Improving Interprofessional Communication

The incidence of medical errors is probably surprising to most people. It is estimated that if accurately accounted for, medical errors would be the third leading cause of death in the United States.¹ Perhaps even more shocking is the extent to which poor communication is a contributing factor or root cause in these adverse events. The Joint Commission defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" that is "not primarily related to the natural course of the patient's illness or underlying condition."^2,3 From 2012 to 2014, communication errors were one of the top three root causes for sentinel events, the leading cause of delays in treatment, and the third cause of events related to falls.⁴

Efforts at cost containment resulting in pressure to see more patients in a shorter time, along with an increase in the volume of knowledge and technical information required to provide advanced medical care, places incredible demands on providers. "A British study examined the communication load for a head nurse in an emergency department and documented over 1,000 separate communication events over a ten-hour shift…. 30 percent of communications were interruptions to a task already at hand…in which a person interrupted an ongoing communication event. An error rate of only 1 percent could potentially lead to ten errors relating to patient management over the course of a typical shift."⁵ Since most O&P encounters lack the urgency of emergency departments or critical care units, the consequences of poor communication and practitioner error are less likely to result in sentinel events. Over the course of several decades working closely with other healthcare providers, I can recall only two interactions where communication broke down so completely that the patient's care could not continue. In many more situations, however, poor communication impeded the provision of optimum care. This article examines the use of a tool that can facilitate communication between O&P practitioners and other healthcare providers.

Development of SBAR

During a perinatal patient safety training session in 2002, Doug Bonacum, MBA, CSP, CPPS, CPHRM, vice president of safety management for Kaiser Permanente, heard doctors and nurses describe their frustrations with communication about important patient issues.⁶

During his eight years on active duty as a chemical engineer in the U.S. Navy's submarine force, he had become familiar with a structure used to communicate critical information across a rigid hierarchy. Individuals lower in the chain of command must have the opportunity to contribute their perspective so that good decisions about critical situations can be made promptly. Using a formal communication structure allowed every member of the crew to provide input in a way that could be used effectively by those with decision-making responsibility. Bonacum saw that this structure could improve communication among members of a healthcare team, and eventually developed the acronym SBAR to describe the elements of that structure:

S  = Situation (a concise statement of the problem)

B= Background (pertinent and brief information related to the situation)

A= Assessment (analysis and considerations of options—what you found/think)

R= Recommendation (action requested/recommended—what you want)

The Institute for Healthcare Improvement offers a toolkit that includes an SBAR template. (See Figure 1).⁷

A Review of the SBAR Structure

Patient information is passed between individual caregivers or teams during handoffs to ensure continuity of care and patient safety. These exchanges are the focus of significant attention, since omission of crucial information during this process can result in inadequate care. Kathryn Stewart, a nursing student at the University of Tennessee at Chattanooga, with her project director, Kelli Hand, DNP, RN, reviewed 21 empirical studies related to the effectiveness of the SBAR framework during handoffs and identified four themes within the studies.⁸ According to Stewart and Hand, use of the SBAR during a handoff "creates a common language…increases confidence of the speaker and receiver…improves the efficiency, efficacy, and accuracy," and "improves the perception of effective communication and is well received" by healthcare staff.⁸ Use of the structured communication method "temporarily flattens the hierarchy," a benefit Bonacum identified in its application in a military context, and "creates more effective channels of communication between providers."⁸ This is important, given the different ways in which physicians and nurses are trained to communicate. According to Stewart and Hand, nurses are involved in direct caregiving over extended periods of time, and "tend to communicate using a subjective, narrative style that reflects the continuous flow of information" they obtain in the course of performing their daily responsibilities. "In contrast, physicians tend to communicate via an objective, headline approach that echoes the action-oriented method…in which expertise of the diagnosis and treatment of the disease demands quick action based on the objectivity of current evidence…."⁸ In a 2016 review of interprofessional communication in healthcare, Foronda et al. describe how differences between how physicians and nurse are trained to communicate can contribute to frustrations: "Nurses are trained to be highly descriptive and physicians are trained to be succinct…."⁹

Stewart and Hand point out that using a structured communication tool reduces the pressure on the speaker "to edit the content of a report due to the perceived hierarchical status of the receiver" and allows both parties to focus on the information. It increases the chance that important information is included, and that omissions of crucial information can be identified more easily. Because of this, both parties can have more confidence in the exchange of information. Stewart and Hand report one study found that "while decreasing the time for handoff report was not the primary goal, increasing report efficiency and reduced time spent on extraneous and unnecessary patient information allowed healthcare professionals to dedicate more time to activities related directly to patient care."

SBAR in Rehabilitation

In 2008, a group of researchers in Toronto, Canada, reported the results of a three-phase study intended to evaluate "the effectiveness of an adapted SBAR tool for both urgent and non-urgent situations within a rehabilitation setting."¹⁰ In the first phase, focus groups of clinical staff, patients, and family members validated and refined an adapted SBAR instrument. During the second phase, clinical and support staff of the Stroke Rehabilitation Unit were trained on and implemented the SBAR structure. The third phase involved a pre-test/post-test design to evaluate the effectiveness of the instrument based on staff perceptions, patient satisfaction, and safety reporting. To measure perceptions and culture, clinical and non-clinical staff completed a survey prior to and six months after implementation of the SBAR tool. Patient satisfaction was assessed by comparing survey responses from patients discharged six months prior to and six months after implementation. Safety reporting during the six months prior to and following the end of implementation was compared.

