What Did You Say? 2023

This multimedia enhanced book explores the imporance of communication in enhancing patient safety across multiple aspects of healthcare.

Edited by Mauricio Gonzalez, Karolina Brook, Christopher Conley, Rafael Ortega

What Did You Say? Enhancing Patient Safety Through Communication

A Multimedia Enhanced Toolkit

Edited by Mauricio Gonzalez Karolina Brook Christopher Conley Rafael Ortega

What Did You Say? Enhancing Patient Safety Through Communication

About the Cover Art The cover art of “What Did You Say?” features a simple yet powerful image of a clinician, emphasizing the crucial role of listening in effective communication. The design and symbolism of the image invites us to explore the book’s message further, reminding us that the key to genuine communication lies not in words spoken, but in the receptive mind that intently listens.

Dedication

Boston Medical Center One Boston Medical Center Pl Boston, MA 02118

www.bmc.org

First published in 2023

ISBN 979 8 218 28319 3

All rights are reserved. No part of this publication may be reproduced, stored in a re- trieval system, or transmitted in any form or by any means, electronic, mechanical, pho- tocopying, recording, or otherwise, without prior permission of Boston Medical Center. Project directors: Mauricio Gonzalez, Karolina Brook, Christopher Conley, Rafael Ortega Media director: Multimedia Laboratory, Boston Medical Center Copy editor: Felicia Lee

Printing: Kirkwood

Graphic design: Elise Ouellette

Cover art: Rafael Ortega

This book is dedicated to our patients, each with a unique story, who have chosen Boston Medical Center as their haven in the pursuit of healing and wellness.

Disclaimer As with any educational resource, it is important to emphasize that the information presented in this book is not intended to serve as a substitute for professional judgment or individualized guidance in specific situations. While we have made every effort to provide accurate and reliable information, medical practices and legal regulations can vary, and each case may have unique circumstances. Therefore, we strongly encourage readers, especially in situations that may potentially lead to a medical malpractice suit, to consult additional sources and seek advice from qualified professionals. This includes engaging with healthcare providers, legal experts, or other relevant authorities who can provide tailored guidance based on the specific circumstances at hand. This book is intended to serve as a guide and a starting point for further exploration, providing readers with foundational knowledge and insights related to communication in medicine. It aims to foster a deeper understanding of the subject matter and encourage critical thinking. However, it cannot replace the importance of individual judgment and professional guidance in making informed decisions. Healthcare professionals should always adhere to the laws, regulations, and standards of care specific to their jurisdiction. This book does not provide legal advice or establish legal obligations, but rather aims to enhance awareness and knowledge of communication practices within the context of medicine. Use of Artificial Intelligence The contents of this book have been created through a collaborative process involving both the contributions of the authors and artificial intelligence-generated text. The material presented in this publication has undergone refinement for improved readability with the assistance of artificial intelligence (AI) technology. We believe that when used appropriately, AI can play a valuable role in enhancing the quality and accessibility of instructional materials. The application of AI in refining readability involves analyzing and processing the text to optimize its clarity and coherence, ensuring that the content is more comprehensible and engaging for the reader. The concepts presented in this book are the result of the authors’ expertise and experiences in the field of communication in medicine, complemented by content generated through the use of artificial intelligence. By acknowledging the role of AI, we hope to strike a balance between leveraging technological advancements and preserving human creativity and expertise. Conflict of Interest Statement There are no conflicts of interest to disclose in the publication of this book. The chapter authors, editors, and video actors have voluntarily contributed to this project without receiving any financial compensation. Boston Medical Center has generously supported the expenses associated with editing the manuscripts, producing the accompanying digital media, and printing the book. The distribution of the book to Boston Medical Center personnel is provided free of charge, emphasizing its purpose to enhance their ongoing medical education and support our commitment to patient safety. This book is not intended as a commercial venture and has no profit-seeking intentions.

With gratitude and respect,

Mauricio Gonzalez Karolina Brook Christopher Conley Rafael Ortega

4 WHAT DID YOU SAY?

What Did You Say? Enhancing Patient Safety Through Communication

Contributors Benjamin Aronow, MD, MBA Chief Resident Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Maxwell Baker, MSc Research Manager Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Jaime Beer, CRNA Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Wendy Bernstein, MD, MBA, FASA Clinical Professor Vice Chair of Academic Affairs Director of Faculty Development Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Dhanesh Binda, BS Medical Student Boston University Chobanian and Avedisian School of Medicine Karolina Brook, MD Assistant Professor Director of Quality and Safety Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Robert Canelli, MD, FASA Clinical Associate Professor Director of Critical Care Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Christopher Conley, MD, FASA Clinical Associate Professor Anesthesia Residency Associate Program Director Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Justin Damaso, MSN, CRNA Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine

Andrew Kohner, MD Resident Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Jeffrey Y. Liu, BA Medical Student Boston University Chobanian and Avedisian School of Medicine Joseph Louca, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Theodore Lui, MD Resident Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Wissam Mustafa, MD Assistant Professor Director of Trauma Anesthesia Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Mason Merriel, MSc Medical Student Boston University Chobanian and Avedisian School of Medicine Melissa Nadler, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Mark C. Norris, MD Clinical Professor Anesthesia Residency Program Director Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Ala Nozari, MD, PhD, FASA Professor Vice Chair of Research Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Jamel Ortoleva, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine

