This guide was prepared as part of the Victorian Quality Councils

project on improving communication among healthcare

professionals.
July 2010
Promoting effective communication
among healthcare professionals to
improve patient safety and quality of
care
VQC A guide to improving communication among healthcare professionals
2






Published by the Hospital and Health Service Performance Division, Victorian Government
Department of Health, Melbourne, Victoria.
July 2010

This booklet is available in pdf format and may be downloaded from the VQC website at
http://www.health.vic.gov.au/quality council



Copyright State of Victoria, Department of Health, 2010
This publication is copyright. No part may be reproduced by any process except in accordance
with the provisions of the Copyright Act 1968

Authorised by the Victorian Government, 50 Lonsdale St., Melbourne 3000.




Victorian Quality Council Secretariat
Phone 1300 135 427
Email vqc@health.vic.gov.au



VQC A guide to improving communication among healthcare professionals
3

Introduction
Ineffective communication is reported as a significant contributing factor in medical errors and
inadvertent patient harm. In addition to causing physical and emotional harm to patients and
their families, adverse events are also financially costly. In Victoria, the direct cost of medical
errors in public hospitals is estimated at half a billion dollars annually [1]. Today, healthcare is
evermore complex and diverse, and improving communication among healthcare professionals
is likely to support the safe delivery of patient care.

The objectives of this guide are to raise awareness and stimulate discussion and action around
what your healthcare organisation, division or unit can do to improve communication and
teamwork. The guide highlights the critical importance of, and common barriers to, effective
communication in healthcare organisations and institutions, and points to some strategies and
tools available to promote effective communication among healthcare professionals. While this
guide has focussed largely on the acute care setting, the importance of effective communication
among health professionals applies everywhere healthcare is delivered.


The importance of effective communication in healthcare the evidence

Ineffective communication is the most frequently cited category of root causes of sentinel
events. Effective communication, which is timely, accurate, complete, unambiguous, and
understood by the recipient, reduces errors and results in improved patient safety [2].

Much of the evidence connecting poor communication between health professionals with
adverse patient outcomes has largely come from retrospective analysis of sentinel events and
root cause analysis. For example,
The Joint Commission in America has reported that the primary root cause of over 70 per
cent of sentinel events was communication failure [3].
The Department of Veterans Affairs (VA) National Center for Patient Safety in America has
identified communication failure in healthcare as the primary root cause of 75 per cent of
more than 7,000 root cause analyses of adverse events and close calls [4, 5].

The consequences of poor communication in healthcare settings have also been documented in
Victoria and other Australian states.
Twenty per cent of sentinel events in the Victorian public health system in 200809 were
identified as communication issues occurring between staff, staff and patient/family,
and/or translation/ non-English speaking background issues. Communication is ranked
as the second most common factor contributing to these events [6].
In Queensland, 20 per cent of sentinel events in 2005 2006 were due to
communication failures [7].
In New South Wales (NSW), the Special Commission of Inquiry identified inadequate
communication or documentation, including miscommunication between doctors and
nurses and inadequate clinical handover, as a major risk to patient safety in NSW public
hospitals [8].
VQC A guide to improving communication among healthcare professionals
4
The Victorian Audit of Surgical Mortalitys (VASM) Case Note Review booklet (First Edition,
November 2009) has identified the risk to patient safety when nursing and junior medical
staff note clinical deterioration but do not escalate the level of care to senior staff in an
appropriate and timely manner [9].

Supporting evidence from high quality intervention studies
1
, linking ineffective communication
between health professionals and adverse patient consequences [10] is largely lacking, as are
studies demonstrating that effective communication leads to improved patient outcomes (Level
III-3) [11].

