Effective Perioperative Communication to Enhance Patient Care 1.1

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1 CONTINUING EDUCATION Effective Perioperative Communication to Enhance Patient Care J. HUDSON GARRETT, Jr, PhD, MSN, MPH, FNP-BC, CSRN, PLNC, VA-BC, IP-BC, CDONA, FACDONA Continuing Education Contact Hours indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #16526 Session: #0001 Fee: For current pricing, please go to: The contact hours for this article expire August 31, Pricing is subject to change. Purpose/Goal To provide the learner with knowledge specific to effective perioperative communication. Objectives 1. Explain how communication affects patient safety. 2. Identify the components of effective communication. 3. Discuss barriers and challenges to effective communication. 4. Identify ways in which leaders can help improve communication. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP Check with your state board of nursing for acceptance of this activity for relicensure. Conflict-of-Interest Disclosures As an employee of PDI, Inc, and as a recipient of an honorarium from the Competency and Credentialing Institute for publication of this article, Dr Garrett has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. ª AORN, Inc, AORN Journal j 111

2 Effective Perioperative Communication to Enhance Patient Care J. HUDSON GARRETT, Jr, PhD, MSN, MPH, FNP-BC, CSRN, PLNC, VA-BC, IP-BC, CDONA, FACDONA ABSTRACT Breakdowns in health care communication are a significant cause of sentinel events and associated patient morbidity and mortality. Effective communication is a necessary component of a patient safety program, which enables all members of the interdisciplinary health care team to effectively manage their individual roles and responsibilities in the perioperative setting; set expectations for safe, highreliability care; and measure and assess outcomes. To sustain a culture of safety, effective communication should be standardized, complete, clear, brief, and timely. Executive leadership and support helps remove institutional barriers and address challenges to support the engagement of patients in health care communication, which has been shown to improve outcomes, reduce costs, and improve the patient experience. AORN J 104 (August 2016) ª AORN, Inc, /j.aorn Key words: perioperative communication, TeamSTEPPS, Triple Aim, health care communications, interdisciplinary collaboration. Research indicates that the primary cause of medical errors and associated mortality and morbidity is communication breakdowns in health care settings. 1-3 Based on extensive research into the most effective communication methods, the Agency for Healthcare Research and Quality recommends using the TeamSTEPPS program to assess and improve communication. 4 Effective communication enhances patient safety and serves as the basis for effective teamwork. According to The Joint Commission, nearly 66% of all reported sentinel events from 1995 to 2005 occurred as a result of ineffective communication; in addition, between 2010 and 2013, ineffective communication ranked as one of the top three causes of reported sentinel events (eg, wrong site surgery, administration of incorrect medications, surgical fires). 2 Communication enables all members of the interdisciplinary team to effectively manage their roles and responsibilities, set expectations, and measure and assess outcomes. Improving the effectiveness of communication among caregivers is one of The Joint Commission National Patient Safety Goals for Hospitals. 5 A sustainable culture of open communication requires that communication be standardized, complete, clear, brief, and timely. 5 Executive leadership and support is necessary to remove institutional barriers and address challenges that might hinder both short-term and long-term progress toward building a transparent and communicative culture to enhance safety. Engaging and communicating with patients has been demonstrated to improve outcomes, reduce costs, and improve the patient s experience. 6 ª AORN, Inc, j AORN Journal

