicating with a LTC facility was difficult or unsuccessful. Kruse et al. (2018) and Aird et al. (2022) showed that decreased communication, especially during the transfer of care to or from a LTC facility, leads to reduced quality of care and poor patient outcomes. One way to increase this communication is through handoff communication tools (Testa et al., 2020; Baluyot et al., 2022; Leonardsen et al., 2019). For this project, part of the toolkit included a communication handoff form. The communication form was developed to follow the patient through the entire operative process and pass critical information to each receiving party. Overall, perceptions of communication processes between facilities increased with this tool. LTC staff adoption and communication tool use was low (61.9%). However, staff expressed high satisfaction with its use. LTC staff and surgical center nurses felt this tool was helpful, increased handoff communication between facilities, and would like to continue its use. Cross et al. (2023) suggest a high correlation between perceptions of efficient information sharing and quality care transitions. If the receiving facility knows what happened, then the patient's immediate needs can be met. The communication handoff allows the transition of care to occur more seamlessly, and patient care improves when those immediate needs are met. The lack of EMR interoperability to and from LTC facilities has been identified as a communication barrier (Kruse et al., 2018; Aird et al., 2022). It was discovered early on in this project that the surgical center already had access to the EMR from most of the LTC facilities. 19 Processes were established to utilize this resource as soon as patients were scheduled. This information allowed for smoother preoperative assessments and processes. Collaborative Relationships One aspect of successful communication is the collaborative relationship between the communicating facilities (Testa et al., 2020; Farrell et al., 2022; Cross et al., 2023). Testa et al. (2020) suggested that having one designated person of contact would help increase communication processes between facilities. During this project, the author (and nurse at the surgical center) remained the main person of contact with all LTC facilities. They met with all LTC facilities in person, communicated throughout the project by phone, and followed up for post-interviews. Establishing relationships with key facility staff is essential to know who and how best to make contact. These relationships allowed the surgical center and LTC facilities to close the communication loop to ensure appropriate information was conveyed. One unexpected outcome of building these relationships was the ownership LTC facility leadership took upon themselves. When one patient ate breakfast, the director of nursing called the surgical center nurse immediately to explain the situation, take ownership of the cancellation, and came up with a solution so it wouldn't happen again. A few LTC leaders took ownership for not completing and sending the communication form with the patient. One unit manager took ownership of educating their staff on the processes. These relationships allow for more open and honest communication. Developing and fostering these relationships will be essential to sustain these processes in the future, especially when implementing them into new LTC facilities. One facility was the most difficult to communicate with, had the most case cancellations during the project (3 preventable), and had the only incomplete preoperative assessments. When this project began, this LTC facility did not have a director of nursing, and the person of contact 20 for the preoperative processes was a newly hired, overwhelmed social worker. Post-intervention follow-up was expected to be unsuccessful. After three failed attempts on the phone, an impromptu in-person visit occurred. Surprisingly, the site visit successfully established a relationship with the new director of nursing, who was very interested in increasing their communication processes with the surgical center and exchanged contact information. Communication is a two-way street, and there must be appropriate contact on both ends for effective communication. Impact The potential impact of this project is multifaceted. Improving communication processes has the potential to impact the care patients receive. Decreasing case cancellations affects patients because they receive timely dental care. Increasing communication processes influence staff satisfaction in providing quality care for their patients. Case cancellations also have a financial impact on the surgical center. A cost analysis was done to estimate opportunity loss due to case cancellations; see Table 9. The average opportunity loss in 2023 was $2,992.50 monthly and $35,910 in one year. The intervention cost includes about 1 hour of nurse time per scheduled patient. If the surgical center could decrease the preventable case cancellation rate by 40% (about one a month or eleven a year), it could cover the cost of the intervention. If preventable case cancellations could be decreased by more than 40%, there is a potential 20% revenue increase. The nursing staff at the surgical center was receptive and enthusiastic with the intervention. The high toolkit satisfaction has the potential to impact the quality of patient care. Nurses felt they were providing better care because of improved communication and preparation for these patients. 