Engaging Physicians in Patient Safety: A Handbook for Leaders

This excerpt from the new JCR book, Engaging Physicians in Patient Safety: A Handbook for Leaders, offers tips for improving communication in your organization. This book provides an overview of the physician’s role in the culture of safety, outlines common obstacles to physician involvement in hospital initiatives, and describes solutions for getting physicians on board to meet strategic goals and objectives.

Facilitating Physician Participation in Patient Safety: Improving Communication
With the complexity of care today, it is essential that all caregivers—including physicians—have standardized communication tools and share a common language with other health care providers to avoid unsafe situations such as the following:

• Transferring incorrect or incomplete information from one provider to another
• Differing perceptions among caregivers regarding the same patient’s needs
• Disrupting new processes and systems
• Introducing errors into existing processes

Communication failures have been identified as a root cause of 65% of all sentinel events reported to the Joint Commission, and hospitals have made communication issues (completeness, accuracy, timeliness, and clarity) a high priority for patient safety programs.

One of the main roadblocks to effective communication is the difference in communication styles among health care professionals. When calling a physician about a patient’s condition, a nurse may provide a narrative description that gives an overall picture of the situation; the physician, however, prefers to hear a concise statement of a problem with a specific question or suggestion aimed at solving it.1 He or she is not interested in the patient’s entire history, only in those elements that are relevant to the current difficulty. To bridge this gap in communication styles, many hospitals are training staff to approach contacts with physicians in a different way, such as the Situational Briefing model, also known as SBAR (situation, background, assessment, recommendation), which is explained in more detail in Sidebar 1.

Sidebar 1. The Situational Briefing Model of Communication Developed at Kaiser Permanente, the SBAR (situation, background, assessment, recommendation) technique uses a consistent approach to communication that allows for effective information sharing among physicians and other caregivers. Whenever hospital staff members contact a physician, they follow the process outlined here. Situation: What is the situation you are calling about? Identify yourself, your unit, the patient, and the room number. Briefly state the problem, when it happened or started, and how severe it is. Background: What background information is pertinent to the situation? Any of the following may be included: The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, and labs Most recent vital signs Lab results, including the date and time the test was performed and the results of previous tests for comparison Other relevant clinical information Code status Assessment: What is your assessment of the situation? Recommendation: What do you recommend, or what do you want the physician to decide? Source: Institute for Healthcare Improvement: SBAR Technique for Communication: A Situational Briefing Model. Institute for Healthcare Improvement. http://www.ihi.org (accessed Dec. 30, 2005).

Physicians are also being educated in how to ask for the information they want in a nonconfrontational way. Discussions that are clear and succinct reduce the amount of time required as well as the number of subsequent calls for clarification.

Another important consideration is communication between practitioners with different levels of experience in different areas. It is often difficult for health care professionals to realize that all caregivers are not operating from the same knowledge base. On patient safety teams, risk managers or quality improvement staff may quote statistics on nosocomial infection rates without putting the information into context for others on the team. Unless the numbers are presented along with their relevance to the hospital’s population(s) and opportunities for improvement, it is probably just meaningless data to the rest of the group.

Similarly, in an academic hospital, an attending physician may not state problems and solutions clearly to residents, assuming they understand the reasons for each action taken. For instance, hand washing is a task that all caregivers are supposed to perform before and after touching a patient. An attending physician may wash his or her hands automatically without noting for residents what the proper procedure is, or explaining that the hospital has established guidelines for hand hygiene to try to reduce nosocomial infection rates, and that improving compliance with the guidelines is a current patient safety initiative. Or a teacher might diagnose a condition that seems obvious to him or her, and prescribe the appropriate medication, without clearly stating the problem and solution for the student. In either case, there is a risk that residents will not receive the information they need to provide high-quality care in the safest possible manner. Both physicians and staff need to be shown that completeness and clarity, as well as brevity, can save time and reduce risks.

