Background:
Communication among healthcare providers directly affects patient care. In 2005, 69% of The Joint Commission sentinel events reported communication as root cause. 73% of those resulted in patient deaths. In an American Association of Critical Care Nurses sponsored study, 84% surveyed physicians reported coworkers taking shortcuts dangerous to patients. Impact: Nearly three in four medical errors are related to miscommunication. Yet, < 10% were willing to confront colleagues about concerns.
Methods:
Evaluated case reviews for: diagnostic, medication and surgical errors, and deaths. Communication errors were not defined. Goal: Identify communication as a “risk factor” in patient care. Determine Believable, Useable, and Practical communication tools: 1) Immediate communication (“right data to right person at right time”) via SBARR (Situation, Background, Assessment, Recommendation, Response). 2) Change culture through Crucial Conversations skills.
SBARR education introduced hospital-wide. Crucial Conversation taught to Herma Heart Center leadership via outside consultant. Initial class: 20 early adopters and skeptics attended Mastery Course. Phase two: 30 interested staff and faculty. Phase three: 20 staff attended “exposure” course.
Results:
70 team members engaged in a significant time commitment and exposure to culture change. Anecdotal, qualitative observations (similar to social sciences) describe behavioral changes. Team reported an increased success in “safe” communications with challenging patient care interactions.
Conclusion:
To improve patient care, cardiac leadership implemented new communication tools. The challenge remains to create and sustain effective, safe communication. Barriers include lack of tools for quantitative measurement of improvement tied to patient outcomes.