Closing In on Bad Communication

A first-of-its-kind, crisis simulation training zeros in on the critical role of communication in medical care.

By Molly Kelash

There’s no way to gloss over it: Too many preventable medical errors occur in America’s hospitals. Too many people die or suffer harm because of drug mistakes, surgical errors, mistaken identification, improper transfusions and other errors. The Institute of Medicine’s watershed 1999 report To Err Is Human: Building a Safer Health System stunned the medical community by reporting, “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented.” (This is more than die each year in motor-vehicle accidents.) Although the IOM has not updated these numbers, experts in hospital safety agree the number is still high.

The report triggered heavy investment to fix this problem and build “a culture of safety” within each hospital. And, hospitals and oversight organizations continue to dedicate large amounts of time, energy and money to the problem of medical errors.

Incompetence and negligence on the part of medical staff may seem to be the likely culprits, but this is not the case, according to William Riley, of the School of Public Health. In addressing safety in hospital obstetrics units, Riley says, 60 to 70 percent of all medical errors resulting in serious harm and death (also called sentinel events) are caused by simple communication failures and problems with group dynamics.

“It’s not because the physician is not an expert physician or the nurse is not an expert nurse. It’s that the information was available from somebody on the team and they just weren’t able to get it communicated,” says Riley. Riley is leading an interdisciplinary team of University professors, including Helen Hansen (School of Nursing), Karyn Baum (Medical School) and Fairview clinicians, to develop a first-of its- kind training program that allows health-care providers to zero in on communication failures during staged medical crises. Team members from Fairview Health Services include physician Stanley Davis, registered nurse Kristi Miller and chief safety officer Alison Page.

This innovative training program is called “in-situ simulation” or Critical Event Team Training. Riley says, “In 25 years of training, it’s the most powerful teaching method I’ve ever seen.” His goal is that one day it will be required training for all providers.

The simulation training is called “in-situ” because the staged crisis occurs in the hospital where the team works— not in a simulation lab. (In-situ is a frequently used medical term meaning “in its original place.”) During in-situ simulation training, a health-care team is asked to care for a simulated patient (a mannequin or an actor) during a critical medical event. The entire simulation is videotaped.

For the past two years, the research team has partnered with Fairview to conduct the simulation sessions in the obstetrics units of local Fairview hospitals.

This simulation training is based on a training program that the Federal Aviation Administration (FAA) now uses to certify airline pilots. Riley says airline simulation techniques were a natural starting point for the health-care teams because, in both industries, human life is at stake. FAA simulation training is based on real life airline catastrophes that showed communication and group dynamics were preventing critical communication. “The airline industry realized that two people sitting next to each other in a cabin less than the size of a table were not communicating with each other, and were flying planes into the ground.”

Do you read me?

The in-situ simulation training sessions all follow a similar pattern. Members of a health-care team, some of whom may have never worked together, as is often the case in a real event, gather in a patient room. They are instructed to act as they would during an actual crisis, everything from sending for blood to calling a code blue.

At a recent in-situ simulation at a Fairview hospital, the “patient” was a pregnant woman who spoke only Spanish. She was bleeding and ready to deliver her baby. In less than ten minutes, the baby (a mannequin) was delivered, a code blue was called for the baby, who was then rushed to the perinatal ward, and the mother (also a training mannequin) was taken to surgery.

As the critical-event simulation unfolded researchers and hospital evaluators watched by live video feed. Once the training was over, everyone who participated in any part of the exercise––the obstetrical team members, the surgery team, blood lab workers, ward clerks and the perinatal team— gathered to watch the video with the researchers and discuss team dynamics.

As participants watched the video of themselves, the impact was profound. Communication breakdowns that were a blur during the simulated crisis came into clear focus. Researchers stopped the video at critical points where communication appeared to break down. The video playback revealed the team failed to access a Spanish interpreter readily available through the Fairview system. The attending obstetrician clearly saw his role in the communication breakdown. “In a crisis leadership position, I need to be more clear,” he said. And, while watching the video, an obstetrical nurse realized the critical necessity of acknowledging that a message has been received and is being acted on. “Without that report-back, two people could be doing what I asked or no one could be doing it,” she said. (The researchers silently cheered this realization of the need for what they call “closed-loop” communication.)

These video playbacks provide “great moments of self-awareness,” says Hansen, who now believes they teach what cannot be taught in a lab or classroom, but only through a “real” crisis. “I’ve seen physicians say ‘I didn’t even look at the nurse, I didn’t even say hello to the patient, I went straight to the monitor!’,” says Hansen.

Baum says she believes these lapses are due, in part, to how health-care providers are trained. Health-care providers are trained in silos and are not taught to communicate across disciplines or departments; they often lack a common language for the same medical procedures. In addition, they are not taught to take leadership, or to cede it, when appropriate. In hospitals and airplanes, these communication gaps can mean the difference between life and death.

A plan to measure success

William Riley and the research team recently received a major grant from the Agency for Healthcare Research and Quality to continue developing the insitu simulation into a standardized training program. The University researchers want enough providers to go through this simulation training so they can determine, through measurement, that the training is producing a safer hospital environment, more effective health-care teams and, most importantly, better results for patients.

“Before lawmakers and health systems spend a great deal of time, money and resources in making communication training obligatory, we can make sure the patients are better at the end,” says Baum. “In all likelihood, there is a correlation, but we need to prove it.” The grant will allow them to do this.

Closing the loop

At the very least, Riley says this project may help change the “silo” paradigm of health-care education. “In health-care, we train everybody to be perfect, not to ask for help, to manage any situation alone—well, that’s counterproductive and incomplete.”

Baum and Riley now use the video tapes as tools for the cross-departmental course they teach with colleagues in the schools and colleges of nursing, dentistry, medicine, public health and pharmacy. “It allows students from health sciences disciplines to see the communication breakdowns in action and to learn what they could have done better to avoid them,” says Baum.

The team also hopes its research will lead to standard, closed-loop communication protocols like those used in the aviation industry. This would mean that every health-care provider at any level could raise a concern or ask for clarification in terms universally understood within the health-care world. At a minimum, closed-loop communication would require that commands be responded to by restating what was heard and an affirmation of action being taken.

These standard protocols would be a great advance because effective communication is lacking in today’s health-care industry. As Baum sums it up, “Even on the best day with the best team, the worst can happen because we’re not really trained to talk to each other. If you’re preparing for a concert, you would never ask the violins to practice on the third floor, the flutes on the second and the cellos in the basement, and then expect them to come together for a symphony.”