The following post is part of the course work for “Live Exchange” the foundational course on communication for The MBA Design Strategy Program at California College of the Arts. The rest of the posts are presented here.
by Briana Coonan
A couple years ago I got a message from a nurse with orders from my doctor to schedule an appointment for a procedure. Confused, I called the nurse to say that I’d just had that procedure performed. The doctor really wanted me to have it done again? Turns out the doctor had actually wanted me to schedule a related—but very different—procedure! Oops.
It should come as no surprise that communication breakdowns between doctors and nurses lead to poor patient outcomes, but did you know that those outcomes include an estimated 200,000 deaths every year? The lack of emphasis on communication skills in healthcare environments is astounding, particularly to those of us in business school, where much of the curriculum is dedicated to communication skills.
Because, traditionally, doctors, nurses, and ancillary staff have been trained in different academic and clinical environments and any communication focus is on dyadic communication (between the student and patient), they often find that working together as an interdisciplinary team is quite a challenge. Last year the Journal of Healthcare Management published the first study on the economic impact of communication inefficiencies among care providers in US hospitals. The research suggested that the average 500-bed US hospital loses $4 million a year specifically as a result of communication inefficiencies, and the authors were clear in stating that their estimates were conservative.
Patients and profits aren’t the only casualties in this matter. Administrators concerned with employee turnover should keep a close eye on communication issues as well. Nurses, the primary caregivers in hospitals, are notorious for “eating their young” and forming exclusive cliques. Throw in the all-too-common condescension from doctors and the hospital begins to look like the workplace from hell.
It’s tempting to place hope in the new technology requirements for hospitals, as we all know that the healthcare sector lags far behind any forward-thinking business in that sense. Technologies such as Vocera’s hands-free communication device have proven effective, but the value of direct interpersonal communication cannot be overlooked. Especially as hospitals adopt these new technologies, doctors have been increasingly expected to move away from patient care units to remote offices or computer rooms to complete orders and records. The Clinical Informatics Manager at a Midwest hospital recently told me about an incident involving a medication error this past summer. The nurse at fault said the doctor hadn’t communicated directly with her and the electronic order wasn’t clear. The doctor responded by saying, “If doctors had to talk to nurses, no one would get any work done!”
Considering the alarming number of reports of similar attitudes toward nurses, is it any surprise that a 2004 survey by the Institute for Safe Medication found that almost half of hospital staff would rather keep quiet than ask a doctor to clarify medication orders? The industry has been noted for a level of tolerated incivility unseen in other professions, not only toward nurses but medical students as well. Theresa Brown, the nurse who wrote the controversial New York Times op-ed piece “Physician, Heel Thyself,” feels that nurses are practically instructed to view doctors in an adversarial way. Nurses are taught they are the patient’s advocate, implying that the doctor is not. But not questioning a doctor out of intimidation is clearly not acting in the patient’s best interests.
Building the communication skills necessary for diverse, high performance teams is a business school standard. Why not also in medical and nursing schools? We have one of the most expensive healthcare systems in the world, yet policymakers and experts continue to lament the fact that performance and quality of care have serious room for improvement. Most US hospitals are facing unprecedented operational and financial challenges, with only a small minority reporting operating margins over 4 percent and patient volumes continuing to decline. But a new emphasis on internal communication has considerable potential for improved patient satisfaction and profit margins, especially as consumerism continues to reshape patient referral patterns.
The good news is that medical schools are catching up. Earlier this year, the Harvard Medical School graduating class received a commencement speech titled “Cowboys and Pit Crews,” pressing the graduates to think of themselves as part of a team, not the lone cowboy image of the past. Also, at least eight US medical schools, including Stanford and UCLA, now require candidates to pass “multiple mini interviews,” role playing scenarios intended specifically to evaluate their communication skills and emotional intelligence.
In hospitals, through structured communication events or professional development, healthcare professionals need to learn what it means to be part of a team. As we learn in business school, a high performance team has interdependent members that are more efficient working together than alone. There’s a high level of trust among members, and contrary opinions are encouraged. In addition to teamwork skills, healthcare professionals must adopt strong interpersonal, coping, and conflict management skills. Simulation of critical incident scenarios is an excellent teaching method, particularly for learning role clarity, leadership skills, and effective closed-loop communication.
Another successful communication tool developed to bridge gaps in training, experience, and teamwork is the SBAR model, a structured format for sharing critical clinical information between any two providers. Communication failures are most likely to impact patient safety at three distinct points: at time of admission, time of discharge, and any time that the patient’s clinical condition changes. Researchers have proposed that there should be an expectation, even a requirement, for direct interpersonal communication at these points, not the suboptimal phone, email, or fax alternatives. This approach, also called “huddles” or “time-outs,” is heartily backed by medical malpractice insurance providers, of course.
Implementing change in healthcare settings has been notoriously difficult to achieve. In fact, experts suggest that doctors are among the most resistant to change of all professionals. Leading positive change begins with hospital administration but depends on a commitment from all.
As an aspiring communication evangelist, and more importantly, as a patient, I’m excited about the new focus on internal communication in healthcare. Here’s to hoping my own providers will catch on soon.