Shiloh Dawson, BS Medical Student Boston University Chobanian and Avedisian School of Medicine Cory DeSole Faragon, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Dylan Feliu, BS Medical Student Boston University Chobanian and Avedisian School of Medicine Flavio Gilio Andrade de Meneses, MD Resident Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Christian Garcia, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine R. Mauricio Gonzalez, MD, FASA Clinical Associate Professor Vice Chair of Clinical Affairs, Quality and Patient Safety Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Salman Hashim, BS Medical Student Boston University Chobanian and Avedisian School of Medicine Chelsea Hough, CRNA Instructor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Natalia Ibañez, MBA Administrative Manager Department of Anesthesiology Boston Medical Center Kendall Jenkins, BS, MS Medical Student Boston University Chobanian and Avedisian School of Medicine Albert Kalustian, DO Clinical Associate Professor Department of Anesthesiology Boston Medical Center

WHAT DID YOU SAY?

CONTRIBUTORS

Contents

Rafael Ortega, MD, FASA Professor and Chair Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Alexis Ramirez, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Jennifer Richards, MS, CRNA Instructor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Neil Ray, MAPL Education and Multimedia Specialist Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Sundara Rengasamy, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Taylor Shannon, CRNA Instructor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Arturo Toro, BS Medical Student Boston University Chobanian and Avedisian School of Medicine Eduard Vaynberg, MD Assistant Professor Department of Anesthesiology Boston University Chobanian and Avedisian School of Medicine Ananya Vasudevan, BA Medical Student Boston University Chobanian and Avedisian School of Medicine Daniel Warren III, MHA Administrative Director Department of Anesthesiology Boston Medical Center Lori Whynot, PhD RID CI, CT Director of the American Sign Language & Interpreter Education Program College of Social Sciences and Humanities Northeastern University

Foreword

Acknowledgments

Introduction Mauricio Gonzalez, Karolina Brook, Christopher Conley, and Rafael Ortega Communication Fundamentals 1 Enhancing Connections: The Power of Effective Communication in

Diverse Health Care Settings Karolina Brook and Rafael Ortega 2 Components of Good Communication Justin Damaso and Jennifer Richards

3 Enhancing Communication: The Power of Closed-Loop Communication in Health Care Christian Garcia and Jaime Beer

4 Hierarchical Communication in Health Care Rafael Ortega

5 Understanding the Importance of Interdepartmental Communication in Health Care Cory DeSole Faragon and Joseph Louca

6 Communicating About Patient Safety Karolina Brook and Taylor Shannon

7 Effective Sign-Out in Medicine: Ensuring Safe Transitions of Care Mason Merriel and Rafael Ortega

8 Effective Communication Skills for Mentorship in Academic Medicine Chelsea Hough and Wendy Bernstein

9 Effective Communication Techniques for Pediatric Patients: Enhancing Understanding and Cooperation in the Perioperative Period Mason Merriel and Alexis Ramirez

WHAT DID YOU SAY?

TABLE OF CONTENTS

19 Effective Disclosure: Steps for Successful Communication Christopher Conley, Kendall Jenkins, and Shiloh Dawson 20 Legal Communications: Verbal, Written, and Electronic Communications in Malpractice Litigation Arturo Toro, Flavio Gilio Andrade de Meneses, and Mark C. Norris 21 Stressful Conversations and Conflict De-escalation in the Perioperative Arena Jamel Ortoleva and Theodore Lui 22 Benefits of Crisis Debriefing: Learning, Support, and Team Building Melissa Nadler, Scott Doheny and Eric Schmalzried

109

Communication in a Heterogeneous Environment

10 Cultural Factors in Healthcare Communication: Understanding the Impact Wissam Mustafa and Salman Hashim 11 Decoding the Unspoken: The Power of Body Language in Medical Communication Maxwell Baker and Rafael Ortega 12 Bridging the Gap: Promoting Health Equity through Informed Consent Eduard Vaynberg and Dylan Feliu 13 Understanding Different Types of Disabilities and Communicating Through Interpreters Neil Ray and Lori Whynot 14 The Language Labyrinth: Striking a Balance Between Plain Language and Precision in Health Care Maxwell Baker and Rafael Ortega

115

121

125

23 Speaking About Errors: Protected Conversations Jeffrey Liu and Albert Kalustian 24 Unveiling the Ripple Effect: The Impact of Gossip on Communication in the Hospital Environment Sundara Rengasamy

131

135

25 Communicating with Non-Clinical Hospital Leaders and Administrators Daniel Warren III and Natalia Ibañez

139

15 Evolving Terminology: Gender, Race, and More Ananya Vasudevan, Dhanesh Binda, and Rafael Ortega

26 The Future of Communication in Medicine Mauricio Gonzalez and Rafael Ortega

143

16 Navigating the Virtual Frontier: Communication Strategies for Optimal Virtual Care Maxwell Baker and Rafael Ortega

Communication in Specific Situations

17 Communication During a Crisis Robert Canelli and Benjamin Aronow

101

18 Adverse Event Documentation: Goals, Thoroughness, and Mistakes to Avoid Andrew Kohner and Mauricio Gonzalez

105

WHAT DID YOU SAY?

