Raising the communication bar
A cockpit warning system that automatically tells a pilot “pull up, pull up” when the plane is in imminent danger seems pretty straightforward. Unfortunately a few years ago a pilot’s last words on the cockpit voice recorder was his query in Cantonese to his copilot: “What does [English] ‘pull up’ mean?”
Among healthcare providers, communication failures - while rarely as dramatic as that cockpit conversation - do in fact impact the safety of patients. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) reports communication is a contributing factor in at least 80 percent of sentinel events in hospitals and clinics.
More dramatically, the JCAHO has reported from recent studies that ineffective communication has been implicated to cause death twice as frequently as problems with clinical skill. Miscommunication, which often means assuming wrongly that someone understands what you’re saying or didn’t say, has been further linked in JCAHO reports to near misses with death, countless less serious errors in treatment, delays in diagnoses and increased hospital length of stay.
Understandably, the JCAHO has responded, and at the start of 2006 issued a new JCAHO National Patient Safety Goal (NPSG) striving to improve the effectiveness of communication among caregivers. The goal states simply:
“Implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.”
I, like many of you, tend to become a bit defensive when someone tosses out “standardized” in a sentence advising us on how to practice, especially when the reference involves something as cliché-prone as “good communication.” But in this and many cases, standardized is a useful tool that creates a baseline or understanding and a framework for continuing or altering a plan rationally and flexibly. In past columns I’ve noted how the approach is similar to cockpit protocols, and it is also similar to an Incident Command System (ICS), the emergency protocol in place in our hospital. An ICS was successfully deployed, for example, by emergency responders from many disciplines immediately following 9/11 at the World Trade Center. The process sets up clear lines of responsibility and spells out the procedures to be followed — authorizing leaders to spell out when to proceed with the template or deviate. In New York at the twin towers this was shown to be best practice, and its success was one of the few hopeful notes during a fundamentally tragic series of events.
In health care, we have progress notes that communicate to a wide variety of practitioners - physicians, nurses, pharmacists, respiratory therapists and others - just as outside the World Trade Center police, fire, the mayor’s office and medical personnel all used a disaster protocol to ensure everyone was communicating accurately. Properly presented, our progress notes put everyone on the same page.
Of course we must be able to read the progress note, and this starts with something as mundane as legible handwriting. Fortunately, that hurdle will soon be made easier by the electronic medical record. But clearly, the issue goes far beyond clear pensmanship, or even a common language, so let’s take a look at what we have and what is new.
Many of us as physicians or nurses have been accustomed to using a template of sorts, the S.O.A.P. note system, which guides users through Subjective complaints/symptoms to an Objective report of the clinical findings, an Assessment, and finally a Plan.
Now beginning this month SHC nurses, pharmacists, respiratory therapists and other ancillary personnel have agreed to use the next generation version of S.O.A.P. to standardize and fine tune their hand-off communications. The new method is called the “SBAR” communication technique: Here’s how it puts us on the same page:
Situation – A succinct statement of the current problem or issue, when it started and how severe it is;
Background – The circumstances and context related to this situation;
Assessment – A description of the perceived problem or issue;
Recommendation – A statement of the perceived actions needed to correct the problem, as well as its urgency.
Hopefully, you are using this methodology right now. Furthermore, if you receive a communication and you feel it isn’t organized into this format, you have the right to ask for SBAR communication.
And ask, you should. I genuinely believe it is going to help us all do a better job. First, it gives us a plan to organize the information and our thoughts before we talk or write, and then it gives us a checklist or template to assess our patients, form a plan and tell others what we would like or need them to do.
Hopefully, physicians will use this format with each other. I can see it as a great tool to “hand off” to a colleague when we are off call. And our less experienced colleagues, particularly interns, will have a new easier to learn and use tool to help them relay patient information consistently and coherently up the chain of command. And SBAR is ahead of the curve and beyond handwritten notes. It’s fully compatible with our new electronic processes. For example, our internal medicine colleagues are using SBAR principles on the hospital’s Carecast electronic management system to organize patients to be covered by the on call team.
But SBAR isn’t an end in itself. Here are some points to ensure it works best for all of us:
1. Avoid multitasking. Our ability to deliver a clear message to a nurse on the phone will be negatively impacted if we are sending an unrelated email at the same time.
2. Be concrete. Avoid ambiguity. Don’t use phrases such as “the patient is crashing” or “the patient is a bit unstable.”
3. Insist on clarity. “Can you make that verbal order synchronize with what needs to put into the CPOE system?”
4. If a message is not understood, ask questions and/or read back crucial information. “Is that anomalous-sounding lab result really correct?”
Overall, we must be on the same page, and standardized communications is a tool to make that possible. SBAR, common sense and our quest always for best practices will bring clarity to our communication - and increasingly greater excellence to the care we deliver. Good communication is more than a cliché; it’s lifesaving.
A practical guide to the SBAR techniques discussed in this column has been included as a brochure with the October issue of the Medical Staff Update.
