Promoting effective communication among healthcare professionals to improve patient safety and quality of care

Transcription

1 Promoting effective communication among healthcare professionals to improve patient safety and quality of care This guide was prepared as part of the Victorian Quality Council s project on improving communication among healthcare professionals. July 2010

2 Published by the Hospital and Health Service Performance Division, Victorian Government Department of Health, Melbourne, Victoria. July 2010 This booklet is available in pdf format and may be downloaded from the VQC website at council Copyright State of Victoria, Department of Health, 2010 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 Authorised by the Victorian Government, 50 Lonsdale St., Melbourne Victorian Quality Council Secretariat Phone

3 Introduction Ineffective communication is reported as a significant contributing factor in medical errors and inadvertent patient harm. In addition to causing physical and emotional harm to patients and their families, adverse events are also financially costly. In Victoria, the direct cost of medical errors in public hospitals is estimated at half a billion dollars annually [1]. Today, healthcare is evermore complex and diverse, and improving communication among healthcare professionals is likely to support the safe delivery of patient care. The objectives of this guide are to raise awareness and stimulate discussion and action around what your healthcare organisation, division or unit can do to improve communication and teamwork. The guide highlights the critical importance of, and common barriers to, effective communication in healthcare organisations and institutions, and points to some strategies and tools available to promote effective communication among healthcare professionals. While this guide has focussed largely on the acute care setting, the importance of effective communication among health professionals applies everywhere healthcare is delivered. The importance of effective communication in healthcare the evidence Ineffective communication is the most frequently cited category of root causes of sentinel events. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety [2]. Much of the evidence connecting poor communication between health professionals with adverse patient outcomes has largely come from retrospective analysis of sentinel events and root cause analysis. For example, The Joint Commission in America has reported that the primary root cause of over 70 per cent of sentinel events was communication failure [3]. The Department of Veterans Affairs (VA) National Center for Patient Safety in America has identified communication failure in healthcare as the primary root cause of 75 per cent of more than 7,000 root cause analyses of adverse events and close calls [4, 5]. The consequences of poor communication in healthcare settings have also been documented in Victoria and other Australian states. Twenty per cent of sentinel events in the Victorian public health system in were identified as communication issues occurring between staff, staff and patient/family, and/or translation/ non-english speaking background issues. Communication is ranked as the second most common factor contributing to these events [6]. In Queensland, 20 per cent of sentinel events in were due to communication failures [7]. In New South Wales (NSW), the Special Commission of Inquiry identified inadequate communication or documentation, including miscommunication between doctors and nurses and inadequate clinical handover, as a major risk to patient safety in NSW public hospitals [8]. 3

4 The Victorian Audit of Surgical Mortality s (VASM) Case Note Review booklet (First Edition, November 2009) has identified the risk to patient safety when nursing and junior medical staff note clinical deterioration but do not escalate the level of care to senior staff in an appropriate and timely manner [9]. Supporting evidence from high quality intervention studies 1, linking ineffective communication between health professionals and adverse patient consequences [10] is largely lacking, as are studies demonstrating that effective communication leads to improved patient outcomes (Level III-3) [11]. There are numerous intervention studies indicating that the use of structured communication tools or other strategies in health care improves the structure and quality of information exchanged between healthcare professionals, and/or reduces patient harm. Generally, these studies are based on lower levels of evidence. For example, The World Health Organization Surgical Safety Checklist leads to reduced rates of inpatient complications and death (Level III-3) [12]. The use of structured communication tools and briefings in the transfer of patients between health facilities results in improved access to necessary medications on arrival at the receiving health facility (Level IV) [3]. The introduction of perioperative safety briefing before and after surgery resulted in zero wrong site surgeries (compared to three at baseline) and increased reporting of near misses by staff (Level IV) [13]. Implementation of SBAR, a structured communication tool improves the clarity and content of interprofessional communication (Level III-1) [14], (Level IV) [15]. The introduction of multidisciplinary rounds resulted in a decreased patient length of stay (Level IV) [16]. The implementation of team training programs such as TeamSTEPPS leads to reduced rates of seclusion in mental health facilities (Level III-3) [17], and improves performance in the operating room (Level III-2) [18]. While varying in the strength of evidence, the trend suggests that ineffective communication between healthcare professionals is an important risk factor for adverse patient events, and that attempts to improve communication, through the use of structured tools and strategies is likely to optimise patient outcomes. What are the elements of effective communication? In healthcare, effective communication involves arriving at a shared understanding of a situation and in some instances a shared course of action. This requires a wide range of generic communication skills, from negotiation and listening, to goal setting and assertiveness, and being able to apply these generic skills in a variety of contexts and situations [19]. Effective communication also requires individuals and teams having access to adequate and timely information necessary to perform their role effectively and appropriately. The use of technical terms and jargon, acronyms and abbreviations and diagrams to communicate can influence how well information is shared and therefore the effectiveness of communication. As in business, adhering to the five standards of effective communication [19] in healthcare is 1 The rating system referred to is based on the recommendations for intervention studies by the National Health and Medical Research Council (NHMRC). The rating system is described in the table and can be found in Appendix 1. 4

