Part 5 is the importance of excellent communication skills. Communication skills can always be improved, and this is done not only to improve your rapport with patients, but because many errors occur as a result of poor communication skills. Individual clinicians, as well as systems, can improve their communication skills or the processes by which they communicate. There certainly are barriers to good communication. These may include language, culture, the generation of the individuals, education and low health literacy, or simply having information. It's important also to think about communication not simply between physician to physician, but physician to other professionals and other individuals who work in the system of care. Communication is also highly related to teamwork, and teamwork issues also impede communication. There are many different kinds of teams, and it's important to remember who are the people that you work with. For those who work in outpatient settings, there nonetheless are teams that you work with, whether it's the pharmacists, the lab technicians, or the lab that you work with in order to take care of your patient. But patient safety requires teamwork. Teams have to have a common purpose, measurable goals, good communication between them, good cohesion, mutual respect, openness, and good leadership. And this can be seen in various teams throughout healthcare. In practice, the members of a team should use teamwork principles, be mindful of others, pay attention to the patient and include the patient as part of the team, and find ways to resolve conflicts. Other barriers include the lack of a culture of safety, changing roles, changing personnel in the team, an authority gradient, as well as the individualistic nature of medicine, and team instability. A team depends on a leadership structure. It depends on rules for how disputes can be mastered when there are questions about what to do. And good teams that provide safe patient care are those that have paid attention to how to do this. The leadership needs to constantly monitor the situation, to set priorities, to make decisions, learn how to resolve conflicts, to delegate tasks, to empower those who are working on the team with some freedom, and to inspire the team. A key definition for patient safety is what's called the authority gradient. The authority gradient is the concept that there are those in charge whose word or whose decisions cannot be questioned. The higher the authority gradient, the more likely there is a risk for errors and then adverse events. The authority gradient also impedes communication in and of itself. There should be care not to develop a large authority gradient. Authority gradient refers to the balance of power, and the more that this is flattened, as we say, flattening the hierarchy, is a good thing for teamwork and for improving patient safety. Those who want to express concerns, then, in a more flattened hierarchy, have a greater ability to do so, and doing so provides for better care. When we think also about teams, we think about physician competence, and those physicians who are members of the team do have to maintain their own competence. The patient safety culture does not say that physicians have no accountability or no need to maintain their skills or knowledge, but physicians have to play a part on the team and understand how to work together in order to take care of the patient. Team communication is also important, besides flattening the hierarchy. There are some specific forms of communication among teams that have been developed, particularly in health care, that have been helpful. SBAR is one of them. SBAR is a format to facilitate communication between members of the team, situation, background, assessment, and recommendations. Those who follow that oftentimes have an easier way of communicating the pertinent information to each other. Callbacks, callouts, callbacks, or pass the baton are other formats where communication can be eased. As we continue to think about communications, it's important to think about some particular moments in health care where communication is essential. One is transitions in care, sometimes called handoffs in hospitals. It is essential that handoffs occur in a way that allows for face-to-face communication or at least real-time communication, the ability for each person in the handoff to ask questions, to have a reduction in distractions. When these things are present, handoffs can be seen as more reliable and less likely to lead to omissions that can lead to lack of knowledge about a patient and to patient events. This also can be important in discharge planning, where the person is being discharged from the hospital. Another component of good communication is seen in the disclosure of errors to families or patients. To do so is a sign of good patient safety culture. And when done in isolation, it may actually be protective against claims of malpractice or other claims. But it's a way in which to maintain rapport with patients and to maintain the presence of the patient or the family as a part of the team. It's something also you can learn from, from others, and your team can also be involved as you practice how to do it. The disclosure of an error is a means by which a team can actually come together and start the process of thinking about what went wrong and what can be done in the future and whether further reporting within the system is needed. Proper disclosure is a sign of good patient safety culture, good communication skills, and also good leadership. When you're preparing to disclose an error or an adverse event due to an error to a patient or a family member, the team first should come around and begin to prepare and think about who should be going to speak to the patient and what exactly is going to be said. The person talking to the patient or family member should provide an explanation, should provide an admission of responsibility, should provide an apology, should elicit the feelings of the patient or family member, explain what can be done in the future to prevent similar events. This should be done in a timely fashion, and it should also be documented. At one point, as I said, disclosure includes an apology. One should not be afraid to apologize, especially under the patient safety culture tenets. And in fact, many states provide laws that prevent the use of an apology from being used against the physician or the hospital. It's important to also remember that disclosure is a sign of good leadership. A good leader is somebody who is able to bring together the team to discuss what may have happened, where an error may have occurred, and to have the ability to bring that to a patient. There are formal ways in which a hospital system or one's practice can try to look back and investigate what actually happened. But when that's the case, that an error has been found, good disclosure to a family is helpful not only for keeping them as part of a team, but for also continuously improving the quality of one's care.

communication skills

healthcare

patient rapport

reduce errors

barriers to communication