Communication The greatest problem in communication is the illusion that it has been accomplished. --George Bernard Shaw Activity: Play a quick game of telephone Assumptions Fatigue Distractions HIPAA

Objectives Describe how communication affects team processes and outcomes Define effective communication Identify communication challenges Identify TeamSTEPPS tools and strategies that can improve a team’s communication Following this module, you will be able to:

Communication Effective communication skills are vital for patient safety Enables team members to effectively relay information The mode by which most TeamSTEPPS strategies and tools are executed Communication is the lifeline of a well-functioning team and serves as a coordinating mechanism for teamwork. Effective communication skills are vital for patient safety and interplay directly with the other components of the TeamSTEPPS framework. Further, communication is the mode by which most of the TeamSTEPPS tools and strategies are executed. Therefore, this module serves as the basis for the leading teams, situation monitoring, and mutual support modules that will follow.   This module will discuss the standards of effective communication and will present information exchange strategies and specific tools to enhance communication among team members.

Importance of Communication Joint Commission data continues to demonstrate the importance of communication in patient safety 1995 - 2005: Ineffective communication identified as root cause for nearly 66 percent of all reported sentinel events* 2010 - 2015: Ineffective communication among top 3 root causes of sentinel events reported** The continued importance of effective communication in care teams cannot be understated. According to sentinel event data compiled by the Joint Commission between 1995 and 2005, ineffective communication was identified as the root cause of 66 percent of reported errors. More recent Joint Commission data from 2010 to 2015 show that ineffective communication has remained among the top three root causes of sentinel events. As these data illustrate, failure to communicate effectively as a team significantly increases the risk of error. ASK: Can you describe an example in which a communication breakdown was the major contributing factor of an error in care? Or a waste of time/resources? Can you describe an example in which a communication breakdown was the major contributing factor of an error in care? Or a waste of time/resources? * (JC Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005) ** (JC Sentinel Event Data (Root Causes by Event Type) 2004-2015)

Communication is… The process by which information is exchanged between individuals, departments, or organizations The lifeline of teams Effective when it permeates an organization Assumptions Fatigue Distractions HIPAA Communication is defined as the transfer or exchange of information from a sender to a receiver. More specifically, communication is a process whereby information is clearly and accurately conveyed to another person using a method that is known and recognized by all involved. It includes the ability to ask questions, seek clarification, and acknowledge the message was received and understood. One critical result of effective communication is a shared understanding, between the sender and receiver(s) of the information conveyed. Two considerations in communication are whom you are communicating with and how you are communicating information. Whom you are communicating with, or the audience, will influence how information is conveyed. For example, an information exchange with a medical assistant may differ from an exchange with a physician. In terms of how you communicate, there are two modes of communication: verbal and nonverbal.

Communication is… knowing your body language Communication is defined as the transfer or exchange of information from a sender to a receiver. More specifically, communication is a process whereby information is clearly and accurately conveyed to another person using a method that is known and recognized by all involved. It includes the ability to ask questions, seek clarification, and acknowledge the message was received and understood. One critical result of effective communication is a shared understanding, between the sender and receiver(s) of the information conveyed. Two considerations in communication are whom you are communicating with and how you are communicating information. Whom you are communicating with, or the audience, will influence how information is conveyed. For example, an information exchange with a medical assistant may differ from an exchange with a physician. In terms of how you communicate, there are two modes of communication: verbal and nonverbal. Common body language mistakes: crossed arms, slouching, frowning, leaning too far forward, avoiding eye contact, overly intense http://learnthat.com/6-worst-body-language-mistakes-you-can-make-in-an-interview/

Standards of Effective Communication Complete Communicate all relevant information Clear Convey information that is plainly understood Brief Communicate the information in a concise manner Timely Offer and request information in an appropriate timeframe Verify authenticity Validate or acknowledge information AND…. Effective communication is: Complete – Communicate all relevant information while avoiding unnecessary details that may lead to confusion – Leave enough time for questions, and answer questions completely Clear – Use information that is plainly understood (lay terminology with patients and their families) – Use common or standard terminology when communicating with members of the team Brief – Be concise Timely – Be dependable about offering and requesting information – Avoid delays in relaying information that could compromise a patient’s situation – Note times of observations and interventions in the patient’s record – Update patients and families frequently – Verify authenticity, which requires checking that the information received was the intended message of the sender – Validate or acknowledge information

What does effective communication look like in your setting? Closed Loop Know the plan, share the plan, review the risks What does effective communication look like in your setting?

The Theory Effectiveness Team Leadership Orientation Mutual Performance Monitoring Back-up Behavior Adaptability Shared Mental Models Trust Effectiveness Closed Loop Communication Salas, Sims, Burke. Is there a “Big Five” in teamwork? Small Group Research. 2005; 36:555-599. Big 5 Coord. Mechanism When team members trust each other, use closed loop communication, and value team goals above individual goals; that is they are oriented toward the team; they have the ability to adapt, manage complex systems & patients and learn from experience.

