Special CorrespondenceVolume 1, No. 1

Let’s talk about improving communication in healthcare

Emme Deland1,

Jonathan E. Gordon2,

MBA,

Robert E. Kelly3,

MD

1 MBA, Senior Vice President, Strategy, NewYork-Presbyterian Hospital, New York, NY,
2 Director, Strategy, NewYork-Presbyterian Hospital, New York, NY,
3 President, NewYork-Presbyterian Hospital, New York, NY
DOI: 10.7916/D8RF5T5D
Citation:Gordon JE, Deland E, Kelly RE. Let’s talk about improving communication in healthcare. Col Med Rev. 2015 June 22; 1(1):23-27. doi: 10.7916/D8RF5T5D

Abstract

Healthcare providers don’t talk to each other enough. Members of the care team—physicians, nurses, social workers and even caregivers—don’t spend enough time communicating with each other about the patient’s needs, and no one from the care team spends enough time communicating with the patient. The increasingly complex needs of patients, an explosion of medical knowledge, and seismic shifts in healthcare systems have set the stage for a need for more effective communication. Additionally, today’s new models of care are focused on maintaining health rather than responding to acute illness. Success demands team-based approaches that are centered on close collaboration among all types of providers from across the care continuum. As a result, achieving the triple aim of improving quality, lowering costs and enhancing the patient experience can only be done with a significantly altered and improved communication strategy.

 

The statistics cited by the Institute of Medicine (IOM) in a 2012 report1 illustrate some of the challenges. Every year, the average elderly patient sees 7 physicians (5 specialists and 2 primary care physicians) across 4 different practices. Physicians in private practice caring for Medicare patients interact with as many as 229 other physicians at 117 different practices each year. The average surgery patient is seen by 27 different healthcare providers while in the hospital. One excellent recent illustration of the complexity of patient care came from Dr. Matthew Press, who described the interactions he had on behalf of a patient whom he had referred for tumor resection. Press documented 40 communications with 11 other care providers (9 physicians, a social worker and the lab), while his patient had 5 procedures and 11 office visits over the 80 days from the date of diagnosis until the completion of tumor resection.2

 

Not all of the communication problems in healthcare can be attributed to systemic complexity. Patients struggle to remember what they are told; one study showed that patients only recalled 40% of the information they were given, and almost half of what they thought they remembered was incorrect.3 Even when they understand the directions, less than half of non-surgical patients follow up with their primary care provider following discharge.1 Physicians, too, have opportunities to improve an important communication tool, listening: an iconic study by Beckman and Frankel5 found that physicians interrupted patients’ initial statements 77% of the time, and that the average time to interruption by the physician was a mere 18 seconds.

 

This culminates in a huge number of missed opportunities to deliver higher-quality and more cost-effective care. That same IOM report estimated that $765 billion of healthcare spending was wasted in 2010, with more than half attributable to unnecessary and inefficiently-delivered services, as well as missed prevention opportunities.1 While not all of this waste can be ascribed to ineffective or non-existent communication, the data clearly indicate that communication plays a significant role.

 

Fortunately, the literature is also replete with positive examples of the effects of communication.7 Improving communication among the care team has been shown to greatly improve the team’s understanding of goals of care and to decrease length of stay.8 The use of education tools such as the teach-back, which asks patients to explain to a member of the care team the information they have just been provided, has achieved improved comprehension and information retention by patients.91011 Furthermore, high-quality communication between care team members and patients has been shown to have a positive influence on patient health outcomes.12

 

As a result, providers are working to identify and implement programs to improve communication. Non-profits and even technology companies are creating new initiatives and new tools to facilitate communication among the care team and drive better patient outcomes.

