Speak Up: The Role of Communication in Highly-effective Health Care

By Liz Lacey-Gotz
Wednesday, March 8, 2017

The Constellation team helps keep patients safe by making sure providers say the right things, at the right times, to the right people.

When we think of improving patient safety, we are quick to point to checklists or the latest technologies or systems designed to help keep patients safe. They are all important, but so is something that seems to occur with less and less frequency: talking to each other.

Patient Safety Awareness Week comes once a year, but better communication every day is needed to help ensure our patients get the care they need, safely and in an environment of respect, two-way communication and empathetic listening.

Collaboration Thrives on Conversation

Collaboration is a big word in health care today. But simply having a group of people working together toward the same goal does not constitute a true collaborative or partnered approach. To achieve a true collaborative team requires a profound shift in the type of relationships you have between the various professions.

“When there’s great teamwork and collaboration, there’s mutuality, respect and high-level communication,” says Judy Pechacek, DNP, CENP, RN. “Living in a world where people respect and honor what others have to say removes all kinds of friction and fear — the behaviors that erode satisfaction and productivity on the job.”

Dr. Pechacek and Teddie Potter, PhD, RN, FAAN, are two nursing professors at the University of Minnesota Twin Cities who are challenging the status quo and working to shift healthcare teams from the hierarchical and dominance-based approach to a more collaborative model.

“There’s nothing wrong with rank; it’s the abuse of rank that’s the problem,” says Potter. “In a hierarchical culture, nurses eat their young and residents are treated poorly by physicians. They’re socialized that it is okay to treat people without dignity. And it does tremendous harm.”

Pechacek and Potter advocate for a partnership culture, where communication flows both ways, and feedback helps improve processes, avoid errors and improve patient outcomes.

Hierarchical Vs. Collaborative Conversations

In her classes, Teddie Potter, PhD, RN, FAAN, nursing professor at the University of Minnesota in Twin Cities, often uses role-playing to help students understand the difference between partnership- and dominance-based cultures. The following fictitious situation in the OR highlights the extreme differences in team conversations.


Nurse: Doctor, I noticed you contaminated the instrument you’re using.

Surgeon: Who are you to tell me what I can and can’t do? Have you trained as a surgeon? I know exactly what I’m doing and where my equipment is. How dare you say anything to me! As a matter of fact, your supervisor is going to hear about this. As soon as I’m done here, I’m going to write you up.


Nurse: Dr. Smith, I need to alert you that your hand accidentally fell below your waist and now is no longer sterile. The instrument is contaminated.

Surgeon: Oh, thank you! I was so focused I didn’t even notice. I need a glove change and new instrument. Thanks for being vigilant for the patient’s sake! This is exactly the kind of team effort that’s essential for good outcomes and safety. I’m going to talk to your supervisor about your excellent communication. It’s important to have someone like you working in the OR.

The Tools of the Trade

Developing partnership-based teams requires tools and techniques, and the diligence to follow them. Changing attitudes is not enough; a real culture shift can only take place when teams enact the behaviors that lead to partnership.

One of the tools Pechacek and Potter use in their trainings is Team STEPPS, a method developed for the aviation industry by the U.S. Department of Defense and later adapted for healthcare teams. Within the program are guidelines for communication, including SBAR, a technique for communicating critical information that requires immediate attention and action concerning a patient’s condition.

“If you look at aviation — an industry where safety is paramount — you’ll see they have worked diligently to truly form partnerships with pilots and others to make safety the highest priority,” says Pechacek, “And wouldn’t it be a beautiful thing if health care could learn some of those lessons?”

Team STEPPS offers specific guidelines around speaking up when errors occur on the team. To make openness in confronting errors work within a team, high levels of trust must be cultivated, and trust starts with listening and respect.

The aviation system of reporting is proactive. Pilots are trained on the process, and they are incentivized to report errors. In health care today, according to Pechacek, errors are examined when they are discovered, and voluntary reporting is rare. But in a partnership culture in which team members build strong communication skills and develop mutual respect, reporting errors becomes a tool for learning and team growth. This process is key to improving patient care and outcomes, and avoiding sentinel events.