There are numerous intervention studies indicating that the use of structured communication
tools or other strategies in health care improves the structure and quality of information
exchanged between healthcare professionals, and/or reduces patient harm. Generally, these
studies are based on lower levels of evidence. For example,
The World Health Organization Surgical Safety Checklist leads to reduced rates of
inpatient complications and death (Level III-3) [12].
The use of structured communication tools and briefings in the transfer of patients
between health facilities results in improved access to necessary medications on arrival
at the receiving health facility (Level IV) [3].
The introduction of perioperative safety briefing before and after surgery resulted in zero
wrong site surgeries (compared to three at baseline) and increased reporting of near
misses by staff (Level IV) [13].
Implementation of SBAR, a structured communication tool improves the clarity and
content of interprofessional communication (Level III-1) [14], (Level IV) [15].
The introduction of multidisciplinary rounds resulted in a decreased patient length of stay
(Level IV) [16].
The implementation of team training programs such as TeamSTEPPS leads to reduced
rates of seclusion in mental health facilities (Level III-3) [17], and improves performance
in the operating room (Level III-2) [18].

While varying in the strength of evidence, the trend suggests that ineffective communication
between healthcare professionals is an important risk factor for adverse patient events, and that
attempts to improve communication, through the use of structured tools and strategies is likely
to optimise patient outcomes.

What are the elements of effective communication?
In healthcare, effective communication involves arriving at a shared understanding of a situation
and in some instances a shared course of action. This requires a wide range of generic
communication skills, from negotiation and listening, to goal setting and assertiveness, and
being able to apply these generic skills in a variety of contexts and situations [19].

Effective communication also requires individuals and teams having access to adequate and
timely information necessary to perform their role effectively and appropriately. The use of
technical terms and jargon, acronyms and abbreviations and diagrams to communicate can
influence how well information is shared and therefore the effectiveness of communication. As
in business, adhering to the five standards of effective communication [19] in healthcare is

1
The rating system referred to is based on the recommendations for intervention studies by the National Health and Medical
Research Council (NHMRC). The rating system is described in the table and can be found in Appendix 1.

VQC A guide to improving communication among healthcare professionals
5
likely to facilitate improvements in the exchange of information between healthcare
professionals, and information should be:

Complete It answers all questions asked to a level that is satisfactory to
those involved in the exchange of information.
Concise Wordy expressions are shortened or omitted. It includes only
relevant statements and avoids unnecessary repetition.
Concrete The words used mean what they say; they are specific and
considered. Accurate facts and figures are given.
Clear Short, familiar, conversational words are used to construct
effective and understandable messages.
Accurate The level of language is apt for the occasion; ambiguous
jargon is avoided, as are discriminatory or patronising
expressions.

The Joint Commission reports that investing to improve communication within the healthcare
setting can lead to:
Improved safety.
Improved quality of care and patient outcomes.
Decreased length of patient stay.
Improved patient and family satisfaction.
Enhanced staff morale and job satisfaction [20].

What factors contribute to communication failures in healthcare?
Breakdowns in communication in healthcare are reported to occur due to:
Human factors; attitudes, behaviours, morale, memory failures, stress and fatigue of
staff.
Distractions and interruptions.
Shift changes.
Gender, social and cultural differences.
Hierarchy or power distance relationships (for example, junior staff are reluctant to
report or question senior staff).
Difference in training of doctors, nurses and paraprofessionals.
Time pressures and workload.
Limited ability to multitask even when highly skilled.
Lack of a shared mental model regarding what is to be achieved.
Lack of organisation policies and / or protocols.
Organisational culture that discourages open communication.
Lack of defined roles and responsibilities among members of multidisciplinary teams
[3, 21].


VQC A guide to improving communication among healthcare professionals
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A targeted approach for improved communication in healthcare


Many factors have been reported as influencing effective communication in healthcare. These
include individual abilities and characteristics, team behaviours and systemic factors and the
lack of organisational support of a culture of safety [3, 23]. In addition, it has been suggested
that improving communication requires a detailed understanding of the setting and context in
which patient care is delivered and a commitment on behalf of a healthcare organisation to a
culture of safety and quality improvement, such as supporting team-based delivery of care [21,
24].

Sustainable improvements towards effective communication in healthcare settings involve
synchronising efforts across the three levels that is, the individual, the team and the
organisation.

