Safety of care
Chronic care can be improved with skillful communication
Originally published November 2017
Many diseases considered fatal just decades ago are now chronic, treatable conditions. This new reality demands a shift in how care is provided to a growing number of patients. A review of the CMPA’s data shows that in chronic care, communication is an issue. Between 2010 and 2014, 1,140 CMPA medical-legal cases involved chronic conditions. In the cases where peer experts criticized the care (718), about half (343) had issues with communication—either between healthcare professionals or between the doctor and patient.
Patients with chronic diseases often have to manoeuver through a complex healthcare system encompassing multiple healthcare professionals in different locations, and various medication or treatment regimens, all of which leads to many handovers of care. These care transitions are recognized as vulnerable points during which breakdowns in communication might contribute to patient safety incidents.1 In light of these challenges, the ability of healthcare providers to communicate effectively can make a profound difference in whether an encounter supports or discourages decisions that influence a patient’s quality of life.2
This article is based on a research abstract presented at the 2016 annual conference of the Canadian Association for Health Services and Policy Research (CAHSPR).
Analyzing the communication
To determine the role communication plays in the management of chronic disease, the CMPA reviewed five years of closed medical-legal cases involving select chronic diseases. The diseases chosen were cardiovascular disease (e.g. hypertension, stroke), respiratory conditions (e.g. chronic obstructive pulmonary disease, asthma), and diabetes.
Of the 1,140 cases examined, peer experts were critical of care in 718, and in about half of those (343) the criticism involved communication. These communication breakdowns were most often associated with diagnostic issues, treatment delays, and medication issues.
Two main areas of concern regarding communication were identified in the 343 cases. The most common was deficient interprofessional team verbal or written communication, most often involving physician-to-physician communication. The other concern was poor provider-patient communication, which was noted in almost half of the cases, as providers did not tailor the content or tone of the care-related information appropriately.
Sub-optimal interprofessional team communication and documentation was identified in 83% of cases, and while it most often involved physicians, other providers such as nurses and pharmacists were also involved.
These communication deficiencies most often occurred during transitions of care. Incomplete verbal or written communication during handovers was associated with deficiencies in the diagnostic process, primarily affecting clinical decision-making. For example, in some handovers poor communication led to delaying or failing to arrange appropriate testing, or not communicating to a colleague the need to follow up on tests that were ordered. Inadequate patient follow-up also led to missed or delayed diagnoses of complications, or contributed to sub-optimal disease management including delays in adjusting the treatment plan.
Not following a formal process for medication reconciliation occasionally resulted in medications, which had been temporarily discontinued, not being re-started at transitions of care. For example, in some instances anticoagulant therapy was not restarted when the patient was discharged following a hospital stay. In a few cases, the prescribing of a contraindicated medication led to an avoidable drug-drug interaction. Other medication-related areas of concern were inadequate monitoring of the effectiveness or safety of a medication, and not documenting in the patient’s medical record the rationale for changes to a medication regimen.
Communication between providers and patients
Ineffective communication between providers and patients or their families occurred most often with primary healthcare providers or during visits to the emergency department for problems related to their chronic condition.
Common communication themes in these cases included the following: lack of informed consent for treatment, including medication; delay or failure to communicate important and timely information (e.g. treatment plans); failure to communicate information clearly in a way the patient understands; and failure to communicate difficult news about health or prognosis in an empathic way. These conversations most often concerned the seriousness of the chronic disease and the patient’s understanding thereof; the reasoning and rationale for the treatment plan, including the importance of follow-up appointments; and issues related to advance directives and end-of-life care. Not adequately listening to what the patient or their family had to say or discounting their opinions sometimes led to misunderstandings and barriers in the physician-patient relationship.
Of the cases with ineffective communication between healthcare professionals and patients, more than a third involved patients aged 70 and older. This highlights the need for open and clear communication with this growing segment of the population and the family members that may be involved in their care.
The bottom line
Communication issues play a prominent role in CMPA cases involving patients with chronic disease. Focusing educational efforts on communication has the potential to improve patient safety. In addition, better communication skills may reduce the medical-legal risks for healthcare professionals who routinely provide care to patients with complex conditions.
The following key points, based on the peer experts’ opinions in the cases reviewed and on CMPA analysis, are aimed at improving communication in the clinical management of chronic disease:
- Listen actively, show compassion, and partner with patients to achieve care goals. This allows providers and patients to make shared decisions that strike a balance between meeting clinical goals and providing optimal overall quality of life. It also strengthens the provider-patient relationship by building trust.
- Use structured communication processes and tools, such as handover mnemonics. These can help overcome the barriers to effective handovers and can help foster a culture of safety.
- Document discussions, treatment plans, and other clinical issues in patients’ medical records. This can improve continuity of care by communicating to other providers what took place during a patient encounter and the rationale for clinical decision-making.
- Accreditation Canada [Internet]. Ottawa (ON): Accreditation Canada; 2013. Safety in Canadian health care organizations: A focus on transitions in care and required Organizational Practices [cited 2016 Mar 31]. Available from: https://accreditation.ca/sites/default/files/char-2013-en.pdf)
- Thorne S, Harris S, Mahoney K, Con A, McGuinness L. The context of health care communication in chronic illness. Patient Edu Couns [Internet]. 2004 Oct [cited 2016 March 2];54(3):299-306. Available from: https://www.researchgate.net/publication/8387102_The_context_of_health_care_communication_in_chronic_illness_Patient_Educ_Couns doi:10.1016/j.pec.2003.11.009