Communication Challenges Language barrier Distractions Physical proximity Personalities Workload Varying communication styles Conflict Lack of information verification Shift change Challenges may include: Language barriers—Non-English speaking patients/staff pose particular challenges* Distractions—Emergencies can take your attention away from the current task at hand Physical proximity Personalities—Sometimes it is difficult to communicate with particular individuals Workload—During heavy workload times, all of the necessary details may not be communicated, or they may be communicated but not verified Varying communication styles—Health care workers have historically been trained with different communication styles Conflict—Disagreements may disrupt the flow of information between communicating individuals Lack of verification of information—Verify and acknowledge information exchanged Shift change—Transitions in care are the most significant time when communication breakdowns occur   ASK: Have you experienced a situation in your setting involving a breakdown of communication? What are some examples? What is the biggest communication challenge in your setting?

Information Exchange Tools and Strategies Situation – Background – Assessment – Recommendation (SBAR) Call-Out Check-Back Handoffs A number of tools and strategies to potentially reduce errors associated with miscommunication or lack of information are listed. The following four strategies are simple to integrate into daily practice and have been shown to improve team performance: Situation−Background−Assessment–Recommendation (SBAR) Call-Outs Check-Backs Handoffs

SBAR Provides… A framework for team members to effectively communicate information to one another verbally or in written form Communicate the following information: Situation―What is going on with the patient? Background―What is the clinical background or context? Assessment―What do I think the problem is? Recommendation―What would I recommend? The SBAR technique provides a standardized framework for members of the health care team to communicate about a patient's condition. You may also refer to this as the ISBAR, where “I” stands for “Introductions.” In phrasing a conversation with another member of the team, consider the following: Situation—What is happening with the patient? Background—What is the clinical background? Assessment—What do I think the problem is? Recommendation—What would I recommend? Although SBAR is typically used as a communication tool between clinical staff, it can also be modified for use by the patient to communicate with their provider. For example, your facility could provide patients with a version of SBAR to enable them to share information about their own situation, background, assessment, and recommendations, or to ask the provider about their care.

SBAR Video DISCUSSION: How did the SBAR technique improve communication between the nurse and physician?   The pharmacist identified the reason he needed to talk to the physician (about Mrs. Holmes), how much time it would take, and who he is…John, the pharmacist John quickly made Dr. McCarthy aware of Mrs. Holmes’s situation (pain is not well controlled and she is sedated affecting participation in therapies) The background is that Mrs. Holmes has fallen 3x but wants to go home for a family anniversary John’s assessment poor pain control and meds contributing to falls John’s recommendation is to lower the opioids and introduce an anti-inflammatory What did Dr. McCarthy do to support John’s use of SBAR? Asked for his recommendation “what do you recommend?” Gave him feedback “sounds like a good plan” Some find it difficult to state their recommendation; if you don’t provide a recommendation/request, then you may be hinting and hoping using indirect suggestions that may not provide clear or concise patient information How did the SBAR technique improve communication between the pharmacist and physician? https://www.youtube.com/watch?v=fsazEArBy2g

SBAR Exercise Think-Pair-Share Where do you use SBAR to improve communication? Where could you use an SBAR to improve communication? Share an SBAR example. Here is an example of a form that a CEO developed using SBAR to help his staff better communicate their needs when they wanted him to review a document. ACTIVITY: Take the next few minutes to create an SBAR example based on your specific role.

Call-Out is… A strategy used to communicate important or critical information It informs all team members simultaneously during emergency situations It helps team members anticipate next steps A call-out is a tactic used to communicate critical information during an emergent event. Critical information called out in these situations helps the team anticipate and prepare for vital next step. This may or may not be relevant to your clinic practice, but wanted to make you aware of the tool in case you find opportunities for its use later on.

Call-Out is… Play the video available on the AHRQ website at https://www.ahrq.gov/teamstepps/instructor/videos/ts_ldcallout/callout2.html A call-out is a tactic used to communicate critical information during an emergent event. Critical information called out in these situations helps the team anticipate and prepare for vital next step. This may or may not be relevant to your clinic practice, but wanted to make you aware of the tool in case you find opportunities for its use later on.

In what situations might you use a check-back in your setting? Check-Back is… Play the video available on the AHRQ website at https://www.ahrq.gov/teamstepps/instructor/videos/ts_checkback/checkback.html A check-back is a closed-loop communication strategy used to verify and validate information exchanged. This strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received. Here is an example of the use of a check-back (on slide) A check-back is an effective tool for all members of the team, including patients and their family members. For example, patients and families can use the check-back to verify the receipt of care instructions or confirm understanding of symptoms to monitor. ASK: In what situations might you use a check-back in your clinic? In what situations might you use a check-back in your setting?

