Running head: IMPROVED SAFETY VIA COMMUNICATION

Improved Patient Safety by Implementation of Standardized Communication Tool

Jody French-Sroka,
Ferris State University

IMPROVED SAFETY VIA COMMUNICATION

Abstract
This paper will address the need for implementation and use of a standardized
communication tool. Many safety events have a root cause of lack of or poor communication.
Studies indicate the improved communications have been shown to improve safety, teamwork,
and outcomes. There are numerous transitions in care that can be affected by inadequate
communication skills. Work to improve the teamwork and communication can greatly increase
patient safety and patient outcomes.

IMPROVED SAFETY VIA COMMUNICATION

Improved Patient Safety by Implementation of Standardized Communication Tool

In the current system of healthcare, communication of information is vital to the safety of
our patients. Missed or ineffective communication can have severe repercussions for patients
and organizations (Dunsford, 2009). There is a need to prioritize the reversal of this trend of
poor communication, lending to a decrease in errors that may lead to adverse events, injury and
possibly death. Leaders today need to implement and model communication behaviors that have
been shown to reduce the potential risk of harm to the consumer. According to Beckett and
Kipnis (2009), communication failures have been a root cause of adverse patient occurrences
events, with numbers to support that up to 70-80% of medical errors are related to interpersonal
interaction or communication issues (p. 19). This high correlation of error rate can be reduced
by the use of a standardized tool such as the situation-background-assessment-recommendation
(SBAR) tool to improve communication and patient safety. SBAR was originally used in
military and aviation and allows for sharing of structured, concise and focused information
(Shannon, Long-Sutehall, & Coombs, 2011). Adoption of a standardized structured tool will
allow for staff to focus on communication and increase the effectiveness of information transfer.
In an effort to give perfect care to patients we as healthcare providers need to ensure that all
team members are involved and current on the patients situation.

Needs Assessment
The current organization I am affiliated with is not different than many others across the
state or nation. The most recent data for the organization equates to approximately 58% of
reported safety events have some type of communication factor associated. Patient safety events

IMPROVED SAFETY VIA COMMUNICATION

are often classified as failures with various types of communication issues as a contributing
factor; this is especially true on the clinical side of care. Report and handoffs are currently being
completed in multiple ways; dependent on the unit the patient is being housed. Each unit, level
of care, nurse, provider and healthcare team member has a different concept of communication
and how we can deliver the most streamlined, consistent information from one person to the
next. Consistence is lacking throughout the clinical practice areas. There is such variability in
patient reports, shift reports and all clinical communications that this lends itself to be a potential
error in its own right. In the past physicians and nurse have had different communication styles.
Nurses have been trained to use narrative formats with many details for communication of
events, where physicians have used an abbreviated format focused on key information
(Woodhall, Vertacnik, & McLaughlin, 2008).
In addition to the potential for error, the current status of patient report has negative
connotations as well. The reports tend to be long, involve non-pertinent information, staff get of
track due to socializing, creation of a financial impart in regards to overtime waiting for nurses to
finish and also unavailability of staff as they are in report, thus putting patients at risk. As an
organization that is now part of system we will need to look closely at the areas that can be
improved and communication is one. There will be other corollaries of the change also.
Communication events include information that is relayed in regards to patient such as
laboratory results, radiology studies, patient diagnosis and care preformed and anticipated
(Braun, 2012). Often times the information is not presented in a structured fashion or may be
incomplete, thus not allowing the receiver to get all the pertinent information in a well thought
out manner. It is imperative that the communications occur in a timely and prcised manner in
order to prevent patient safety concerns. According to Amato-Vealey, Barba, & Vealey (2008)

IMPROVED SAFETY VIA COMMUNICATION

communication that is timely, accurate, complete, unambiguous and understood by the recipient
reduces errors and results in improved safety (p.769). Implementation and use of a standardized
and structured tool would allow all clinical staff to know what to expect with each occurrence of
report. Proposal of implementation and utilization of a standardized communication tool will
improve care transitions, patients safety, satisfaction scores and patient outcomes (Bekett &
Kipnis, 2009) is being brought forward. The motto to do no harm can be inserted here, as
providers we are held to this standard.

HRO standards, Just Culture and Quality Improvement Models

High reliability organizations (HRO) look to streamline processes and maintain
consistency. Hospitals are starting to embrace the concept of HRO as a way of steering the
management of systems. A key part of becoming an HRO for healthcare organizations is the
internal elements that are spearheaded from the executive suite. Four elements noted have
included executive leadership support, alignment with your business case, linkage of staff
behavior with desired outcomes, and a just culture (Hines, 2008). HROs are sticklers on
measurement and are preoccupied with failure and often engage staff to be aware of processes
that may fail. Staff also tends to be more informed of the overall mission, vision and value of a
HRO as they tend to be personally involved in improvement activities.
Healthcare organizations are moving towards a just culture, leaving behind a culture of
blame. The new culture is one of that allows for staff to bring forward questions or concerns,
without retribution. A Just culture is about creating a culture of learning and designing new
systems or processes to improve care. Many states and healthcare systems have become part of a
Patients Safety Organizations (PSO) which was created as part of the Patient Safety and Quality

