How Communication and Coordination Improve Surgical Outcomes
Both inside and outside the operating room, clear, complete, and respectful communication saves lives. That’s both intuitively true, and increasingly borne out by research.
In a recent example, and one that may turn out to have profound resonance, hospitals in South Carolina were invited to participate in a program based on effective implementation of the World Health Organization Surgical Safety Checklist. The results, recently published in the Annals of Surgery, have been eye-opening. The post-surgery death rate in the 14 hospitals that completed the program fell from 3.38% in 2010, before the program was implemented, to 2.84% in 2013. Meanwhile, over the same time period, in the 44 South Carolina hospitals that chose not to participate, the death rate rose from 3.5% to 3.71%.
The study is considered especially important because although the WHO checklist has been proven effective in previous controlled studies, this study suggests that profound gains can be made in larger real-world settings. It “demonstrates that when done right, the Surgical Safety Checklist can significantly improve patient safety at large scale,” says lead author, Dr. Alex Haynes, associate director of the Ariadne Labs Safe Surgery Program and a surgeon at Massachusetts General Hospital.
In other words, there’s no question: Better communication produces better outcomes.
But communication can be extremely challenging in healthcare environments. In a 2008 study designed to improve communication throughout a major metropolitan hospital, the Denver Health Medical Center, researchers enumerated what they called the interrelated dynamics that often impede communication: Briefly, they say, (1) health care is complex and unpredictable, with professionals from a variety of disciplines, often dispersed over several locations, providing care at various times throughout the day; (2) providers tend to have their own disciplinary views of what patients need, and tend to prioritize the activities in which they specialize; (3) hierarchical organizational structures create significant power disparities between physicians and other healthcare professionals; (4) differences in education and training lead to different communication styles that can result in ineffective communication; and (5) the educational curricula for most healthcare professions focus primarily on technical skills, with little or no attention paid to the importance of teamwork or communication skills.
Those are a lot of barriers to overcome. No wonder the Joint Commission has said that poor communication is “the most frequent root cause of sentinel events” and the Agency for Healthcare Research and Quality has said that communication problems are the most common root cause of medical errors.
Notably, both the South Carolina study and the Denver study emphasized the importance of multidisciplinary participation, the support of surgical and executive leaders, and the understanding that culture change takes time. Both also began with pilot programs that were later scaled up. Such significant changes don’t come about overnight, but they can be reached.
Better overall communication
The Denver study sought to improve communication between providers and other staff by implementing several communication strategies.
- The SBAR (situation, background, assessment, recommendation) communication format. SBAR provides a standardized means for communicating about patient care and helps bridge differences in communication styles.
- Team huddles. Literature suggests that daily team huddles reduce interruptions during the rest of the day and provide immediate clarification of issues. Recommended guidelines include having them at a standard time and location each day, making attendance mandatory, and limiting them to 15 minutes.
- Multidisciplinary rounds with daily goal sheets. Patient-centered rounds can include any staff member or provider involved in the patient’s care, and focus on open and collaborative communication, decision-making, information sharing, care planning, safety issues, cost and quality of care issues, setting daily goals and communication with patients and/or family members.
- An escalation process. The hospital created an algorithm for timely, appropriate communication between nursing staff and providers when patient conditions worsened but fell short of code situations. Previously, no standardized process had existed, which often led to confusion and delays in appropriate and adequate patient care.
The initiatives bore fruit, say the authors. Communication time surrounding patient concerns decreased, so treatment and resolution improved. Nurses felt more empowered and were more satisfied both with communication and the higher rates of resolution of patient issues.
Scribes promote communication
Better communication is one of the fundamental principles behind the development and training of medical scribes. The exhausting demands placed on physicians by, among other things, the requirements surrounding data entry and other clerical work are bound to be an impediment in an environment that requires clear and thorough communication. By helping to reduce that burden and allowing physicians to focus on overcoming the barriers that can impede communication, and by facilitating and enabling communication between and among providers, scribes can help ensure the best possible outcomes for patients.