Strengthening Patient Safety and Engagement Through System Standards

March, 2018

Safety culture and patient engagement are the focus of Safety Awareness Week, March 11-17. The theme of the week is “We are all patients.”

In the spirit of the week, we’re sharing excerpts from our recent report from the Experience Innovation Network, part of Vocera. It’s called Clinical Communication Deconstructed: A framework for successful, human-centered clinical communication.

The report’s chapter on System Standards for Optimal Communication showcases a wealth of perspectives and insights from healthcare leaders and patients. It’s sure to spark ideas for improving patient safety and better engaging with patients all year long, and beyond.

System standards for optimal communication in healthcare are essential to allowing human connection to flourish.

And just what are they?

They are policies, processes, guidelines, and even unwritten norms that govern how communication should take place in various situations.

In this chapter of our report, Wendy Ron, a patient advocate and cancer thriver, shares a story about system standards that she recommends to help care teams recognize and support the goals patients have for their care:

“The concept of a shared goal is powerful. I’m a teacher. I create goals with my students all the time. But if I don’t share a goal with the student, he or she can’t achieve it.

It’s the same in healthcare. If the team’s goal is to get the patient discharged, and the patient doesn’t know it, then the patient can’t work towards the goal.

In my hospital stays, there was usually a whiteboard with a section on it for goals. But often it wasn’t filled out, so I would write on it myself. Some days my goal was to not throw up on my care team. Some days it was to enjoy my lunch. Some days I wanted to be able to walk around the unit.

Sometimes the goals aren’t aligned. They think your goal is to go home, but it’s to understand your meds so you feel safe. Or maybe you know your meds but you just want to feel steady on your feet.

The really important thing is that the care team and the patient should define the goal together. It should be a reasonable goal – from both perspectives. My care team didn’t always ask me.

Some of the nurses or CNAs would write their goals: I want to make sure you shower, and I would say, ‘I want to make sure I’m hydrated.’

Even just writing the goal on the board was powerful. I had a lot of trouble sleeping in the hospital (there’s all that beeping, and they come in and wake you). I’d write a goal of having a restful night. Then the nurses and team members would know I wasn’t sleeping well.

But the best is the care team sharing their goal, and then asking, ‘what is your goal?’ And then you can arrive at a shared understanding.”

Policies: Balancing Structure and Flexibility to Improve Patient Care

The most structured system standards hospitals put in place tend to revolve around situations of greatest risk; for example, calling codes. In risk situations, system standards make it possible for all participants share the same mental model and communication habits to support safety and outcomes.

In other situations, such as in coordinating care, there can be a lack of clarity in policy which can lead people to communicate critical information in nonstandard ways.

The challenge for leaders is to strike the balance between implementing policies that make operations efficient and effective, and allowing frontline workers the flexibility to devise communication approaches that work optimally for unique situations.

Fostering Safety Culture with a Three-Challenge Rule

The report’s chapter on system standards features a good case study from Beth Boynton, RN, MS, who is a strategic organizational development consultant.

She shares the story of a program called TeamSTEPPS that the Agency for Healthcare Research and Quality (AHRQ) promotes. TeamSTEPPS is designed to train clinical teams on the skills and systems required for exceptional teamwork that leads to safe care. Ms. Boynton recommends taking a component of TeamSTEPPS one step further.

One of the program’s principles is the two-challenge rule, designed to ensure that all team members speak up about safety concerns.

In the two-challenge rule, if a person notices a safety concern, he has to speak up and state his safety concern.

If his peer or the group ignores him, he has to speak up again (first challenge). If he is still ignored, he must take his concern up the clinical ladder until it is addressed (second challenge).

The system is designed to encourage all team members to speak up, even if it means challenging people with more institutional authority or power. It grants everyone permission to escalate concerns.

Ms. Boynton argues that this doesn’t go far enough. “There should be a third challenge – to identify why people are ignoring the person in the first place. That is the origin of the problem,” she explains.

“Too often we look at a communication breakdown and say that people aren’t speaking up. Just as often, the problem is that people aren’t listening effectively. Speaking up and listening are interrelated and both are critical for promoting a culture of safety. By invoking this third challenge, we could explore individual or organizational patterns that signal areas for deeper work.”

Ms. Boynton advocates for experiential training, such as improvisational workshops, that teach the core skills of listening and sharing power, not just learning structured tools for specific communication situations.

Engaging Nurses and Physicians for Rounding, to Better Engage Patients

The report also showcases a great example from Parkview Health of system standards for optimal communication applied to patient rounding:

The concept of nurses and physicians rounding on patients together isn’t new. The practice allows the patient and her primary nurse and physician to share information and agree on a plan of care. But the practicalities of getting nurses and physicians in the same place at the same time can be daunting.

At Parkview Health, nurses and doctors created a process that is individualized based on the unit needs.

On the medical units, doctors arriving on the unit check the nurse call system to see which nurses are assigned to their patients. At the same time, nurses on surgical units who see a doctor arrive on the floor send out a group-wide text so that nurses can make themselves available for the round.

“The nurse is engaged with the physician and is also watching for patient comprehension,” explained Kimberly Burns, MSN, RN, CMSRN, educator, nursing professional development and clinical care. “Sometimes as a nurse you can help explain something in a different way to the patient or help clarify a question. And sometimes the patient needs to hear something directly from the doctor.”

The system has been so successful the team has adopted it house-wide, as part of the Parkview Way. “We do it because it works. It’s effective, it decreases work, increases satisfaction, builds relationships, and helps us educate the patient.”

Learn More

Read the Clinical Communication Deconstructed report’s chapter on system standards for optimal communication to see more perspectives from healthcare leaders and patients about how to strengthen communication, patient engagement, and safety.

At the end of the chapter you’ll find questions designed to help you reflect on your system’s strengths and opportunities for improvement in this area.

I invite you to download the report today to learn more about system standards for optimal communication and the other elements of effective clinical communication.

Learn about Vocera solutions that can help strengthen patient safety and engagement.