TABLE OF CONTENTS

Foreword

In the depths of sorrow and the hushed moments of grief, life takes on a different hue. It was on one such August morning, just before dawn, that tragedy struck our family. The news arrived with an unforgiving phone call, shattering our world and leaving us breathless. My beloved father-in-law, a vibrant soul who had been playing on the soccer field a few days prior, had succumbed unexpectedly after a routine surgical procedure. The weight of our loss pressed heavily upon us as we grappled with the cruel twist of fate. Questions echoed through our minds, pleading for answers that seemed elusive. How could this have happened? Why didn’t anyone recognize his persistent burning chest discomfort? We had entrusted his care to capable hands, and yet we were left to question our own judgments, plagued by the relentless grip of guilt. Should we have delayed the procedure? Could we have prevented this heart-wrenching outcome? Days merged into nights, blurred by tears and haunted by the absence of his cherished presence. The warmth of summer turned cold, the taste of food grew insipid, and everyday routines became poignant reminders of a life abruptly severed. We clung to treasured mementos, finding solace in their tangible connection to the past. Prayers and remembrance wove through our days, entwined with the lingering question of how we would face future celebrations without him. Then, four months later, the hospital beckoned us. A group of physicians and nurses gathered to provide a painful account of the mistakes that had led to this tragedy. It was not the narrative we yearned to hear, nor the reality we wished to inhabit. Yet, amid our grief-stricken hearts, we recognized a flicker of hope. The hospital, driven by a commitment to patient safety, stood resolute in acknowledging its failures and took decisive steps toward improvement. We learned of the painstaking analysis that followed, delving deep into the communication gaps between care teams. Changes were implemented, and safeguards strengthened. A more comprehensive evaluation process would now exist for patients with post-operative complaints of chest pain, ensuring heightened vigilance and supervision before discharge. The errors, as so often is the case, stemmed from breakdowns in communication.

WHAT DID YOU SAY?

FOREWORD 13

Acknowledgments

We understand that medicine, with its inherent complexities and unpredictability, cannot promise absolute prevention of every error. Our world is imperfect, our systems imperfect, and our treatments imperfect. But surrender is not an option. We must persistently seek improvement through critical thinking, analysis, and a relentless dedication to progress. This book has come to fruition as a result of the profound emotions and insights that have emerged from our family’s tragedy. We share our story, our pain, and our aspirations, trusting that you will seize the knowledge within these pages to amplify communication and become a fervent advocate for patient safety. In the face of tragedy, it can be all too easy to succumb to despair. Yet, in the story of our family’s loss, we find a powerful reminder of the resilience of the human spirit. Through our grief and pain, we found a glimmer of hope in the commitment of Boston Medical Center to improve patient safety. Let our pain be a catalyst for change and a source of inspiration for others. May our story inspire you to embrace a spirit of relentless dedication to progress and to honor the memory of those we have lost by striving for a better world.

We would like to extend our heartfelt gratitude to all the individuals who played a vital role in the creation of this book. Their contributions and support have been invaluable in bringing this project to life. First, we would like to express our deep appreciation to the authors of each chapter for their dedication, knowledge, and expertise. Their insights and experiences have shaped this book into a comprehensive resource, providing valuable guidance on effective communication in the hospital setting. We would also like to thank the individuals who participated in the simulated scenarios, reenacting various communication situations. Despite not being trained actors, their willingness to step forward and bring these scenarios to life deserves our sincere appreciation. Their commitment to highlighting specific areas of communication in the healthcare environment have greatly enriched the educational experience for our readers. We extend our gratitude to Felicia Lee for her outstanding editing work. Her keen attention to detail and expertise as an editor have significantly contributed to the overall quality of each chapter. Dr. Abbie Chase, a first-year anesthesia resident, deserves heartfelt appreciation for meticulously reviewing each chapter and offering insightful comments that surpassed expectations. We would also like to acknowledge Scott Friedman for his motivation and encouragement in undertaking this project. His vision and belief in the importance of communication in medicine inspired us to embark on this journey. We are grateful for his continuous support and guidance throughout the entire process. We must also thank Elise Ouellette for her invaluable contribution to the creation of this book. Elise played a pivotal role in every stage of the process, meticulously managing all the intricate details and integrating the graphic elements and text. Her sharp eye for design and commitment to excellence ensured that every page of this book was a visual delight. Thank you, Elise, for your outstanding work and support throughout this journey. To all those mentioned above, as well as the countless others who have supported us in various ways throughout this endeavor, we extend our gratitude. Your collective efforts and unwavering support have made this book possible. We hope that it serves as a valuable resource, facilitating better communication and ultimately improving patient care at Boston Medical Center and beyond.

Mousab Eteer, MD

Thank you all for your outstanding contributions and commitment to this project.

WHAT DID YOU SAY?

