Hospital communication challenges and impact on patient experience (YEL 2022)

Date:  26 October 2022

Hospital communication challenges and impact on patient experience (YEL 2022)

Authors: Dr Moustafa Abdelwahab (UAE) (Co-Chair); Searchmore Chaparadza (Zimbabwe) (Co-Chair); Dr Turki Asiri (Saudi Arabia); Dr Carmen Lam (Hong Kong).

Reviewers (YEL Alumni): J. Antônio Cirino (Brazil), Sudha Pathak (UAE).

Introduction

Effective communication is essential in any business, but it is even more so in healthcare. Poor communication in healthcare may have extremely serious consequences, and can negatively affect patients’ outcomes. It frequently results in misdiagnoses and other medical errors that can easily lead to avoidable morbidity and mortality. Communication failures in United States hospitals and medical practices were responsible at least in part for 30% of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years, according to the Risk Management Foundation of the Harvard Medical Institutions (2016). The Joint Commission International (JCI) (2018) goes further to state that communication failure is the root cause of most sentinel events.

According to Cirino (2021), communication is intrinsically linked to the international goals for patient safety:

  • Correct patient identification
  • Effective communication
  • Safe use of medications
  • Safe surgery
  • Prevention of risk of infections, injuries and falls

Effective communication is believed to assist in ensuring the above goals are met in a hospital set up. As an everyday service delivery issue, communication challenges happen across the whole patient experience journey. There are many instances when communication does not go well between the hospital and the patient, the different clinicians, the hospital and the doctor, as well as the hospital/doctor and relatives. All these cases result in serious gaps in service delivery, which affect patient experience.

There are various communication challenges that may be frequently encountered. These communication challenges can be physical, emotional, cultural, language, gender-based, and interpersonal. Below are some examples noted from the different experiences of the authors.

1 Clinical Redundancy causing unnecessary patient anxiety

In Hong Kong, taking surgical oncology patients as an example, the patient journey usually requires 4-6 weeks from initial assessment to work up, confirmation of diagnosis, and decision to operation. Although the clinical information is all uploaded as electronic patient records, it is not uncommon that these patients are asked the same set of questions when they are referred from one specialty to another for assessment. This ensures important signs and symptoms are not overlooked. Unfortunately, this also leads to unnecessary patient anxiety and frustration.

The perioperative service model could be remodeled to reduce redundancy across different clinical referrals. An integrated patient care program with IT solutions should be in place to facilitate the logistics and information flow. For example, a perioperative dashboard could be established such that each of the various disciplines could share an overview of the patient journey and a multidisciplinary approach adopted to lean the procedures and eliminate the repetitive history taking and investigations.

The Hospital Management Asia (2022) has also advised that the cornerstone of improving efficiency and patient safety is to enhance clinical communications for the hospital. In an environment where there is an ageing and rising population, pressure on healthcare facilities is increasing, and to deliver care effectively, there needs to be better collaboration amongst the people who deliver the care, using technologies like mobile handsets.

2 Inconsistencies during shift handovers thereby affecting patient experience

In Saudi Arabia, United Arab Emirates and Zimbabwe, there has been a notable challenge of inconsistent communication when staff shifts are handing over to each other. This has resulted in an adverse experience for patients as they are treated by one shift after the other, and repetitive tasks in a subsequent shift being performed. According to the JCI (2018), approximately half of communication failures in a hospital occur during patient handoffs. A notable observation was that despite lack of agreement on content and rationale, peer ratings of handoff quality were high, which seemed to mask the extent of the problem of communication at handover.

One of the solutions implemented in such a scenario has been to be more deliberate at shift handovers for both doctors and nurses in the emergency department by introducing new lead staff to the patients being treated during shift handover. For in-patients, it has been an issue of introducing the new team leader in the ward to the already admitted patients, so that they are aware that while people treating them are changing, they are fully briefed.

In Singapore, a study by Wong et al. (2019) during the Getting-Research-into-Practice session with the 3-ward nurses found a problem emerging;, there was registered nurses’ inconsistency in the clinical handover process. A review session was arranged with a few nurses from the three participating wards to target the identified non-compliance results. This was complemented with a paper survey for registered nurses (n=60) to highlight issues they faced with handing over. Consequently, the root causes of the non-compliance were identified and action plans were derived from the participants (Figure 1).