21 The LTC residents are already vulnerable with increased comorbidities, decreased ability to care for themselves, and limited access to dental care (Lemaster, 2013; Walgama et al., 2018; Yoon & Steele, 2012). Getting the LTC resident to the surgical center for needed dental care can be an extensive process with several working parts. Case cancellations can be distressing for the patient experiencing discomfort due to unmet dental care. Preventable case cancellations can be mitigated through improved communication, which increases patient access to dental care. There is considerable potential to increase the capability to service more patients at the surgical center by refining the toolkit and focusing on other preventable preoperative processes. Limitations This project encompassed a small sample size and was limited due to time restraints. Initially, only one LTC facility was going to pilot the toolkit. With limited time, the decision was made to expand enrollment to all LTC facility patients scheduled at the surgical center during the project period. This allowed for more exposure, use, and feedback from LTC facilities and surgical center staff on the toolkit. Even with expanding enrollment, varying use and exposure occurred among staff and facilities, limiting feedback results. Post-intervention semi-structured interviews did not use a verified or formal assessment tool. The interviewer, who works with the surgical staff regularly, may have biased their results by performing the interview and did not allow for candid answers. One anesthesiologist, the surgical center’s medical director, was unavailable for a post-intervention interview. Feedback from LTC facilities was limited and varied. Not all facilities could be reached, and feedback was mainly provided by staff not directly involved in the process. This project was specific to the population at one surgical center, and participant demographics were not diverse, thus limiting the generalizability. The toolkit was tailored for 22 processes at the surgical center, and communication between facilities and results should be viewed with this in mind. It was challenging to compare pre- and post-intervention data because the chart review showed considerable variability in the number of cases and cancellations each month. The number of cases doubled during the project compared to the previous twelve months. Several variables could have accounted for the increase in volume, including a change in the scheduling processes and an easing on Medicaid prior authorization criteria. In addition to the intervention, these recent changes could have all played into these extenuating circumstances, and there is no way to pinpoint what variable influenced these changes. Preventable case cancellation rates were calculated based on known causes. The chart review showed 14 (24.6%) cases cancelled for unknown or undocumented causes. Postintervention data accounted for all cancelled causes and had a higher preventable cancellation rate. It’s unknown if these unknown cancellations were preventable; thus, the chart review preventable cancellation rate may be higher than calculated. The toolkit was implemented, but exact preoperative protocols were not well established before implementation. Developing universal protocols that worked at all ten facilities was a learning process. Toward the end of the project, the processes became more solidified. Better results may have occurred had these processes been well established from the beginning. Conclusion Though case cancellation rates did not decrease, there was high satisfaction with the toolkit and increased communication between the LTC facilities and the surgical center. Through continual refining and use, communication will improve, case cancellations will decrease, and more patients will receive needed dental care. Overall, all users verbalized satisfaction and ease 23 of use of the toolkit and said they would like to continue using it. At this point, sustainability will depend on training and investing in a designated preoperative nurse and making communication forms electronic. Though not generalized outside the surgical center, once refined, the toolkit will be expanded and used with all LTC facilities and eventually with all adult dental patients. The QI team will monitor quarterly cancellation rates for continual evaluation and changes. Further investigation is needed to review the preoperative processes, specifically paperwork and case scheduling, leading to preventable cancellations. There is an excellent potential for a return on investment for the business side of the surgical center if they can decrease preventable cancellation rates and increase their capacity to see more patients. LTC residents will receive timely and quality dental care through improved communication. Funding Funds from the Dick and Timmy Burton Foundation were used to incentivize participant feedback in this project. 24 Acknowledgments I would like to thank the administration staff at the surgical center for taking a risk and trying something new. Pulling this project off took a lot of effort, and I could not have done it without them. Jasmine, though not directly involved in the project, was there daily printing off forms and patient information to make this all possible. Nursing and anesthesia staff pitched in to ensure processes were going smoothly. Staff at the long-term care facilities, who work tirelessly to provide patient care, took time to participate and make these processes manageable. Of course, this project could not have been possible without the dentist, who strives to make a difference in the lives of vulnerable patients through dental care. Thanks to my classmates, colleagues, and instructors for supporting and guiding me through the learning