July 2019, Volume XXXIII, No 4

Care Teams

Improving communications

The nurses’ perspective

ecognizing that effective communications and coordination benefit all parties, doctors at Johns Hopkins Hospital years ago designed a system to reduce medical errors through improved teamwork and communication. It involved a patient safety checklist and one golden rule: listen to nurses and other frontline staff when safety rules aren’t followed. Initially, the system was so successful at lowering mortality that other hospitals adopted it to reduce medical errors.

But more recently, Johns Hopkins failed to follow its own system, the Tampa Bay Times has found. The result? Allegations of preventable, egregious adverse events. According to the report, in at least nine recent cases, basic safety rules were not followed, even though nurses and other frontline staff brought the safety lapses to the attention of hospital executives, and those problems continued long after. At least eight employees warned supervisors about issues with two heart surgeons at Johns Hopkins All Children’s Hospital. The complaints fell on deaf ears. By the time the hospital responded, the mortality rate in its Heart Institute had tripled, and at least 11 children had died.

Johns Hopkins Hospital responded, “The Tampa Bay Times has identified occasions where it is apparent that as an organization we failed to act quickly enough, we failed to listen closely enough and, in some instances, we failed to deliver the care our patients and their families deserve.” It’s clear that breakdowns in health care team communications create dangerous gaps in care.

It takes a team

Health care teams include not only nurses and physicians, but others involved in care delivery. These professionals work cooperatively and share responsibilities to provide quality and effective care through trust and mutual respect. Effective teams that trust each other, respect each other, and collaborate to work through challenges ensure the best outcomes.

Interdisciplinary teamwork promotes effective communication and cohesiveness during patient handoffs among caregivers with different levels of education, skills, and patient care goals. Over the course of a five-day hospital admission, a patient may interact with more than 50 hospital staff. Interactions among health care teams are far more frequent.

Under the strains of a fast-paced, stressful, high-liability setting, critical information must be communicated accurately and effectively. Also, positive communication between nurses and physicians can improve job satisfaction, improve patient outcomes, and result in fewer medical errors.

Effective communication promotes teamwork and information flow; clarity of purpose; quality patient care, safety, satisfaction, and decreased lengths of stay; the prevention of delays in patient care; reduced medical and treatment errors; heightened staff morale, satisfaction and retention; and reduced costs to insurers, government, and patients.

When communications break down

Teams that don’t know what the others are doing are ineffective and put patients at risk. And it’s not just patients. Breakdowns in communication take a toll on physicians and nurses as well. Physician and nurse suicides are on the rise. One nurse cited poor communications between health care team members as a likely cause during a recent podcast on physician suicide.

A 2015 Malpractice Risks in Communications report shows that communication breakdown was a key factor in 30% of all malpractice claims and 37% of all high-severity injury cases (including death) filed between 2009 and 2013. The study of 7,149 cases examined facts, figures, or findings that were miscommunicated between persons who had the information and those who needed it.

Improving individual communication skills is not the answer. Health care team members already have good communication skills. Critical medical mistakes arise when vital information is unrecorded, misdirected, never received, never retrieved, unclear, overlooked (such as changes in a patient’s status), or simply ignored.

Critical information must be communicated accurately and effectively.

Modes of communication

Webster’s Dictionary defines communication as “the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs.” However, 93% of communication involves body language, attitude, and tone. While spoken and/or written words contain critical information, it’s only 7% of the communication. When caregivers rely on written communication and don’t talk to each other at all, nuances in body language, attitude, and tone are missed.

Structured communication techniques streamline the process and decrease miscommunications. An environment where frontline caregivers can express concerns in the best interest of patient care—without fear of retaliation—reduces medical mistakes and improves overall effectiveness. Health care facilities that tolerate ineffective interpersonal working relationships among health care staff or that do not support educational efforts to improve behaviors perpetuate unacceptable conditions that put patients at risk.

The nurses’ perspective

An effective care team can provide quality, improved patient care through collaboration. For example, an Advance Practice Registered Nurse (APRN) depends on the pharmacist to provide alternative formularies that might be cheaper but equally effective as brand-name medications. A good best practice for an APRN is to always discuss difficult cases with other nurse practitioners and doctors on the care team to identify better treatment options. Good health care team communication and collaboration is just as important for patients who need community services. APRNs collaborate with social workers to assist patients and their families find available community resources, providing quality care while utilizing the expertise and skills of team members.

Attributes of successful care teams include open communication, nonpunitive environments, clear direction, clearly defined roles and tasks, respect, shared responsibility, an appropriate balance of member participation, acknowledgment and processing of conflict, clear specifications regarding authority and accountability, clear and known decision-making procedures, regular and routine communication and information sharing, an enabling environment with access to needed resources, and mechanisms to evaluate outcomes and adjust accordingly.

