Improved communication techniques enable residents to provide better care now and in the future

Effective communication is a key component and common denominator in successful organizations and businesses, and medical practices are no exceptions to this rule. Studies have consistently demonstrated that effective communication is essential to delivering safe and high-quality patient care.^1,2 Until recently, residents have not been required to complete standardized courses in communication, and the subject has never been a formal component of graduate medical education. However, the emphasis placed on communication has increased since the Accreditation Council on Graduate Medical Education (ACGME) has identified it as one of the six core competencies for physicians.³

Consequently, many surgical training programs are teaching residents to become more effective communicators and developing processes to improve care coordination and provide more patient-centric care. As surgical training continues to evolve, renewed focus and innovative approaches in communication across disciplines ultimately will enhance the quality of patient care.

Health care documentation has advanced from paper charts to electronic health records (EHR). This new method of communication between health care providers eliminates many potential errors. Illegible handwriting, misplaced orders, and delays in the processing of orders are all less likely to pose problems because of the new system.

As medicine has evolved over the last few decades, so has surgery. Historically, patients who required surgery were brought into the operating room (OR), and the procedure began when the surgeon made the incision. Times have changed. Currently, a number of systematic protocols are implemented prior to patients undergoing surgery. With the advent of surgical checklists to confirm variables, such as patient’s consent, site of surgery, and procedure performed, morbidity and mortality have declined.

Furthermore, as health care has become increasingly specialized, it has concordantly become more fragmented. Patients with complex diseases may often encounter multiple specialized health care teams during their hospital stay, each with its own management priorities and treatment plans. Communication failure among different health care providers is one of the most frequently cited causes of preventable harm to patients, and The Joint Commission has reaffirmed the relevance of improving the effectiveness of communication among care providers as a national patient safety goal.⁴

In addition to the communication challenges addressed here, it is important to note that the 80-hour workweek has completely changed surgical training. In order to abide by this rule, residents are engaged in the practice of sign-outs. These sign-outs place responsibility on the resident on call. Although the continuity of care by the same resident is compromised, the overall care of the patient should not be. Thorough and accurate sign-outs between residents ensure that everyone is reading off the same page and that the safety and quality of patient care remains intact.

Checklists—a tool for enhanced communication and teamwork

The aviation sector developed the first checklist after pilot Maj. P. Hill piloted a Boeing Model 299 that took off in Dayton, OH, on October 30, 1935, but then stalled and crashed. An investigation concluded that Maj. Hill forgot to release the elevator lock before taking off. The crash was classified as “pilot error,” and newspapers reported it was “too much airplane for one man to fly.” A group of test pilots evaluated the incident and instead of abandoning the plane or requiring longer training, they created a checklist. This checklist resulted in the Model 299 flying nearly 2 million miles without an accident.⁵

Health care practitioners have been using checklists to improve patient safety and quality of care for at least 20 years. The Northern New England Cardiovascular Disease Study Group developed a checklist for all cardiac surgery patients in the early 1990s, which decreased the number of patient deaths by almost 300.⁶ In 1998, the American Academy of Orthopedic Surgeons made it standard practice for surgeons to initial, with a marker, the operative site before bringing a patient to the OR.⁶ In 2003, The Joint Commission approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.

In the medical literature, checklists have shown successful reduction of morbidity and mortality. One memorable demonstration was by Peter Pronovost, MD, PhD, FCCM, senior vice-president for patient safety and quality and director, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, who created a five-item checklist for preventing infection during insertion of a central venous line.⁵ Although the five steps are simple and obvious—wash hands; clean the patient’s skin with chlorhexidine; put sterile drapes over the entire patient; wear a mask, hat, sterile gown, and gloves; and put a sterile dressing over the insertion site—Dr. Pronovost found that even experienced clinicians skipped at least one step in more than one-third of patients. After several years of implementing the checklist during central venous line insertion, his hospital and other hospitals in the U.S. successfully reduced infections and deaths, and there was a demonstrated reduction in costs. At Johns Hopkins, the checklist decreased the 10-day line-infection rate from 11 percent to only two line infections in more than two years, resulting in $2 million in savings. When the checklist was implemented in Michigan intensive care units (ICUs), hospitals saved more than 1,500 lives and approximately $175 million in the first 18 months.⁵

Despite the obvious benefits of using checklists, they were met with some resistance. Some physicians believe their jobs were far too complicated to be reduced to a checklist or that clinical judgment was superior to protocol. Some physicians were offended by the suggestion that they needed checklists, and viewed checklists as beneath them and an embarrassment.⁵ Tom Piskorowski, MD, an ICU physician, said, “Forget the paperwork. Take care of the patient.”⁵ Others were concerned that the checklist had been developed by nonphysicians without their input. Some surgeons saw it as an irritation or an interference with their turf. They feared that the checklist broke with the surgical tradition of the virtuoso surgeon who could do it all himself.