 

Given the financial and quality imperatives facing health care, it is not surprising that providers are at the forefront of developing new programs and tools to foster communication. Innovative providers have borrowed from best practices in other industries, such as aviation, that are also critically dependent upon effective communication. A notable example is the adoption of the checklist, popularized by the work of Peter Pronovost at Johns Hopkins University.13 This tool can be used in many different clinical environments to ensure that the entire team has the same understanding of the situation. Because culture is a major driver of improving care, many organizations have adopted a “just culture,” in which employees are encouraged to speak up about their own actions and the actions of others without fear of reprisal,14 thereby enabling the identification of appropriate causes of error.

 

These efforts have begun to bear fruit. Medical errors are declining as physicians and hospitals have accepted and embraced the responsibility of patient safety. In 2013, NewYork-Presbyterian (NYP) launched an effort to create a safe and highly reliable organization that centered on establishing a just culture. This included both ensuring that all staff felt free to speak up if they saw something they felt could negatively affect patient care, and communicating with and among staff about the nature and causes of errors that are discovered.

 

Building on this culture of safety work, NYP, Columbia College of Physicians and Surgeons and Weill Cornell Medical College collaborated to create and implement Making Care Better (MCB), which was launched in January 2014. MCB, with its 13 core elements, has been designed to provide the highest quality, safest and most reliable care for patients by improving communication and collaboration among the care team and patients. In addition to reinforcing openness and communication about errors, MCB adds daily structured interdisciplinary rounding to ensure communication between members of the care team. The use of a discharge bundle assures all relevant providers are informed about a patient’s needs upon discharge, and teach-back is used to enhance patient comprehension and retention of discharge instructions. Finally, assessing patients for palliative care eligibility, which is another care element, requires that the care team has held comprehensive, in-depth conversations with both patients and their families. Already in phase II of its development, internal data show that MCB has begun to deliver improvements in communication that, over time, are expected to lead to improved outcomes.

 

Efforts to foster and improve communication in healthcare to date have largely focused on addressing clinical needs. Even though health expenses are the leading cause of personal bankruptcy,15 cost has long been seen as a secondary issue in health care. With the advent of high deductible health plans and health insurance exchanges, where the average annual patient responsibility is over $5,000.16. Mountain View (CA): HealthPocket; [updated 2013 Dec 12; cited 2015 May 22] Available from: https://www.healthpocket.com/healthcare-research/infostat/2014-obamacare-deductible-out-of-pocket-costs#.VV-I3N4vSBj], pricing transparency has moved to center stage. Unfortunately, neither the patient nor the members of the care team have a strong understanding of the financial expense of their care. “Costs of Care” is a not-for-profit that has worked to raise awareness of the issue by soliciting stories from both patients and members of the care team that illustrate how poor communication has led to unexpectedly high costs for patients.17 Costs of Care, in conjunction with the American Board of Internal Medicine and their Choosing Wisely campaign, is now building didactic materials and tools to help members of the care team communicate with patients about costs—something that is not currently a part of nursing school, medical school or residency curricula.

 

Technology is also beginning to play an important role in enhancing communication by improving connectivity and facilitating information flow. While electronic health records and health information exchanges have provided more robust and consistent access to patient information, providers have been slow to change their practice to maximize these opportunities. Healthcare technology start-ups such as Cureatr have stepped into this gap to create secure messaging platforms to enable the care team to communicate easily while maintaining the required privacy protections. Other start-ups such as Noom and VitalScore have created patient engagement tools to increase the frequency and consistency of patient-clinician interactions, helping improve the rate of compliance with care regimens.

 

Improving communication is essential if we are to transform into a value-oriented healthcare system. While there are many structural and cultural barriers to overcome, the good news is that there are patients, care providers, administrators and entrepreneurs working together to achieve that goal. To do so, we will need to define clear metrics for success, identify champions, build consensus and iterate based on experience. It will not be a short journey, but at least we will have something to talk about along the way.

 

Conflicts of Interest

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Jonathan Gordon reports he is a Director of Costs of Care and an advisor to VitalScore. No other disclosures were reported.

 

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