1. The individual
a. Human factors, such as communication skills, fatigue and stress levels of staff,
personality and attitudes, memory failures, and distractions and interruptions
have been reported to influence the effectiveness of communication [3, 25].
b. Individuals can develop many useful skills, including assertiveness, active
listening and negotiation as a means of improving communication in healthcare.
Assertiveness from time to time, a healthcare worker may feel it
necessary to challenge a particular decision regarding patient care;
however this may be difficult due to hierarchical power relationships
between senior and junior doctors for example. Learning to be assertive,
without being inattentive or aggressive is considered a positive move
towards improved patient safety [26].
Active listening this involves healthcare staff having the skills to listen,
to stay focussed on others messages, and resist distractions. It also
means keeping an open mind to others ideas even if they disagree. You
can tell if the healthcare professional you are talking to is a good listener
from their eye contact, posture and facial expression [27].
Negotiating this involves individuals developing self-awareness around
differences in communication styles and skills to confer with health
professionals from other disciplines, value others perspectives and
opinions and manage conflict if the situation arises [22].
2. The team
a. Multiple players are often involved in the management and delivery of patient care
[25, 28]. While there is often an underlying assumption that healthcare
professionals are inherently good communicators, the lack of formal training and
assessment in this area would suggest otherwise [3]. With different technical
expertise and communication styles among members of multidisciplinary teams,
communicating effectively is considered important if teams are to function
optimally and ensure patient safety and quality of care. Members will have
Communication and other teamwork skills are essential to providing quality healthcare and
preventing medical errors and harm to patients [22]
VQC A guide to improving communication among healthcare professionals
7
advanced technical training and are likely to have different communication styles
and this can compromise the effectiveness of communication. Skills development
and training may be necessary to improve communication among teams.

b. It has been reported that improved teamwork results in enhanced effectiveness,
fewer and shorter patient delays, improved staff morale and job satisfaction,
increased efficiency, and reduced levels of stress among staff [21, 29].
c. The provision of feedback among teams assists in continuous improvement.
Feedback is information provided for the purpose of improving team performance
and should be focused on behaviours not personal attributes, and should be
constructive and timely [27].
3. The organisation
a. It has been reported that organisational culture plays an important role in
facilitating and supporting effective communication across the organisation. For
example, open channels for communication, transparency and trust,
assertiveness and strong leadership are considered important factors facilitating
the effective flow of high quality information and the sharing of knowledge [21]. An
understanding of the workplace culture allows opportunities for targeted
improvement such as enhancing communication among multidisciplinary teams.
b. Leadership support Communication within the health service can be improved
with an organisation providing strong leadership, through implementation of
policies and procedures and identifying clinical leaders to drive improvements in
communication and patient safety [3].
c. Effective communication can be supported by a healthcare organisation or
institute which:
Clearly links effective communication and teamwork to patient safety.


Clearly articulates the organisations expectation on how communication
will be carried out.
Fosters a communication process that facilitates continuous
improvement in patient safety and quality of care.
Assesses the current organisational culture of patient safety and
identifies areas for improvement,

for example, conducts an assessment
of staff perceptions and current practice in the delivery and management
of safe patient care.
Fosters and promotes a work culture that values cooperation, teamwork,
openness, collaboration, honesty and respect for each other and
promotes open and effective communication.
Creates an atmosphere where team members feel safe to speak up
about issues relating to patient care regardless of their position or rank.
Provides resources and identifies appropriate communication strategies
to ensure that information is effectively exchanged between people


depending on the situation, different communication methods may be
required [3, 20, 21].
VQC A guide to improving communication among healthcare professionals
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How to improve communication in healthcare?
In addition to clinical leaders and policy makers supporting effective communication and
teamwork in the healthcare setting, a number of tools and training programs have been
developed to assist with improving communication and teamwork among healthcare
professionals. Some examples of tools and techniques available to healthcare organisations to
assist with improving communication and teamwork is described below, including the level of
evidence supporting the effectiveness of these tools to improve communication among
healthcare professionals using the National Health and Medical Research Council (NHMRC)
hierarchy of evidence rating system.