Figure (1): Root causes analysis of clinical handover problems based on the cause-and-effect Fishbone Diagram (Wong et al., 2019)

One hospital in the United Arab Emirates has standardized hand off documentation using an automated tool which the clinical teams have found very helpful. The automated tool program is evidence based, flexible and was easily incorporated into the hospital’s already existing handoff bundle. At implementation, the hospital recognized early engagement of physicians, stakeholders’ support, ongoing observation and feedback as critical factors in the successful adaptation, implementation and sustained use of the tool.

In addition, several strategies were adopted by various healthcare institutions in Saudi Arabia, especially at shift handovers, and ensure more effective communication of information to patients. These include:

  • The RELATE Model (Reassure, Explain, Listen/Answer questions, Take action, Express appreciation). Candrian et al. (2020) reported that evaluation of 15 Advance Care Planning (ACP) Guides found that trained ACP Guides could effectively use the RELATE model of communication to support ACP conversations;
  • The STICC Protocol (Situation, Task, Intent, Concern, Calibrate) has been adopted for providing structure to briefings and ensuring that critical information has been understood (HIPPA, 2022); and
  • The BATHE Protocol (Background, Affect, Troubles, Handling, Empathy) is useful for establishing a rapport with patients, to put them at ease, give them reassurances and listen to their concerns. The BATHE approach proved to be effective in outpatient settings at improving patients’ experience and their satisfaction scores (HIPPA, 2022).

3 Social media upsurge versus healthcare regulatory provisions for hospitals

In countries like Zimbabwe and Nigeria, regulations against advertising by hospitals have resulted in limited information going through to patients either because hospitals themselves are hesitant to interact with the generality of their patients, or they take long checking with their regulators on whether what they would like to communicate does not amount to prohibited advertising practices. At the same time, there has been a notable proliferation of healthcare related information on most social networks, with a real risk of non-factual or incorrect information being disseminated very rapidly. This has affected the natural assimilation of clinicians’ and the hospital’s communication to patients as they will be processing otherwise conflicting information at the same time, with a possible adverse experience as they carry out some instructions differently from what they were advised by the doctors.

There has been some concerted effort to loosen the regulations around hospitals public communication systems and some improvements have started to come through in countries like Zimbabwe where some form of information sharing is being accommodated. This has helped healthcare facilities disseminate some crucial information, albeit to a limited extent. Further to that, the rule of thumb for many hospitals now is to ensure that all communication is channeled through a properly trained and qualified team who understand the nuances of strict regulations but are also able to delicately balance the needs of patients and the clinical requirements of the hospital.

In addition, in order to reduce the impact of misinformation from use of social media to gather medical information, some communities have started collaborating with clinicians to provide healthcare information as prescribed by the doctors. For instance, according to Ulmer and Robishaw (2010), a clinician can use an electronic health record (EHR), to send an information prescription to a community librarian, who finds and delivers appropriate health information, then documents it in the EHR. Patient feedback surveys are designed to compile data on how the information was used. Doctor surveys assess use/failure to use and any observed impact of the information prescription on their patients’ health behavior.

4 Clusters of communication unrelated to each other

One challenge identified in the Philippines has been different internal clusters that handle hospital communication and the real meaning gets lost along the way. This is a source of misinformation among internal staff and can affect the service they deliver, and consequently the patient experience. When communication is not structured, there is likely going to be different interpretations by different groups of caregivers, with a resultant impact on how they deliver their service.

Challenges have been noted to be more complex during organisational transformation when getting complex information to reach the frontline team can prove difficult. Another scenario involves communication of the hospital performance metrics to all staff, which has been a subject of distortion due to misinterpretations at department level, as some supervisors will always need to communicate to their teams in the absence of hospital leadership during weekends and after hours.

Most hospitals have introduced leadership town hall meetings and newsletters to staff and external stakeholders, as a way of bridging the internal and external communication gap. In addition, champions have been selected to communicate specific areas of interest to the different teams, in a more concise manner. One hospital in Portugal put in place a customer satisfaction champion who is just responsible for buttressing how the team is performing in terms of its customer experience scores and help them track such scores regularly. That way, team members understand clearly how they are performing and what they need to do to improve such scores and enhance the patient experience.

Janjua et al. (2019) noted that high quality healthcare is currently available with the development of smart healthcare applications and communication systems. Healthcare systems can be categorized into three major application areas, i.e., hospital environment, remote healthcare, and disaster response unit, among which effective communication is a continuous challenge (Figure 2). Figure (3) presents the deployment of 6G technologies in different areas of healthcare system to overcome the communication challenges.