processes. To my project chair, Dr. Teresa Garrett, who believed in me and was very patient with my struggles. To my family and dogs, who sacrificed the most, I would not be here without you. Trent, William, Patrick, Luna, and Mollie, I look forward to all the upcoming summer adventures. Thank you to my in-laws, who wholeheartedly supported me and invested in their daughter-in-law’s potential. Finally, thank you to all the heavenly support who helped me push through the late nights and long weekends, Mom! To the divine inspiration and guidance, I felt through the many difficult and joyful moments. The journey has been long and hard, but it is worth it. 25 References Aird, T., Holditch, C., Culgin, S., Vanherheyden, M., Rutledge, G., Encinareal, C., Perri, D., Edward, F., & Boyd, H. (2022). An analysis of a novel Canadian pilot health information exchange to improve transitions between hospital and long-term care/skilled nursing facility. Journal of Integrated Care, 30(4), 399-412. https://doi.org/10.1108/JICA-03-2022-0022 Altun, A. Y., Ozer, A. B., Aksoku, B. T., Karatepe, U., Kilinc, M., Erhan, O. L., Demirel, I., & Bolat, E. (2020). Evaluation of the reasons for the cancellation of elective procedures at level 3 university hospital on the day of surgery. 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Gerodontology, 29, e525-e535. https://doi.org/10.1111/j.1741-2358.2011.00513.x 29 Table 1 Chart Review and Post-Intervention Case Cancellation Rates and Causes Cases and Cancellations Chart Review (%) Post-Intervention (%) Average (12 months) Actual (4 weeks) Mean ± SD 14.25 ± 5.9 30 Median (Min, Max) 13 (8, 27) NA Mean ± SD 4.75 ± 3.5 10 Median (Min, Max) 4 (1, 14) NA Mean ± SD 2.3 ± 1.7 7 Median (Min, Max) 3 (0, 4) NA Actual (12 months) Actual (4 weeks) Total Number of Cases Scheduled 171 (100%) 30 (100%) Total Number Cases Cancelled 57 (33.3%) 10 (33.3%) Total Preventable Causes 28 (49.1%) 7 (70%) Cases Scheduled per Month Cases Cancelled per Month Preventable Cancellations Preoperative Compliance 10 (17.5%) 2 (20%) Preoperative Processes 13 (22.8%) 4 (40%) Transportation 5 (8.8%) 1 (10%) Total Not Preventable Causes 15 (26.3%) 3 (30%) Patient Caused 9 (15.8%) 2 (20%) Unavoidable Conditions 6 (10.5%) 1 (10%) Unknown 14 (24.6%) 0 (0%) 30 Table 2 Demographics of Patient Participants Demographic Variable LTC Facility Patients N=27 (%) Age (years) Mean ± SD 57.5 ± 8.9 Median (Min, Max) 61 (29, 81) Gender Male 14 (52) Female 13 (48) Other 0 (0) Ethnicity Hispanic or Latino 0 (0) Not Hispanic or Latino 22 (81) Other 0 (0) Missing 5 (19) Caucasian 21 (78) African American 0 (0) Native American/Pacific Islander 1 (4) Other 0 (0) Missing 5 (19) Race Facility Location Location 1 6 (22.2) Location 2 6 (22.2) Location 3 3 (11.1) Location 4 3 (11.1) Location 5 2 (7.4) Location 6 2 (7.4) Location 7 2 (7.4) 31 Location 8 1 (3.7) Location 9 1 (3.7) Location 10 1 (3.7) 32 Table 3 Post-Intervention Staff Participant Demographics Demographic Variable Participants N=19 (%) Age (years) Mean ± SD 45.4 ± 13.6 Median (Min, Max) 41 (25, 71) Gender Male 8 (42%) Female 11 (58%) Other 0 (0%) Ethnicity Hispanic or Latino 1 (5%) Not Hispanic or Latino 18 (95%) Other 0 (0%) Caucasian 17 (89.5%) African American 0 (0%) Native American/Pacific Islander 0 (0%) Other 2 (10.5%) Race Professional Experience (years) Mean ± SD 16.2 ± 13.7 Median (Min, Max) 14 (0.9, 44) Professional Degree Social Worker 1 (5.25%) Licensed Practical Nurse 3 (15.8%) Registered Nurse 8 (42.1%) Certified Nurse Anesthetist 2 (10.5%) Anesthesiologist 1 (5.25%) Dentist 1 (5.25%) 33 Dental Anesthesiologist 2 (10.5%) Other 1 (5.25%) Education Level Vocational 2 (10.5%) Associate 5 (26.3%) Bachelor 5 (26.3%) Master 1 (5.2%) Doctoral 6 (31.6%) Years at current facility Mean ± SD 5.3 ± 7.1 Median (Min, Max) 2 (0.08, 30) 34 Table 4 Toolkit Use and Adoption Toolkit Component Utilization Number of Patients * Number Completed (%) Preoperative Assessment Form 28 26 (92.9%) Preoperative Handoff Communication Form 21 13 (61.9%) Medication Reconciliation 20 20 (100%) Anesthesia Record 20 20 (100%) Postoperative Handoff Communication 20 20 (100%) 20 20 (100%) Arrived with Patient Form Discharge Instructions * Depending on number of patients scheduled, how many cancelled, and how many procedures were completed. 35 Table 5 Surgical Center Nurse Participant Post-Intervention Interview Responses Pre-Intervention Nurse Themes Theme Subtheme Quotes Frequency (%) Feeling Difficulty “Driver said they had to finish their 5 (100%) Unprepared Verifying NPO breakfast.” Status “Had a case where we couldn’t verify NPO status… Found out halfway through the case that they ate breakfast.” “Had to cancel the case because the patient was not NPO.” “Problems with NPO time, patients eating.” “[I] tried. [About] NPO [status]. I was not successful.” Missing “No idea how much they weighed… Important can the person transfer?” Health “…Oxygen need, medications they Information were taking, bleeding. [They were] supposed to stop but didn’t.” “Patients on oxygen. No way to send home with oxygen.” “…Diabetic, didn’t do their blood sugar.” “From time to time. Don’t know everything.” 5 (100%) 36 “Oxygen needs afterwards…. it was hard to communicate and coordinate an oxygen tank.” Difficulty Difficult to “Usually, I don’t expect to get a hold Communicating Contact of anyone after.” with LTC “Not often, sometimes they never call Facilities back.” 5 (100%) “One in five [will] answer. It’s hard to communicate.” “…Getting a hold of a nurse is impossible.” “[LTC facilities are] still hard to get a hold of.” Time “Sometimes [I] have waited on hold Consuming for long periods of time to get in 2 (40%) contact with someone.” “It was a process. It took 15 minutes to get an answer.” Inadequate Discharge “Funny. [I] always handed them Documentation Instructions Not “your child.’” Relevant to the “Children’s instructions, [I] changed Population the whole thing. [I] crosses out child.” “Not relevant to adult patients.” “[I would] write out specific information for the patients.” “Not specific to the population.” 