No one debates the importance of timely and accurate communication with patients and their families or among staff members. Too many, however, do not recognize that poor communication can have profound ethical, clinical, personnel and financial costs.
“Malpractice data shows that communication-related factors contribute to about 30% of claims. When communication is disrespectful, unclear, or simply missing, risks to patient safety and provider liability are amplified, whether the communication is between providers or between a provider and the patient/family,” wrote David L. Feldman, MD, CMO, The Doctors Company and Healthcare Risk Advisors, in a June 27, 2022, article for KevinMD.com, referencing the National Surgical Quality Improvement Program. According to the I-PASS Patient Safety Institute, “Interruptions, distractions and insufficient staffing lead to hurried handoffs, medical errors and costly overtime.”
Feldman and the I-PASS Safety Institute’s comments are not surprising, and it should be obvious that significant improvements to communication and its processes can be strengthened to prevent patients and staff from being compromised by inadequate, untimely, and confusing and contradictory information.
Given the undeniable recognition that improved communication will enhance patient care and staff interaction—while reducing adverse outcomes and burnout—several steps can be taken.
1. Appoint a staff survey task force composed of physicians, nurses, an ethicist if one is available, a chaplain, an ethics committee member and an individual from the education department to assess the areas in which physicians, nurses and other clinicians believe there are opportunities to enhance communications. Consider drafting the survey using a five-point Likert scale (1. Strongly disagree; 2. Disagree; 3. Neither agree nor disagree; 4. Agree; and 5. Strongly agree). The survey results will be useful in establishing baseline data for comparison with results obtained after improvement programs have been implemented.
2. Speak with families of patients who have died in the ICU to obtain their impressions of end-of-life communications by intensivists and other specialists. They can be asked to assess the hospital’s care in three areas: overall care of the patient, how well the patient’s pain and symptoms were managed, and the adequacy of the staff’s communication with the patient and the patient’s family. Fifteen years ago, I conducted a study for a hospital, approved in advance by the patients’ primary care physicians, with the relatives of 21 patients. The responses were summarized and presented to the hospital’s end-of-life task force and ethics committee (see sidebar).
The study’s methodology and interview results, which are detailed in “Family Evaluation of End-of-Life Care—An Essential Perspective,” published in the May/June 2009 issue of Health Progress, confirmed that communicating appropriately with families of terminally ill patients is rarely easy. It is even more challenging when the patient has no advance directive and lacks decision-making capacity. At the point that additional invasive diagnostic or therapeutic procedures will not benefit the patient, physicians sometime discuss withdrawal of care. Care, however, should never be withdrawn, and inadvertent misuse of this term unnecessarily complicates an already-difficult task of speaking with relatives who are emotionally distressed.
3. Read articles about improving communication with patients and among clinicians, such as those listed on the I-PASS Patient Safety Institute website from JAMA, the New England Journal of Medicine and other publications. Begun in 2010 with the first I-PASS Intervention Bundle created for resident physicians involving a multisite study at nine children’s hospitals, hundreds of hospitals use the bundle, which offers a package of best practices to standardize inpatient transitions in care.
4. Devote special attention to improving communication with patients who are considering experimental treatment for incurable diseases. Although the Food and Drug Administration has sped up access to new medications for conditions lacking effective treatments, the FDA’s recent efforts have not been unblemished. For example, its June 2021 accelerated approval of Aduhelm to treat Alzheimer’s disease was originally priced at $56,000 per year, and then it was reduced to $28,200 at the beginning of 2022. The cost, however, will only be covered by Medicare for patients enrolled in a clinical trial or a study approved by the Centers for Medicare & Medicaid Services or the National Institutes of Health, according to a 2022 post by the Commonwealth Fund. Cleveland Clinic, Johns Hopkins, UCLA and the University of Michigan are among many organizations that have stated they are unwilling to prescribe or administer Aduhelm. Keeping patients informed of such developments that might have a direct effect on their care is crucial.
5. Become familiar with the work of Bryan Sisk, MD, and James DuBois, DSc, PhD, at Washington University in St. Louis, who explain why communication virtues, specifically empathy and caring, adaptability, validation, and empowerment, contribute to more effective communication. Their article, “The Microethics of Communication in Health Care” in the Aug. 22, 2022, issue of The Hastings Center Report, provides insights into why communication should be considered an ethical act.
6. Remember the vital importance of timely communication when a clinical error has occurred. Studies have confirmed that prompt disclosure, apologizing, describing steps being taken to prevent subsequent similar mistakes, keeping the patient and family apprised of these efforts and, when appropriate, offering compensation have multiple benefits.
Patients and families realize clinicians are fallible and mistakes can happen. When there is complete transparency, risk managers and healthcare attorneys know both the likelihood of a lawsuit and the size of settlements often are diminished when a timely and appropriate offer is made to compensate for the pain and suffering associated with the mistake.
Every facility has its own unique culture and values. Nonetheless, it is worthwhile to identify evidence-based best practices in healthcare organizations that have adopted successful interventions to improve timely and accurate communications with patients and their families. Doing so can help leaders determine which ones will be compatible with your institution’s culture and values.
Paul B. Hofmann, DrPH, LFACHE, is president of the Hofmann Healthcare Group, Moraga, Calif., and co-editor of Managing Healthcare Ethically: An Executive’s Guide, published by Health Administration Press, and Management Mistakes in Healthcare, published by Cambridge University Press (hofmann@hofmannhealth.com).