The survey of staff perceptions showed small, statistically insignificant improvements within the Stroke Unit. When compared with the rest of the hospital, the Stroke Unit made significant gains and scored higher (> 5 percent) in seven dimensions…."¹⁰ Improvements were statistically significant for only two dimensions: organizational learning-continuous improvement, and feedback and communication about errors. Patient satisfaction improved marginally and "there was a trend to increase incident reporting across both the organization and within the study unit…."¹⁰ The authors caution, however, that this may have been a result of multiple initiatives within the organization, rather than implementation of the SBAR instrument in one unit.

It may seem counterintuitive that a program designed to improve safety would result in more reports of adverse events. However, organizations can only address the root causes of adverse events that they are aware of. Adverse events must be reported in order to determine the cause and develop solutions. An increase in reporting is an indication of a higher level of trust in the process, and greater willingness to evaluate and improve behavior. A 2010 paper related to the study describes how using the SBAR tool improved the unit's response to adverse events:

In the past, debriefs following adverse events were perceived by staff to be punitive and stressful. By utilizing the SBAR process to structure debrief discussions, there was enhanced focus on the background and assessment components that supported a more thorough review of the incident, contributing factors, and processes, and helped to reinforce a safety culture of openness. The team felt that this structured process enhanced accountability and a ‘‘solution-focused approach'' to strategies rather than blaming the individual. This process allowed the team to develop more effectively concrete actions to help resolve the issue….¹¹

The researchers reported that the SBAR had a similar positive effect on addressing administrative issues, such as workload and staffing levels, "by helping the team to depersonalize issues as they ‘worked the problem' and identify appropriate and meaningful actions."¹¹

SBAR in O&P

It is likely that more dramatic improvements in safety and the quality of care are seen in units caring for patients with more critical and urgent healthcare needs than those seen in most O&P practices. However, Velji et al. demonstrated that the SBAR tool has the potential to improve patient care even in lower-risk settings. Prosthetists and orthotists interact with a wide range of healthcare providers outside of O&P practices, as well as providers within their own organizations. Most O&P practices are private facilities not formally affiliated with the healthcare organizations for which they provide services, and they are outside the normal channels of communication within those organizations. A narrow scope of practice, a small number of clinicians, and lower prioritization of our services may put us at a disadvantage when competing for the time and attention of referring physicians. While there may be differences of opinion regarding where O&P practitioners fall on the hierarchy of healthcare providers, it is certain to be significantly lower than the physicians who refer patients. Other allied health professionals typically have more education and more exposure on the healthcare team and may take a more active role in discussions about O&P interventions. Communicating effectively will increase the likelihood that referral sources consider clinicians' recommendations when prescribing interventions and making other treatment decisions.

Like nurses, we interact with many of our patients over a longer period than most physicians. Because of this experience, it is tempting to provide more background information than necessary in attempts to justify our recommendations. Quoting a study related to home health, Foronda et al. report that "it only takes a few seconds of listening to a clinician's report of a patient's condition for the physician to determine if he or she trusts their opinion." The physician's trust can be earned "by skillfully communicating the facts [and] making targeted recommendations with confidence…."⁹ One study found that "use of SBAR leads to an emphasis on current situational information with less focus on background…."⁸ Curtis et al. recommend using "graded assertiveness" when practitioners have "misgivings about a patient's condition or the doctor's proposed course of action." Increased assertiveness moves on a continuum involving expressions of initial concern, making an enquiry or offering a solution, asking for an explanation, and issuing a definitive challenge that requires a response.⁵

Conclusion

There are numerous benefits to good communication between members of the healthcare team, the most important of which are improvements in patient care and safety. However, the benefits go beyond reducing errors. Improvements in communication with referral sources, other members of the healthcare team, and within individual practices can also reduce stress, improve collaboration, and increase job satisfaction.⁵ As sensitive as practitioners may be to the way that hierarchy influences the patient care process when interacting with referral sources, it can be difficult to see how interactions between clinicians, administrative staff, and technicians is impacted by the same dynamic. The stakes may be lower when discussing billing, scheduling, fabrication, or cleaning procedures, but structuring our communication is likely to help resolve frustrations in all these areas. The greatest benefits of adopting a structure come through the active participation of all members of the team but doing so unilaterally can help us be more focused and effective in the part we play in any interaction. Implementing a structure for communication with stakeholders within and outside of our practices can be an effective way to improve patient outcomes and our own experience providing care.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.

References

1. https://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors
2. https://www.jointcommission.org/assets/1/6/CAMH_2012_Update2_24_SE.pdf
3. https://www.jointcommission.org/assets/1/18/Event_type_2Q_2016.pdf
4. http://www.tsigconsulting.com/tolcam/wp-content/uploads/2015/04/TJC-Sentinel-Event-Root_Causes_by_Event_Type_2004-2014.pdf
5. Curtis, K., A. Tzannes, and T. Rudge. 2011. How to talk to doctors–a guide for effective communication. International Nursing Review  58(1):13-20.
6. http://www.ihi.org/resources/Pages/AudioandVideo/ProfilesinImprovementDougBonacumofKaiserPermanente.aspx
7. http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx
8. Stewart, K. R., and K. A. Hand. 2017. SBAR, communication, and patient safety: An integrated literature review. MEDSURG Nursing  26(5):297-305.
9. Foronda, C., B. MacWilliams, and E. McArthur. 2016. Interprofessional communication in healthcare: An integrative review. Nurse Education in Practice  19:36-40.
10. Velji, K., G. R. Baker, and C. Fancott et al. 2008. Effectiveness of an adapted SBAR communication tool for a rehabilitation setting. Healthcare Quarterly  15;11(Sp).
11. Boaro, N., C. Fancott, R. Baker, K. Velji, and A. Andreoli. 2010. Using SBAR to improve communication in interprofessional rehabilitation teams. Journal of Interprofessional Care  24(1):111-4.