—Tracy Cardin, ACNP-BC, nurse practitioner, hospital medicine section, University of Chicago Medical Center, Team Hospitalist member
As leaders of patient-care teams, hospitalists communicate with a wide array of care providers—case managers, nurses, pharmacists, trainees, and social workers to name a few. When the number of regular contacts increases, so, too, does the chance for miscommunication.
“Hospitalists are very non-discriminatory. We can miscommunicate with anybody,” says Jack Percelay, MD, FAAP, MP, SFHM, a pediatric hospitalist at Hunterdon Medical Center in New York City. “We all get burned at different times and that reminds us of the need to be careful, redundant, and very specific when communicating.”
How a hospitalist expresses important information with members of the care team affects the quality of patient care and the efficiency with which it’s delivered, says Sandeep Sachdeva, MD, FACP, a hospitalist at Swedish Medical Center in Seattle and a clinical assistant professor of medicine at the University of Washington. The following five scenarios demonstrate general areas of hospitalist-provider miscommunication and corrective actions that can be taken to reduce communication errors.
Scenario: An attending hospitalist quickly discusses with residents the plan of care for several patients and doesn’t invite questions, assuming the residents understand everything he is saying. For the most part, the residents comprehend the information, but some are uncertain on the more complex points. Nonetheless, no one asks questions for fear of being perceived as unintelligent or unprepared.
Corrective action: Miscommunication often is not about what’s said, but about what’s unsaid, says Sandeep Sachdeva, MD, FACP, a hospitalist at Swedish Medical Center in Seattle and a clinical assistant professor of medicine at the University of Washington. Opportunities for communication are missed when hierarchical barriers lead more experienced physicians to skip over information they believe others know and less experienced physicians to refrain from asking questions, he says.
Adopting a team approach that encourages inquiry helps to open lines of communication between attendings and residents, Dr. Sachdeva says. “In my experience, the more questions I ask not only helps me, but helps the other person, too,” he says. “The intellectual back and forth stimulates the mind and fosters collaboration.”
To facilitate teamwork, hospitalists must be respectful of other people’s experience, Dr. Percelay says.
“A hospitalist might feel his knowledge area is up to a level 8 out of 10, but he has to realize that something very clear to him won’t be as clear to someone used to working at the 5 or 6 level,” he says. “The hospitalist really needs to talk out loud and explain the situation to make sure everyone is on the same page.”
Seek to Understand
Scenario: A nurse practitioner comprehensively communicates the plan of care to a patient and her family. A short time later, and before advising the nurse practitioner, a hospitalist visits the patient and outlines substantial changes to the plan. The nurse practitioner loses credibility with the patient and family, and throughout the rest of the hospital stay the patient questions the accuracy of the information the nurse practitioner provided. The patient also wonders if the entire HM team is on the same page and providing a high level of care.
Corrective action: A hospitalist should communicate changes in a patient’s plan of care with all pertinent care-team members before informing the patient or the family, says Tracy Cardin, ACNP-BC, a nurse practitioner in the hospital medicine section at University of Chicago Medical Center and Team Hospitalist member.
It demonstrates to the patient that the HM team is in sync and avoids patient confusion. It also gives the hospitalist and team members an opportunity to discuss the change and the reasoning behind it, Cardin says.
“I think it’s important for hospitalists to stop and understand where other providers are coming from before they try to make themselves understood,” she says. “Once they understand why someone is proposing to manage a patient a certain way, it may help them communicate their plan and what they want to do differently.”
By first seeking to understand, Cardin says, a hospitalist might also realize that their plan isn’t the best option, or that a better plan can be developed through compromise.
“There have been times where I’ve had a particular treatment modality that I believed was correct and a non-physician provider recommended another, and I leaned toward what they recommended because they presented a solid case for it,” says O’Neil Pyke, MD, SFHM, chief medical officer for Medicus Healthcare Solutions, a healthcare consulting and staffing company based in Salem, N.H. “Similarly, there have been times where they’ve explained their treatment plan and I’ve said no.”
The key is listening before making a final decision, he notes.
Scenario: A hospitalist signing out fails to communicate a patient’s end-of-life wishes to the hospitalist assuming care. The patient has a DNR, however, when the patient stops breathing, a Code Blue is called and the patient is revived.