3 August 2016, Vol. 104, No. 2 Effective Perioperative Communication The Institute for Healthcare Improvement is a leader in identifying the principles of change management and collaboration across the continuum of care. 6 Perioperative leaders and nurses should be familiar with the core tenets of the Institute for Healthcare Improvement s Triple Aim project: improving the quality of care provided, reducing costs of care, and improving the patient s experience of care. 6 HEALTH CARE COMMUNICATION CHALLENGES The OR is a highly complex, fast-paced environment that involves professionals from multiple disciplines (eg, surgeons, nurses, anesthesia professionals, surgical technologists, pharmacy personnel, environmental services personnel, central sterile processing personnel). Most adverse events and their associated morbidity and mortality are not associated with competency-related issues, but rather breakdowns in communication during the course of health care delivery. 2 Each professional discipline has a unique culture that can present different communication challenges, such as low-reliability systems, difficult communication between disciplines, or poor patient hand overs between department personnel. These challenges can negatively affect the patient experience, impair patient safety, and result in adverse events. In addition, many ORs host students, residents, and fellows, who add to the existing hierarchal complexity of the perioperative setting by creating additional layers or stress. The presence of learners is common in academic medical centers that have a teaching culture and can result in procedure delays. Improving Communication Health care professionals can use communication practices and experiences from other industries such as the airline industry, which uses long-standing, sustainable systems of effective communication. These systems rely on what is known as a top down, bottom up approach to accountability and collaboration, which means that communication flows from management to frontline personnel and back. 7 Perioperative nursing leaders and other health care professionals are an integral component of a culture of safe communication and can drive accountability by modeling effective communication skills. Perioperative nursing leaders must demonstrate their ability to communicate and collaborate across all disciplines and departments to set an example for their staff members. In addition, nursing leaders must consider the audience targeted for change and use the most appropriate messaging vehicle, which could include social media, internal facility intranets, external resource web sites, and s and memos. Given generational differences in communications preferences, flexibility in delivery mechanisms is necessary to cater to each intended audience. 8 COLLABORATION TOOLS AND TECHNIQUES The OR is a dynamic, fluid environment requiring adaptability and cross-functional collaboration across departments and disciplines throughout the patient s continuum of care. Because of the wide variety of health care disciplines that practice in the OR, tools and techniques with a strong evidence base that demonstrate multidisciplinary effectiveness are necessary to ensure continuity of care, improve patient safety, and reduce medical errors. Effective communication also can encourage critical thinking and greater team engagement when used properly and consistently. 9,10 In addition, the experiences of other industries (eg, the aviation industry) can be directly applied to improving safe and clear communication in the OR. 10,11 Perioperative leaders can become certified in Lean Six Sigma 12 and other high-reliability concepts and techniques. Training is available from multiple providers, and these additional training opportunities can add to the existing toolboxes of perioperative leaders and enable them to approach complex issues from a process orientation standpoint. The following examples are common communication tools that can be easily applied to the perioperative environment. TeamSTEPPS The acronym TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety, an evidence-based curriculum and a comprehensive systemsbased approach to improving overall communication techniques across the continuum of care. 13,14 It is a model for building a sustainable and transparent culture of communication independent of professional disciplines that focuses on improving patient safety. The model consists of training for all health care professionals and uses various tools to facilitate effective communication. The purpose of the TeamSTEPPS techniques is to improve health care communication and teamwork, which in turn optimizes patient outcomes. Although many silos exist in health care, evidence-based approaches to improving communication such as TeamSTEPPS enable perioperative nurses to more effectively communicate across disciplines. Perioperative managers can benefit from AORN Journal j 113

4 Garrett August 2016, Vol. 104, No. 2 TeamSTEPPS Master Trainer certification, which is available from the Agency for Healthcare Research and Quality at no charge to health care facilities, 13,14 and personnel can send interprofessional teams to be trained as ambassadors for health care communication in their facilities. SBAR The acronym SBAR stands for Situation, Background, Assessment, and Recommendation. 11,13 The SBAR technique is an evidence-based tool to improve interdisciplinary communication, especially between the RN and other providers, because of the short duration of time that team members are typically interacting with each other. Following are the recommended steps that are part of the SBAR technique: Situation: The care providers should review and communicate the patient s current status, along with any recent changes. Background: The care providers should complete a comprehensive review of the patient s clinical background relevant to his or her current status. Assessment: The care providers should complete a formal patient assessment to gather facts and data to communicate issues and recommendations to the care team. Recommendation: The care providers should provide a wellarticulated, thoughtful patient care recommendation to the team based on all available information. Leaders can ensure patient care recommendations are clearly communicated by engaging staff members in developing policies, procedures, and, most importantly, training and implementation. The SBAR approach standardizes critical communications among team members and ensures that information is gathered and relayed in a consistent manner. 11,13 This approach is an extremely useful tool in standardizing communications between the nurse and other health care providers. It also encourages the sender and receiver to use critical thinking to communicate important facts about the patient and brainstorm proactively about potential solutions that can help ensure patient safety. 11,13 Hand Overs Hand overs are formal transfers of critical information between care providers at different stages of patient care (eg, when transferring a patient from the OR to the postanesthesia care unit). 14 Hand-over communication is necessary to allow the clinician receiving the patient to ask questions, clarify any unclear information, confirm the appropriate next steps in the patient s care plan, and anticipate any potential complications. Perioperative leaders must set the expectation that staff members perform these patient transitions consistently and accurately to maximize patient safety and minimize adverse events. Leaders must ensure that all staff members, regardless of discipline, are trained to use these patient transition techniques so that they use the same vocabulary and standardized approach to communicate about patients. Hand overs are designed to ensure that continuity of care is maintained regardless of the personnel involved. The handover process must be carefully structured to ensure that critical information necessary to provide safe patient care is not omitted or lost during the transition of care. A proper hand over includes a formal transfer in patient care responsibility and accountability, unambiguous information, verbal communication of all relevant information necessary to care for the patient, a verbal acknowledgment that the patient s care plan and current status is understood by the receiving clinician, and an opportunity to ask questions about the information provided. 14 Hand overs also demonstrate team member compliance with The Joint Commission s National Patient Safety Goals. 5 The following tool is an example of a hand-over tool that can be used to improve this process. I Pass the Baton The I Pass the Baton tool is used to formalize the hand-over procedure between the perioperative RN and other health care providers. 15 It consists of several key steps as follows. 14,15 Introduction: The caregiver introduces himself or herself to the patient and identifies his or her role and function. This helps avoid patient confusion about his or her caregivers and can help reduce patient anxiety. Patient: The caregiver confirms the patient s name, key identifiers according to facility protocol, age, sex, and location. Assessment: The care provider asks the patient to state his or her chief complaint and then assesses relevant vital signs, history, and health issues and obtains pertinent information about current and past diagnoses relevant to the procedure. Situation: The care provider continuously monitors the patient s condition to reduce the risk of adverse events and harm. 114 j AORN Journal