ACKNOWLEDGMENTS

Introduction Enhancing Communication in Medicine: A Path to Patient Safety and Quality Improvement

In the fast-paced and complex world of medicine, effective communication plays a pivotal role in delivering high-quality care and ensuring patient safety. Each interaction, whether it’s between healthcare providers, patients, or their families, carries immense importance. However, it is often through adversity and adverse outcomes that we truly recognize the significance of effective communication in healthcare. This book is born out of a profound inspiration—an adverse outcome that a patient endured. We firmly believe that adversity can serve as a catalyst for positive change, and it is our mission to channel this experience into an educational instrument that fosters better care and prevents mishaps in the hospital setting. By addressing the crucial topic of communication, we strive to create a resource that not only enhances patient safety but also promotes continuous refinement in the healthcare services we provide. Within these pages, you will embark on a journey that explores communication in medicine from various angles. Our aim is to equip healthcare professionals, students, and all those involved in the medical field with the tools, insights, and strategies to facilitate effective communication across different contexts and challenging scenarios. From navigating language and cultural barriers to engaging in meaningful conversations with pediatric patients, as well as addressing difficult conversations following incidents that have caused patient harm, each chapter delves into a specific aspect of communication in medicine. We recognize that the challenges in healthcare communication are diverse and multifaceted. However, through the collective expertise and experiences shared by our contributors, we aspire to provide practical guidance and valuable perspectives to help bridge communication gaps and promote positive outcomes. The overarching goal of this book is to foster a culture of open, empathetic, and effective communication within healthcare. By doing so, we firmly believe that we can cultivate an environment that not only enhances

patient safety but also empowers healthcare providers to deliver “exceptional care for all”. We invite you to delve into the chapters that lie ahead, absorbing the knowledge, insights, and practical advice they offer. Together, let us embrace the power of communication to drive positive change, improve patient outcomes, and forge a brighter future for healthcare. Let this book be the foundation upon which we build a future of communication excellence at Boston Medical Center—a future where every interaction becomes an opportunity to make a difference and improve the lives of those we serve. Our vision for this book goes beyond traditional printed pages. It is a hybrid publication, thoughtfully designed to embrace the power of multimedia. Each chapter features QR codes that, when scanned, unlock access to videos featuring simulated scenarios followed by observations and explanations. This approach immerses the reader in a dynamic and rewarding learning experience, allowing them to witness communication strategies in action and gain a deeper understanding of their application in clinical practice. As you embark on this educational journey, we encourage you to embrace the diverse perspectives and practical strategies presented within these pages. Let them serve as a catalyst for change, empowering you to cultivate a communication- rich environment that promotes positive patient experiences, fosters meaningful connections, and drives improved health outcomes. This book stands as one more contribution to the ongoing efforts to enhance patient care at Boston Medical Center. It is our hope that its insights, combined with your commitment to continuous learning, will ignite a transformation within your own practice and inspire a ripple effect of positive change throughout our medical community. Together, let us bridge the gap in communication, nurture a culture of safety and empathy, and forge a future where every patient’s experience is characterized by effective and compassionate care.

16 WHAT DID YOU SAY?

INTRODUCTION 17

Communication Fundamentals

18 WHAT DID YOU SAY?

Karolina Brook Rafael Ortega 1 Communication serves as the cornerstone in healthcare, enabling the building of strong relationships, fostering trust, and delivering optimal care. It goes beyond mere information exchange and holds the potential to shape lives, transform outcomes, and profoundly impact both patients and providers. This significance becomes even more critical within the dynamic environment of an urban Level 1 trauma center and a culturally heterogeneous hospital, necessitating comprehensive communication strategies. In this book, “What Did You Say?”, we delve into the multifaceted dimensions of communication within healthcare, exploring topics such as patient safety, disability, body language, documentation, intercultural interactions, and telemedicine, among others. Through this exploration, our aim is to shed light on the intricacies, challenges, and immense opportunities that effective communication presents in the ever-evolving healthcare landscape. Nonverbal communication, particularly body language, is a crucial aspect of effective communication that plays a significant role in conveying messages and building rapport. Its impact on communication outcomes cannot be understated, which is why we have dedicated an entire chapter to exploring nuances and the importance of nonverbal communication. By accurately recognizing and interpreting these phenomena, healthcare professionals can enhance their communication skills and foster better understanding with patients and colleagues alike. Healthcare professionals often find themselves in high-stress conversations that require delicate handling, such as delivering difficult news, resolving conflicts, or managing challenging situations. Navigating these

Enhancing Connections: The Power of Effective Communication in Diverse Health Care Settings

conversations with compassion, empathy, and effective communication skills is essential for maintaining trust and achieving positive outcomes. These critical aspects of communication are thoroughly explored and discussed in multiple chapters throughout the book, providing comprehensive guidance and insights for healthcare professionals. Conflict is inevitable in any complex environment, including healthcare, making the development of de-escalation skills crucial for fostering a safe and collaborative workplace that ultimately translates into better patient care. Additionally, in a culturally heterogeneous hospital where diverse backgrounds and perspectives converge, addressing and mitigating rumors and gossip is important to prevent erosion of trust, divisions, and compromised patient care. Rumors are typically unverified information circulating among people, often related to broader situations, while gossip involves the sharing of personal or private information about specific individuals. Both can have significant social and personal impacts, but their nature, intent, and verifiability differ. Limited English proficiency can significantly contribute to miscommunication and misunderstandings, resulting in adverse effects on patient outcomes. For instance, healthcare providers may unknowingly employ medical jargon or idiomatic expressions that patients with limited English proficiency cannot comprehend, leading to confusion and frustration. Additionally, cultural disparities can influence patients’ understanding and interpretation of medical information. For instance, individuals from cultures valuing stoicism and emotional restraint may express pain or discomfort differently compared to those from cultures emphasizing emotional expressiveness. These linguistic and cultural differences underscore the importance of

