It Should Be Easy To Do the Right Thing (part 2)

Communicating in a siloed world.

In their review, The Doctors Company stated that “The largest number of cases revealed weaknesses in systems and processes that were depended upon by nurses and physicians.”

The first thing that strikes me here are the words: systems…and processes.  These are incredibly important.  They highlight that it is not just about knowledge, it is not just about intention, but about the tools we give our providers to do their jobs well.

The second, is that these are processes that depend on nurses and physicians.   Again, we are human.  So what systems and processes can we put in place to take some of that error-prone dependence off of care providers?  

Perhaps the biggest opportunity for improvement and reduction in error, is redesigning how clinicians communicate.  Medicine is a team effort yet our tools are focused on the individual. When we take a step back and evaluate the systems through which healthcare workers communicate with each other, we are able to understand the gaps:

1. Cutting the paper trail:  One of the best kept secrets in healthcare is that clinicians are forced to rely on paper for the minute to minute work.  Paper is used for rounding lists, to jot down tasks, to track new symptoms, for handoff guidance and in many places, for progress notes as well. This dependence on paper makes standardization nearly impossible, causes inefficient workflows, and unclear or incomplete documentation.  Additionally, paper lists are carried in pockets where no one else can see them – hardly a collaborative communication model. Yet this is what medical teams are expected to use on a daily basis, to do an incredibly high stakes job.Paper based documentation creates data silos, duplicative documentation and what’s more, paper is easily lost or misplaced, losing the clinicians’ notes completely and presenting significant security implications. 
2. Ineffective handovers: Handoffs are an essential component of safe patient care; not just within the a hospital, but also transitioning in and out of the acute care setting.  In fact, a Joint Commission International study in 2012 recognized that ineffective hand-off communication is a critical patient safety problem in health care, contributing to 80% of serious medical errors. In addition to causing patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital. According to a study by the ACGME, 69% of residency programs do not have standardized handoff procedures, which can lead to miscommunication and increase risks to patients. 
3. Electronic Health Records: All that glitters is not gold. Physicians report that the EHR are not structured to the needs of the patient or the provider. A National Physician Toll (The Harris Toll) conducted by Stanford University found that “nearly half of primary care physicians (44%) are of the opinion that the primary value of their EHR is digital storage, while less than one in 10 (8%) cite key clinically related items such as disease prevention/management (3%),clinical decision support (3%), and patient engagement (2%). At the same time, almost 50% say that using an EHR detracts from their clinical effectiveness.” I am by no means saying EHRs are not important assets, because they are.  However we have missed the mark with usability and design, limiting their effectiveness and often worsening errors and inefficiencies.

Data trapped on paper lists, lack of standardization during care transitions and EHRs that are not empowering clinicians with the data they need at the point of care have made a complex patient care workflows even harder to manage.