In surgery, communication in the OR is complicated by having multiple team members who often have never worked together, including the circulating nurse, scrub nurse, anesthesia assistant, anesthesiologist, surgeon, and surgical assistant.⁵ Studies have shown that nearly half the time the operating staff did not know each other’s names, but the silver lining was that when they did, communication ratings improved substantially.⁵

Recognizing the dangers in surgical care, health care professionals met at the World Health Organization (WHO) headquarters in 2007 to initiate the WHO Safe Surgery Saves Lives Campaign.⁵ At this meeting, leading experts identified problems, such as unsafe anesthesia, infections, and the surgeon’s lack of communication and respect for anesthetists and nurses.⁵ Several surgeons had experience with OR checklists, and with their input, the WHO group came to a consensus on several checkpoints important in surgery.

A WHO working group took these checklists and condensed them into one document with three pause points where the team must stop to run through the checks before proceeding⁵:

1. Before induction of anesthesia
2. Before skin incision
3. Before the patient leaves the OR

Much of the recent attention on surgical checklists evolved from the work of Atul Gawande, MD, MPH, FACS, who led the WHO Safe Surgery Saves Lives program and authored The Checklist Manifesto. The WHO group agreed on a 19-item checklist in spring 2007.⁵ This checklist decreased the rate of death from 1.5 percent to 0.8 percent, the rate of complications from 11 percent to 7 percent, the rate of surgical site infection from 6.2 percent to 3.4 percent, and the rate of unplanned reoperation from 2.4 percent to 1.8 percent (all p <0.05).⁷ The WHO checklist has been translated into 11 other languages, and it has been studied, adapted, and applied in various different countries.^8,9

The WHO Safe Surgery Saves Lives team had 10 objectives they hoped the checklist would address, and one was, “The team will effectively communicate and exchange critical information for the safe conduct of the operation.”⁸ The checklist was designed to enhance communication and calls for all members of the OR team to introduce themselves by name and role.⁹

Checklists are designed to address (1) the fallibility of memory, (2) the fallibility of attention (for example, distraction), and (3) the minimum necessary steps. Checklists can protect anyone, even the skilled and experienced surgeon, against failure. They ensure people communicate, coordinate, and accept responsibility.

Checklists revolutionized aviation and prevented pilots from making human errors while flying. Like pilots, surgeons are susceptible to making mistakes while performing complicated tasks. Fortunately, the American College of Surgeons (ACS) acknowledges the benefits of combining communications team training with an international recognized surgical checklist.¹⁰ Currently, more than 3,000 hospitals participate in the WHO Safe Surgery Saves Lives Campaign and use the organization’s checklist.^9,10

Coordination of care

Communication and coordination of care are two significant challenges currently facing the delivery of surgical care and are critical to its success. Patients with multiple, complex comorbidities that require attention from numerous providers with distinct areas of expertise frequently find themselves navigating through diagnoses and treatments from an often disjointed and loosely associated group of providers.¹¹ In U.S. hospitals, where resources are abundantly available, one would expect care to be better coordinated and communication to be more effective. However, failures in these two essential components of care continue to contribute to the shortcomings of the nation’s health care system and have been underscored by the Institute of Medicine.⁴

To meet the challenges of communication and coordination of care, health care must be delivered in an environment of collaboration with a focus on delivering patient-centered, high-quality surgical care. In her book High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience, Gittell observes that “when doctors, nurses, therapists, case managers, social workers, other clinical staff and administrative staff are connected by shared goals, shared knowledge, and mutual respect, their communication tends to be more frequent, timely, accurate, and focused on problem solving, enabling them to deliver cost-effective, high quality patient care.”¹¹ This intricate interdependency between relationships, communication, and coordination in the setting of shared goals, shared knowledge, and mutual respect defines relational coordination.¹¹ Because surgeons spend a significant portion of their day in the OR away from inpatient care activities, successful and well-developed relational coordination can help bridge the gaps in patient care.