Studies
Type of
intervention
Year
(Reference)
Country Context Experimental
design
NHMRC
hierarchy of
evidence
WHO Surgical
Safety Checklists
2009 [12] Canada,
India, Jordan,
New Zealand,
Phillipines,
Tanzania,
England, USA
Hospitals,
non-cardiac
surgeries
Prospective,
multi-centre, pre-
and post-
intervention
Level III-3
Checklists and
briefings
2004 [3] USA Kaiser
Permanente
hospital to
skilled
nursing
facilities
Single centre,
pre- and post-
observation
study
Level IV
Briefings 2004 [13] USA Kaiser
Permanente
hospital,
perioperative
setting
Single centre,
before and after
intervention
Level IV
SBAR, ISBAR

2009 [14] Australia Medical
students,
simulation
Single centre,
clinical
simulation
environment,
Pseudo-
randomised
control trial
Level III-1
2008 [15] Canada Rehabilitation
setting
Single centre,
Uncontrolled
before and after
study
Level IV
TeamSTEPPS 2010 [18] USA Large south
eastern
community
based
hospital
system,
operating
room (OR)
teams
Multi-centre (two-
campuses),
quasi-experiment
with one pre- and
one post-
intervention
Level III-2
VQC A guide to improving communication among healthcare professionals
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Type of
intervention
Year
(Reference)
Country Context Experimental
design
NHMRC
hierarchy of
evidence
2009 [17] Australia Mental health
Facility
Single centre
(mental health
facility),
uncontrolled
before and after
study
Level III-3
2010 [30] USA NA Systematic
literature review
NA
Source: Rating system for hierarchy of evidence for intervention studies: NHMRC (2000). How to
use the evidence: assessment and application of scientific evidence, page 8. Accessed March
2010 at http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp69.pdf

Effective clinical handover, for example at shift changes, requires good communication.
Ineffective handover may lead to a failure to appreciate critical aspects of a patients condition
or care, lead to delays in a patients treatment and result in adverse patient outcomes. Providing
tools and solutions for effective clinical handover as a means of improving patient safety and
quality care is a key program initiative of the Australian Commission on Safety and Quality in
Health Care (ACSQHC). The Victorian Quality Council has acknowledged the potential risks to
patient safety associated with inadequate clinical handover and has developed a set of generic
tools to assist with shift to shift clinical handover. The tools are available at:
http://www.health.vic.gov.au/qualitycouncil/activities/handover.htm#download



Additional resources
Institute for Healthcare Improvement (IHI) (USA): http://www.ihi.org/ihi
IHI/ Topics / Patient Safety: http://www.ihi.org/IHI/Topics/PatientSafety/

NHS Evidence Health (UK): http://www.evidence.nhs.uk/

Australian Commission on Safety and Quality in Health Care (ACSQHC):
http://www.health.gov.au/internet/safety/publishing.nsf/Content/home
Clinical handover tools:
http://www.health.gov.au/internet/safety/publishing.nsf/content/PriorityProgram-05#Tools

Joint Commission Resources (USA): http://www.jcrinc.com/
http://www.jcrinc.com/Books-and-E-books/IMPROVING-HAND-OFF-COMMUNICATION/1225/
http://www.jcrinc.com/Quality-and-Safety-Risk-Areas/Patient-Safety/

Centre of Research Excellence in Patient Safety (Australia): http://www.crepatientsafety.org.au/
Research: http://www.crepatientsafety.org.au/research/

VQC A guide to improving communication among healthcare professionals
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Appendix 1

The National Health and Medical Research Council (NHMRC) rating system recommendations for
intervention studies.

Rating Evidence
Level-I Obtained from a systematic review of all relevant
randomised control trials.
Level-II Obtained from at least one properly designed randomised
control trial.
Level-III-1 Obtained from well designed pseudorandomised control
trials (alternative allocation or other method).
Level-III-2 Obtained from comparative studies (including systematic
reviews of such studies) with concurrent controls and
allocation not randomised, cohort studies, case control
studies, or interrupted time series with a control group.
Level-III-3 Obtained from comparative studies with historical control,
two or more single arm studies, or interrupted time series
without a parallel control group.
Highest












Lowest
Level IV Obtained from case series, either post-test or pre-test/post-
test.

Source: NHMRC (2000). How to use the evidence: assessment and application of scientific
evidence, page 8. Accessed March 2010 at
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp69.pdf
VQC A guide to improving communication among healthcare professionals
11

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