5 August 2016, Vol. 104, No. 2 Effective Perioperative Communication Safety concerns: The surgical team uses risk management strategies by reviewing the patient s medical record and identifying risks such as falls, medication reactions, or critical laboratory values that could affect the care outcomes. Background: The team assesses the patient for comorbidities and other past medical history that can positively or negatively affect the outcome of the procedure. Actions: The team uses clear communication to identify past interventions (eg, use of vasopressors to sustain blood pressure) and anticipated future needs, including possible developments that will require intervention and necessary actions. Timing: The perioperative nurse identifies the level of urgency and attention necessary to properly care for the patient, briefs all members of the care team about the plan of care, and remains alert for changes in the patient s condition. Ownership: The team identifies needed patient care (eg, vascular access, respiratory therapy, anesthesia monitoring) and who will be responsible for this care. All members of the perioperative team must be familiar with team member roles and responsibilities. Next steps: The perioperative nurse should communicate the suggested and appropriate next steps and review any anticipated changes in the patient s condition as well as needed contingency plans. The I Pass the Baton tool is a uniform way of communicating the current and future safety concerns related to a particular patient or issue during transfer of care. It also encourages accountability at the frontline levels of patient care. Briefing and Debriefing Briefings and debriefings are standard mechanisms to improve patient care by helping to ensure continuity of communication throughout the patient s perioperative experience. Briefings usually occur before surgical interventions and are a method to share the plan of care with the entire care team to ensure alignment of the team and prepare for possible negative outcomes. Team members roles and responsibilities, the clinical status of the patient, the current and future plan of care, and the potential issues that might adversely affect the operations of the team should all be discussed during briefings. 16 Debriefings most often occur after an event or at the conclusion of the perioperative RN s shift. Debriefings can improve communication and provide insight into the effectiveness of interdisciplinary collaboration. With the tremendous information flow in the delivery of patient care, these debriefings help to reduce error, improve patient outcomes, and ensure continuity of care. 16 Clarifying Questions When engaged in team communication before and during a procedure and during hand overs, team members may have questions or need clarification about information shared or actions being taken. The following techniques can help resolve these uncertainties. Two-challenge rule The two-challenge rule is a communication tool that is designed to encourage and empower all members of the care team to speak up as patient advocates without fear of retaliation. 17 For example, in the OR setting, if the perioperative RN verbally requests clarification about an issue from the surgeon and the request is not acknowledged, then the RN could use the twochallenge rule to escalate the concern in a nonconfrontational manner. When a perioperative nurse is unable to resolve a concern initially with another professional, the two-challenge rule can be used by engaging another colleague, typically a supervisor or nonbiased third party in the department, to amicably resolve the matter. This approach fosters a respectful but candid conversation between all members of the care team when the plan of care is unclear. It is the responsibility of the individual with the question to speak up at least twice (if the first request is not responded to) to seek clarification. If the request is still not validated, then the team member should escalate the matter to a supervisor or another appropriate person in the chain of command. 17 CUS words An additional technique referred to as CUS words (Concerned, Uncomfortable, and Safety issue) 18 allows team members the ability to advocate for patients and assert their position in a nonconfrontational manner (eg, using CUS words to speak up and question a colleague). Most facilities have an established verbal cue that alerts other team members to the clinician s concern. This minimizes risk for the patient and allows professionalism to be maintained regardless of the individual asking the questions. This technique focuses on the potential effects on patient safety and stops the procedure (also known as stopping the line) until the concern is successfully resolved. For the use of CUS words to be effective, the nurse must first state why he or she is concerned about the situation, then provide detail about the issue creating discomfort, and finally state the specific safety AORN Journal j 115