5 (100%) 37 Not Enough “It was complicated and confusing. Room to So much information to fit on one Document on little sheet.” Anesthesia “Not enough room to write vital signs Record down… Not as much room for the 3(60%) diagnoses…” “Not enough space, hard to document a good history.” Anesthesia “It was vague. [Only] putting Record is Time important information. [It] takes time Consuming to write it all out. 2 (40%) “[It took] five minutes to look at the diagnosis and medications. I felt rushed and [sure I] missed some stuff.” Post-Intervention Nurse Themes Theme Subtheme Quotes Frequency (%) Feeling More Better Quality “One hundred percent. [The] care 5 (100%) Prepared Care [given] before [the intervention]; [we were] doing our best, it could have been better, but scraping by. [It’s] vital to give the best care.” “Will help the patient’s quality of care. Keeps us on our toes.” “Yes, [I] feel [I’m] providing better care. If I can assess beforehand to know what to expect, then I can provide safer care." 38 “We can give better care if prepared.” “Yes. [We] know the patients and their issues, [and] how to prepare and give care ahead of time.” Knowing What “Good to know my patients, instead to Expect of flying blind and hoping for the 5 (100%) best.” “Better idea of what is coming.” “Just makes us more prepared.” “If I can assess beforehand to know what to expect…” “I know what patients are coming.” Increased General “Effective communication… Helped Communicatio Communication a lot when it comes.” n with LTC 5 (100%) “Good communication handoff.” Facilities “I wish I had the entire time. I have been hand writing on the DC instructions.” “I like it, [I] wish more facilities would fill it out before they come. [We are just] lucky to see the patient.” “Helps better communicate with patients too.” Verifying NPO “Effective communication. Filled out Status the same day, [know] what is going 3 (60%) 39 on. Helps facility know they are NPO.” “Helpful when they fill it out, more aware they were going to surgery instead of just going to the dentist. More aware of what they are going in for [and] NPO status.” “So easy to come on shift and know if the patient was NPO or not. As long as it was used; very helpful.” Relevant Population “More in-depth.” Documentation Specific “Information is great for adults.” 5 (100%) “Applies to the patient.” “Specific to older people…” “I like that it is more specific to the population.” Better Handoff “Specific for the last time Toradol Documentation was given.” “Communicates with the nurse afterwards. [It] documents what I did on my end. [A] way to communicate what was done.” “Good communication handoff.” “I wish I had the entire time. I have been hand writing on the DC instructions.” 4 (80%) 40 Toolkit Useability, Feasibility, and Satisfaction Tool Answer Quotes Frequency (%) “Overall, much better. Before had 5 (100%) Do you like them? Overall Yes nothing.” Anesthesia Yes “Yes, I prefer them. They are better.” 5 (100%) Yes “It’s easier to see all meds on one 3 (60%) Record Medication Reconciliation page instead of scanning through the meds on the list.” No “I would rather underline. [It’s] easier 1 (20%) to see typed ones.” Discharge Neutral “Yes and no.” 1 (20%) Yes “Way more than the other ones.” 5 (100%) Yes “Helped a lot when it comes.” 5 (100%) Yes “Yes, prefer this.” 5 (100%) “Yes, with more use, [will be] 5 (100%) Instructions Communicatio n Handoff Preoperative Assessment Are they easy to use? Overall Yes easier.” Anesthesia Yes “User friendly.” 5 (100%) Yes None 4 (80%) Neutral “Yes and no.” 1 (20%) Record Medication Reconciliation 41 Discharge Yes None 5 (100%) Yes None 5 (100%) Yes None 5 (100%) Learning Curve “Learning.” 1 (20%) Contacting the “Hardest part is facility 1 (20%) Facility communication, trying to get a hold Instructions Communicatio n Handoff Preoperative Assessment What are barriers to use? Overall of people.” Anesthesia Time “Time in the morning to do the first Record Consuming patient.” Learning Curve “Time. Getting used to it. [It’s a] 1 (20%) 2 (40%) learning curve.” Medication Time “Time to fill them out.” 2 (40%) Reconciliation Consuming Redundant “Feel [it is] redundant.” 1 (20%) Learning Curve “Still learning.” 1 (20%) Ease of Use “A little busy.” 1 (20%) Facility Use “Getting the facility to use them.” 2 (40%) Preoperative Contacting the “It was hard because we don’t have 2 (40%) Assessment Facility time to wait on the phone.” Learning Curve “Processes, more use.” Discharge Instructions Communicatio n Handoff 1 (20%) 42 Would you use in the future? Overall Yes None 5 (100%) Anesthesia Yes None 5 (100%) Yes None 3 (60%) Maybe “Depends. If the doctor wants them 2 (40%) Record Medication Reconciliation written out, [then] I would.” Discharge Yes None 5 (100%) Yes None 5 (100%) Yes “Yes, prefer this.” 5 (100%) Instructions Communicatio n Handoff Preoperative Assessment 43 Table 6 Surgical Center Anesthesia Post-Intervention Interview Responses Anesthesia Themes Theme or Subtheme or Question Answer Current Inadequate Quotes Frequency (%) “Limited. Varying degrees… Usually 3 (60%) Preoperative sent an email 1-2 days before.” Preparation “Poor, [they] generally try and send Processes the demographics, MAR, and