The Importance of Speaking Up

In a partnership-based culture, says Pechacek, it is critical that the individuals on the team are respected, valued for their contributions and expertise, and given permission to speak up when they see something not going right.

In a domination-based culture, leadership is a philosophy of power over others. Communication only flows top down, never both ways. In a collaborative or partnership-based culture, a good leader knows that they can use that power to lift people up, to give them a voice to speak up, and to bring their team to their highest level of potential.

“Trust is key. You can’t build trust if you are a person who knows everything and makes people wrong, you have to actually understand others’ experience,” says Pechacek. “Then, you use the tools and techniques to help shift the culture to a new way of working.”

In a partnered approach, leaders can help the team develop respectful, two-way communication, where people are encouraged to innovate and to be creative. This respect and openness flows from the healthcare team to the patient. “The whole system can be healed when we shift the way we relate to one another,” says Potter.

“When we set aside our hierarchy and domination, and set aside our ‘We know best,’” says Pechacek. “We get humble, we learn and we grow.”

Putting Partnership into Practice

Potter and Pechacek are now putting these principles into practice system-wide at Fairview’s M Health in Minneapolis, which has already started to use partnership-based health care as part of its professional practice model.

“The key is to shift the culture. That’s the beauty of partnership-based health care,” says Potter. “You would not go back to abusive structures that harm one another. This shift creates a stable organization where the best practices and the best strategies really have a chance of making a difference.”

Breaking Points: Where Breakdowns in Communication Can Harm Patients Most

Recognizing that lawsuits often occur as a result of breakdowns in communication, one task force endeavored to identify key gaps that can be helped by talking, both with patients and among healthcare teams. The group, called PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency and Satisfaction), was funded by a grant from the Agency for Healthcare Research and Quality (AHRQ). Here are their five domains — ambulatory care areas at risk for errors that could lead to patient harm.

1. Communication Related to Three Key Risk-prone Processes

Experience with ambulatory malpractice claims point to several high-risk areas, with recurring problems showing up in three processes: (1) test results, (2) referrals and (3) medication instructions/warnings/indications. In each of these areas, communication should be a closed loop; e.g., if a physician orders a referral for a patient, they should know in a timely manner — not a year or two later — if the referral took place or failed, and be sure to follow up with the patient if necessary.

2. Communication Among Care Team Members

Every clinic needs a culture of safety that encourages employees to voice concerns — including admitting when something has gone wrong — without fear of retribution. In a 2012 survey, only 44 percent of healthcare providers described the response to error at their organization as “nonpunitive.” Building a culture that is supportive and understanding, and in which people feel comfortable reporting errors, is key to improving patient care; when errors are unknown, they are likely to be repeated.

3. Communication with Patients During and Between Encounters

Overall risk can be reduced by fostering effective, respectful listening and shared decision-making, and by ensuring that doctors are attuned to their patients’ health literacy. The teach-back method is recommended — writing notes or talking with patients, then asking them to repeat back what they heard to help ensure they understand.

4. Communication Related to Hearing Patients’ Concerns and Ideas

Get feedback from your patients. It’s important to ask patients what they like, but also what they dislike. As you pat yourself on the back for successes, also seek to understand and improve areas of concern or dissatisfaction for patients.

5. Communicating with Dissatisfied Patients and Families

When something goes seriously wrong, patients need extra attention immediately. They may have a serious adverse reaction to a medication, or kidney failure from a contrast procedure, or any number of predictable or unpredictable negative outcomes. Rather than acting defensively out of fear, continue to communicate as their doctor — someone who cares for them and in whom they have placed great trust for their care.

Liz Lacey-Gotz is the editor of Brink, a patient safety and risk solutions magazine published quarterly by Constellation Inc. Constellation is a growing partnership of medical professional liability insurers across the U.S. To request a copy or a PDF of Brink, email Liz.Lacey-Gotz@ConstellationMutual.com.