Communication & Quality Care

Talking and communicating with someone are not the same things.

In fact, since the aim of communication is to impart information and meaning; talking often widely misses the mark – as anyone who has found themselves in a situation similar to the following can attest.

A colleague told me this story of taking his 85-year-old father to a local hospital for care. The father is a borderline diabetic with vascular insufficiency in one leg and subsequent gangrene of the great toe. The patient is nervous, overwhelmed, slightly disoriented and hearing impaired, and he has had little to no hospital experience.

Upon their arrival, multiple caregivers continually come and go, all asking the same question, “Why are you here?”

A parade of 15 healthcare professionals (doctors, residents, nurses, lab techs, cardiac technicians, etc.) file past, all asking the same questions over and over again. When the son responds that the information must be in the record or the computer, staff display indignation.

“You’re dealing with a different department and you have to answer the questions again,” they’re told.

During admission, a nurse enters the room, and, in a matter-of-fact way, asks, “Mr. B., on a scale of one to 10, what’s your pain?” The patient looks puzzled and appeals to his son for help. The son offers no assistance because he can’t answer this question on behalf of his father. After a hesitation, the father says, “Seven.” The nurse asks if he has any problems with pain meds and leaves the room. She returns with pain pills which she administers to the patient.

“Dad, why did you answer ‘seven’?” the son asks. His father replies, “I didn’t know what she was talking about so I chose seven because that was Mickey Mantel’s number.” When the son asks his father if he has any pain, his father says he does not. Then he says, “It doesn’t matter. They aren’t listening to me anyway.”

Call for Improvements

My colleague believes had he not been there the potential for medical errors more serious than administering some unneeded pain pills would have been infinitely greater, because none of the hospital staff took into account his father’s confusion, anxiety, disorientation and hearing deficits.

As a nurse, I find this story disconcerting. As a risk manager, I find it educational and a call to help foster improvement in the system.

Better clinical communication is proven to lower patient complaints and reduce the incidence of lawsuits and adverse public opinion about an organization. In short, poor communication and unthoughtful behavior reflect negatively on the health care organization, endangering both patients and the bottom line.1

Some of these issues are rooted in health care system design, while others are the result of inadequate protocols at point of service. Unskillful communication often makes patients’ visits frustrating and unpleasant, not to mention limiting their quality of service.2

On the surface, communication seems an easy concept; however, many times we make assumptions about others’ understanding of our terminology and systems. Many patients lose their way in the healthcare system because of poor communication on the part of doctors and nurses, complicated, perhaps, by their own anxious state while in the doctor’s office or hospital.3

MORE NURSING ARTICLES ON SYNERGY IN HEALTHCARE

Communication is at the heart of every facet of the care continuum, including patient transfers or change-of-shift hand-offs, administration of medications, sharing of lab or x-ray results, informed consent and discharge instructions.

Nurses
Numerous studies prove the adverse impact of poor communication in a healthcare setting. For example, the Society for Health Systems in 2008 investigated the effects of communication complexity on patients’ perceived quality of care. The survey questioned patients’ about their expectations of a hospital visit, as well as about their actual experience of their hospital stay. The results showed specifically lower satisfaction rates for patients who talked to more nurses during their hospital visit, suggesting that patients would feel better if they had to deal with fewer nurses, communicating better.4

Doctors
A study published in the March issue of Pediatrics finds that when a physician completes a shift and hands off information to the replacement physician, in most cases, insufficient information is transferred, even among doctors who believe they have good communication skills.4 Despite proven miscommunications, interns on both sides of a patient hand-off consistently rated the quality of their communication as very high. Boaz Keysar, PhD, a professor of psychology at the University of Chicago and co-author of the paper, said that this disconnect between perceived and actual success of communication is common in other settings as well.5

Discharge Summaries

A research study from the Regenstrief Institute and the Indiana University School of Medicine concluded that hospital discharge summaries were grossly inadequate in capturing and documenting tests, pending results and information about which doctor should receive post-discharge test results.

  • Although all the patients had pending test results, only 16 percent of the 2,927 tests with pending results were mentioned in the discharge summaries.
  • Only 67 percent of discharge summaries indicated which primary care outpatient doctor was responsible for following up with the patient after discharge.

“We found that a huge number -72 percent – of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider likely would not even have known that the results of these tests needed to be followed up,” said one of the study’s authors, Martin Were, MD, MS.5

Patients’ Care Perceptions Count

A patient’s perception of quality of care is often based on how skillfully care givers communicate with them, how often, and the duration of each interaction. Simple techniques can help establish rapport with patients. Although many are based on research concerned with physician-patient interactions, the same principles apply to interaction between the patient and any other member of the clinical team.5

EARN CE CREDIT

Be Courteous
Using simple courtesies, such as a warm handshake, using the patient’s name and engaging in clearly audible introductions can reassure a patient and reduce their anxiety. Knocking before entering the room shows concern for the patient’s privacy and gives them a sense they are being treated with dignity and respect.

Engage the Patient
Research has shown that the use of positive body language actually increases the patient’s understanding of information as well as increasing patient satisfaction. Positive body language consists of maintaining eye contact, leaning forward, facing the patient and sitting close. This also conveys a sense of caring and concern.

Pay Attention 
Avoid distractions and behaviors that may damage communication and jeopardize the quality of the interaction, such as paying more attention to the medical record than the patient, standing in the doorway holding the door knob, yawning, stretching or slouching.

Listen 
Active and attentive listening is critical to the success of any interaction. Focus exclusively on the patient and allow the patient enough time to express their concerns. Researchers who have observed interactions with physicians and their patients have found that, on average, patients are given as little as 18 seconds to recite their complaints at the outset of a clinical encounter. Typically that allows a patient to express only a single problem. When patients are allowed to speak longer, they enumerate as many as four complaints.

Don’t Interrupt 
Interrupting the patient during the initial interaction may result in a significant loss of information, which may lead a provider down an inappropriate clinical path that may have a serious downside. Information is as important as medicine and can be considered medicine when dispensed well.

Remain Unbiased 
Studies show physicians give more information and more time to those who are college educated, of upper-middle class status or higher, or female. Conversely, they divulge less information to less educated patients, those of lower socioeconomic status, and males. However, when patients are polled, they all say that they want the same amount of information: as much as possible. Be aware of your biases and keep in mind that all patients expect and want the same amount of – intelligible – information.

Skillful Communication

The components of effective communication should be kept in mind whether communicating with patients or other care givers. Information must be accurate, consistent, evidence-based, credible, reliable, timely and understandable

Skillful communication is critical when dispensing medications, obtaining informed consent, during transfers and hand-offs, issuing discharge instructions, sharing test results and for the development of a strong patient-provider relationship.

Place yourself in the patient’s shoes. Ask yourself, “What information would I like to have, and how would I like to be spoken to, if I were in their position?”

The observations, comments and suggestions we have made in this report are advisory and are not intended nor should they be taken as medical/legal advice. Please contact your own medical/legal adviser for an analysis of your specific facts and circumstances. References for this article can be accessed here.

Ken Felton is Senior Vice President, National Health Practice, Willis America. He is a Fellow and Certified Professional in Healthcare Risk Management in the American Society for Healthcare Risk Management and holds many other industry distinctions. He began his healthcare career in the emergency department of Bon Secours Hospital, a large acute healthcare facility in Virginia.