6 Garrett August 2016, Vol. 104, No. 2 aspects of the issue. For example, the scrub person could say, I am concerned that there may be a 4 4 sponge missing. I have counted twice and I cannot find it. I would like you to search the surgical field and the patient s abdomen to prevent a retained sponge. 18 Checklists Checklists have demonstrated value in other industries, such as the automotive, manufacturing, and aviation industries, in reducing errors and assisting with effective communication. Checklists can be used across disciplines in continuous process improvement. However, they must be used correctly to act as validation tools to ensure good clinical processes are consistently adhered to and the results are communicated to the entire care team to create quality improvement. 19 Checklists such as those produced by the World Health Organization, if used consistently and correctly, can dramatically improve patient outcomes, improve operational efficiency, and reduce adverse events and medical errors. 20 All of these tools can help surgical team members effectively communicate and collaborate. Leaders who use these evidence-based tools to solve problems and remove interprofessional barriers set an example for the entire team to be open and transparent with each other. Each leader and his or her team members must decide which tool will work best in a given situation. It is through understanding of these processes that shared communication among all team members is fostered. CONCLUSION As the perioperative environment continues to evolve, perioperative leaders and team members must strive to maintain patient safety, improve outcomes, and reduce associated costs of care using communication and collaboration skills. Nurse leaders play an instrumental role in maintaining the culture of open communication between all members of the entire perioperative team, from managers and directors to frontline staff members. Editor s note: TeamSTEPPS is a registered trademark of the Agency for Healthcare Quality and Research, Rockville, MD. References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; Sentinel event data summary. The Joint Commission. Accessed June 14, Communication during handoffs: root cause of error. Medscape. Accessed April 27, TeamSTEPPS Fundamentals Course: Module 3. Communication. Agency for Healthcare Research and Quality. professionals/education/curriculum-tools/teamstepps/instructor/ fundamentals/module3/igcommunication.html. Accessed April 27, National patient safety goals effective January 1, 2016: hospital accreditation program. The Joint Commission. Accessed April 27, IHI Triple Aim Initiative. Institute for Healthcare Improvement. Accessed April 27, Anderson N. Top-down or bottom-up approaches to successful change. pproaches-to-successful-change.accessedapril27, Sherman RO. Leading a multigenerational nursing workforce: issues, challenges and strategies. Online J Issues Nurs. 2006; 11(2):3. 9. TeamSTEPPS core curriculumdimportance of communication. Agency for Healthcare Research and Quality. professionals/education/curriculum-tools/teamstepps/instructor/ fundamentals/module3/igcommunication.html. Accessed April 27, Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5): Kao LS, Thomas EJ. Navigating towards improved surgical safety using aviation-based strategies. J Surg Res. 2008;145(2): Lean healthcare. The Lean Six Sigma Institute. sigmainstitute.org/#!healthcare/csnq. Accessed May 4, TeamSTEPPS core curriculumdsbar. Agency for Healthcare Research and Quality. curriculum-tools/teamstepps/instructor/fundamentals/module3/ igcommunication.html. Accessed April 27, TeamSTEPPS core curriculumdhandoffs. Agency for Healthcare Research and Quality. curriculum-tools/teamstepps/instructor/fundamentals/module3/ igcommunication.html. AccessedApril27, TeamSTEPPS core curriculumdi Pass the Baton. Agency for Healthcare Research and Quality. education/curriculum-tools/teamstepps/instructor/fundamentals/ module3/igcommunication.html. Accessed April 27, TeamSTEPPS core curriculumdbrief. Agency for Healthcare Research and Quality. curriculum-tools/teamstepps/instructor/fundamentals/module3/ igcommunication.html. AccessedApril27, j AORN Journal

