Improving Clinical Communication Across the Care Continuum

Healthcare executives should consider five best-practice approaches when implementing strategies to improve collaboration and reduce risk.

The research findings speak for themselves. Communication breakdowns in healthcare settings contribute to serious problems—rising malpractice claims, decreased productivity, delayed care, costly readmissions, aggravated patient complications, and, most alarmingly, deaths.

• ECRI Institute Patient Safety Organization’s 2015 Deep Dive on Care Coordination analysed 223 events reported by 38 facilities, including both near-miss events and events that reached the patient, a few of which caused temporary or permanent harm. The top four contributing factors to care coordination events in inpatient and discharge scenarios were human factors (associated with 131 events), communication breakdowns (98 events), policies and procedures that were either unclear or not in place (65 events), and limitations on staff qualifications (53 events). Almost two of every five care coordination events in the inpatient setting involved inadequate handoffs.
• Events reported to ECRI Institute Patient Safety Organization reveal gaps in communication about patients’ care—between hospital and clinicians, among clinicians, and between long-term care facilities and hospitals or other providers. Poor care coordination with patients’ next level of care was the No. 2 concern on ECRI Institute’s 2014 Top 10 Patient Safety Concerns for Healthcare Organizations.
• A CRICO Strategies CBS Report, Malpractice Risks in Communication Failures , found 30 percent of all national claims filed from 2009 to 2013 involved communication failure. Malpractice costs amounted to $1.7 billion, with 7,149 cases contributing to patient harm and 57 percent of those reflecting miscommunication between two or more providers. There were 1,744 deaths.
   
• More than a quarter of hospital readmissions could have been avoided with improved communication, according to an observational study published in 2016 by the University of California, San Francisco. Researchers found that of 1,000 readmissions within 30 days of discharge at 12 academic medical centers, 269 were deemed potentially preventable. The study called attention to the need to improve communication among care teams and between clinicians and patients.

Despite widespread awareness of the need to make clinical communication a top priority, physicians and nurses still struggle to communicate in a timely manner to coordinate the care of their patients.

The Communication Challenge

In a 2015 survey of nearly 1,000 healthcare professionals, conducted online by Harris Poll and commissioned by PerfectServe, 71 percent of clinicians indicated they have wasted time trying to communicate with the broader care team. Although 95 percent believe that successful care collaboration leads to reduced readmissions, clinicians feel hindered by a patchwork of antiquated or underutilized communication technologies, wasted exchanges, and concerns about privacy and security. 

Providers face a range of complex challenges brought about by health care’s fragmented cottage-industry structure, which inherently creates departmental communication barriers and critically hinders care team collaboration. Inefficiencies are characteristic in this siloed work culture, and if left unaddressed they can compromise patient safety. 

For example, various provider types—physician specialists, home care agencies, rehabilitation facilities—may independently support the very same episode of care. Consequently, patients are forced to navigate their self-care with these various providers. Each of these specialty organizations has its own distinct way of managing and receiving patient information, as do acute care hospitals. The idea of a seamless health information exchange among stakeholders becomes virtually impossible to realize. 

Furthermore, the mode of communication between providers depends on situational variables, such as time, day, and clinical circumstances. Since these variables relate to care delivery, all communication must be reliably interpretable by the end receiver or a third party such as a call-center or answering-service operator. 

Consider the example of a practice that issues a paper-based physician call schedule each day to its affiliated hospitals. By the time the schedule posts to the different hospital floors, it is outdated, potentially causing communication breakdowns. The same scenario may apply to a home health agency that tracks hospitals. In both cases, the initiator of a communication must refer to the paper instruction to connect to the right person or to a third party who has an outdated schedule. Patient care delays and errors are bound to happen.  

Amazingly, in modern medicine the telephone endures as the primary tool for cross-organizational clinical communication. Under HIPAA security laws, organizations may be criminally liable and subject to fines for any resulting privacy incidents.

Five Keys to Process Improvement

As organizations juggle new care and payment models and adjust to changing regulations, communication processes and technologies are also evolving to accommodate the growing number of clinical specialists working in various care settings with outside extended-care teams.

When working to improve collaboration and reduce risk, healthcare executives should consider five best-practice strategies.

Think care continuum, not single facility . A comprehensive communication solution will address the diverse care coordination and workflow requirements of care team members, regardless of setting. Larger practices and multisite health systems require advanced directory capabilities to coordinate transitions within a facility, system, or accountable care organization, with the appropriate workflow processes built in. Patient updates should be generated in real time.

Provide a standardized yet flexible way to communicate. Clinicians need easy-to-use options that account for advances in technology (e.g., smartphones and texting), while still remaining HIPAA-compliant. In establishing protocols for clinical communication among care teams, organizations should aim to reduce variabilities to mitigate the risk of breakdowns such as security gaps. Antiquated communication methods such as referencing binders, faxed schedules, and taped notes should be phased out.

Address process complexities with intelligent routing. Schedules, workgroup rules, team mobilization requirements, and escalation paths vary at different stages of a patient’s care plan. These should be configured automatically to ensure that each care team member is connected appropriately.

Endorse more effective consults. Enabling clinicians to communicate major aspects of therapy or diagnoses is critical for supporting expanded care networks. For instance, clinicians must be permitted to inform referring physicians about a change in patient status, obtain a critical result from the lab or X-ray, or confer with a social worker.

Use it or lose it. No communication solution will effect change if physicians and nurses are slow to adopt it or if long-term training is not provided. Organizations should ensure that clinicians know their role in achieving the desired communications outcomes.

Promoting Accountability

The push to implement lean management techniques has led healthcare organizations to uncover new areas in which to improve accountability and reduce waste. This effort encompasses the clinical communication process. 

Moving a patient safely through the admissions, treatment, discharge, and post-acute care processes requires extensive coordination, efficient communication, and a sound clinical integration strategy. Given the wealth of evidence connecting poor clinical communication to poor outcomes and patient harm, healthcare executives are accountable to make clinical collaboration a top priority. 

Terry Edwards is president and CEO, PerfectServe, Knoxville, Tenn.

Christopher Jamerson, MD, FAAP, is vice president of clinical informatics, Advocate Medical Group, and medical director of informatics, Advocate Children’s Hospital, Park Ridge, Ill.