problem list. [I] prepare from there. Limited. [I usually only receive it] 50% of the time.” “Last time [I] did not [receive any patient history beforehand].” Adequate “Usually do [receive patient histories 2 (40%) beforehand].” Thomas “Yes, [I usually receive a patient history] one day before.” Did you ever No “No, not quality of care. I adjust or feel you didn’t modify [the plan]. Sometimes it is less provide quality than ideal, [I will] slightly change care because of [the] routine.” information you “No. [I] wouldn’t do a case that is were missing? compromised.” “No. Dr. Maberger is a good communicator. Able to clear up any questions before hand.” 4 (80%) 44 “Not really. If I’m looking at the records, [if I have] questions, [I] usually get them through the nurse… Not really help[ed] me make any decisions on whether to do the care. If [I] entertain the thought, then not a case we should be doing at the surgical center.” Yes “Yes, diabetic care. [If] blood sugars 1 (20%) high or low… [If they use a] CPAP regularly, bring it with them. [For] diabetics, make sure they take their Lantus the night before.” Communication Successful “Yes, called directly.” with LTC Contact “Called facility, spoke with provider at Facilities 4 (80%) facility.” “… [I will] call and talk with the nurse, how bad is it? Call to clarify information…” “[I] contact the facility directly, after shift change, [and talk to the] nurse taking care of the patient… that night [before their procedure].” Difficult “[I] tried, but unable to get a hold of them… [I] would like to [contact the facility, but it’s] too difficult to get a hold of people. [I would] prefer to but [it’s] too difficult.” 2 (40%) 45 “Communicating with facilities, it’s hard. Hope to bridge that gap.” Internal “Internal communication with LTC Communication facilities, [it’s] not [a] routine dental Difficult [visit]… [Need to] train head 1 (20%) nurse…This is how we do things, on their briefings… [It’s the] pass of between nursing at the facility when we have problems. Friday staff to Sunday staff. Sunday staff don’t remember they are NPO.” How do you Assume NPO “If [I] can’t verify [NPO status], [I] verify NPO Orders Were will cancel the case.” status? Not Followed “[I] assume [the] patient is not NPO… 3 (60%) If [they have a] cognitive impairment, ask transport. If unsure, any doubt, call the facility.” “Had to call the center to establish timing. Did cancel a case based on NPO status. CNA had fed the patient that morning.” Assume NPO “[I] assume it was followed... [I] take Orders Were [the] transporters word for it.” Followed “I will assume NPO unless I hear 2 (40%) otherwise. Toolkit Satisfaction Tool Answer Quotes Frequency (%) Anesthesia With changes “[It needs] more space to write… 2 (40%) Record Clean up a little bit. [I] like the lines 46 for medications. Getting used to them.” “Yes, like more space. Can combine and move around. Like the meds on there.” Like it “Makes it so you can look at the 1 (20%) patient history easily… [I] like the extra space to write in medications.” Neutral “Pretty much the same.” 1 (20%) Difficult “History form [is] hard… Would 1 (20%) rather have it written down from each system.” Medication Like it Reconciliation “Yes.” 2 (40%) “Yes, prefer it.” Redundant “Redundant.” 2 (40%) “Redundant. Most get from the facility… No value added. But [should be] standardized across the board.” Neutral “It’s a lot of work for the nurses, but 1 (20%) nice.” Discharge Like it Instructions “Fantastic.” 2 (40%) “Yes, [I] like them.” Ability to write “Good to have some avenue to write Additional orders for care facilities.” Orders “Good when sending home on oxygen, 2 (40%) to write an order for it.” Communication Increased Handoff Communication “Yes, all good information.” 4 (80%) 47 “Good form, especially when [the patient is] not a good historian. Sheet is helpful.” “[It’s the] pass of between nursing at the facility when we have problems. Friday staff to Sunday staff. Sunday staff don’t remember they are NPO… [If they] fill out the form, [it’s a] memory tick. Wait. They are going in for a dental procedure?” “Yes, handoff.” Preoperative Like it “I like it.” Assessment “Great to know [this information]. Is it Form and necessary? Don’t need to know ahead Processes of time… [However,] less likely to cancel a case if you know this information.” “Took a whole team to get people here. It’s hard to cancel. It would be helpful to get this information a few days before hand.” “Yes, if you can get them on the phone. [I] like the questionnaire. This is huge.” “[A] nurse should review, not needed on every patient [to] pass onto me [if they are] healthy and nothing going on.” 5 (100%) 48 Table 7 Long-Term Care Participant Post-Intervention Interview Responses LTC Facility Themes and Satisfaction Theme or Subtheme or Quotes Frequency (%) Question Answer Preoperative Like it or like “Really thorough. I like it all. Helped 6 (75%) Handoff idea of it a lot with communication.” Communication “Helpful and good idea.” Form “I like it. Saves me time. Like the form. Has everything on it.” s “Yes, helpful.” “Like idea… We know what’s going on.” Forgot to Use “Forgot.” 1 (12.5%) Not involved in None 1 (12.5%) “New. I got caught up and forgot.” 3 (37.5%) processes Barriers to using Forgetting Preoperative “Forgot to fill out.” Communication “Remembering.” Handoff Learning curve “New. I got caught up and forgot.” 2 (25%) “Learning curve. I like it more than not enough.” Education on “Hard to get nurse to attach to facility side appointment packed. Education on 1 (12.5%) our side.” NPO Signs They Were “Yes.” Used “Used in one patient.” 