A Hospital Case
In the hospital setting, “do more with less” appears to be one dominant cultural theme. Continued calls for efficiency and cost control and reductions are commonly heard. As lengths of stay have been significantly reduced, this has resulted in little available time for meaningful and effective communication among patients and providers of care.
The Institute of Medicine books To Err is Human and Crossing the Quality Chasm, have certainly heightened awareness of the need for improved quality and safety in hospitals. They highlight how miscommunication as a major cause of errors in care.
Consider the following:
In a teaching hospital, each morning there are medical rounds. This consists of an attending physician, fellows, residents and interns going around to see their selected group of patients. One of the residents as they get to each patient, provides an oral summary of test results and results from the last physician exam. The resident orally provides treatment plan recommendations. These are orally discussed and a treatment plan agreed to. One of the residents writes notes, which must then eventually be transcribed onto the chart.
It’s the end of the day shift and the evening shift is about to begin. The day nurse makes the last rounds of assigned patients. When visiting each patient, the nurse reviews each chart, looking at other nurses’ notes, lab and other tests, latest vital signs results, latest physician orders and asks the patient about how the patient “feels,” complaints or concerns. The nurse writes all these down for the handoff or inter-shift report for the incoming shift, in which the nurse provides an oral report from notes regarding every patient. The oral report then gets transcribed by the incoming nurse.
After several days, a patient is visited by his/her attending physician, who says something like: You will probably be discharged tomorrow as long as your vital signs remain within normal range. The following morning the nurse comes in to see the patient.
The patient says: “The doctor said I am being discharged today.”
The nurse replies: “I don’t see discharge orders in the chart and the doctor did not tell me you are supposed to be discharged today.”
Several hours later the nurse arrives and says: “I spoke to the doctor and the doctor will be coming in to do a final exam and write the discharge orders. The doctor will also give you post-discharge instructions.”
Several hours later (and there has been a change of shift for nurses), the physician arrives, does a final exam, provides the patient with post-discharge instructions and says:
“Yes you will be discharged today. Before you can leave the hospital, the nurse has to give you instructions.” Much of what the physician told the patient, the patient did not completely understand but was “afraid” or too “ashamed” to ask questions.
The patient gets dressed, expecting to be discharged imminently. Several hours pass. The nurse arrives with a long list of post-discharge instructions, some of which match up with those given by the physician, but some do not…some are written and some are verbal. Again, the patient did not completely understand all the instructions.
After a day or two after discharge the patient did not remember much of what was conveyed verbally.
Please answer the following questions:
What were the barriers to effective communication which could have affected patient quality of care, safety, and satisfaction?
Propose how your identified ineffective communication practices could be overcome.
Consider communication channels and feedback
Consider the need for greater coordination for improved patient care