IMPROVED SAFETY VIA COMMUNICATION

Improvement Act of 2005 (ECRI). Membership in a PSO allows for aggregate data to be
collected in regards to near misses and adverse events across systems for analysis deeper into the
problem.
There is a human factor in the just culture that should be factored in also. Employees
can knowingly make decisions or choices that may not follow organizational policy or values,
therefore leading the event error down a different path. Safety events or errors are reviewed
through a process to determine the underlying problem that caused the error to occur this process
is called a root cause analysis (RCA). Events are gateways to review current processes and
practices to determine if the error that occurred was a system, process or people problem. Once
the root cause of the error is determined a corrective action plan can be implemented to prevent
any further instances of harm or occurrences of the event. An example of this would be a wrong
site surgery that occurred. A surgeons office called to schedule a frenulectomy, this was
repeated back to the office staff member and the case was boarded. The patient arrived, consent
was reviewed with parent, site was verified and patient was prepped. The surgeon came in and
did not actively participate in the time out and proceeded with the case. A circulating nurse had
questions to the validity of the consent and if it should have read frenulectomy or frenotomy and
also laterality noted. The staff member did not feel comfortable confronting the provider,
assuming there was a difference in the upper and lower lip, the operation proceeded and at
completion it was identified that indeed the wrong site had been operated on. In retrospect the
consent was to be for an upper lip frenotomy and a lower lip frenulectomy had been performed.
This caused the patient to return and be exposed to a second surgical event involving anesthesia
the next day. The event was fully disclosed to the family.

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RCA of this event identified several issues with the surgical case boarding process, the
verification process and also the culture within the surgical services area. As a result of this,
many processes were reviewed and changed, staff education has occurred, the organization have
strongly supported a culture of no blame. Front line staff was eager to be engaged in this review
and process improvement project, which also facilitated the engagement of physicians and all
surgical staff. Safety event reporting has significantly increased as executive leadership and
management has supported this Just culture change. It became obvious that prior to this that
many near misses or events may not have been reported due to fear of repercussions. Another
consequence of the changing culture and staff engagement in quality and safety improvement
projects was that our staff and physician satisfaction scores increased.

Proposition to implement a change

Nursing sensitive indicators (NSI) look to see how the day to day work of nurse can affect the
outcomes of patients. Communication is a large part of the daily interactions that the nurse has
with the patient and other care givers, such as shift change, break relief, transfers to other units or
communications with other departments. It is imperative that these interactions are effective and
remain accurate, concise, complete, specific, relevant and timely (Amber-Walsh, Flanagan, &
Ebright, 2010)
Communication among healthcare providers allows for transmittal of pertinent
information that must be shared between team members to ensure safe, seamless transfer of
patient care (Iaconao, 2009). Implementation and roll out of the standardized SBAR tool will
require several phases. This can take several months but time and dollars invested will reap
reward in the end.

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Initially an ad hoc group of involved stakeholders will convey to determine how to

proceed with the implementation of the proposed change. The stakeholders will include bedside
nurse, physicians, therapists, pharmacist, leadership and other clinical personnel as deemed
necessary. Senior leadership support will be required (Dunsford, 2009) and also need to be
garnered prior to implementation. When leadership teams are provided with strong
communication strategies, improvements as multiple provider levels occurs thus improved in
patient safety and outcomes ( Beckett & Kipnis, 2009). Scope of the project, such as which
areas to include and determination for timeline for implementation and rollout will be created,
along with defining of rolls and responsibilities. The timeline will need to incorporate allowance
for staff education and competency, form development, and creation of metrics. Ultimately it
would be a great assess and time saver, if the SBAR tool could be converted to an electronic
format that is capable of pulling the data into a report for the nurse to review.
In order to determine if our change will be effective, metrics will be defined and
baselines data documented. Metrics will should include areas such as staff education, audits of
compliance and satisfaction, both patient and staff. Staff will be informed of the metrics so that
they will be able to interpret the results. Completion of the prerequisite tasks will allow for
rollout of the tool on the specified units. Data collection will occur on a daily basis in order to
give immediate feedback to staff. This will also allow for modeling of the behavior, if needs are
identified for correction or improvement. The time and resources to implement this change could
easily be a return on investment if one patient safety event was avoided.

Healthcare practice patterns

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Nurses at all levels have an ethical responsibility to ensure safe patient care. According to the
ANA Nursing Scope and Standards of Practice (2004) as part of Standard 11 the nurse
communicate with patient, family and healthcare providers regarding patient care and the nurses
role in the provision of that care (p. 38) to ensure the best outcomes for the patient. Nurses and
other healthcare providers do not knowingly place their patients at risk. Education to healthcare
providers of the evidence that indicates use of a standardized communication tool reduces the
potential for misinformation or ineffective communication to occur may facilitate their
engagement. SBAR would allow the staff to communicate assertively and effectively, reducing
the need for repetition ((Shannon, Long-Sutehall, & Coombs, 2011). The ability to communicate
and work collaboratively with the physicians was shown to increase with utilization of the SBAR
tool (Meester, K., Verspuy, M., Monsieurs, K., & VanBogaert, 2013). Implementation of a
standardized tool could help to reduce the number of adverse events or near misses if the tool
was utilized at the facility, system and state level. Utilization of the SBAR tool would also give
the clinical staff the autonomy to use critical thinking skills and formulate possible
recommendations for care, which all professionals strive for. According to Dunsford (2009),
once institutionalizing the tool it provides a shared mental mode, improves communication and
by extension, safety: (p. 388).

Summary
Healthcare systems across the nation are striving to improve patients safety, quality and
outcomes. Every organization needs to implement practices that have been shown to improve
and ensure increased safety for the patients; this is expected by the consumer. Implementation
and use of a standardized and structured communication tool will decrease the adverse events

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10

that have contributing factors related to the root cause. Concise timely delivery of the
appropriate information has been shown to improve safety, patient satisfaction. Patient safety
and quality indicators are being compared nationwide in an effort to excel the standards of care.
Communication expectation will continue to grow as patients become more engaged in their care
and want their voice to be heard.

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