20 WHAT DID YOU SAY?

ENHANCING CONNECTIONS

effective communication strategies in providing equitable and patient-centered care. Healthcare providers must be able to communicate with patients who have different cultural backgrounds. In a culturally heterogeneous hospital, like Boston Medical Center, diversity in the patient population can pose a challenge to effective communication.

saying “a diabetic patient,” it is now preferred to say “a patient with diabetes.” Diverse political and philosophical viewpoints among healthcare personnel can also impact their relationships and patient care in large urban hospitals. Examples include abortion rights, vaccination, gender-affirming care, and refusal of blood products for religious reasons, among others. These differences can create tension and hinder effective communication among colleagues, potentially straining teamwork and collaboration. In the context of patient care, divergent beliefs may influence how healthcare providers approach sensitive issues, potentially affecting the provision of comprehensive care and patient counseling. It is crucial for healthcare professionals to navigate these differences respectfully, uphold professional standards, and prioritize patient-centered communication to ensure equitable care and maintain trust with patients and colleagues. Effective communication between people of different generations can be disrupted by different communication styles and preferences, such as the use of technology, language choices, and preferred modes of communication. Misinterpretation and misunderstandings can arise when individuals from different generations do not adapt their communication styles to bridge this gap. Additionally, generational differences in values, beliefs, and experiences can lead to misalignment in understanding and perspectives, making it challenging to establish common ground and mutual understanding. Overcoming these barriers requires open- mindedness, active listening, and a willingness to adapt communication approaches to accommodate the diverse needs and preferences of individuals from different generations. How should we communicate with individuals who have substance use disorders, are experiencing homelessness, or have mental health issues? These challenges requires specific strategies to ensure understanding, empathy, and support. First, it is essential to approach these individuals with compassion and without judgment, creating a safe and non-threatening environment for open communication. Active listening is crucial, allowing individuals to express their thoughts and feelings while demonstrating

Communication is the cornerstone of healthcare provision.

Respecting cultural and generational norms fosters effective communication and enhances patient safety in diverse healthcare settings.

empathy and validating their experiences. Using plain language and adapting communication to their level of understanding can enhance comprehension and engagement. Building trust and rapport through consistent and reliable communication is vital, as individuals may have experienced stigmatization or mistrust in the past. Collaboration with interdisciplinary teams, including mental health professionals and social workers, can provide comprehensive care and support for these individuals. The COVID-19 pandemic has significantly impacted healthcare communication practices, driving rapid adaptations and innovations for safe and continuous care. Virtual tools like video conferencing and telehealth platforms have become essential, enabling remote consultations and interprofessional collaboration. Technology adoption has accelerated, with digital platforms facilitating seamless information sharing and coordination. Its use has hindered traditional communication, affecting nonverbal cues and clarity of speech. Emotional support and empathy have become vital, while the rapid dissemination of evolving information has

relied on healthcare workers providing accurate guidance. Collaboration among healthcare disciplines has intensified, facilitated by virtual meetings. Language barriers, hearing impairments, and cognitive disabilities have necessitated accommodations for equitable access to healthcare. Given the rise of telemedicine, especially in urban areas, the book dedicates a chapter to telecommunication in healthcare. It explores the unique challenges and opportunities presented by this medium, including effective remote communication with patients, ensuring privacy and confidentiality, and maintaining rapport and empathy despite physical distance. Telemedicine has become integral to healthcare delivery, requiring healthcare professionals to adapt their communication skills to this evolving landscape. Video conferencing platforms such as Zoom™ have had a profound impact on communication in medicine, revolutionizing the way healthcare professionals connect and collaborate. With its virtual platform, Zoom™ has facilitated seamless video conferencing, enabling efficient communication and collaboration among

To address these challenges, healthcare providers must be trained in cross-cultural communication. This involves developing an understanding of different cultures and communication styles, as well as strategies for overcoming linguistic barriers. Cross-cultural communication is not just about language; it also involves understanding the cultural norms and values that influence how patients interpret and respond to medical information. In the United States, the sociopolitical climate has also significantly impacted the way we communicate in healthcare. One notable example is the shifting terminology used to describe individuals and communities, particularly in the context of gender, race and ethnicity. This has led to changes in how healthcare providers communicate with patients and each other. For instance, there has been a push for the use of person-first language, which emphasizes the individual’s humanity rather than their medical condition or identity. For example, instead of

WHAT DID YOU SAY?

ENHANCING CONNECTIONS

Justin Damaso Jennifer Richards 2

Components of Good Communication

medical teams, researchers, and educators. It has bridged geographical distances, allowing for remote consultations, multidisciplinary meetings, and knowledge sharing. Zoom™’s screen sharing and document collaboration features have enhanced communication efficiency and facilitated real-time exchange of medical information. The accessibility and convenience offered by Zoom™ have transformed healthcare communication, enabling effective and timely interactions that contribute to improved patient care and advancements in the medical field. By acknowledging the challenges and addressing the evolving landscape of healthcare communication, healthcare providers can strive for effective, inclusive, and patient-centered communication practices that contribute to improved patient outcomes, enhanced patient safety, and a positive healthcare environment. When it comes to communication, taking action with intentionality is of paramount importance, especially in the context of healthcare. Intentionality means being deliberate, purposeful, and mindful in our communication efforts, ensuring that our words and actions align with our desired outcomes. It goes beyond simply going through the motions of speaking or listening; it involves actively considering the impact and consequences of our communication choices.