To smoothly run the hospital operations, efficient communications between administration, physicians, medical staff, and patients is always required. Commonly used technologies for communication within the hospital are emails, mobile phones, pagers and two-way radios. However, new methods are being used to improve the healthcare services in the hospital; collecting and maintaining the health records electronically help in reducing human errors, saves time and improves communication between physicians and patients. Other efficiencies have been brought by introducing artificial intelligence to make the better decisions in diagnosis, involving robots to achieve high precision in surgery as well as supporting the medical staff, and internet of medical things allowed the wearable devices and sensors to send data directly to the medical data collection center.

Figure (2): Healthcare system categorization (Janjua et al., 2019)

Figure (3): Technologies for healthcare system challenges under the 6G vision (Janjua et al., 2020)

EMI: Electromagnetic interference                PLS: Physical layer security

REM: Radio environment mapping               RIS: Reconfigurable intelligent surface

THz: Terahertz                                               UAV: Unmanned aerial vehicle

VLC: Visible light communication

McGinnis et al. (2021) stated that digital health has grown as a broad term, including electronically captured data, along with technical and communications infrastructure and applications in the healthcare ecosystem. Recent developments, e.g., cloud computing, artificial intelligence, machine learning, telehealth, and mobile health applications are increasingly used in health care, communication, and biomedical science. These developments promise to provide better communication, and improved outcomes for patients.

5 Summary recommendations

As discussed above, effective communication is an important ingredient towards achieving a positive patient experience, and coupled with other factors, helps to achieve the universal goal of patient experience. The following diagram illustrates this:

Figure (4): Effective communication as a contributor towards and patient experience

The recommendations above can be summarized in the following illustration model designed by the authors. It is believed that implementation of the summarized model in relation to clinical redundancy, shift handover periods, social media upsurge and dealing with separate clusters of information contributes towards helping a hospital to communicate effectively. This in turn helps towards an enhanced patient experience.

Figure (5): Summarised communication model for hospitals

6 Conclusion

While these communication strategies are important to boost patient safety, staff must also be provided with the communication tools they need. Many hospitals are still reliant on outdated communication technologies such as pagers and faxes, are not using mobile devices, and communication technologies are not integrated with electronic health records. Modern clinical communication and collaboration platforms have greatly improved communication in hospitals. These help to ensure the right information is communicated to the right people at the right time.

Through collaboration and learning initiatives like the International Hospital Federation’s World Hospital Congress, critical topics like hospital communication strategies are shared and this has continued to shape the skills development globally. The 2022 Congress to be held in Dubai, United Arab Emirates, will also focus on such learning areas as communication and international collaboration to improve the same.

References

  1. Cirino JA. Management of hospital communication. Appris Editora (2021)
  2. Ulmer PA and Robishaw S. Information Prescriptions: Providing Health Information at the Inpatient’s Point of Medical Need. Journal of consumer health on the internet (2010)
  3. Joint Commission International. How to overcome communication challenges in healthcare (2018)
  4. Hospital Management Asia. The importance of clinical communication and collaboration in healthcare (2022). (Online: https://www.hospitalmanagementasia.com/patient-safety/the-importance-of-clinical-communication-and-collaboration-in-healthcare/?utm_source=organic&utm_medium=social&utm_campaign=HMA+digital+2022+)
  5. CRICO Strategies. National Comparative Benchmarking System (CBS) Report: Medication-related Malpractice Risks (2016)
  6. Wong X, Tung YJ, Peck SY, Goh ML. Clinical nursing handovers for continuity of safe patient care in adult surgical wards: a best practice implementation project. The Joanna Briggs Institute (2019); 1003-1019.
  7. Candrian C, Hertz SL, Matlock D, Flanagan L, Tate C, Kutner JS, et al. Development of a Community Advance Care Planning Guides Program and the RELATE Model of Communication. Am J Hosp Palliat Care. (2020); 37(1): 5–11. doi:10.1177/1049909119846116.
  8. Communication Strategies in Healthcare. Website: Communication Strategies in Healthcare (hipaajournal.com). Accessed on: October 12th, 2022.
  9. Janjua MB, Duranay AE and Arslan H. Role of Wireless Communication in Healthcare System to Cater Disaster Situations Under 6G Vision. Front. Comms. Net. 2020; 1:610879. doi: 10.3389/frcmn. (2020). 610879.
  10. McGinnis JM, Fineberg HV, Dzau VJ. Advancing the Learning Health System. New England Journal of Medicine (2021); 385:1-5. Doi: 10.1056/NEJMp2103872.

Written by:

Katherine Bennett

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