Accountability

Many people believe that individuals—not organizations—should be held liable for serious medical mistakes through lawsuits, fines, and suspensions or other encumbrances on a professional’s license. The human tendency to blame bad outcomes on an individual’s personal inadequacies, rather than on situational factors beyond the individual’s control, is a serious barrier to preventing or mitigating inevitable errors that occur in all complex organizations, not just health care.

Ninety-three percent of communication involves body language, attitude, and tone.

Miscommunication and medical errors are not always the sole fault of a team member. Organizational barriers may also play a role. For example, care teams may be challenged by the layout of a hospital, or even a unit. When a charge nurse is responsible for both a second-floor transitional care unit and a first-floor emergency department, it is reasonable to assume there may be serious systems communication barriers.

Lean management

From an APRN’s perspective, there continues to be waste in health care, despite the push to manage resources. For example, unnecessary tests may be ordered by different providers who fail to communicate or collaborate as a team. The same test may even be ordered by different providers for a single patient.

Lean management can address some of these issues, but multiple challenges remain:

Electronic handoffs. Lean principles stress efficiency in all phases of care and may urge eliminating face-to-face or phone communications during handoffs. Time is money. However, handoffs are a critical point of care, because the exchange of information between caregivers is critical.

According to the Joint Commission, health care professionals must avoid making hand-offs using solely electronic or paper communications. If face-to-face communication is not possible, communicate in real time via telephone or videoconference. Provide ample time and opportunities to ask questions and get feedback. The Joint Commission requires all health care providers to “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions” (2006 National Patient Safety Goal).

In addition, e-handoffs do not allow for one-to-one interaction and leave no room for questions, clarification, and feedback between providers, which might lead to medical and treatment errors. Still, proponents of e-handoffs argue that e-handoff tools such as those presented at www.tinyurl.com/mp-handoffs help resident physicians improve patient care, increase medical efficiency, and reduce errors caused by faulty/ineffective communication.

Value-based reimbursement models may also limit autonomy and decision-making authority, as can consolidation and increasingly large organizations. Quality of communication is key to both large and small teams. To assess improvements in care team communication, look at team effectiveness on a case-by-case basis.

Online care models. To ensure continuity of care and appropriate follow-up, telemedicine providers—both in rural and urban areas—must make efforts to communicate/share information with their patients’ primary care providers. Remote “tele-sitters,” where one person monitors several high fall risk patients from a single room, is Lean Management that puts patients at high risk of harm and impedes efficient communication between the “sitter” and the primary care nurse. A physical presence in the patient room allows for quick reaction and intervention. Nurses agree, it cannot be emphasized enough that remote tele-sitters create a dangerous intervention time lag that puts the patient at risk of serious injury or death.

Team size. Smaller teams work best when each member knows and owns a specific role. The chain of communication is shorter, and information reaches each team member at a quicker pace. As a team grows, it is critical that each team member is assigned a specific role to avoid duplication and confusion. Large-team communication must be specific, clear, and concise. There must be trust and mutual respect, and opinions from each team member must be considered.

Summing up

Care team communication has gradually improved as health care organizations push for better communication and partnership. Studies have shown that health care professionals cite improved teamwork and communication as among the most important factors in improving both clinical effectiveness and job satisfaction. Still, nurses continue to find their complaints to management falling on deaf ears, putting patients at grave risk of serious harm. Working together to achieve a high-functioning team is ever more challenging in our continuously changing health care system—especially when expectations around quality become directly linked to patient outcomes.

Providing the most effective patient care that decreases the risk of harm begins with clear and appropriate communication. Without communication, true collaboration among professionals is impossible.

Collaboration between physicians, nurses, pharmacists, and other health care professionals increases each team member’s awareness of the type of knowledge and skills of their colleagues, leading to continued improvement in decision making and high quality, efficient patient care. Effective teams have trust, respect, open communication, clear direction, shared responsibilities, mechanisms to handle conflicts, clear specifications of authority, and accountability.

Team members must communicate effectively.

Jackie Russell, RN, JD, is the Nursing Practice and Regulatory Affairs Specialist at the Minnesota Nurses Association (MNA). A registered nurse for 21 years, she started her nursing career in open-heart step-down, then moved to emergency and trauma. She has practiced in various levels of hospitals, including remote access, community, and Level II Trauma. She practiced as a prosecutor in New Mexico before relocating to Minnesota to work for MNA and will begin her Master of Laws (L.L.M.) in Health Law at Loyola University Chicago School of Law in fall 2019.

Felicia Ikebude, DNPc, MSN, FNP-BC, APRN, works as a nurse practitioner at Hennepin County Medical Center in Minneapolis. She is currently completing her Doctor of Nursing Practice (DNP) program at the University of Wisconsin-Eau Claire.

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Felicia Ikebude, DNPc, MSN, FNP-BC, APRN, works as a nurse practitioner at Hennepin County Medical Center in Minneapolis. She is currently completing her Doctor of Nursing Practice (DNP) program at the University of Wisconsin-Eau Claire.