3 (37.5%) 49 They Were Not “No.” Used or “Not used.” Unknown if Used 4 (50%) “Not on him. [Not sure] what happened [but was already] NPO.” The Signs “It helped.” Helped “Yes. Yes definitely… [It helped] 2 (25%) family members [know they were] NPO.” Requested “[We] will take them.” More Signs “Bring to me.” Postoperative They “Yes… Very helpful… [I] can see [it] Communication Remember and follow up with the resident.” Handoff Seeing it “Yes. Nurse takes picture, upload [to Returned and it EMR].” was helpful 2 (25%) 5 (62.5%) “Yes. Helpful.” “Yes. Need it.” “It was good. [Had postop instructions for] no straws. Nurse on floor [reviews]. [Then DON] review[s] next.” Don’t None 3 (37.5%) “Perfect to fax.” 7 (87.5%) Remember Seeing it Returned Was it helpful to Yes, It Was have a physical Helpful, or Will “Electronic upload helpful.” Be in the Future order form? 50 “Yes, good.” “Yes, [gives a] heads up.” Unable to None 1 (12.5%) “Helpful to combine. [Will] decrease 5 (62.5%) answer Would you like Yes to see the paperwork.” discharge “One [form] easier to keep a of hold paperwork and for transport.” handoff form “Alright to combine.” combined? “Combined.” “Sure, [a] combination.” Neutral “It doesn’t matter.” 1 (12.5%) Unable to None 1 (12.5%) “Call. Paper gets lost in the other 4 (50%) Answer Preoperative A Phone Call Assessment: forms.” Would You “Nurse call. [It will be] helpful.” Rather Have a “Call easier.” Phone Call or Fill Out “Call.” Yourself? Neutral “No preference. Okay to be called.” 2 (25%) “What works best for us.” Fill Out the “Paper better. Getting in touch [is] Form hard.” Themselves 2 (25%) 51 “Easier [with a] form. [Hard for a nurse to] stop to make a phone call.” Who Enters Nursing “DON enters. Put’s a copy in the NPO Orders in Leadership: chart.” the EMR at Your Director of “DON, [then] communicates with Facility? nurses.” Nursing (DON), Assistant Director of 6 (75%) “DON schedules appointments. Night shift enters.” Nursing “ADON. Lots of moving parts. [Put (ADON), Unit on my] personal calendar.” Manager “ADON.” “Unit Managers.” Floor Nurse “Any nurse is able to do that.” 1 (12.5%) Unable to None 1 (12.5%) “Yes. Definitely.” 7 (87.5%) Answer Want to see Yes continued use of “Yes. Continue either way.” processes and “Enjoy. Help on both ends.” forms. “Continue.” Unable to None 1 (12.5%) Preop “[It’s] a lot of work. [It takes me] 20- 1 (12.5%) Paperwork is 30 minutes [to fill it out].” Highland Answer Other Feedback Extensive 52 Table 8 Dentist Post-Intervention Interview Dentist Interview Themes and Satisfaction Question or Theme Answer or Quotes or Concepts Subtheme Do you like the new Yes processes? “Like anything that makes my job easier.” “Good with anything [to] improve process.” “I know the stuff is in now. [I] check [the EMR, and] NPO orders [are] already there.” Paperwork Overload Preoperative Other facility only has “…one piece of paper.” Paperwork “Why so much paperwork?” “In general, too much paperwork. Preop paperwork, most concern. Forms are ridiculous… Overwhelming… They have to track down [the] family member who usually signs consent.” Postoperative Expressed concern over too much Paperwork postoperative paperwork. Would like to see the discharge instructions and handoff form condensed. Personal Workload Time Consuming “It takes a lot of time going to facilities, [getting them] paperwork, follow up... Cheaper to pay a nurse.” Doing Most of the “Directly scheduling with the transporter, can’t Work Himself rely on someone else.” Doing all the work himself. It’s hard for him. Managing all himself. 53 “Doing it all night… Works so much. Confirming the time, transportation, paperwork… doing it all.” Dentist’s wife (and assistant) “[It] would be great to have someone full time scheduling and doing this.” 54 Table 9 Cost Analysis: Based on Chart Review Data PreIntervention Decrease Preventable by 20% Decrease Preventable by 40% Decrease Preventable by 60% Decrease Preventable by 80% Month/Year Month/Year Month/Year Month/Year Month/Year # Cases Done 9.5 / 114 9.9 / 119 10.4 / 125 10.9 / 131 11.3 / 136 # Cases Scheduled 14.25 / 171 14.25 / 171 14.25 / 171 14.25 / 171 14.25 / 171 # Cases Cancelled 4.75 / 57 4.3 / 52 3.8 / 46 3.4 / 40 2.9 / 35 # Preventable 2.3 / 28 1.8 / 22 1.4 / 17 0.9 / 11 0.5 / 6 # Decreased by 0 0.5 / 6 0.9 / 11 1.4 / 17 1.8 / 22 PreIntervention ($) Decrease Preventable by 20% ($) Decrease Preventable by 40% ($) Decrease Preventable by 60% ($) Decrease Preventable by 80% ($) Estimated Revenue ($630/pt) +5,985.00 +6,262.20 +6,564.60 +6,854.4 +7,144.20 Estimated Staff Cost ($233/month) -233.00 -186.40 -139.80 -93.2 -46.6 Cost of Intervention ($30/pt scheduled) 0 -427.50 -427.50 -427.50 -427.50 Estimate Total Revenue +5,752.00 +5,648.30 +5,997.30 +6,854.40 +7,144.20 Opportunity Loss ($630/pt cancelled) -2,992.50 -2702.70 -2412.90 -2123.10 -1833.30 Potential Revenue Increase 0 -103.70 (1.8%) +245.4 *(4.3%) +1,102.40 (19%) +1,392.20 (24.2%) Cases Costs *Reduction in preventable case cancellations by 40% covers the cost of the intervention. 