Can We Talk?
By Betty VanWoert
What skills make a good clinician? To answer, many of us begin by listing technical skills like “They always start IVs on the first try,” organizational skills like “Their appointments always run on time” or indications of satisfaction, “Residents and families always have the best things to say about them.” The last time you considered your clinical skills or those of your colleagues, did communication skills come to mind? Rarely do we think of communication skills when asked to describe clinical skills, yet failure to communicate critical information in a timely manner or to speak up about a concerning observation can lead to devastating outcomes.
Care team communication gaps: What’s in the data?
Communication failure has long been identified by the Joint Commission as a leading root cause of sentinel events—unexpected occurrences involving death or serious injury. A Constellation analysis of 2,413 medical professional liability claims found that communication failure is a contributing factor in 35 percent of claims asserted from 2012 to 2016. CRICO Strategies’ Comparative Benchmarking System (CBS) found similar results in analyzing 23,658 medical malpractice case experiences from across the United States: Communication was a factor in 30 percent of these cases.1
According to CRICO Strategies data, failed healthcare team communication occurred in 57 percent of the above-mentioned cases and accounted for 73 percent of the cases that incurred losses. The most frequent breakdowns occurred with healthcare team miscommunication in the following areas:
Miscommunication of the patient’s condition—26 percent of cases,
Poor documentation—12 percent of cases,
Failure to read the medical record—7 percent of cases.1
Because communication within care teams is more often a contributing rather than a causative factor in malpractice claims, it can be overlooked when first seeing an unexpected patient outcome or completing a root cause analysis. Don’t be fooled! Claims with care team communication missteps resulted in indemnity payments 49 percent of the time—14 percent more than when communication with the patient breaks down.1
Care team communication gaps cause harm that can also result in reputational damage to clinicians and organizations. Patients, residents and families who feel wounded are not only inclined to make a claim, but also to share their experience across social media.
Complexity lends itself to poor communication
It may not look like it to those of us practicing inside the system, but healthcare is complex. Individuals and teams tend to overlook this complexity when processes become routine, or familiarity with co-workers leads to assuming I know what the other person thinks or wants. Patient care situations that once seemed exceptional are now standard:
Multiple care team members within the same organization now provide care to the same patient or resident,
Many patients and residents receive care at satellite locations or increasingly via telemedicine, and
Referrals are made to multiple practitioners, labs, diagnostic centers or specialty facilities.
Making assumptions is a human reaction to working in a complex environment. But allowing casual, presumptive communication to become the norm across multiple team members can lead to the cracks that patients—and their safety—fall through.
The EHR as a means of communication
A great deal of team communication about patients and residents happens through clinical records within the electronic health record (EHR). While the patient or resident is present at their every experience, it would be impossible for any single clinician to be present at each patient encounter. So the EHR provides not only invaluable real-time documentation of events, but the means of communication for care teams throughout and across organizations.
Many communication processes are now integrated into the EHR, adding even more complexity. Remote access to clinical records further makes timeliness of entries even more critical so as to avoid miscommunication. In addition, the complexity of documenting follow-up for consultations, referrals and patient-related messaging between clinicians can be high-risk processes for team members, who may assume that the other party will be responsible to communicate with the patient. Patients, for their part, also assume they’ll hear from someone and get confused when they don’t hear from anyone.
Assessment tools, such as the SAFER Guides for EHRs found in the resources section below, can help organizations easily review their practices and find ways to improve with this aspect of team communication.
How patients view communication
Much of the time, a clinician’s perspective can be centered around their unit, department or organizational teamwork culture. healthcare is a team sport, and like any sports team, members play both leadership and supporting roles and watch each other’s back.
But patients and residents think in broader terms of their healthcare community. This can include transitions of care across outpatient services, hospitalization, and their home, which could be a senior living facility. Effective communication becomes more daunting when it occurs between healthcare facilities. Involvement of more than one physician or healthcare facility caring for a patient or resident multiplies the opportunities for communication breakdowns.
Teamwork and satisfaction play a role
What part does team satisfaction play in a discussion about communication? It turns out that communication and teamwork influences the quality of working relationships and job satisfaction, and it can profoundly impact patient safety.2 When a team has good communication around tasks and responsibilities, evidence has shown significant reduction in nurse turnover3 and improved job satisfaction due to a culture of mutual support4. Job satisfaction can have a positive effect on patient-centered communication. In one study, Larson and Yao found a direct relationship between clinicians’ level of satisfaction and their ability to build rapport and express care and warmth with patients5.
Organizations can support clinician satisfaction by creating a work environment to include elements contributing to care team satisfaction, such as feeling supported administratively and inter-personally; feeling respected, valued, understood and listened to; and sharing a clear mental model of the team’s mission and objectives.
Next steps: Communication systems and policies
Communication awareness, tools and processes can enhance collaboration, strengthen transitions of care, and improve inefficient workflows within organizations and across communities. Improving communication is an often-untapped opportunity to increase clinician effectiveness as well as patient safety.
The primary risk management objectives for any organization are:
Effective communication systems among the entire care team to identify and resolve problems that may compromise patient care and result in injuries,
Effective policies, procedures and protocols that are consistently followed by administration, clinicians and other staff.
To meet these objectives, periodic review of current communication systems and processes can help ensure identification and promote resolution of potential problems.
Enhancing your communication culture, tools and processes
These questions will help you assess your organization’s current baseline of communication fitness. See Resources for more ways to get started.
Do you operate under informal practices that have evolved over time? Risk of patient injury increases when team members operate under differing practices or understandings. Convert informal practices into formal written policies and procedures.
Do you ensure that every care team member is empowered to speak up and bring issues to the forefront for resolution? Be a learning culture where everyone learns from patient concerns and incidents where communication gaps play a role.
Do you proactively set follow-up and communication expectations with clinicians on both sides of referrals and consults? Once care has been initiated, clinicians on each side should include in their documentation who has responsibility for follow-up care and communication with the patient.
Do you educate or mentor clinicians and care team members on communication skills? Initial education is the first step. Then, sustain positive communication skills by formally recognizing proficient communicators and have them mentor new team members.
Do you meet across traditional silos with community health providers to identify and repair communication issues? TeamSTEPPS® can be valuable, as it offers customizable best practices in teamwork tools and processes. It’s easy to use, publicly available, and has been researched and field-tested by high reliability organizations for over 35 years.
Betty VanWoert, RN, BSN, CCM, CPHRM, is a Senior Risk and Patient Safety Consultant, MMIC
References
CRICO Strategies. Malpractice risks in communication failures: 2015 CRICO Strategies National CBS Report. bit.ly/2rhkaaP Accessed December 5, 2017.
AHRQ. About TeamSTEPPS.® www.ahrq.gov/teamstepps/index.html Accessed December 11, 2017.
Lein C, Wills CE. Using patient-centered interviewing skills to manage complex patient encounters in primary care. J Am Acad Nurse Prac. 2007;19(5):215-20.
DiMeglio K, Padula, C, Piatek C, et al. Group cohesion and nurse satisfaction; examination of a team-building approach. J Nurs Adm. 2005;35(3):110-20.
Larson, EB, Yao, X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005;293(9):1100-6.
Resources
AHA: AHA Team Training Featuring TeamSTEPPS® bit.ly/2AX2n1c
AHRQ: About TeamSTEPPS® bit.ly/2nAx32X
HealthIT.gov: Safer EHRs: An Introduction to the SAFER Guides www.healthit.gov/safer
Institute for Healthcare Improvement: How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations bit.ly/2BLmGw4
This article is reprinted by permission from the Spring/Summer 2018 issue of Brink magazine, published by Constellation.