The chronic problem of communication: Why it's a patient safety issue, and how hospitals can address it

Effective communication at hospitals and health systems contributes to the development and sustainability of a culture of safety. Yet, miscommunication remains a consistent and pervasive problem.

A CRICO Strategies study indicated communication failures were linked to 1,744 patient deaths in five years and $1.7 billion in malpractice costs. Additionally, the CDC estimates that on any given day, 1 in 25 patients have an infection that they picked up in the hospital.

Further, a study from the University of California, San Francisco, found more than a quarter of hospital readmissions could be avoided with better communication among healthcare teams and between providers and patients.


Why is communication a problem?

Healthcare professionals, for the most part, know how to be effective communicators, collaborative leaders and team players. So why does communication remain a persistent problem?

According to Beth Boynton, RN, an organizational development consultant and author of Successful Nurse Communication: Safe Care, Healthy Workplaces & Rewarding Careers, and Martie Moore, RN, former CNO of Portland, Oregon-based Providence St. Vincent Medical Center and current CNO of Medline Industries, there are multiple reasons.

The main reason, says Ms. Boynton, is because communicaiton effects every aspect of healthcare. "Our teamwork, leadership, and workplace cultures are all impacted and communication failures can be linked to all of our big problems, like sentinel events, workforce harm, poor patient experience or wasted resources," she says. "We tend to see these problems as separate issues, but they have common underlying dynamics involving our interactions."

Second, it is much more complex than people realize. Communication is really about behavior, which is notoriously difficult to change. In the workplace this includes individual behavior and organizational behavior. And various factors can be added to this mix, such as educational differences, skill level, ethnicity, language, personality and past experiences, both personal and professional. For instance, an individual who grew up learning that throwing a tantrum, pouting and withholding information was a way of effective communication may bring aspects of those behaviors into the workplace, Ms. Moore explains.

Third, helping people master communication skills requires a different approach than traditional clinical training models where healthcare professionals learn from lectures, research or memorizing scientific information. An intellectual approach, such as a video on "how to listen" or a poster that shows the guidelines for giving and receiving constructive feedback, will not effectively get at the underlying human growth that must occur to practice the skills, according to Ms. Boynton.

"We don't see communication as a serious enough problem, and so we find we don't have time in schools to have courses on communication. We don't have time in our workdays to manage conflict. Those things do take time and we have to make it a priority to do it right," she adds.

The chaotic hospital environment also makes effective communication difficult, which is why it is important to be cognizant, clear and concise about what pieces of vital patient information can be compartmentalized, and what pieces should be prioritized, Ms. Moore says.

Doing that, though, takes certain skills and that takes organizational direction to help people understand the need, Ms. Moore says. It also takes energy, and it takes energy of the individual practitioners to be aware.

Medical improv

That's where training, such as medical improv, comes in. Medical improv, taught by Ms. Boynton, is a specific form of applied theater improvisation that uses experiential learning activities to teach healthcare professionals communication and interpersonal skills.

There are a few principles and many activities that promote emotional intelligence, communication, teamwork and leadership. Activities can easily be framed around important organizational initiatives like creating a culture of safety, promoting employee engagement, developing communication skills or improving patient experience.

Ms. Boynton develops workshops based on specific organizational initiatives and group composition. A group of nurses might benefit from a focus on assertiveness whereas a group of physicians may learn more from listening activities. A mixed group could focus on both with experiences lending to collaborative work. There are many activities that can be adopted for various groups.

For instance, one activity involves synchronized storytelling, where two people try to tell the same story at the same time.

"In pairs, one person tells a story while the other watches the person and tries to tell it at the same time. So if I say, 'Once upon a time,' the idea is that my partner is going to say that at the same time that I am. It's a little slow at first, and what happens is the person following the storyteller becomes intently focused on that person. It is one of the most effective ways to teach listening that I know of," Ms. Boynton says.

Medical improv and other training resources can help provide healthcare professionals with the proper tools and skills to improve communication, but it is up to healthcare workers to practice these skills when talking to colleagues, all in the name of patient safety.

Ms. Moore recalls a pediatric trauma case in which the patient's initial exam showed no underlying complications, but members of the care team felt there was an issue. The team communicated that to the surgeon, who stated he disagreed, but the team persisted. The child was taken for a CT scan and clinicians found a subdural hematoma, which resulted in immediate surgery.

This case could have had a very different outcome if the team had not communicated their concerns, Ms. Moore says. The hospital had worked hard to create an atmosphere of mutual respect through communication skill building. This allowed the care team to not defer to perceived status and power of the surgeon.    

Prioritizing the patient

To improve communication, hospitals and health systems must also make it clear the patient is the first priority, according to Ms. Moore. There are certain high-risk tasks that require very clear and concise communication. Hospital staff need to define what high- risk procedures are and what type of communication should be occurring when actions are taken, she says.

Hospitals and health systems "should have visual cuing or nonverbal communication that says, 'In this area of concentration, safety is first, do not interrupt,'" she says. "It's really having the passion about patient safety that you're really infusing communication standards around it. Not only is it teaching people how to have really hard, tough conversations, but skill sets such as active listening and seeking out information also helps people to respect what is high-risk."

Additionally, hospital leaders must be committed to developing strategies and continuously train staff to help them perform at their highest level.


More articles on patient safety:
Mallinckrodt Pharmaceuticals shows support for Patient Safety Awareness Week
Patient Safety Awareness Week highlights how timeliness plays a part in the era of value-based care delivery
5 things healthcare organizations can do to improve patient safety today


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