55 Figure 1 Case Cancellation Causes: Chart Review 56 Figure 2 Case Cancellation Causes: Project Data 57 Appendix A Communication Processes Flowchart 58 Appendix B Preoperative Assessment 59 Pre-Opera( ve Nursing Assessment Name: __________________________________________ Birth Date: ___________________ Func#onal Assessment: Pa#ent Weight: ____________ If NO explain: Able to walk on their own? YES NO Requires the use of a wheelchair? YES NO Can they transfer to and from wheelchair without assistance? YES NO ***If UNABLE to transfer easily, will Are there diet restric6ons? YES NO YES NO YES NO YES NO Aspira6on risk? (ie: Do they easily cough and choke on thin liquids?) History of falls within the past 3 months? Any cogni6ve impairments or disabili6es? If YES, is it motorized? YES NO If NO explain level of assistance needed: need to be transported in a stretcher Explain: Explain: Explain: Explain: Notes: ________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Preop Nurse Signature: __________________________________ Date: ________________ January 2024 2 60 Appendix C Medication Reconciliation 61 Appendix D Patient History and Anesthesia Record 62 Appendix E Discharge Instructions and Orders 63 Appendix F Preoperative Orders and Communication Handoff 64 Appendix G Postoperative Communication Handoff 65 Appendix H NPO Sign 66 Appendix I Executive Summary Dental Surgical Center and a Quality Improvement Project Summary: Poor communication between the long-term care (LTC) facilities, the dentist, and the surgical center leads to case cancellations. A quality improvement project successfully increased communication by implementing a toolkit and establishing communication processes. Background: The dentist’s patient population primarily encompasses LTC residents with complex medical histories and needs. Previous processes lack proper preoperative assessment and communication with LTC facilities, often leading to case cancellation due to improper preoperative preparation. Case cancellations are costly for all parties, are mostly preventable, and lead to unnecessary use of resources and decreased patient access to needed dental care. Intervention: A retrospective chart review from January to December 2023 was performed on all one dentist’s cases, documenting case cancellation rates. Communication bottlenecks were identified between the surgical center, the dentist, and the LTC facilities. A literature review suggested using a nurse-led preoperative assessment, handoff communication tool, and developing relationships with LTC facilities to decrease case cancellation rates. For this project, a toolkit was designed and implemented between January 12 and February 9, 2024, to address communication bottlenecks. It included a preoperative nurse assessment form and processes, a preoperative order set, a preoperative nurse communication handoff tool, an updated anesthesia record, a medication reconciliation form, an updated discharge instruction form, and a postoperative nurse handoff communication form. Results: Of the 30 cases scheduled, ten were cancelled (33.3% compared to 33.3% pre-intervention), and 7 (70% compared to 49.1% pre-intervention) were preventable. Though there was no significant change in cancellation rates, the project was successful because of its impact on staff satisfaction. Overall, surgical center staff (nurses and anesthesia) were very satisfied with the new toolkit and processes. The toolkit was easy to use, and they would like to continue to use it and feel the processes are feasible. They felt the toolkit increased their communication processes with the LTC facility. LTC facilities were also satisfied with their use of the toolkit and processes. Though their adoption rate was 61.9%, compared to 100% with the surgical center staff, they agree it’s a learning curve and would like to improve their compliance because they felt it’s an integral part of increasing communication. Though the dentist didn’t use the toolkit directly, he was satisfied with the increased communication processes. Financial: According to the twelve-month chart review: Monthly Average cases done: 9.5 Average cases scheduled: 14.25 Average cases cancelled: 4.75 Average preventable: 2.3 Yearly 114 171 57 28 Estimated average monthly revenue with cancellations: $5,752.00 Estimated average monthly opportunity loss with cancellations: -$2992.50 Estimated average monthly cost of intervention: -$427.50 If decrease preventable case cancellations by: 40% (11 per year, 0.9 per month): intervention) 60% (17 per year, 1.4 per month): 80% (22 per year, 1.8 per month): 4.3% estimated profit increase per month (covers cost of 19% estimated profit increase per month 24.2% estimated profit increase per month Recommendations: These recommendations are ranked in matter of importance. Following this recommendation should decrease preventable case cancellations, increase opportunities for patients to receive dental care, and maximize profit: 1. Refine the toolkit and associated processes. 2. Maximize electronic medical record (EMR) to improve process flow. 3. Implement with all adult patients. 67 Appendix J Patient Preoperative and Day of Procedure Tracking 68 69 Appendix K Post-Intervention Semi-Structured Interview Outline Surgical Center Nurse: Tell me about your experience working with the dentist’s patients prior to this project? 1. Specific to communication with LTC facility, before and after procedure: 2. Did you ever need to call the facility to get information, was it successful: 3. How do you verify NPO status: 4. How do you asses the patient as a reliable historian: 5. How do you get the health history: 6. How do you verify medications: 7. How was charting pre and post procedure: 8. How were the discharge Instructions: 9. Anything you felt went well: 10. Anything you felt didn’t go well: 11. Did you ever feel you couldn’t provide the best care because you were missing information: 12. Any examples: 13. Tell me about your communication with anesthesia: 14. Do you feel it is adequate: 15. What concerns do you communicate to anesthesia preop and postop: 16. Any noteworthy examples of communication with anesthesia: 17. How do you feel you could improve communication with anesthesia: 18. Anything else: After working with the new forms and processes, what are your thoughts: For each of the following forms: Anesthesia/patient history form: Med rec form: DC instructions: Communication handoff: Preop assessment form: 1. 