Hospital da Luz, Portugal
In organizational terms, communication is an essential variable for the proper functioning of any system. In healthcare, communication is responsible for problems related to patient safety and reduced efficiency, contributing to increased costs and imposing sustainability challenges. Communication failures are recognized in the literature as the biggest source of errors in hospitals, being responsible for about 70% of sentinel events in healthcare.
Countless professionals participate in the activity, with different training, assorted styles and communication methods, work at separate times and locations, but need to share and manage information. Therefore, an enormous amount of clinical and non-clinical information circulates. It is stored in various formats and exchanged in various forms such as face-to-face or telephone conversations, letters, e-mail and electronic or paper medical records. The massive introduction of technology has not helped to solve this complexity.
To date communication in healthcare, similarly to its organizational model, has been treated in silos. Communication studies have always been restricted to specific and delimited locations, such as the operating room or to more specific situations, such as patient transfers and handovers between professionals. This circumscribed view leads to a lack of coordination between the different professionals and their activities. The World Health Organization (WHO) has identified this lack of communication and coordination as the top priority for patient safety research in developed countries. But until now, an assessment of communication and cooperation throughout the patient’s clinical journey has never been conducted and, consequently, a methodology for this has never been developed.
Nowadays, healthcare is undergoing one of the biggest disruptions ever with the shift to Value-Based Healthcare. This implies abandoning a system organized around the doctor to build a system organized around the patients’ needs. The adoption of this new paradigm presupposes the implementation of an organizational model based on Clinical Pathways (CP), where the organization that was previously based on medical specialties is now established by diseases.
Although the problem of intra-hospital communication predates CP, its implementation implies the rethinking of the entire organizational structure. This includes creation of new circuits and sequences of information flows arising from the need for greater coordination between the multidisciplinary care team and the patients, throughout its journey.
In the case of communication, healthcare professionals are only aware of the part of the process in which they participate and are hardly aware of the coordination and communication problems that occur. The patient is the only one that have a clear view of the complete journey and their interconnection. Thus, the patient’s perspective can show their needs and difficulties and help to identify problems of coordination and communication between professionals to take them into account in the redesign of processes.
In this sense, the objective of this project was to analyze the entire intra-hospital communication circuit within the scope of CP from the patient’s perspective. This knowledge will allow to build a knowledge base to develop a model of communication with the patient, which can contribute to improving the safety and efficiency of care delivery.
For this purpose, a human factors engineering methodology was used with a human centered system perspective of observation in the field. The project started in early 2019, was suspended in March 2020, due to the pandemic, and restarted in September 2021 until the end of the year. Patients were shadowed in 3 CP: Colorectal carcinoma (n=2); Chronic obstructive pulmonary disease (n=36); and stroke (n=25) in all interactions with the hospital.
One analyst for each CP accompanied the patients throughout the hospital journey (consultations, exams, treatments…) collecting the moments and content of all communications between professionals and patients. Subsequently, all positive or negative incidents related to this communication/cooperation were recorded, identified, and treated.
The results showed all the benefits of this approach for obtaining data to improve the communication quality. The methodology for patient shadowing in the field was defined and included the development of a checklist with the variables that must be considered in the observation of communication in each phase of the patient journey. Its application demonstrated the enormous complexity and variability of information flow and made evident the difficulties experienced by patients and its causal effects.
There are two types of factors that stand out from the observation at the various moments of the follow-ups. In the first place, cultural and organizational issues, which cause a lack of intra and inter-professional coordination and cooperation. It is essential that the analysis of the patient’s perspective coexists with the perspective of professionals, but it is not possible to improve communication with the patient without first solving some communication difficulties between professionals. Improving teamwork communication between health professionals and patients requires redesigning the work and process to support more effective communication.
Second, the lack of patient information at several levels. One is the widely known lack of health literacy that makes it difficult to understand the messages that are transmitted to them. Another is the lack of written information. Very often, instructions for care or treatments are transmitted orally to patients in moments of stress, due to the quantity information that receives or because sad news where communicated. So, this information must be delivered in written form (analog or digitally) for further analysis. The lack of information also means that the patient does not understand some necessary redundancies, namely, in the questions raised by the doctors, so the lack of explanation of this need gives an idea, here false, of lack of coordination between the parts.
Furthermore, it is necessary to be aware that communication and teamwork problems cannot be solved exclusively with technological solutions. The state-of-the-art of communication in healthcare is still in a very primitive state of development and structure that does not allow to develop a purely technological solution that can respond to the complexity of circulating information.
The differences between the 3 CPs were also evident. Coordination between the professionals involved is more systematized and developed in the initial phase of stroke CP. The importance of this critical phase forced it, which proves that it is possible to improve in other situations. The CP of colorectal carcinoma, which is the one in which more professionals participate, was clearly the one with the most points to improve. The main positive results and possibilities for improvement identified in the study were later disclosed to the organization, not only for internal awareness of the need to improve communication with the patient, but also for the development of solutions built together by professionals and operational managers, within the framework of the working groups. From a human factors’ perspective, healthcare professionals and patients should be co-designers of healthcare services. It is not possible to continue not to consider their needs, capacities, and limitations in the design of the socio-technical health system. The price that has been paid in terms of safety and sustainability is too high.