Corrective action: It’s essential for hospitalist teams to adopt a standard process for handing off patients to new providers during shift changes, says Peter Thompson, MD, chief of clinical operations for Apogee Physicians, a physician-owned and operated hospitalist group based in Phoenix.
Mandatory off-service notes that follow a set template are one simple approach, says Kenneth G. Simone, DO, SFHM, president of Hospitalist and Practice Solutions, a hospitalist practice management consultation company based in Veazie, Maine. The off-service notes can include a patient’s SOAP (subject, objective, assessment, and plan) note, as well as address code status, current medication list, primary-care physician, and family contact name and number.
“This simple tool dramatically reduces miscommunication and errors that occur during care transitions,” Dr. Simone says. “I implemented this approach when I was directing a hospitalist program and it worked remarkably well.”
Experts agree handoffs always work best when providers can communicate face-to-face. The incoming provider can get a better feel of what’s happening with the patient; the outgoing provider can make sure that the information conveyed is understood, says Christina Lackner, PA-C, lead physician assistant for the Collaborative Inpatient Medical Service (CIMS) at Johns Hopkins Bayview Medical Center in Baltimore.
Regardless of how the handoffs are conducted, Lackner says they should be as detailed as possible.
“Physicians that I’ve gotten the best sign out from are the ones who clearly convey what they want, state specifically what they did and what they’re looking for, and give me a little background on the patient,” she says. “Also, to double check that I’m comprehending the information, they ask me questions to make sure I’m giving them the right answers.”
—O’Neil Pyke, MD, SFHM, chief medical officer, Medicus Healthcare Solutions, Salem, N.H.
Scenario: A hospitalist neglects to inform the social worker that a stroke patient is resistant to outpatient physical therapy because he can’t afford the care and lacks a means of transportation to the facility. The social worker spends considerable time arranging for the physical therapy. After being discharged from the hospital, the patient doesn’t adhere to the therapy regimen.
Corrective action: Holding multidisciplinary patient-care rounds in which the social worker and other providers (nurses, pharmacists, case managers, etc.) actively participate can have a positive impact on communication and collaboration, Dr. Simone says. In addition to reviewing the treatment approach and clinical response, teams can discuss discharge planning, insurance coverage, and patient adherence.
“These rounds must be well organized, so they do not become time consuming and decrease the efficiency of all involved,” Dr. Simone says, adding some HM groups impose a time limit of two minutes per patient or discuss only the most acute patients or those approaching discharge.
If interdisciplinary rounds aren’t possible, hospitalists can work with other providers to develop content expectations that should be entered in the patient’s chart daily or as appropriate, Dr, Simone says. Each provider would then be required to read the daily entry in the patient’s progress note.
“As the head of the interdisciplinary team, hospitalists have to make sure what they are trying to do gets dispersed to all the members of the team,” Dr. Pyke says. “The progress record is probably the most consistent way to do that.”
Many electronic health record (EHR) systems don’t provide as much detail as traditional written records, Dr. Pyke says. He advises hospitalists teams use an EHR that, in addition to providing templated information, can transcribe doctors’ dictated notes in real time.
Scenario: An expensive, broad-spectrum antibiotic is administered to a patient in the ED because doctors haven’t identified the offending organism. Once stabilized, the patient is transferred to the medical floor. Rather than switching to a less expensive, equally effective medication when the culture results come back, the hospitalist continues ordering the expensive drug.
Corrective action: HM teams can develop treatment approaches to common medical conditions based on data in the literature that defines best practices, Dr. Simone says. These evidence-based clinical order sets can be pre-printed so that each hospitalist can approach the same diagnostic workup and treatment in a standardized manner.
“It encourages physicians to utilize proven methods,” he says.
Dr. Pyke recommends hospitalists input medication orders in the computer system. Physician order entry forces the hospitalist to look at the patient record, which makes it more likely they order the appropriate intervention, he says.
“Because the physician is going off of solid information about that particular patient, there’s less chance of a mistake happening or something getting overlooked,” Dr. Pyke says.
Lisa Ryan is a freelance writer in New Jersey.