2. 3. 4. 5. 6. 7. Do you like them: Why or why not: Are they easy to use: What are the barriers to use: Would you use them in the future: Why or why not: Changes: Did you participate in any preop assessments: 1. What are your thoughts on preop assessments: 2. Was it easy to find the information: 3. What information was hard to find: 70 4. Did you ever have to call a facility to get information: 5. Was your attempt successful: 6. Do you feel the preop assessment was helpful: 7. What other information would you include on the form: 8. What would you take out: 9. What would you change about the preop assessment process: 10. Would you, as the nurse, like to know the preop assessment, med history, and medications before the day of procedure: 11. Would you, as the nurse, like to do the preop assessment for your own patients: 12. Do you feel it would change the way you provide care if you knew the preop information: 13. If so, how: 14. Any other thoughts on the preop assessment: Overall, what are your thoughts with these new processes: 1. Do you like the changes: 2. Why or why not: 3. Do you feel these changes are worthwhile: 4. Overall thoughts on usability: 5. Would you use these forms and processes in the future: 6. Do you feel these forms and processes change the quality of care you provide: 7. Explain: 8. Would you like to see these changes implemented to all LTC facilities: 9. Would you like to see these changes applied to ALL the dentist’s patients: 10. Any other thoughts, questions, concerns, changes: Anesthesia: Tell me about your experience working with the dentist’s patients prior to this project? 1. What are your preop processes: 2. Did you receive and review med lists and health history: 3. Did you ever need to clarify a patient history or medication: 4. If yes, what did you do: 5. Did you ever need to write preop orders for a patient depending upon their diagnosis or medications: 6. If yes, what was it and who did you contact: 7. How do you verify NPO status: 8. What do you do if you can’t verify NPO status: 9. Any examples: 10. What conditions or status would you cancel a case: 11. What information would you like to know preop, preferably before the day of: 12. Any examples: 13. Are there any medications you want patients to take preop: 14. Are there any medications you would like your patient to hold: 15. Did you ever feel you didn’t provide quality care because of information you were missing: 16. Any examples: 17. Have you ever needed to communicate with a LTC preop or postop: 71 18. Have you ever needed to write post op orders or additional instructions postop: 19. Do you feel your communication with nursing staff is effective: 20. Preop: 21. Postop: 22. Any examples: 23. Any communication concerns you have: 24. Any thoughts on how to improve communication processes: 25. Any other thoughts: After working with the new forms and processes, what are your thoughts: For each of the following forms: Anesthesia/patient history form: Med rec form: DC instructions: Communication handoff: Preop assessment form: 1. Do you like them: 2. Why or why not: What are your thoughts on the preop nurse assessment: 1. Do you think it’s a good idea: 2. Is the information on the form relevant: 3. Would you like to be emailed a copy of this preop with med lists: 4. Is there any other information you think would be helpful to know for anesthesia to provide safe care: 5. If a nurse were to communicate with you preop, what would be your preference on how: 6. If you were to write any orders prop, what would it be: 7. Ideally, how many days before a scheduled day would you like to see the preop history, meds, and any information: 8. Any other ideas, thoughts, or concerns on processes or forms: LTC Facility Staff Preoperative Handoff Communication Form: 1. Did you use it personally: a. If yes: i. Was it easy to use: ii. Any barriers to filling it out: iii. Would you use it in the future, why: iv. What would make it easier: v. Any suggestions: b. If no: i. Any feedback from staff: ii. Would you use it the future, why: iii. What would make it easier: iv. Any suggestions: 72 NPO Sign: 1. Do you remember seeing or using the NPO sign: 2. Was it helpful, would you use it in the future: Postoperative Communication Form: 1. Did you use or see it personally for any patients postop: a. If yes: i. Do you remember receiving it back filled out: ii. Was it helpful: iii. Why: iv. Would you like to see this in the future: v. Would you like to see the DC paperwork and Handoff communication form combined: vi. Any suggestions to make processes or paperwork easier: b. If no: i. Any feedback from staff: ii. Would you like to see this in the future: iii. Would you like to see DC paperwork and Handoff communication form combined: iv. Any suggestions to make processes or paperwork easier: Preoperative Orders: 1. Who enters orders into the computer at your facility, and/or processes: 2. Was it helpful to have a physical order form: 3. We started faxing these orders with the preop communication form. Was it helpful, or would that be helpful in the future: 4. Ideally how far in advance would you like the orders faxed or sent over to you: 5. What is the best fax number to send it to: Preoperative Assessment: 1. For the preoperative assessment, would you like your nurses to fill out the form and send it back to us or would you like us to call and ask the information: 2. Any thoughts or suggestions to help make handoff communication better: