Miscommunications are funny when playing the “telephone game,” sometimes even hilarious; however, there is nothing funny about those that occur in medical practices because they can result in medical errors, poor outcomes, poor quality, unhappy patients, malpractice, higher costs, and/or lost revenue.
Unfortunately, our practices are rife with multi-handoff communication processes which resemble those in the “telephone” game, virtually guaranteeing miscommunications. Unlike this game which has only one communication channel, medical practices have multiple, often intersecting, channels, and this dramatically increases the odds of miscommunication. These channels include those between doctors and patients, doctors and staff, staff and patients, and also between the practice and outside entities such as hospitals, labs, third party payers, and outside physicians. Medical practice communications are further complicated by the use of technical language, the need for feedback and future follow-up, and the utilization of multiple delivery modes which include paper, electronic, phone, and oral (in person). Since communication processes are present in both the clinical and business aspects of a practice (which diverge independently from one another even though they are often initiated at the same contact point), any type of miscommunication in either area is capable of impacting clinical and financial outcomes simultaneously.
Before a practitioner can improve office communications, s/he must first recognize and acknowledge that communication problems exist. The question is not whether these problems exist, but rather, how many exist, how often they do occur, and where are they located? A focus on eliminating these problems must be elevated to high priority. Once this goal is established, the doctor needs to acquire a better understanding of communication processes so that s/he will be able to find the sources of miscommunications. The rewards for investing time and effort in learning about and improving communication processes include: an increase in clinical quality, a reduction of medical and business errors, better treatment outcomes, higher patient satisfaction, a reduced likelihood of malpractice claims, lower overhead, and higher revenue.
W. Edwards Deming and other “quality gurus” have determined that 93% of the root causes of errors and poor quality in any business are caused by poorly designed processes rather than by people (assuming that staff is well trained and competent at their specific jobs). For this reason, when we have well-trained staff, we cannot significantly improve quality or reduce errors by limiting our focus solely to people; rather, we must improve our processes. JACHO statistics reveal that 65% of all sentinel events leading to malpractice claims are caused by poor communication processes, and poor communication processes cause a similar percentage of errors in non-clinical processes (such as scheduling or billing). For these reasons, our primary process improvement focus must be on improving the effectiveness of communication.
If we were to diagram the dozens and dozens of interconnected steps in a typical office workflow, from scheduling an appointment through check-in, examination, treatment, documentation, and follow-up, we would see that, at each step, some type of communication occurs, presenting multiple opportunities for miscommunication. Communications might be received in person, over the phone, by fax, through a written document or note, or through a computer. Once a communication is received, it typically needs to be transmitted to multiple people and locations using a multi-handoff process similar to that present in the telephone game. In addition to the possibility of miscommunication at the initial step of a process, each subsequent step presents an additional opportunity for breakdown or for information to “fall through the cracks.” The probability of miscommunication grows exponentially as volume increases, making improvement in communication processes even more important today since the advent of managed care has resulted in high volumes of patients and information.
To see where breakdowns in communication might occur, consider one step in office workflow, the point at which the patient is ready to exit a treatment room. S/he may need instructions, prescriptions, supplies, lab tests, outside consultation, and/or a follow-up procedure or appointment. Some type of communication and communication feed-back needs to occur for any of these tasks to be completed successfully. The doctor seldom has a fail-safe way of knowing if the patient has received all necessary communications; s/he has no way of knowing if a prescription is filled, if the patient complies with instructions, or whether lab test results are noted (It is possible for lab test returns to be filed in a chart without the doctor ever seeing the results). The ability to track follow-up care after a patient leaves the office is critical, and there needs to be an effective “external” communication process for accomplishing this. Since all patient contact is connected – from check-in, to treatment, to follow-up – the communication process needs to be “connected” from beginning to end, and there must be an effective feed-back and tracking communication process which will make the system as fail safe as possible.
In addition to the presence of ineffective communication processes in their practices, many doctors are themselves ineffective communicators. Researchers have shown that patients are typically interrupted by doctors eighteen seconds into explaining their problems and that fewer than two percent get to finish their explanations. According to Dr. Wendy Levinson, vice chairwoman of the University of Toronto’s department of medicine, a common malpractice theme is “communication gone awry.” Her research shows that what prompts patients to sue “is the feeling that they were not listened to and that they did not have the doctor’s full attention.” Doctors cite time constraints as the primary reason for cutting patients off, but Dr. Levinson’s research indicates that allowing patients the time to talk actually leads to shorter appointment times and more satisfied patients. According to other studies, only 15% of patients fully understand what their doctors tell them, and 50% leave their doctors’ offices uncertain of what they are supposed to do. Additionally, if patients do not have written instructions, they forget one third or more of what they have heard in the office by the time they arrive home. These problems all result from poor or miscommunication.
Better listening skills, coupled with well written instructions, will go a long way towards “fixing” the doctor/patient communication process. In June of this year, a new “clinical-skills assessment test” was instituted to gauge, among other things, a medical school graduate’s ability to communicate with patients. The AMA has been critical of the test, but Peter V. Scoles, senior vice-president of assessment programs for the NBME, defends this test as a matter of patient safety. Obviously, the “need” for this test was based on a wide perception that doctors’ listening and communication skills are critical to better patient safety and better outcomes. Interestingly, in virtually every patient survey where patients are asked what they most want in a doctor, listening and explaining skills consistently rank amongst the most important concerns. It turns out that effective communication is not just important for the reasons previously stated; it also provides a marketing advantage which will result in practice growth. When effective communication is coupled with taking more time to listen to patients (which actually results in shorter visits), the end results are: increased patient satisfaction, better treatment outcomes, and lower overhead costs, all of which present compelling reasons for improving communication.
While much can be done to help doctors become better communicators, major problems will still exist if the “telephone game” communication processes are not fixed. To better understand where to start, it helps to picture the communication process as a chain, with each link in the chain representing one step or hand-off. Since the goal is to improve the entire chain (i.e. make it stronger), the focus becomes making each link stronger. In the case of a communication chain, the most effective way to make the entire process stronger is to first remove weak or unnecessary links (handoffs), starting with the weakest. The next step is to make each remaining link stronger, which might require additional staff training, and implementation of better monitoring, feedback, and tracking mechanisms. To do this, it is necessary to evaluate each error or miscommunication, identifying why it occurred, and seek solutions for preventing similar occurrences in the future.
A book written by Richard J. Schonberger entitled “Building a Chain of Customers” provides a unique approach to evaluating communication processes using this chain concept. While we tend to think of patients as the customers who are the final recipients of our services, Schonberger defines a customer as the next person in line to receive our work. Much of this “work” is actually the transmission of information through some type of communication process, or chain, which means that the doctor or staff member’s “customer” at any point in time is the person who directly receives his/her communication (another doctor or staff person, a patient, or an outside contact such as an insurance company representative or hospital staff). In order to improve the entire communication chain, each person in that chain must focus on finding ways to improve the quality of work, or communication, sent to his/her customer (the next person to receive that work). By seeking ways to improve quality of service (communication) to the next person in the chain, quality will be improved throughout the entire chain, resulting in better service (communication) to the final customer – the patient. Improving quality might require that you change the method or manner of transmission, or even better, find a way to by-pass your next customer altogether, thus reducing the number of unnecessary handoffs.
While there are a number of non-technological ways to improve the quality of communication to “next customers,” today’s technology offers numerous effective channels for by-passing handoffs, receiving automatic feedback, and communicating with multiple people and locations simultaneously. For example, notes that are made using an electronic medical record (EMR) not only by-pass the transcription and filing steps, but they can be viewed by multiple people, in multiple locations, immediately and simultaneously and are never “lost.” Since billing codes are picked up automatically from EMR notes, the intersecting billing process requires no communication subsequent to the doctor keying in his/her notes. There is no handoff of a superbill to the billing staff, a handoff which requires keying in to a computer at a later time. Printing of patient instructions can be programmed to occur automatically, and this information can be simultaneously transmitted to where it can be used for tracking and following-up on care, assuring that this essential part of patient care does not “fall through the cracks.”
Since communication between doctors and patients, doctors and staff, staff and patients, and the practice and outside entities has such an enormous impact on the quality of outcomes in both the clinical and business areas of a medical practice, the combination of improving doctor and staff communication skills and streamlining multi-handoff communication processes will have major, positive impacts on every area of a practice. There is much that can be learned in the area of communications which will benefit podiatric physicians. For this reason, PICA has chosen to focus its 2005 loss prevention seminars on the topic of communication. The proposed title is “The Chains of Communication: Are You the weakest Link?” Even though PICA’s primary goal is to improve communications for the purpose of reducing the incidence of malpractice claims, possessing this knowledge will influence your clinical and financial outcomes in ways that extend well beyond malpractice avoidance and, hopefully, increase your “happiness quotient.”
