Healthcare Communication Chain
Hospitals are epicenters of communication. The moment a patient arrives at a hospital, a complex chain of communication kicks off. The patient is admitted, their medical records are retrieved, a bed is assigned, care team members are assigned to their case, a discharge plan is created, diagnoses and treatment plans are recorded and handed off to new clinicians, the patient is eventually discharged with education and instructions, and someone clears the bed.
Clear communication in each of these events is crucial to maintaining quality of care throughout the process and operational efficiency. And yet, the Joint Commission found that poor communication is the root cause of more than 65 percent of sentinel events (events that cause death or serious harm).
A 2015 report published by CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions, Inc., provided several illustrative examples, including:
- A provider fails to respond to calls from a diabetic patient, which were documented but not relayed to the provider by office staff. The patient collapses and dies from diabetic ketoacidosis.
- A positive pathology result is entered into the EHR (electronic health record) but isn’t flagged for primary care provider review. As a result, the patient is not notified and her cancer diagnosis is delayed by a year.
- A text message about vital sign changes is sent to a patient’s doctor. The doctor has switched phone numbers and does not receive the text message, leading to the patient’s decline.
Why is communication in hospitals suffering so much? Factors include increasing clinician workloads, outdated technology, and lack of communication skills training.