5 likely to facilitate improvements in the exchange of information between healthcare professionals, and information should be: Complete Concise Concrete Clear Accurate It answers all questions asked to a level that is satisfactory to those involved in the exchange of information. Wordy expressions are shortened or omitted. It includes only relevant statements and avoids unnecessary repetition. The words used mean what they say; they are specific and considered. Accurate facts and figures are given. Short, familiar, conversational words are used to construct effective and understandable messages. The level of language is apt for the occasion; ambiguous jargon is avoided, as are discriminatory or patronising expressions. The Joint Commission reports that investing to improve communication within the healthcare setting can lead to: Improved safety. Improved quality of care and patient outcomes. Decreased length of patient stay. Improved patient and family satisfaction. Enhanced staff morale and job satisfaction [20]. What factors contribute to communication failures in healthcare? Breakdowns in communication in healthcare are reported to occur due to: Human factors; attitudes, behaviours, morale, memory failures, stress and fatigue of staff. Distractions and interruptions. Shift changes. Gender, social and cultural differences. Hierarchy or power distance relationships (for example, junior staff are reluctant to report or question senior staff). Difference in training of doctors, nurses and paraprofessionals. Time pressures and workload. Limited ability to multitask even when highly skilled. Lack of a shared mental model regarding what is to be achieved. Lack of organisation policies and / or protocols. Organisational culture that discourages open communication. Lack of defined roles and responsibilities among members of multidisciplinary teams [3, 21]. 5

6 A targeted approach for improved communication in healthcare Communication and other teamwork skills are essential to providing quality healthcare and preventing medical errors and harm to patients [22] Many factors have been reported as influencing effective communication in healthcare. These include individual abilities and characteristics, team behaviours and systemic factors and the lack of organisational support of a culture of safety [3, 23]. In addition, it has been suggested that improving communication requires a detailed understanding of the setting and context in which patient care is delivered and a commitment on behalf of a healthcare organisation to a culture of safety and quality improvement, such as supporting team-based delivery of care [21, 24]. Sustainable improvements towards effective communication in healthcare settings involve synchronising efforts across the three levels that is, the individual, the team and the organisation. 1. The individual a. Human factors, such as communication skills, fatigue and stress levels of staff, personality and attitudes, memory failures, and distractions and interruptions have been reported to influence the effectiveness of communication [3, 25]. b. Individuals can develop many useful skills, including assertiveness, active listening and negotiation as a means of improving communication in healthcare. Assertiveness from time to time, a healthcare worker may feel it necessary to challenge a particular decision regarding patient care; however this may be difficult due to hierarchical power relationships between senior and junior doctors for example. Learning to be assertive, without being inattentive or aggressive is considered a positive move towards improved patient safety [26]. Active listening this involves healthcare staff having the skills to listen, to stay focussed on others messages, and resist distractions. It also means keeping an open mind to others ideas even if they disagree. You can tell if the healthcare professional you are talking to is a good listener from their eye contact, posture and facial expression [27]. Negotiating this involves individuals developing self-awareness around differences in communication styles and skills to confer with health professionals from other disciplines, value others perspectives and opinions and manage conflict if the situation arises [22]. 2. The team a. Multiple players are often involved in the management and delivery of patient care [25, 28]. While there is often an underlying assumption that healthcare professionals are inherently good communicators, the lack of formal training and assessment in this area would suggest otherwise [3]. With different technical expertise and communication styles among members of multidisciplinary teams, communicating effectively is considered important if teams are to function optimally and ensure patient safety and quality of care. Members will have 6

