JKF Journal: It All Comes Back to Communication

Thursday, June 7, 2007

It All Comes Back to Communication

In the nearly five years that I have been participating in this patient safety movement, I have met thousands of wonderful healthcare providers. I have visited hospitals all over the country. I have sat and listened to dozens of patient safety conferences and grand rounds. I have learned big words like nosocomial infections.

Through it all I have told Josie's story and every step of the way I have tried my best to inspire caregivers to incorporate patient safety best practices into their everyday experience on the job. I have looked and listened, and have been amazed at all of the good I see, while also being confused as to why things can't happen faster and why 98,000 people still continue to die from medical errors every year.

The thing that really continues to amaze me is the communication issue. Josie died because people didn't listen. They didn't listen to me, and they didn't listen to each other. I can't tell you how many stories I have on my computer from families who have been affected by medical errors, and there always seems to be a common thread, "They didn't listen."

Correct me if I'm wrong. Doesn't the Joint Commission report that over 60% of all sentinel events are due to a breakdown in communication? I am not a doctor or a nurse. I am not at the bedside, and I am not an expert in the field of patient safety; however it seems to me that if people communicated better we'd all be safer. I believe in high tech solutions. It is where we are heading, but wouldn't we get more bang for our buck if we communicated better?

I was in Pennsylvania a few months ago at a wonderful hospital by the name Abington Memorial. I was presenting at their Grand Rounds. After the presentation, I was lucky enough to join them on their Patient Safety rounds. The team consisted of two nurses, a doctor, and a board member. I was struck by two things:

The first was the presence of the board member. There is a lot of talk these days about getting board members involved, especially when it comes to safety and quality. It was so great to see first hand a hospital that was doing just that.

The second thing that struck me- Every unit we went to, the patient safety officer would ask the nursing team on the floor a question:

"If you could have anything you wanted on your floor to keep patients safe what would it be?"

Each floor had variations on the same response:

"I wish we could get into the doctors' heads."
"I wish we were more like a team."
"I wish we communicated better."

That is what they wanted. They did not ask for fancy equipment or the latest in technology. They wanted to understand what the doctors were thinking. They wanted better communication between the nurses and the doctors. The thing that amazes me even more is that I hear this everywhere I go. Communication- and it is not just between the doctors and the nurses. It is between the patients, their families and those who are caring for them.

It seems so simple, but I am learning that changing behavior is not an easy thing to do. I don't know what it takes, maybe time, maybe another generation, hopefully not more deaths.

I will tell you one thing. The board member that day heard that message loud and clear and I bet she shared what she learned with her fellow board members, at least I hope she did.

Labels: by Sorrel, Communication, Hospital Visit

3 Comments:

At June 8, 2007 at 7:30 AM , Unknown said...

Sorrel, greetings. I read your blog this morning as I get ready to give a talk in Toronto probing some of the challenges to a culture of safety. Like you, one of the places I found myself going is around the failure of effective communications and particularly our inability to listen to each other as well as our patients and families. In work you helped inform, patients and families around the world told IHI what they expect from the healthcare system 100% of the time. At the top of the list they say "listen to me, trust me, respect me as a partner in care" Around the country we are finding organizations where communication is being structured through approaches such as team training and SBAR. As your note suggests we can't just tell people to "do better." They already want to "do better." What we have to take is a sytematic approach to communications.

I also wanted to comment on your visit to Abington Hospital. They have been informing the leading edge of improvement in quality and safety for years--an amazing team. The inclusion of board members on rounds is exactly what the IHI 5 Million Lives Campaign Board on Board intervention recommends and celebrates--Board members experiencing the amazing care and caring as well as learning the realities of practice. Last week I was in a small critical access hospital in Vermont--Springfield Hospital. Monthly the Board chair and CEO meet with patients and families to discuss their experiences in care. From that they drive and inform their priorities moving forward.

I too am in awe of the hard work by so many and yet struck by the continued harm. Whether patient, family member, leader, staff member, trustee, the work ahead requires that we optimize listening and learning. Thanks for all you are doing to move that along in the name of Josie.

Jim Conway
SVP IHI
At September 8, 2007 at 3:39 PM , Unknown said...

Sorrel,
I heard your story at JHHCG orientation. You are an amazing woman who has inspired the health care community to "do the right thing" This is a living example of transparency and not just a slogan.
System failures across settings is the next wave of safety and quality. Interesting how the basics such as communication is the missing ingredient. How do you measure it and improve it will be the next question asked. Perhaps that is where Lucian, Peter and IHI come in. The Patient Safety net was an incredible tool to take to the clinician level as the capacity to measure is limited by knowledge and resources. Again I commend your brother in law for bringing this tool to the clinician level.
Your are the "angel" of safety bringing the "heart" of healthcare back into focus....
DAT
At October 11, 2007 at 4:49 PM , Lisa Lindell said...

There is no doubt, our 108 day hellish ordeal is 100% the fault of repeated failures to communicate. Furthermore the facility has procudures and rules in place which effectively banish all communication, not only between family/pt and medical staff, but amongst medical providers.
Again I think this stems from disdain towards the pt/family and let's face it, the arrogance of physicians.
I was at an event earlier this year and an administrator commented to the presenter that in their facility they don't seek feedback from their patients because the patient has a different "perspective." Hmmmm.
I can think of no other business that doesn't value feedback from their customer. Often they pay big money for feedback, market research, etc. If General Motors adopted the same attitude towards consumers, it would sound like this: "You can't possibly understand how complicated engineering a motor vehicle is, what with all the emission standards and government regulation we have to contend with. And you people don't drive them correctly, anyway, it says right in the owner's manual not to drive a new engine over 55 mph, you don't pay any attention or appreciate how much work we do in building you an automobile, we could care less if you like the steering wheel or not."
GM wouldn't be selling very many cars, now would they? In my opinion, this is very much the same attitude and hostility consumers have been faced with by the health care professionals. We just don't matter.
--
Lisa Lindell
www.108DAYS.com/home

Thursday, June 7, 2007

It All Comes Back to Communication

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