The Communication Conundrum

By Thomas Crocker
Thursday, August 30, 2018

It is difficult to overstate the importance of communication to clinical outcomes, patient safety, and organizational finances and reputation, but for many healthcare organizations, it is an Achilles heel. What can be done to prevent communication gaps?

Given the complexity of the healthcare system and high number of providers that may be involved with each patient’s care, especially during transitions between care venues, it should, perhaps, come as no surprise that communication failures are a pervasive problem.

“Nearly 70 percent of all sentinel events — unanticipated occurrences resulting in death of or serious injury to patients — involve communication and teamwork issues, according to The Joint Commission,” says Kristi Eldredge, RN, JD, CPHRM, Senior Patient Safety Consultant at MMIC, the Midwest’s largest policyholder-owned medical professional liability insurance company. “Virtually every malpractice claim contains communication or teamwork failures.”

In a study of 2,413 medical professional liability claims from 2012 to 2016, MMIC and parent organization Constellation found 35 percent (852 claims) contained a communication breakdown that played a part in a poor outcome, injury or adverse event. Sixty-five percent of those communication failures took place between providers and patients or families — miscommunication about expectations and informed consent accounted for the most of those, at 14 percent, with insufficient education a close second at 12 percent — and 42 percent were between providers. In an analysis of 23,658 medical malpractice cases, Boston-based CRICO Strategies, a division of The Risk Management Foundation of the Harvard Medical Institutions Inc., identified communication lapses as a factor in 30 percent of them.

Poor communication can prove costly in ways both quantifiable and difficult to measure. The 35 percent of claims identified in the Constellation/MMIC study as containing communication breakdowns accounted for $131.4 million in total costs incurred. On average, claims involving problems with communication incurred approximately $17,600 more in costs than claims that did not feature a communication failure. When communication suffers, so does reputation: Aggrieved patients and families are more likely to file claims and share their experiences via social media if they perceive harm as a result of poor communication, according to Betty VanWoert, RN, BSN, CCM, CPHRM, Senior Risk and Patient Safety Consultant at MMIC.

The Formation of Information Gaps

Why is communication challenging for healthcare organizations? These factors play a role:

  • Communication is undervalued and overlooked in academia. Many medical programs do not train providers-to-be in effective communication.
  • Teamwork is not intuitive. Multidisciplinary care is widely acknowledged as crucial to high-quality, successful care for a variety of medical conditions, but for many providers, operating as members of a team does not come naturally. This stems from how they were trained, according to Eldredge.
  • “Traditionally, physicians, nurses and ancillary providers have trained differently in different clinical environments,” she says. “They often find that working together as an interdisciplinary team is quite challenging. Every team member needs to understand that communication is the best risk management tool they have.”
  • Complex, urgent medical situations are more susceptible to communication breakdowns. Any time interactions between healthcare providers are rushed, such as during emergent situations, the potential for gaps in communication increases, Eldredge says.

Transitions of care between providers and healthcare settings are prime points at which communication gaps are likely to emerge. A 2005 study estimated that 80 percent of serious medical errors occur as a result of communication failures during hand-offs care between providers.

“A patient may receive care from her primary care physician in an outpatient clinic and then transition to the care of a hospitalist and a hospital nursing team during an inpatient stay before moving into the charge of another care team at a skilled nursing facility,” Eldredge says. “There is a lot of vital information to communicate during those transitions, and passing it from one team to the next can resemble playing a game of telephone.”

If communication is poor, transitions of care can lead to potentially dangerous assumptions on the part of care team members, Eldredge says. For example, in the absence of clear communication about which providers need to see a test result and how that information will be transmitted, team members may wrongly assume that all key stakeholders have seen the test result, to the detriment of patient safety.

Treating Between the Lines

Communication failures — so often occurring with adverse events — have a way of hiding behind the events themselves. That is because poor communication alone is rarely the cause of an injury or undesirable outcome; rather, it is often a key contributor, according to VanWoert. The natural tendency, she says, is to focus on what happened, not the factors that led to the result.

“When a patient sustains an injury during an interaction with the healthcare system, what first draws our attention is what went wrong during care delivery, such as unintended retention of a foreign body during surgery,” VanWoert says. “How we arrived at that problem may have been due, in part, to a lack of communication during the planning phase of treatment — if, for example, a surgical team did not have a preoperative huddle to ensure everyone was on the same page.”

When an adverse event occurs, it is essential to dig deep into what happened via root cause analysis instead of settling for a surface-level explanation.

“Communication is easy to overlook when doing an investigation following an event because more obvious items, such as administration of the wrong medication, draw attention and focus away from underlying issues that may explain how and why the event occurred,” VanWoert says. “For some individuals and healthcare organizations, root cause analysis is uncomfortable, but it’s important. Instead of settling for the fact that the wrong medication was given, leaders need to ask, ‘How did we give the wrong drug?’”

Strategies for Communication Optimization

Patient care is predicated on information, and, in the medical world of today, much of that information is digitized in EHRs. These digital records are a boon to healthcare teams because they allow providers to view patient documentation in real time from any location, but EHRs can only live up to their up-to-the-minute promise if information input is timely and accurate.

“So many providers contribute to patient-centered health care: specialists, primary care physicians, nurse practitioners, physician assistants, rehabilitation therapists and office staff, to name a few,” VanWoert says. “Everything those individuals can provide for each other in terms of documentation in an EHR is going to help with patient care, but it’s critical to update the record in a timely manner so everyone has the most current information. It is also important to standardize how everyone on a team communicates. If, for example, I use shorthand or abbreviations not everyone is familiar with, the information I’m entering into the EHR will lack clarity and won’t go forward as I intend.”

Clarity is an essential component of effective communication. To increase clarity, VanWoert recommends adopting closed-loop communication, a strategy that can eliminate misunderstandings in relaying information and break down blind spots providers may have regarding how others perceive their communication style. To communicate in a closed-loop manner, the provider giving an order should ask the recipient to repeat it to him or her to confirm the information was received and understood. Closed-loop communication is especially effective in hectic patient-care venues, such as the emergency department, where rushed orders are typical and the potential for communication gaps is high.

“Speak up, ask questions and identify barriers to effective communication,” VanWoert says. “As providers, we may not always have the best understanding of how our own communication comes across, or we may resist hearing what someone else shares with us. We want to identify and eliminate as many barriers to successful information sharing as possible, and closed-loop communication is one way to do that.”

Most importantly, VanWoert encourages providers to welcome questions, which can be key guarantors of clear communication, and, therefore, patient safety.

“When someone on your team asks a question, that person is rarely challenging your authority, knowledge or skill,” she says. “Questions help ensure everyone is on the same page. They are mutual support tools because what’s clear to you may not be to others.”

MMIC offers a variety of resources to help policyholders improve their teams’ communication skills, including webinars and online tools, claims reviews, Brink magazine, and in-person training by Kristi Eldredge and Betty VanWoert, both of whom are certified trainers for TeamSTEPPS, the Agency for Healthcare Research and Quality’s evidence-based teamwork system. For more information about everything MMIC has to offer, visit