7 advanced technical training and are likely to have different communication styles and this can compromise the effectiveness of communication. Skills development and training may be necessary to improve communication among teams. b. It has been reported that improved teamwork results in enhanced effectiveness, fewer and shorter patient delays, improved staff morale and job satisfaction, increased efficiency, and reduced levels of stress among staff [21, 29]. c. The provision of feedback among teams assists in continuous improvement. Feedback is information provided for the purpose of improving team performance and should be focused on behaviours not personal attributes, and should be constructive and timely [27]. 3. The organisation a. It has been reported that organisational culture plays an important role in facilitating and supporting effective communication across the organisation. For example, open channels for communication, transparency and trust, assertiveness and strong leadership are considered important factors facilitating the effective flow of high quality information and the sharing of knowledge [21]. An understanding of the workplace culture allows opportunities for targeted improvement such as enhancing communication among multidisciplinary teams. b. Leadership support Communication within the health service can be improved with an organisation providing strong leadership, through implementation of policies and procedures and identifying clinical leaders to drive improvements in communication and patient safety [3]. c. Effective communication can be supported by a healthcare organisation or institute which: Clearly links effective communication and teamwork to patient safety. Clearly articulates the organisation s expectation on how communication will be carried out. Fosters a communication process that facilitates continuous improvement in patient safety and quality of care. Assesses the current organisational culture of patient safety and identifies areas for improvement, for example, conducts an assessment of staff perceptions and current practice in the delivery and management of safe patient care. Fosters and promotes a work culture that values cooperation, teamwork, openness, collaboration, honesty and respect for each other and promotes open and effective communication. Creates an atmosphere where team members feel safe to speak up about issues relating to patient care regardless of their position or rank. Provides resources and identifies appropriate communication strategies to ensure that information is effectively exchanged between people depending on the situation, different communication methods may be required [3, 20, 21]. 7

8 How to improve communication in healthcare? In addition to clinical leaders and policy makers supporting effective communication and teamwork in the healthcare setting, a number of tools and training programs have been developed to assist with improving communication and teamwork among healthcare professionals. Some examples of tools and techniques available to healthcare organisations to assist with improving communication and teamwork is described below, including the level of evidence supporting the effectiveness of these tools to improve communication among healthcare professionals using the National Health and Medical Research Council (NHMRC) hierarchy of evidence rating system. Studies Type of intervention WHO Surgical Safety Checklists Checklists and briefings Year (Reference) 2009 [12] Canada, India, Jordan, New Zealand, Phillipines, Tanzania, England, USA Country Context Experimental design Hospitals, non-cardiac surgeries 2004 [3] USA Kaiser Permanente hospital to skilled nursing facilities Briefings 2004 [13] USA Kaiser Permanente hospital, perioperative setting SBAR, ISBAR 2009 [14] Australia Medical students, simulation 2008 [15] Canada Rehabilitation setting TeamSTEPPS 2010 [18] USA Large south eastern community based hospital system, operating room (OR) teams Prospective, multi-centre, preand postintervention Single centre, pre- and postobservation study Single centre, before and after intervention Single centre, clinical simulation environment, Pseudorandomised control trial Single centre, Uncontrolled before and after study Multi-centre (twocampuses), quasi-experiment with one pre- and one postintervention NHMRC hierarchy of evidence Level III-3 Level IV Level IV Level III-1 Level IV Level III-2 8

9 Type of intervention Year (Reference) Country Context Experimental design 2009 [17] Australia Mental health Facility Single centre (mental health facility), uncontrolled before and after study 2010 [30] USA NA Systematic literature review NHMRC hierarchy of evidence Level III-3 Source: Rating system for hierarchy of evidence for intervention studies: NHMRC (2000). How to use the evidence: assessment and application of scientific evidence, page 8. Accessed March 2010 at Effective clinical handover, for example at shift changes, requires good communication. Ineffective handover may lead to a failure to appreciate critical aspects of a patient s condition or care, lead to delays in a patient s treatment and result in adverse patient outcomes. Providing tools and solutions for effective clinical handover as a means of improving patient safety and quality care is a key program initiative of the Australian Commission on Safety and Quality in Health Care (ACSQHC). The Victorian Quality Council has acknowledged the potential risks to patient safety associated with inadequate clinical handover and has developed a set of generic tools to assist with shift to shift clinical handover. The tools are available at: NA Additional resources Institute for Healthcare Improvement (IHI) (USA): IHI/ Topics / Patient Safety: NHS Evidence Health (UK): Australian Commission on Safety and Quality in Health Care (ACSQHC): Clinical handover tools: Joint Commission Resources (USA): Centre of Research Excellence in Patient Safety (Australia): Research: 9

10 Appendix 1 The National Health and Medical Research Council (NHMRC) rating system recommendations for intervention studies. Rating Highest Evidence Level-I Obtained from a systematic review of all relevant randomised control trials. Level-II Obtained from at least one properly designed randomised control trial. Level-III-1 Obtained from well designed pseudorandomised control trials (alternative allocation or other method). Level-III-2 Obtained from comparative studies (including systematic reviews of such studies) with concurrent controls and allocation not randomised, cohort studies, case control studies, or interrupted time series with a control group. Level-III-3 Obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel control group. Lowest Level IV Obtained from case series, either post-test or pre-test/posttest. Source: NHMRC (2000). How to use the evidence: assessment and application of scientific evidence, page 8. Accessed March 2010 at 10