Learning Objectives 1. Understand the importance of active listening in health care communication. 2. Familiarize oneself with the SBAR communication tool and its application in promoting effective interdisciplinary communication and reducing errors during handoffs. 3. Recognize the significance of creating a culture of safety in health care settings.

Introduction Communication is a vital process through which information is exchanged between individuals. While important in various aspects of life, its significance is particularly critical in the healthcare setting. Inadequate or flawed communication can directly lead to poor patient outcomes, especially as patient care becomes increasingly complex. Clinical communication, defined as a structured approach for timely, truthful, and respectful information exchange among patients, healthcare providers, and various members of health professional teams, plays a crucial role in promoting safety for both patients and healthcare workers. Regrettably, communication failures are the leading causes of unintentional patient harm. The overwhelming majority of sentinel events, as identified in an analysis of 2,455 cases by The Joint Commission, can be attributed to communication errors, accounting for over 75% of such incidents. Effective communication, on the other hand, has the potential to prevent mistakes and reduce patient harm. Numerous factors contribute to communication breakdowns. Later in this chapter, we will briefly explore a tool used to mitigate such failures. Communication in the healthcare setting can take various forms, including verbal, nonverbal, written language, and even symbols. Regardless of the method employed,

communication should prioritize clarity, conciseness, and concreteness, relying on evidence and reasoning rather than implicit statements. Effective clinical communication employs techniques such as active listening, explaining complex concepts in layperson language, providing adequate descriptions of therapeutic intervention outcomes, and seeking others’ perspectives. This chapter aims to delve into the concept of effective communication and examine how healthcare providers can enhance patient safety through improved communication strategies.

When communicating about patient safety it is important to have a systematic approach that that encourages assertive communication.

WHAT DID YOU SAY?

COMPONENTS OF GOOD COMMUNICATION 25

Essential Components of Good Communication

The third component of effective communication is speaking or acting on the information that has been listened to and processed. Creating a culture of safety is crucial in healthcare settings to encourage individuals to speak up and protect patients from harm. A culture of safety promotes an environment where all providers feel respected and empowered to voice concerns about potential risks. It breaks down hierarchical barriers and fosters open communication, improving teamwork and reducing errors. Effective leaders play a vital role in flattening the hierarchy and creating a sense of familiarity, enabling individuals to feel comfortable raising concerns. Establishing a culture of safety is essential for patient well- being and enhancing teamwork within healthcare settings. By understanding and implementing these components, healthcare providers can enhance patient safety, improve outcomes, and foster a patient-centered care environment.

Acronym

Explanation

Example

What is currently happening to the patient that raises concern

“Patient X has a blood pressure of 86/50 and a hemoglobin of 6.4g/dL.”

Effective communication is an increasingly valued skill, particularly in the healthcare field, as evidenced by its inclusion as a required core competency in many medical programs. Various frameworks and authors have identified essential components and skills of good communication. The Kalamazoo Consensus Statement outlines seven communication tasks, while Arnold and Boggs describe ten skills. For simplicity, effective communication can be broken down into these essential components: listening, thinking and processing, and speaking or acting. The first component, listening, is argued to be the most crucial in ensuring safe patient care. In the perioperative setting, for instance, actively listening to the patient in the pre-operative area establishes rapport and encourages honest communication about health concerns. Actively listening involves nonverbal skills such as maintaining eye contact, using an open and attentive posture, and nodding to encourage the patient to share information. Paraverbal components, including tone, pitch, pacing, and volume of voice, also play a significant role. Listening and creating a trustworthy provider-patient relationship enhance patient compliance, satisfaction, and the overall quality of care. The second component of effective communication is thinking or processing the information that is heard. This can be done internally or externally by discussing it with the patient or other team members. Externalized processing, such as interdisciplinary collaboration, fosters teamwork and improves patient safety. By voicing concerns and seeking input from different specialties, healthcare providers can optimize patient care. Externalized processing is exemplified in the practice of patient rounding, where a group of medical professionals from various specialties collaborates to develop the best care plan for a patient. The complexity of patient care in the 21st century necessitates a culture that invites collaborative external processing.

Situation

Who is the patient and what is their pertinent history related to the current situation

“Patient X is a 33yo female who had a C-section twin birth 2 hours ago with estimated blood loss of 2 liters.”

Background

What the healthcare provider believes is the cause for concern

“Patient X has hypotension and hypovolemia related to acute blood loss intraoperatively.”

Assessment

What the healthcare provider requests as a solution to the case

“I think we should consider an IV crystalloid bolus and 1 unit packed red blood cells administration.”

