Communication at Transitions


The Journal of Participatory Medicine recently published an article I authored, Communication at Transitions: One Audacious Bite at a Time. During my 40+ years as a nurse, 30+ years as a caregiver, and many years with a chronic illness, I can think of nothing more common than transitions: hand-offs between team members occur many times a day and moving between settings (e.g., home to clinic, hospital to home) occur many times a year for anyone who’s sick.

How can it be that our health system is so bad at transitions? It’s as if Mass Transit couldn’t manage transfers from bus to subway, airlines couldn’t transfer bags from one airline to another, or banks couldn’t transfer money from my bank to a store or my employer to my bank. Without transfers mass transit, airlines, banks couldn’t exist.

I wrote this article with incredulous frustration. Here’s an overview of the article. Please read the article and let me know your thoughts. How can solving this communication issue become essential for the healthcare community?

The Journey

To be audacious and take significant steps toward achieving the Quadruple Aim (improving the patient experience of care; improving the health of populations; reducing the per capita cost of health care; and improving the work life of clinicians and staff), we patients and caregivers need to better understand key features of our health journeys.

When on that health journey, we are patients interacting with a series of care teams: our home team (social network), our community agency teams, our emergency care team, our hospital teams, and on and on. These care teams include ourselves, our caregivers, clinicians, other professionals, and direct care and support staff — people at the center of care. The actions taken by people at the center of care to improve, maintain, or adapt to our health or illness represents our health care.

Actions can be diagnostic, taking medications, undergoing procedures, learning, living life and getting help living life. So, our health journey is teams of people at the center of care taking such actions to provide healthcare and service to us.

Transitions — What a Mess

During this journey, we transition from one setting to another, from one team to another, repeatedly. Communication knits this maze of actions, interactions, and transitions together. At its core communication is two or more people or parties sharing some information via some channel (voice, paper, digital, dramatic), one time or several times in a particular setting, hoping to accomplish something that moves us along in our health journey.

One of the most persistent and ubiquitous frustrations in health care is that of poor communication. Poor communication at transitions is at the root of much overuse, underuse, and misuse of health resources, and results in the inability of patients to complete recommended treatment.

For the patient and their family this means unnecessary delays in returning to health or worse. For those professionals on the care team the incidents of harm, burnout, stress, and frustration cause financial, emotional and career-ending consequences. Poor communication at transitions impacts each of the Quadruple Aims.

Why the Mess?

The content, manner, and place of transition of care communication vary widely.

The effectiveness of transition communication decreases as the difference between professions, departments, systems, and levels of care increases (nurse shift-to-shift strongest, across departments weaker, across systems and from acute or clinic to community based or home is weakest).

Communication at shift hand-offs between nurses can vary depending on age and experience of the nurses, their team dynamics, acuity and diagnoses of the patients. Thirty-year-old clinicians may communicate differently than 60-year-old clinicians. Intensive care unit (ICU) professionals share different information than emergency department (ED) professionals.

And for all clinicians, there is a wide range in the degree of comfort about when to include patients and their families in discharge and care planning.

In general, a tension exists between the wealth of transition information needing to be communicated and the time needed to create, share, absorb, and understand that information. Acute care and clinic settings have the most time constraints. Chronic care and non-acute settings have more time, hence more opportunity for relationship building and person-centered information.

Unfortunately, it seems that many organizations and teams only allocate adequate resources for improving transition communication after pain points have been reached or are threatened (harm, lawsuits, financial loss, public attention, and complaints) rather than proactively and systematically. Financial pressure to keep labor expense per patient as low as possible impacts effective communication.

What Can We Do?

Meeting the audacious goal of collaborative, sustainable, and effective communication at all transition nodes in the health journey requires an infrastructure for implementing that change. This transition of care communication infrastructure includes patient and caregiver engagement, policies and standards, workforce management, technology, workflow and life flow, governance, and learning.

Building the infrastructure is an iterative, learning task with common system and leadership requirements. Designing the work flows and tools for specific transition nodes has unique local, operational components depending on the participants, the setting, and the culture.

So, let’s accept standards for transition plans. Let’s create each plan with all parties involved including family and personal care partners and destination facilities. And let’s document those plans with communication channels suitable to the users, lay and professional. Such standards could address a wide range of communication barriers, from external barriers like distinct electronic systems to internal barriers like age-related communication issues.

Most important, the only consistency across transition nodes is the patient and their family and personal care partners, yet the industry is only beginning to include them in communication planning, workflow, learning, and technology. The Institute of Medicine (IOM) recommends that patients become a full partner in their own care. Patients can be an important safety net in catching errors before they lead to harm.

‎Communication usually occurs in dyads — a dynamic of two individuals or two teams (nurse-nurse, patient-doctor, hospital-nursing home, etc.). Each individual or team in the dyad can have widely varied comfort and skill in that communication. That variation occurs for clinicians, support staff, patients, families, and sites of care. Individuals and teams need to take their dyad partner where they are and persistently increase comfort and skill.

This means first, understand the stages of skill and comfort (engagement, activation, background, experience), next quickly assess your dyad partner’s stage, and then fine-tune the communication to that assessment. All this requires learning and continuous improvement: orientation, training, continuing education, coaching, process and outcome measurement, and workflow refinement.

Healthcare Administrators Can Make a Difference

The Quadruple Aim can be significantly accelerated by effective communication at transitions. Why don’t health care organizations invest more in comprehensive, sustainable solutions?

I believe the potential return for the investment in communication crosses over one or more organizational boundaries. Organization boards and the C-suite customarily focus on activities within their institutions, not between. The daunting nature of the challenge, caused by the sheer volume and variety of transition nodes, can paralyze those in decision making roles, leading to smaller, more manageable internal solutions that don’t address the root challenges.

I support building a more holistic solution that includes the necessary governance, infrastructure, habits, and relationships. This leads to systematically applied common standards for local, node-specific solutions.

Development should include all persons at the center of care in governance, design, operations and learning for systemic and local solutions. Refined clinical workflow should be constructed to respect patient and care partner life flow. Solutions should use interoperable technology to aid, not replace, communication. Transition information and processes should be transparent to patients and their care partners.

Critical to success:

  • Board and C-suite prioritize
  • All levels of management accountable
  • People at the center of care included at every step
  • Persistently and continually improve and apply lessons learned
  • Emphasize transparency of information and processes to all stakeholders.

Patients and Caregivers Can Make a Difference

  • When you are well enough and have space in your life, get a seat at the table. Pick a table that suits you. You may have had an unsettling or delightful experience at a hospital, clinic, agency — any setting. You may be good at governance, design, publicity — you know what you are good at. Speak with the boss — the Executive Director, CEO, chief physician. Ask to join the board, the Patient Advisory Committee, wherever decisions are made.
  • Pay attention to communication at transitions. Ask to shadow people at the center of care. Ask questions. See where communication works and where it doesn’t. Put the topic on the agenda and share what you’ve learned.
  • When you are a caregiver of a patient in a hospital or going to the doctor or moving along a health journey, pay close attention to communication at transitions. Who is communicating with whom? How is the patient involved; how are you involved? Ask questions. Find out who to contact when you leave that setting. Expect a name, number, or link. Questions always come up even if you record everything.

You’re on your way! It’s worth it for patient experience, clinician well-being, population health, and every bottom line.

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