Providing safe and effective care requires all healthcare providers to work closely together to achieve optimum patient outcomes. One study completed in the intensive care setting found that communication between physicians and nurses was the most significant factor associated with patient mortality.
The study Silence Kills: The Seven Crucial Conversations in Healthcare found that more than half of the healthcare workers surveyed had occasionally witnessed broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect and micromanagement. They witnessed colleagues cutting corners, making mistakes and showing serious incompetence. Yet, 90 percent of them failed to discuss their concerns. In fact, a majority of these healthcare workers believe it is not their duty or responsibility to call attention to these issues. Those individuals also felt that the repercussions from having a conversation about the actions or mistakes they witnessed outweighed the benefit. Researchers found the 10 percent who do speak up achieve positive outcomes for their patients, the hospital and themselves.
What can happen?
In healthcare organizations, it is not uncommon for a situation to arise that requires a healthcare professional — a nurse, aide, assistant or technician — to speak up. Below are some examples, which are for illustrative purposes only, of what can happen in a clinical setting:
- A surgeon performs a wrong-sided surgery resulting in a patient suffering a stroke. When the staff is questioned, they state that they were afraid to confront the surgeon even though they strongly suspected he was operating on the wrong side. When asked why they were fearful, they explain that past acts of bad behavior resulted in shaming and publicly belittling staff by the surgeon.
- The colleagues of a pediatric nurse are concerned about her competency and take it upon themselves to follow her and check on her patients. This work-around is not sustainable and an error occurs when a child requires resuscitation.
- A pharmacist, whom colleagues have noted is distracted by personal problems, is not performing standard quality checks. This results in the filing of an incorrect drug for a patient who later dies.
All of these cases illustrate the missed opportunity for a crucial conversation to occur. If the surgeon's behavior had been addressed, or the staff's work-around for the nurse been brought forward, perhaps harm could have been avoided.
Risk reduction strategies:
- Review current policies and procedures regarding communication and what steps are available in the event staff feels they are not being heard and patient safety is being compromised.
- Determine if these steps are being followed and if not, why not. Interviews with staff may be helpful to determine how effective communication is in current setting.
- Is there a zero tolerance for behavior that would inhibit staff/physicians from speaking up as a patient advocate? Are codes of conduct regarding behavior equally applied across all disciplines?
- Is insidious intimidation tolerated in your facility? For example passive aggressive behavior, non-verbal insidious behavior: staring, sighing, or positioning to exclude others. Gossiping and sarcasm are types of verbal intimidation. These types of behavior inhibit the building of a safe patient environment. Question staff on experiences regarding this type of behavior. Ask them what they did about the behavior and what resulted from the action.
- Consider training staff in effective ways to communicate. Examples include Team STEPPs. Many of the state hospital associations in conjunction with AHRQ have engaged with various providers to offer training courses. During these sessions they go over effective ways to communicate within the healthcare environment. A few examples are the use of CUS, two challenge rule, and DESC. CUS is an acronym for I am Concerned, I am Uncomfortable, this is a Safety Issue! Stop the line.
- Remember that this is not a one and done type fix. Continuous monitoring is recommended to ensure that change is maintained.
Industry data, as well as findings from root cause analysis of incidents, tells us that communication breakdowns are factors in malpractice cases 30 percent of the time. Not having the capability to speak up puts patients as well as the healthcare entity at risk. Focusing on communication will help to ensure safe patient care for all.
Should the unexpected occur, it is crucial to have the right insurance protection. The Hanover offers tailored coverages that address the unique risks faced by healthcare providers and facilities. In addition our risk solutions team provide an array of tools and resources to help you minimize risk and create a culture of safety.
- Silence Kills The Seven Crucial Conversations in Health care. D. Maxfield, Joseph Grenny, Ron McMillan, Kerry Patterson and Al Switzler. VitalSmarts Industry Watch.
- Joint Commission on Accreditation of Healthcare Organ- izations, Root Causes of Medication Errors 1995-2003.
- To Err Is Human: Building a Safer Health System. Institute of Medicine. National Academy Press. November 1999.
- AHRQ Pub. No. 14-0001-2. Revised Dec. 2013. ISBN 978-0-16-092760-7
- Malpractice Risks in Communication Failures. 2015 Annual Benchmarking Report. Crico Strategies. The Risk Management Foundation of the Harvard Medical Institutions Incorporated.