High levels of relational coordination among care providers have been associated with shorter hospital stays, greater patient-perceived quality of care, and improved clinical outcomes.¹¹ A successful multidisciplinary and collaborative approach has been reported in the surgical oncology literature and was shown to affect patient treatment plans.^12,13 Expanding the concept of relational coordination into the realm of surgical rounding with different disciplines may provide an opportunity to improve communication, as well as patient care and satisfaction. Some health care institutions and providers have experimented with different models to achieve these aims.^14-19 At Penn State, a multidisciplinary process known as “collaborative care rounds” was instituted based on the aforementioned principles. This process includes daily mid-day bedside rounds with multiple providers, including residents, nurses, social workers, and care coordinators. Morning plans are reassessed; new data are reviewed; and patient questions, concerns, and future plans are addressed from the patient’s perspective. Educational elements are emphasized as these collaborative care rounds provide an opportunity to reinforce lifestyle and behavioral modifications in a concerted and unified fashion. As a result of these bedside rounds, patients have reported feeling they are at the center of their care and are primary participants in the interaction, discussion, and formulation of their care plans. Six months into implementation, unit and service-based Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores improved dramatically.

The literature on multidisciplinary rounding, as a basis for collaborative care, is limited—particularly for surgical patients.^14,15 Multidisciplinary rounding has been implemented in many different forms with varying levels of success with respect to cost savings, length of stay (LOS), and quality outcomes.^16-19 In a model that used regularly scheduled multidisciplinary rounds in a conference room setting, Felten and colleagues demonstrated cost savings and decrease in LOS in general surgery patients with participants reporting improvements in communication and teamwork.¹⁴ Even in studies that failed to support benefit in LOS and hospital costs, the benefit of multidisciplinary rounds on teamwork, collaboration, and efficiency of the workday persisted.²⁰ Observational studies have demonstrated that higher ratings of collaboration and teamwork have been associated with better patient outcomes.^15,20-22 Furthermore, higher nurse retention and greater job satisfaction among team members has also been shown.²³ A recent Cochrane review addressing the impact of interprofessional collaboration and the effects of practice-based interventions on professional practice and health care outcomes described these efforts as “promising” and recommends further dedicated research.²⁴

Notably, surgical care is undergoing a paradigm shift from a physician-centered model to one that is patient-centric. The emerging model embraces a partnership between the patient and health care providers and is guided by the principles of patient autonomy by allowing patients to make informed decisions based on the expert knowledge of providers to guide their care. Patient-centered care requires successful relational coordination, deliberate collaboration, and communication between health care teams and their members.

Health care is changing. Delivering high-quality, cost-effective care with high patient satisfaction is an imperative. Successful outcomes in surgical patients will no longer be defined solely on operative success. The coordinated efforts between health care providers with different but equally important skills will be essential to achieving these goals.

Effects of work-hour restrictions

While the implementation of checklists and multidisciplinary rounds represents a significant improvement in health care delivery over the past decade, there have been sweeping changes related to regulation of resident duty hours. In 2003, the ACGME implemented a series of resident work-hour rules, including the controversial 80-hour workweek, which was intended to reduce resident fatigue and thus improve patient safety.

More recently, a series of additional restrictions were implemented, including a new rule that limits interns to no more than 16 hours of continuous duty. This policy has led to the widespread adoption of shift coverage among junior residents. Although the impact of these changes is still being evaluated, they do not appear to have resulted in a measurable improvement in patient outcomes. However, as these rules have been implemented, a number of issues have been identified, particularly in surgical residency training programs. With the limitation on resident work hours, it has been challenging to optimize the service-to-education ratio in order to maximize time spent involved in direct patient care and the OR. As a result, many programs have expanded service coverage by hiring mid-level providers to offset the resident workload and hours regulations. For these reasons, there has been an increase in the number of sign-outs among residents and midlevel providers, leading to more than 300 patient sign-outs for the typical intern over a one-month period.²⁵