Recommendation

Table 1a: SBAR Tool

Conclusion Effective communication is a fundamental component of healthcare, enabling the establishment of trust, collaboration, and improved clinical outcomes. Interpersonal communication skills play a vital role in decision making and achieving desired patient outcomes. Additionally, effective teamwork and collaboration are essential for delivering safe and reliable patient care. By implementing standardized communication tools and techniques, healthcare providers can significantly enhance patient safety and improve teamwork. One prominent communication tool, SBAR, offers a structured approach to communication, providing a common and predictable framework for sharing information among healthcare professionals. Utilizing tools like SBAR, along with checklists and standardized forms, can help bridge communication gaps, reduce errors, and enhance patient care. These tools are particularly effective when combined with clinician communication education, ensuring that healthcare providers are equipped with the necessary skills to communicate effectively and promote a culture of safety. To achieve optimal communication and teamwork, it is essential for healthcare providers to prioritize the basics of listening, thinking,

relay information between healthcare providers in a clinical setting. The use of SBAR provides a common and predictable structure to communication, enhancing clarity and reducing misunderstandings. The goal of implementing tools like SBAR is to minimize communication gaps during transfers of care. The development of SBAR stemmed from the need to address communication errors and standardize communication practices among healthcare professionals who often receive different training in communication techniques. For instance, nurses are taught to provide broad and narrative descriptions, as they focus on patient care rather than making diagnoses, while physicians are trained to communicate concisely and succinctly. By utilizing standardized communication tools like SBAR, interdisciplinary communication can be improved, leading to enhanced patient care. By incorporating tools such as SBAR and checklists into healthcare communication practices, the aim is to create a more standardized and reliable approach to communication, bridging the gap caused by varying communication styles among healthcare professionals. These tools facilitate effective interdisciplinary communication, improve patient safety, and contribute to better overall patient care.

The pillars of effective communication are: listening, thinking and processing, and speaking or acting, in that order. Tools of Good Communication Handoffs between different providers involved in a patient’s care can be a vulnerable area for communication errors. To mitigate these risks, tools such as checklists and standardized forms have been implemented to improve communication and reduce errors. One widely recognized communication tool is SBAR. SBAR stands for Situation, Background, Assessment, and Recommendation, and it is a structured communication tool used to effectively

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COMPONENTS OF GOOD COMMUNICATION 27

Jaime Beer 3

Enhancing Communication: The Power of Closed-Loop Communication in Health Care

and speaking up. Active listening, thoughtful processing of information, and creating a culture of safety that encourages open communication and the sharing of concerns are critical elements for success. In conclusion, healthcare communication competency, along with effective teamwork and the utilization of communication tools, such as SBAR, are key factors in delivering safe and reliable patient care while avoiding poor patient outcomes. By continuously improving communication skills and fostering a culture of safety, healthcare providers can enhance patient safety, improve clinical outcomes, and provide high-quality, patient-centered care.

Christian Garcia

Learning Objectives 1. Understand the concept of closed-loop communication and its significance in various industries, particularly in healthcare settings. 2. Identify the potential problems and consequences of open-loop communication in critical fields such as aviation and healthcare. 3. Explore the application of closed-loop communication in medicine, including its role in improving patient safety, reducing errors, and enhancing collaboration among healthcare teams.

“The single biggest problem in communication is the illusion that it has taken place.” -George Bernard Shaw

Introduction In our daily lives, we often encounter situations where uncertainty lingers after a communication exchange. “Did they receive my email?”, “Did they understand what I just asked?”, “I wonder if they heard me?” Most of this uncertainty can be resolved simply by “closing the loop” in the communication exchange. In its simplest form, closed-loop communication is a system of communication feedback which involves a sender delivering information, a receiver acknowledging and repeating the message, and the sender verifying receipt and accuracy. This chapter explores the importance and application of closed-loop communication in various industries, with a particular focus on its significance in health care settings. Identifying Problems in Open-Loop Communication Open-loop communication, where messages are delivered without any confirmation or feedback, can lead to several potential communication errors. The sender may deliver an incorrect or irrelevant message, or the receiver may fail to receive or understand the message. Furthermore,

even if the receiver comprehends the message, without the opportunity for further clarification there is a risk that the receiver may engage in subsequent actions that were unintended by the sender. In critical fields such as aviation and health care, these miscommunications can have devastating consequences. History of Closed-Loop Communication The need for closed-loop communication was recognized historically in radio communications, leading to the early development of standardized terminology. The Federal Aviation Administration (FAA) established a Flight/Controller Glossary to define these terms. This glossary includes terms such as “ROGER” (I have received all of your last transmission), “WILCO” (an abbreviation for “Will Comply”) and “READ BACK” (repeat my message back to me). Note that “ROGER” does not mean “yes” but is merely an acknowledgment of receipt, and “AFFIRMATIVE” (yes) or “NEGATIVE” (no) should be used to answer yes-or-no questions. Following tragic incidents such as the O’Hare airport collision in 1972 and other aircraft disasters that occurred due to

Suggested Reading 1 Borhani-Haghighi, A. (2022).

How can clinical communication skills improve patient-physician relationship building? Galen Med J, 11, e2480. 2 Kurtz, S., Silverman, J., Benson, J., & Draper, J. (2003). Marrying content and process in clinical method teaching: Enhancing the Calgary- Cambridge guides. Academic Medicine, 78(8), 802-809. 3 Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care, 13(1), 85-90. 4 Twedell, D., & Pfrimmer, D. (2009). Teamwork and communication. The Journal of Continuing Education in Nursing, 40(7), 294-295. 5 Warnecke, E. (2014). The art of communication. Australian Family Physician, 43(3), 156-158.