Handoff is… The transfer of information, responsibility, and accountability during transitions in care across the continuum Includes an opportunity to ask questions, clarify, and confirm The handoff strategy is designed to enhance information exchange at critical times. More important, it maintains continuity of care despite changing caregivers. 19

Handoff Consists of… Responsibility: Person is aware of assuming responsibility Accountability: You are accountable until both parties are aware of the transfer Uncertainty: Clear up all ambiguity before the transfer is complete Communicate verbally Acknowledged: Ensure that the handoff is understood and accepted Opportunity: Ask questions and evaluate the situation for both safety and quality A proper handoff includes the following: Responsibility—When handing off, it is your responsibility to know that the person who must accept responsibility is aware of assuming responsibility. Accountability—You are accountable until both parties are aware of the transfer of responsibility. Uncertainty—When uncertainty exists, it is your responsibility to clear up all ambiguity about responsibility before the transfer is completed. Communicate verbally—You cannot assume that the person obtaining responsibility will read or understand written or nonverbal communications. Acknowledged—Until it is acknowledged that the handoff is understood and accepted, you cannot relinquish your responsibility. Opportunity—Handoffs are a good time to review and have a new pair of eyes evaluate the situation for both safety and quality.   It is important to highlight that both authority and responsibility are transferred in a handoff. As identified in root cause analyses of sentinel events and poor outcomes, lack of clarity about who is responsible for care and decision making has often been a major contributor to medical error. 20

“I PASS THE BATON” Introduction: Introduce yourself and your role/job (include patient) Patient: Identifiers, age, sex, location Assessment: Present chief complaint, vital signs, symptoms, and diagnosis Situation: Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment Safety: Critical lab values/reports, socioeconomic factors, allergies, and alerts (falls, isolation, etc.) THE Background: Comorbidities, previous episodes, current medications, and family history Actions: What actions were taken or are required? Provide brief rationale Timing: Level of urgency and explicit timing and prioritization of actions Ownership: Who is responsible (nurse/doctor/team)? Include patient/family responsibilities Next: What will happen next? Anticipated changes? What is the plan? Are there contingency plans? Know the plan, share the plan, review the risks

Hand-off Play the video available on the AHRQ website at https://www.ahrq.gov/teamstepps/instructor/videos/ts_ISHandoff/INPTSURG-768.html

Review of the Video Think about what went well in this scenario. Was proper communication demonstrated? Was communication brief, clear, timely, closed loop? Was this strategy effective to achieve an effective hand-off? Why or why not? How do handoffs in your setting compare to this strategy?

The Ineffective Hand-Off Two inpatient nurses needed coverage for 3 patients so that they could attend a continuing education meeting that began at 1130. The nurse providing coverage (Susie) did not arrive until 1145 so the nurse manager (Jan) took report from the 2 inpatient nurses at 1115. Jan handed off the 3 patients to Susie at 1145. Jan instructed Susie to administer medications to 2 of the 3 patients using print outs instead of using the electronic BCMA program because Susie did not have access to the BCMA program. Jan had given 2 medications to one patient but none to the two other patients. Susie followed Jan’s instructions and the print out to administer the medications that had not been given. Thus, she bypassed the check provided by the BCMA. RESULT: Two medication errors—one patient received medications they were not to have received until the next day (wrong meds); the other patient did not receive 2 ordered medications (omissions) because Jan had checked off on the print out that 2 medications had been given when they had not. The covering nurse did not have electronic access to the BCMA program. Many problems with this scenario: Unclear expectations of the nurse covering Not following protocol on appropriate medication management Not having clear expectations that the on duty nurses would have completed all medication and charting prior to leaving for their meeting

Review of the Scenario Think about what went poorly… Did Jan understand that she was handing off responsibility and accountability for these 3 patients to Susie? Did Jan’s handoff address uncertainty using verbal communication? Did Susie acknowledge that she understood the actions she needed to take; did she accept responsibility and accountability? What threats to patient safety did Jan and Susie miss? (they did not take the opportunity to evaluate safety and quality)

Tools & Strategies Summary BARRIERS Inconsistency in Team Membership Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Followup with Coworkers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity TOOLS and STRATEGIES Communication SBAR Call-Out Check-Back Handoff OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!! Communication skills interact directly with leadership, situation monitoring, and mutual support:   Team leaders require effective communication skills to convey clear information, provide awareness of roles and responsibilities, and provide feedback. Team members monitor situations by communicating any changes to keep the team informed and the patient protected. Communication facilitates a culture of mutual support when team members request or offer assistance and verbally advocate for the patient. Communication tools that can enhance teamwork include the SBAR, call-out, check-back, and handoff. These tools facilitate effective and efficient communication within and across teams. Good communication facilitates the development of shared mental models, adaptability, mutual trust, and patient safety.