Clinical Communication Deconstructed
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Clinical Communication Deconstructed A framework for successful, human-centered clinical communication Executive Summary Communication is the lifeblood that makes healthcare work. More than just listening for facts, communication is at the core of building sacred, trusted, and healing relationships between doctors, nurses, patients, and families. It is what keeps care team members connected to their healing purpose, and what allows them to understand and serve the needs of patients and families. Whether for coordinating care between teams, sharing critical lab data, educating and instructing, or soothing emotional anxiety, communication lies at the heart of healthcare. Yet it also remains Listen to your“ patient; a continual challenge, exacerbated by the increasing complexity “ of medicine. Pressures to reduce costs and improve efficiency, he is telling you the technologies that increase care providers’ administrative and regulatory burden, and patients from varied cultural backgrounds presenting with diagnosis. higher acuity conditions all add to the challenges of delivering care, and of clearly planning and communicating care priorities. Sir William Osler, M.D. In creating this report, we examined clinical communication from every angle. We reviewed academic studies and spoke with experts in clinical communication, current leaders in clinical practice, as well as patients and families. Our efforts uncovered numerous challenges as well as promising solutions and innovative protocols to promote effective clinical communication. We found that connection to purpose and the power of trusted relationships are the foundation of all successful clinical communication – whether informal or structured, between teams or with patients and families. © Vocera Communications, Inc. 2017 Clinical Communication Deconstructed 2 Executive Summary (continued) Armed with this information, we devised a framework for successful, human-centered clinical communication that consists of: • Shared Purpose • Awareness of Personal and Interpersonal Dynamics Shared Purpose • Healing-Focused Content and Context • Situational Awareness • Human-Centered Ecosystem • Respectful Communication Mode • System Standards for Optimal Communication Human-Centered Healing-Focused Communication Content and Ecosystem Context Leaders seeking to enhance successful clinical communication across their organizations should: • Embrace human-centered communication as a core value. Attention to All decisions, from the boardroom to the bedside, have an impact Situational Personal and Awareness Interpersonal on communication. Keeping communication front-and-center Dynamics in decision making is essential. • Examine workflow through a relationship lens. Respectful Communication Workflows support communication when they are designed Mode with team-based care and shared decision-making in mind. • Train the skills of clinical communication. System Standards for Like technical skills, all care team members need training across their careers to support human-centered communication. Optimal Communication • Apply technology that enhances human connection. Seek out intuitive, user-friendly tools that allow team members, patients, and families to connect and create the foundation for human-centered communication. © Vocera Communications, Inc. 2017 Clinical Communication Deconstructed 3 “ Healthcare is built on a sacred and trusted relationship. As medicine has moved into the 21st century, we’ve lost the ability to focus on patients’ stories and to know one another’s stories as care team members. As a result, we have broken, fragmented care that leaves patients and families frustrated and limits their healing, and we’re burning out a generation of caregivers. The solution lies in reclaiming narrative stories in medicine and recognizing the power of voice and human connection. Only when we gear our processes, our technologies, and our values around this sacred, healing relationship will“ we be able to restore humanity to healthcare. M. Bridget Duffy, M.D. © Vocera Communications, Inc. 2017 Clinical Communication Deconstructed 4 Table of Contents Introduction 8 Authors Framework 10 Shared Purpose 11 Attention to Personal and Interpersonal Dynamics 17 Healing-Focused Content and Context 26 Situational Awareness 34 Liz Boehm Evan LaBranche, MPH Respectful Communication Mode 41 Human-Centered Ecosystem 49 With support from System Standards for Optimal Communication 57 M. Bridget Duffy, M.D. Discussion 65 Rachel Abrahams, MPH Ben Fleury Acknowledgments 66 Anne Purdy Endnotes and Bibliography 67 Ann Ruiz RJ Salus, MSW Rachel Urbis, MPH © Vocera Communications, Inc. 2017 Clinical Communication Deconstructed 5 The Power of Effective Clinical Communication Cost Sentinel events Clinical outcomes A study examining costs associated with According to The Joint Commission, In interviews with cancer patients who perceived wasted physician time, wasted nurse time, communication was the third most common an avoidable and problematic event had occurred and increases in length of stay estimated that a root cause of sentinel events (serious patient during their treatments, 47% believed the error 500-bed hospital loses over $4 million annually safety events resulting in death, permanent stemmed from communication breakdowns alone, as a result of communication inefficiencies.i harm, severe temporary harm, or intervention and 24% blamed a combination of inadequate required to sustain life) in 2014.ii The top two medical care and communication. Of the patients root causes of sentinel events – human factors who attributed the cause to communication, 48% (for example, staff supervision) and leadership said the breakdown damaged the relationship (for example, organizational planning) – also with the provider, 30% suffered physical harm, have communication components. and 100% felt psychological or emotional harm.iii Adherence Patient experience Burnout and emotional exhaustion A meta-analysis of studies examining In a study that examined 3,123 patients A pediatric intensive care unit introduced communication and patient adherence to admitted in internal medicine, each one- multidisciplinary, structured work-shift medical instruction concluded that patients point increase in overall attending physicians’ evaluations as a means of coming together twice have a 19% higher risk of non-adherence when communication behaviors correlated to a 0.58 a week to discuss how well the workday had physicians communicate poorly than when point increase in overall patient satisfaction.v gone and how to drive improvement. As a result they communicate well.iv When physicians The study examined whether the physician of the intervention, the team experienced a 21% are trained on communication skills, patients treated the patients as equals, listened without increase in satisfaction with team communication are 1.62 times more likely to adhere to their interrupting, discussed options for their as well as a significant reduction in levels of doctor’s recommendations than when their care, and encouraged patients to be active emotional exhaustion among PICU staff.vi physicians are not given any training. participants in their care. More on the importance of communication in healthcare can be found on the Institute for Healthcare Improvement (IHI) website: http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ © Vocera Communications, Inc. 2017 Clinical Communication Deconstructed 6 The Scope of the Problem 1hour 2 x 0.5-23 Time spent by nurses daily Greater likelihood that cross- Number of times each hour doctors tracking down physicians vii disciplinary communication will and nurses are interrupted in ED, fail versus intra-disciplinary ICU, and surgery ix communication viii 3 x 30% 43% Greater likelihood that patients Communication events that included Frequency with which interruptions with a communication disability a failure during surgical procedures. disrupt direct patient care tasks will experience medical Thirty-six percent of these resulted or interventions xii or clinical complications in consequences such as tension compared to other patients x among team members, delays, or procedural errors xi © Vocera Communications, Inc. 2017 Clinical Communication Deconstructed 7 Introduction and Methodology Communication is a complicated topic. Methodology All healthcare stakeholders are concerned with aspects of communication quality, but most have a partial focus on those We conducted a large-scale literature review covering topics elements of communications that affect them most. including: care team communication, clinical communication, nurse-patient communication, nurse-physician communication, In our work with clinical, experience, and administrative physician-patient communication, patient-centered executives, we hear many concerns about communication communication, shared decision making, and safety culture quality, and encounter a variety of programs aimed at improving and communication. it. These programs often focus on relational skills and alignment of purpose. Among leaders, some gravitate to clinician-to- To limit our scope, and in recognition of the rapid evolution of patient and family communication topics. Others zero in on clinical communication technologies, we focused our search interdisciplinary and peer-to-peer communication challenges. on sources dating from 2010 and later. When we shadow nurses and doctors on hospital floors and in In addition to reviewing literature, we conducted more than outpatient