As the frequency of patient sign-outs increases, particularly among complex surgical patients, concern that communication breakdowns may lead to medical errors is on the rise. The effects of sign-outs on patient care has been challenging to study, as it involves a qualitative evaluation of the sign-out process and longitudinal follow up of patient outcomes. Recently, Yeung and colleagues examined the effect of frequent patient sign-outs on a busy trauma service to determine whether they affected patient outcomes.²⁶ In a retrospective review of more than 4,000 patients, they observed no difference in time spent in the emergency department, ICU length of stay, ventilator days, or mortality when patients were admitted during shift change periods (6:00 to 8:00 am and 6:00 to 8:00 pm) versus those admitted during other times of the day. However, they observed a small but significant increase in overall length of stay (five versus four days) in patients admitted during shift change periods. Although these data are encouraging, more studies designed to evaluate the impact of frequent patient sign-outs need to be carried out to fully understand the true effect on patient care.

Traditionally, one of the tenets of surgical residency training has involved pre-rounding as a junior resident. This process typically involves arriving at the hospital early, reviewing patient data, and assembling this information into a patient list for the surgical team. In the context of resident duty hours, this process consumes 10 percent or more of an intern’s assigned shift. Also, the integrity of patient data may be compromised during the transcription process. The enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has led to the widespread adoption of the EHR in hospitals across the U.S.

Despite the variety of high-quality EHR products available, few suppliers have developed software to facilitate patient sign-off among health care providers. Recognizing that patient data are largely maintained in an electronic record, a number of surgical training programs have developed computerized database programs to seamlessly translate patient data into a working patient list and sign-out tool. The leader in this area has been the University of Washington, Seattle, which developed a computerized rounding and sign-out instrument (CORES) in 2003.²⁷ This program was designed with three goals: improve workflow efficiency, enhance sign-out communication quality, and increase the time spent in direct patient-care activities. As the program was implemented, some individuals expressed concern that medical errors may arise because residents were not directly reviewing patient information, medications, and other data in the patient’s electronic chart before rounding because the information was automatically populating in the report on rounds. To study this potential problem, a randomized crossover cohort study was performed, comparing residents (internal medicine and general surgery) who rounded in the traditional way versus using the new computerized rounding report. Researchers found that adoption of the CORES program resulted in reduced pre-rounding time, improved the quality of patient sign-out, and did not increase medical error.²⁷ A number of surgical residency programs have followed the University of Washington’s lead and developed their own computerized sign-out tool. These range from a simple Excel spreadsheet model to a formalized, custom-built program via collaboration between the residents, program directors, and hospital administration.^25,28 In each system, the authors observed a measurable decrease in time spent pre-rounding and an improvement in communication and patient sign-out.

Moving forward, it is clear that changes in resident duty-hour regulations will require constant adaptation to maintain educational standards and to optimize delivery of quality patient care. Present challenges include transitioning to a shiftwork schedule among junior residents, which has resulted in more frequent patient sign-outs. The rounding and sign-out process can be integrated with the data in the EHR, which would streamline these tasks and increase resident efficiency, resulting in more time spent in direct patient care and the OR. Development of a high-quality electronic sign-out tool requires the support of the hospital administration and collaboration among residency programs. As these instruments are developed and sign-out procedures are standardized, continued research into their effects on patient safety and outcomes needs to be conducted to identify methods to improve these tasks.

Conclusion

This year, the ACS commemorates its 100th anniversary. Since its establishment in 1913, the ACS has continued to make efforts in starting committees, initiatives, and setting the standard for surgeons to improve quality in hospitals and, most importantly, patient care. The ACS’s goal of Inspiring Quality: Highest Standards, Better Outcomes remains constant as health care delivery changes.

Many aspects of communication in surgery have received particular attention in the past decade in an effort to advance quality improvement. Surgery checklists have undoubtedly revolutionized standards of practice and prevented errors. Patients undergoing surgery 100 years ago were more susceptible to infection and other preventable morbidities. Although complications may be inevitable, checklists have yielded concrete results, including decreases in infection rates and preventable errors. Another communication transformation is the increased frequency of collaboration and coordination among health care providers. These types of relational coordination are a key component of patient-centered care. Lastly, changes in duty-hour regulation have required residency programs to adopt better sign-out methods.

The ACS will always have a strong commitment to ensuring that the surgical patient receives quality care. These current and future communication initiatives will provide young surgeons and surgeons in training with the skills they need to provide optimal care to surgical patients for the next 100 years.

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