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miscommunication, the aviation industry adopted closed-loop communication principles to enhance safety. This became an integral part of Crew Resource Management (CRM), that emphasizes best practices for aircrews and supporting personnel and plays a vital role in preventing accidents caused by miscommunication. Application in Medicine In the medical field, closed-loop communication is crucial for ensuring patient safety and quality care. It helps to prevent errors, improve outcomes, and enhance patient satisfaction, and studies have shown its importance in the relationship between members of healthcare teams, different medical specialties, patients and caregivers, and trauma teams. For example, a study evaluating the ability of closed-loop communication to improve time-to-task- completion in pediatric trauma activations found that there was a significant reduction in time-to-task-completion when closed-loop communication was utilized and that orders with closed-loop communication were completed almost four times more quickly than orders via open-loop communication. Another study found a 75% decrease in medical errors after adopting closed-loop communication in an emergency department. Paging systems are a ubiquitous form of communication in the healthcare setting. In its usual form, paging is a one-way communication system that involves an indirect, delayed response from a different device such as a

paging terminal or telephone system. However, when real-time, closed-loop communications are needed, traditional paging systems may be inadequate. Use of communications systems such as mobile phones, texting systems, or hands-free voice-activated devices provides instant access to individuals of the care team, enables staff to communicate quickly, and improves overall communication. Closed-loop communication is critical in conveying test results accurately and ensuring appropriate follow-up. The Joint Commission, in its Quick Safety Issue 52, addressed the importance of closed-loop communication in reporting test results and included a case report in which a woman who underwent mammography was not informed she required follow up due to a suspicious area of calcifications. When she was finally notified of the abnormality a year later at a check-up with her primary care physician, she was diagnosed with stage 3 advanced breast cancer. Failure to communicate “sub-critical” test results promptly can lead to delayed care, compromised patient safety, and distress. Implementing consistent processes, notifying patients of critical results through verbal means with confirmation of receipt, and establishing alternative channels for unacknowledged results are crucial steps to reduce diagnostic errors. room provides a practical setting for the implementation of closed-loop communication. Consider the following example: Example 1A During vascular operations, anesthesia providers are often asked to administer heparin to reduce the risk of thrombosis. In an arterio-venous shunt placement, the vascular surgeon verbally announces to the room, “Let’s give 6,000 units of heparin,” without directly addressing the anesthesia provider. Amidst ongoing vocal communications and elevated ambient noise, the anesthesia provider does not hear the request for heparin administration. Approximately 30 minutes later, the surgeon looks up and asks the anesthesia provider how long it has been since the administration of heparin. The anesthesia provider explains that no heparin has been given In anesthesia practice, the operating

industry, through Crew Resource Management, has demonstrated the positive impact of closed- loop communication on enhancing safety and reducing errors. Recognizing the importance of closed- loop communication, regulatory bodies like The Joint Commission have addressed its significance and provided recommendations to enhance communication practices, especially in critical areas such as reporting test results and reducing diagnostic errors.

due to the initial request being unheard.

Now, consider the same scenario in an environment that consistently employs closed- loop communication. Example 1B The same situation unfolds as described earlier. While performing the operation, the surgeon announces to the room, “Let’s give 6,000 units of heparin.” Amidst other vocal communications and ambient noise, the anesthesia provider does not hear the request for heparin administration. However, since the surgeon does not hear a confirmation from the anesthesia provider, the surgeon pauses and makes direct eye contact, repeating the request, “Can you give 6,000 units of heparin, please?”. The anesthesia provider promptly responds, “Absolutely! 6,000 units of heparin” and seeks clarification, asking, “Would you like that to be administered now?”. The surgeon confirms the IV route of administration and asks the anesthesia provider to verify once the dose has been given. A few minutes later, after the heparin has been prepared, the anesthesia provider announces, “Heparin 6,000 units IV, being given now.” The surgeon says “Thank you”, acknowledging the anesthesia provider’s response. Conclusion In conclusion, closed-loop communication is a vital element in effective and safe communication within various industries, including healthcare. It serves as a powerful tool to mitigate potential errors, misunderstandings, and misinterpretations that can have serious consequences. By establishing a feedback loop between the sender and receiver, closed-loop communication ensures that messages are accurately transmitted, received, and understood. Throughout history, incidents in aviation and healthcare have highlighted the dire consequences of inadequate communication practices. These experiences have led to the development and implementation of closed-loop communication principles, such as the use of standardized terminology, read-backs, and acknowledgement of messages. The aviation

Two colleagues engaging in closed-loop communication. The receiver acknowledges and repeats the message, and the sender verifies receipt and accuracy.

In anesthesia practice, the operating room exemplifies a practical setting where closed-loop communication can be effectively applied. The examples discussed highlight the stark contrast between a communication breakdown and the successful implementation of closed-loop communication, emphasizing the critical role it plays in ensuring patient safety and optimal care delivery. By embracing closed-loop communication as a standard practice, healthcare professionals can create an environment of clear and effective communication, fostering collaboration, reducing errors, and ultimately improving patient outcomes. As we continue to prioritize patient safety and quality care, integrating closed-loop communication principles into everyday clinical practice will be paramount, helping us bridge the gap between intention and understanding, and ensuring that the single biggest problem in communication—the illusion that it has taken place—is effectively addressed.

Closed-loop communication is particularly important in the operating room where medication errors can lead to catastrophic complications.

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