Residency

Teach residents and staff communication skills to improve patient safety

Residency Program Insider, June 19, 2007

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While faculty and hospital administration may know that patient safety is an important concept, teaching residents communication and teamwork skills to help prevent error is an excellent training tool to improve outcomes and competency. Program administrators can implement a specific set of behaviors in any program or institution to mitigate errors and improve communication.

Teamwork components that are applicable in any practice environment include:

Time-based practices

Briefings help the clinical team understand what the "game plan" is. These short meetings go over what will happen during a particular procedure or day. They can be done at the beginning of the day by an attending physician or just before an operation. Make sure everyone involved in the briefing is acknowledged and included. For example, ask everyone to state their name and their role in the procedure during pre-operation briefings.

Debriefings are short meetings at the end of the day that provide an opportunity to discuss what did and did not go well during a particular operation or day. Routinely ask residents what went well, and what the team could do next time to make the procedure go more smoothly. Note: Make sure you have a process improvement plan in place if you are conducting a debriefing. It is not useful to talk about improvements that you are not going to do.

Communication structures

Closed-loop communication is a basic way of ensuring participants have transmitted information correctly. Participants can perform read-back or hear-back methods. For example, if a physician asks for the record of Melissa Jones, the person obtaining the record will re-state the order back to the physician by saying, "You need the record of Melissa Jones."

Structured communication is exercised verbally by participants through the Situation Background Assessment Recommendation (SBAR) or participants can write an SBAR by using a Subjective, Objective, Assessment, and Plan (SOAP) format. These two methods frame the critical evaluation of a problem by allowing the participant to communicate information in the best way possible.

Physicians and healthcare workers need SBAR because, although physicians are taught how to present cases and how to write a progress note (usually in the SOAP format), they are not often taught how to verbally impart urgent information or frame it in the best manner for the recipient.

Cross-monitoring is a form of mutual support that allows members of a team to monitor and protect individuals from work overload. When cross-monitoring, individual participants should ask for, and offer, help and support. This communication structure requires a willingness to speak up and also to acknowledge the concerns of others.

Critical language, if established correctly, should indicate to other team members that there is a problem. For example, other industries have codified critical language, using a mutually-understood phrase such as "I need clarity," to indicate that activity should stop, and participants should explore the concern, and then either explain or act upon that concern.

In order to successfully implement the above techniques into a curriculum, programs need strong leadership and institutional support. In addition, any program may be able to measure the effectiveness and behavior of residents by using an observation tool or 360-degree evaluation that can measure individual residents in the skills outlined above.

This type of learning and evaluation will not only improve patient safety, but is effective for teaching and assessing residents and faculty in systems-based practice and practice-based learning and improvement, and interpersonal and communications skills, three of ACGME's core competency requirements.

Lastly, faculty and role models must model this teamwork behavior themselves in order to teach residents of its importance. Leadership and faculty must take every opportunity to reinforce values and expectations, whether during orientation, faculty workshops, educational retreats, individual program training, internal review, or house staff meetings. 

Editor's note: The above recommendations and information was provided by Jo Shapiro, MD, senior associate director of graduate medical education, and Allen S. Frankel, MD, director of patient safety for Partners Healthcare in Boston, during the April 26 HCPro, Inc. audioconference, "Teaching and assessing patient safety in GME: Teamwork, communication, and error prevention." For a more detailed look at this topic, see the related article in the July issue of Residency Program Alert newsletter.



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