11 References 1. Victorian Auditor General s Office (VAGO). Patient Safety in Public Hospitals. Victorian Auditor General s Office, Victorian Government Publishers, May Viewed 30 October 2009, < 2. The Joint Commission National Patient Safety Goals. The Joint Commission, Viewed 27 October 2009, < A-8DB9-C2EA28C9BB33/0/07_lab_npsgs.pdf>. 3. Leonard, M., Graham, S., and Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care, 13 Suppl 1: p. i Salas, E., Almeida, S.A., Salisbury, M., et al. (2009). What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf, 35(8): p Dunn, E.J., Mills, P.D., Neily, J., et al. (2007). Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf, 33(6): p Victorian Department of Health. Building Foundations to support patient safety: Annual report of the Sentinel event program. Victorian Department of Health, November Accessed on 6 April 2010 at 7. Wakefield, J. Patient Safety: From Learning to Action. First Queensland Health Report on Clinical Incidents and Sentinel Events. Queensland Health, April Viewed 30 October 2009, < 8. Garling, P. Final Report of the Special Commission of Inquiry: Acute Care services in New South Wales Public Hospitals, Volume 2 Chapter 15 Communication. NSW Government, 27 November Viewed 30 October 2009, < olume2.pdf/$file/e_volume2.pdf>. 9. VASM. Case Note Review Booklet, First Edition. Royal Australiasian College of Surgeons Victorian Audit of Surgical Morality Management Committee, November Williams, R.G., Silverman, R., Schwind, C., et al. (2007). Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg, 245(2): p Williams, M., Hevelone, N., Alban, R.F., et al. (2010). Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg, 210(1): p Haynes, A.B., Weiser, T.G., Berry, W.R., et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med, 360(5): p DeFontes, J. and Surbida, S. (2004). Preoperative Safety Briefing Project. The Permanente Journal,, 8(2): p Marshall, S., Harrison, J., and Flanagan, B. (2009). The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual Saf Health Care, 18(2): p Velji, K., Baker, G.R., Fancott, C., et al. (2008). Effectiveness of an Adapted SBAR Communication Tool for a Rehabilitation Setting. Healthc Q, 11(3 Spec No.): p O'Mahony, S., Mazur, E., Charney, P., et al. (2007). Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med, 22(8): p Stead, K., Kumar, S., Schultz, T.J., et al. (2009). Teams communicating through STEPPS. Med J Aust, 190(11 Suppl): p. S

12 18. Weaver, S.J., Rosen, M.A., DiazGranadoa, D., et al. (2010). Does Teamwork Improve Performance in the Operating Room? A Multilevel Evaluation. Joint Commission on Accrediation of Healthcare Organizations, 36(3): p Murphy, H.A., Hildebrandt, H.W., and Thomas, J.P. Effective Business Communications. 7th ed. McGraw-Hill/Irwin The Joint Commission. The Joint Commission Guide to Improving Staff Communication. Joint Commission on the Accreditation of Health Care Organizations Oandasan, I., Baker, G.R., Barker, K., et al. Teamwork in Healthcare: Promoting Effective Teamwork in Healthcare in Canada Canadian Health Research Foundation (CHSRF), June Viewed 19 October 2009, < 22. Department of Defense. TeamSTEPPS Instructor Guide [TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety]. USA Department of Defense & Agency for Healthcare Research and Quality, Rockville, September Fitzgerald, L. Human Factors Engineering in Healthcare. Australian Federation of Medical Women, 21 October 2008, last updated 7 November Viewed 5 November 2009, < 24. Clancy, C.M. (2009). Ten years after to err is human. Am J Med Qual, 24(6): p Zeltser, M.V. and Nash, D.B. (2009). Approaching the Evidence Basis for Aviation-Derived Teamwork Training in Medicine. Am J Med Qual (in press). 26. Pickering, M. (1986). Communication. Explorations, 3(1): p Linney, G. (2007). Communication Skills Predict Success. The Physician Executive, July- August 2007: p Oriol, M.D. (2006). Crew resource management: applications in healthcare organizations. J Nurs Adm, 36(9): p The Australian Commission on Safety and Quality in Health Care (ACSQHC). Measurement for Improvement Toolkit, Part B: Background Information and Resources. The Australian Commission on Safety and Quality in Health Care, Commonwealth of Australia, Viewed 30 October 2009, < DCA BD2/$File/Toolkit_PartB.pdf>. 30. Zeltser, M.V. and Nash, D.B. (2010). Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J Med Qual, 25(1): p