7 August 2016, Vol. 104, No. 2 Effective Perioperative Communication 17. TeamSTEPPS core curriculumdtwo challenge rule. Agency for Healthcare Research and Quality. professionals/education/curriculum-tools/teamstepps/instructor/ fundamentals/module3/igcommunication.html. Accessed April 27, TeamSTEPPS core curriculumdcus words. Agency for Healthcare Research and Quality. curriculum-tools/teamstepps/instructor/fundamentals/module3/ igcommunication.html. AccessedApril27, Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1): Safe surgery: why safe surgery is important. World Health Organization. Accessed April 27, Resources TeamSTEPPS research evidence base: surgical care and OR. Agency for Healthcare Research and Quality. TeamSTEPPS Master Training Course. Agency for Healthcare Research and Quality. -course. J. Hudson Garrett, Jr, PhD, MSN, MPH, FNP-BC, CSRN, PLNC, VA-BC, IP-BC, CDONA, FACDONA, is the vice president, Clinical Affairs, for PDI, Inc, Atlanta, GA. As an employee of PDI, Inc, and as a recipient of an honorarium from the Competency and Credentialing Institute for publication of this article, Dr Garrett has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. This CE meets eligibility requirements to recertify the Certified Surgical Services Manager (CSSMÒ) credential, and eligibility requirements to apply for the CSSMÒ exam. Learn more at cc-institute.org/cssm. AORN Journal j 117

8 EXAMINATION Continuing Education: Effective Perioperative Communication to Enhance Patient Care PURPOSE/GOAL To provide the learner with knowledge specific to effective perioperative communication. OBJECTIVES 1. Explain how communication affects patient safety. 2. Identify the components of effective communication. 3. Discuss barriers and challenges to effective communication. 4. Identify ways in which leaders can help improve communication. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at QUESTIONS 1. Research indicates that breakdowns in communication in health care settings are the primary cause of medical errors and associated mortality and morbidity. a. true b. false 2. One of the top three causes of reported sentinel events is a. understaffing. b. medication use. c. ineffective communication. d. information management. 3. A culture of open communication requires that communication be 1. standardized. 2. complete. 3. clear. 4. brief. 5. timely. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5 4. To remove institutional barriers and address challenges related to effective communication, is necessary. 1. executive leadership 2. executive promotion 3. executive support 4. executive funding a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 5. Some of the challenges of effective communication in the OR include 1. unwillingness to use communication techniques. 2. multiple professional disciplines. 3. low-reliability systems. 4. difficult communication between disciplines. 5. the highly complex and fast-paced environment. 6. poor patient hand overs between department personnel. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 6. Many ORs host students, residents, and fellows, who a. decrease the existing hierarchal complexity. b. add to the existing hierarchal complexity. c. cannot participate in the hierarchal complexity. d. are not relevant to the hierarchal complexity. 118 j AORN Journal

9 August 2016, Vol. 104, No. 2 Effective Perioperative Communication 7. Perioperative nursing leaders must demonstrate their ability to 1. communicate. 2. collaborate. 3. set an example. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 8. Nursing leaders do not need to consider the audience targeted for change when implementing changes. a. true b. false 9. Leaders can ensure that patient care recommendations are clearly communicated by engaging staff members in 1. developing policies and procedures. 2. training. 3. funding. 4. implementation. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and Leaders must ensure that all staff members, regardless of discipline, are trained to use patient transition techniques that include 1. hierarchical approaches. 2. using the same vocabulary. 3. using nursing vocabularies. 4. using a standardized approach. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 AORN Journal j 119

10 LEARNER EVALUATION Continuing Education: Effective Perioperative Communication to Enhance Patient Care This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Explain how communication affects patient safety. 2. Identify the components of effective communication. 3. Discuss barriers and challenges to effective communication. 4. Identify ways in which leaders can help improve communication. CONTENT 5. To what extent did this article increase your knowledge of the subject matter? 6. To what extent were your individual objectives met? 7. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 8. Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.) 8A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 8B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 9. Our accrediting body requires that we verify the time you needed to complete the 1.1 continuing education contact hour (66-minute) program: 120 j AORN Journal