It is important to note that striving for completeness can be a double-edged sword. Although everyone involved in an initiative needs to know what’s going on and receive feedback on different aspects of the project, everyone does not need to get all the information about everything. Inundating physicians with e-mails, memos, and voice mails that do not directly concern them is one of the surest ways to cause overload. As with discussions about a patient, physicians want to know what the situation is and what needs to be resolved. Copying clinicians on every communiqué between every member of the team is unnecessary, time-consuming, and counterproductive. The following points should be considered when setting up lines of communication for patient safety initiatives:

• Decide at the beginning of the project who needs to be informed of what and make these decisions clear to team members. If participants feel they need more or less information, they will have the opportunity to say so.
• Use multiple but limited channels for communication. For example, if a process has been drafted by certain members of the team, it can be e-mailed or sent in memo form to others for review. If leaders or facilitators want to confirm meeting attendance beforehand, voice mail or e-mail can be used. In each case, it is an either/or decision; using both channels is overkill. It may help to let team members know up front what channels will be used for messages, because some people check e-mail far more frequently than voice mail or vice versa. Some prefer working with hard copy, whereas others like to edit online. Trying to accommodate members’ preferences encourages their completion of tasks.
• Use team members’ specific skills and knowledge to determine who needs to review what. For example, if a redesigned process is spread across three settings within the same hospital, representatives from each setting would be asked to comment on the issues that affect their area. This lessens the amount of work required of each member and concentrates his or her efforts where those efforts can produce the most benefit.
• As discussed for verbal communication, keep messages and instructions concise and clear.
• Although communication is one of the most important processes to evaluate for time efficiency, others also contribute to overload if they do not run smoothly.

Streamlining Processes
The goal of many patient safety initiatives is to improve processes to reduce risk; however, the elements of the improvement process itself can prove cumbersome and in need of redesign as well. It is also necessary to make the steps in the process as time efficient as possible. Leaders need to examine how patient safety initiatives are conducted and how they can be structured to save physicians and staff valuable time.

For example, meeting attendance is often seen as the most onerous task of any project. Spending several hours discussing possible solutions to ambiguous problems can make even the most dedicated safety experts throw up their hands in frustration. Several time-management strategies can make meetings not only bearable but useful:

• Scheduling. Plan meeting times around physician and staff availability. Frequently, first thing in the morning is the best time to meet. Or choose scheduled breaks such as lunchtime. Because physicians typically have responsibilities outside the hospital, meeting by conference call may be the most practical solution. Many hospitals use their secure intranet site to post documents and presentations for use during conference calls.
• Established times and agendas. Send an agenda to all team members before the meeting. The agenda should include the start and end times, location (or phone number for a conference call), items to be covered, and who is responsible for presenting each item. Meetings should begin and end on time to be respectful of team members’ other responsibilities and commitments.
• Advance preparation. To make the best use of meeting times, team members need to commit to being prepared for meetings. The team should set realistic goals for what needs to be accomplished at each meeting and then assign responsibilities as needed to meet those goals. If a team regularly fails to address most or all of the items on the agenda, the team leader or facilitator should evaluate the agenda for appropriateness.

This is only one part of the day-to-day routine that can be streamlined to lift a bit of the burden from physicians and staff who are participating in initiatives. Others may include communication problems, addressed earlier, and troubles associated with computers. Hospitals rely heavily on their computer systems, but clinicians and staff often have trouble using them—whether because of lengthy log-in procedures, a lack of compatibility from one area to another, or extended wait times for access to a terminal. If a problem arises getting information to those who need it, leaders need to work with their information technology department to resolve issues.

Persuading physicians to become involved in patient safety initiatives requires proving to them that the cause is worthwhile, that improvement can be realized through a team effort, and that participation in such efforts will not take up every spare moment they have. The best proof, of course, is the acknowledged success of an initiative that has already made a positive difference in patient outcomes. Being able to celebrate fewer near misses involving look-alike/sound-alike drugs, a decrease in fall rates among geriatric patients, or fewer surgical site infections can provide as much incentive as reward.

Reference

1. Groff H., Augello T.: From theory to practice: An interview with Dr. Michael Leonard. Forum pp. 10–13, Jul. 2003. http://www.rmf.harvard.edu/files/documents/Forum_V23N3_a5.pdf (accessed Dec. 30, 2005).

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