An article for physicians by physicians
Physicians and other health care professionals all agree on the importance of effective communication among the members of a health care team. However, there are many challenges associated with effective inter-professional (between physicians and other health care providers) communication, and these difficulties sometimes lead to unfavourable patient outcomes.
The CMPA's case files reveal inter-professional communication issues are associated with a wide variety of medico-legal problems, including delays in diagnosis, mishaps in surgery, medication adverse events, and failures in monitoring or follow up of patients.
Several key communication themes emerge from the data and highlight the importance of:
- communicating clearly
- providing sufficient (adequate) information
- offering timely information
- notifying the appropriate health care provider about the patient's condition, including any changes in that condition
- being polite and respectful
- responding to other health care professionals
- reviewing notes from nurses and other health care professionals
- using specific communication tools, e.g., the surgical safety checklist
Unfortunately, these elements of good communication are sometimes overlooked and this can lead to medico-legal consequences. Physicians can, however, evaluate and improve their inter-professional communication skills and this can benefit patients, reduce risks for physicians and meet the needs of other health care providers.
- Communication basics: Communication with other health care professionals should be clear, comprehensive and timely.
- Collaborative care: More and more physicians are working with other health care professionals to provide care to patients, and this trend highlights the importance of collaborative decision-making.
- Structured communication tools: There are a number of communication approaches and tools developed to provide structure and better clarity of communications between providers1.
- Communication in the operating room: Effective communication in the operating room is essential for patient safety.
- Working with pharmacists: Physicians communicate with pharmacists on a regular basis, be it with hospital pharmacists, in a community setting or as part of an inter-professional care team.
- Nurses' and other health care professionals' notes: While face-to-face, verbal communication is preferable, it is not always possible.
- Documentation: In documenting their clinical care, physicians should include the important information communicated to them and its source, along with any actions proposed or taken for the care of the patient.
- Written communications: The importance of effective written communications between physicians and other health care professionals cannot be underestimated.
Talk to the CMPA
If you, as a CMPA member, have specific concerns about inter-professional communication, you should contact the Association for advice. Our medical officers will discuss the facts of the case with you and provide guidance. In these cases, we encourage you to call us at 1 800 267-6522 or submit a medico-legal assistance/web mail form.
You are also encouraged to review previous CMPA publications about effective inter-professional communication (click on the Education link) and to complete the eLearning activity on team communication.
Interactions should be polite and show respect for fellow care providers. Active listening on the part of physicians is a helpful technique, as it focuses attention on the speaker. Clarifying an understanding of each health care team member's role and responsibilities for care and follow-up will benefit everyone.
There may be times when other health care providers find it difficult to speak up and share their opinions about an evolving clinical situation or impending adverse event. They may be afraid to do so because they are not encouraged to share their thoughts and opinions. Physicians should be attentive to this possibility, and welcome and facilitate the provision of input from all health care professionals.
Communication and collaborative care
To support effective and timely collaboration within and across teams, physicians and other health care providers should use good communication skills and be aware of scopes of practice, roles and responsibilities, and applicable policies and procedures. Common goals, shared mental models and appropriate accountability also help care teams to communicate effectively and build trust.
- SBAR is a technique used to clarify communication, and is often used to support telephone communications. SBAR is an acronym that stands for Situation, Background, Assessment and Recommendation. The health care provider uses these terms to communicate about the patient case or condition, including the recommendation about what action is required and how urgently.
- A model used in handovers is ANTICipate, an acronym that stands for Administrative Data, New Information (clinical update), Tasks (what needs to be done), Illness and Contingency plan.
- Another model is SIGNOUT, which stands for Sick or DNR; Identifying data; General hospital course; New events; Overall health status/clinical condition; Upcoming possibilities with plan; and Tasks to complete the plan.
- DRAW stands for Diagnosis, Recent changes, Anticipated changes and What to watch for.
The use of any of these or other structured communication tools can help to organize and simplify intra- and inter-professional patient care discussions, and all have the potential to improve the clarity of communications and patient safety.
Communication in the operating room
Operating rooms have long histories of provider hierarchies and limited communication, but this is changing. Surgical safety checklists and other initiatives are now used to expand OR teamwork and communication, and to improve culture. Physicians are reminded to use checklists and structured tools to give a voice to all members of the surgical team and to ultimately contribute to the culture of patient safety.
Working with pharmacists
The CMPA has previously recommended the establishment of a procedural framework that clearly defines and describes the collaborative relationship between physicians and pharmacists.
Establishing and maintaining effective communication between physicians and pharmacists is essential since both parties have responsibility to work together with the patient to optimize drug therapy. Physicians may consider establishing a system where pharmacists with whom they have established a collaborative relationship prioritize communication when prescriptions are changed, renewed or initiated without first consulting the physician. This may include specifying that any communication in this regard be in writing and sent within a defined period of time. It is also prudent to clarify in advance the expectations regarding follow up care, and who will typically be responsible for conveying care and information to the patient. Physicians should also consider documenting discussion with the pharmacist and/or the patient regarding treatment decisions in the medical record.
There is also value in establishing effective office or clinic processes that support the timely review of communications received from pharmacists. The use of a system, such as designating a time during which the physician reviews correspondence and other consultations from pharmacists with respect to any changes in patients' medications, should be considered.
Nurses' and other health care professionals' notes
Nurses and other health care professionals are trained to document their observations and their efforts to communicate with physicians, including noting when they have called a physician. Physicians should take care to review the notes of nurses and other health care professionals.
Documentation of communications
For example, this might include notes about a clinical discussion with a supervising or attending nurse; the retention of notes made in a physician's pocket booklet or handheld device; or other forms of communication such as email.
Effective written communications
For example, physicians should provide sufficient documentation to facilitate team members' comprehension of the patient's history, physical findings, diagnosis and rationale for the diagnosis, treatment and care plan. Physicians should also write patient care orders and prescriptions to convey the appropriate degree of urgency. Standardized abbreviations should be used and legibility is important. Physicians should also document the rationale for significant deviations from established processes or guidelines2.
- The CMPA does not endorse any specific structured communication tool or approach. These are offered as examples of techniques that many patient safety experts consider hold promise to improve communication. Several are being studied to establish their effectiveness.
- Frank JR, Brien S, (Editors) on behalf of the Safety Competencies Steering Committee. The Safety Competencies: Enhancing Patient Safety Across the Health Professions. Ottawa, ON: Canadian Patient Safety Institute; 2008.