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Bill Klaproth: Welcome to the ASHRM Podcast, made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ASHRM.org, that's ASHRM.org/membership, to learn more and to become an ASHRM member. I'm Bill Klaproth.

So as a risk management professional, what can you do and what do you need to know to help prevent healthcare miscommunication? Well, let's talk with Michael Grace, licensed attorney and certified professional in healthcare risk management.

Michael, thank you so much for your time. It's great to talk to you. This is really an interesting topic. As we know, miscommunication certainly is an issue in the world that we live in today. But it can be even more serious when it comes to healthcare miscommunication. So how did you become interested in the topic of healthcare miscommunication.

Michael Grace: Great to talk with you today, Bill. I've always been interested in communication and combining with healthcare, really bring the two passions of my life together. I was the kind of kid from a young age, my parents said, "You should be a lawyer because you argue so much." So that led me to become a high school debater. I went to college on a debate scholarship. I majored in college in speech communication, went on to grad school at the Department of Rhetoric, again studying communication. And then, went to law school with an emphasis on a trial practice, became a trial lawyer. Quickly realized that the most fun content for any trial lawyer is healthcare and medicine. So I've spent my career on the defense side, representing doctors, hospitals, and nurses. And now, I teach communication and law to nurses through the University of California's Extension Program, teaching them how to be effective communicators as expert witnesses in depositions in court testimony.

So that's why I'm interested in healthcare communication. And what impressed me once I was a trial lawyer is that miscommunication is the source of so many injuries that are avoidable. And so much harm and money spent, and that was reinforced when I later became a hospital risk manager and patient safety officer at a major hospital as sort of a second career after my trial practice. And again, then my job was to keep patients safe and often the root cause was miscommunication either between patients and doctors and nurses or among the healthcare providers themselves.

Bill Klaproth: Absolutely. Well, you've got a varied career and a lot to draw from. No question about that. And might we add author to your list of accomplishments? This is very interesting. You wrote the book, The Mumbo Jumbo Fix: a Survival Guide for Effective Doctor-Patient-Nurse Communication. This speaks directly to what you were saying, is part of the bigger problem or one of the many reasons of errors in the medical industry is miscommunication. So why did you write this book?

Michael Grace: I felt that I had something important to say that hadn't been before by anyone else. And certainly nobody with my, I'll call it boots-on-the-ground experience as a trial lawyer, and then as a hospital risk manager and now as an educator. There are lots of books written on healthcare communication. But it's a very siloed approach. Doctors typically write books for doctors. Nurses write books for nurses. Almost nobody writes a book for patients. And my book is unique because it addresses all three essential participants as stated in the subtitle, doctors, patients, and nurses. I think that was the missing piece.

Communication is a core curriculum, a core subject in every medical school, in every nursing school and always emphasized in allied healthcare professional training. And yet, we're not significantly moving the needle decreasing harm from miscommunication. Why is that? My belief is it's because of this siloed approach. I think it's akin to a family therapist who talks to some family members, excludes and avoids other family members and never brings everybody together in the same room. Is it any surprise that we are left with healthcare miscommunication as one of the leading causes of patient injury?

So that's why I wrote the book and why I think it's unique. If I may, I can give you one quick example of how that plays itself out. Every nursing school teaches an acronym, a model for communication with physicians, it's called SBAR, S-B-A-R, Situation-Background-Assessment-Recommendation. And yet surprisingly, almost no medical school teaches the same acronym or model for good communication. As a risk manager in my hospital, I asked for show of hands at one of the semi-annual meetings, educational programs that I put on with the physicians, the medical staff, and only a couple of physicians raised their hand that they were even aware of it. And that's been reinforced by talking to other doctors. Is it any surprise then, that if we're not even educating doctors and nurses to communicate with each other in the same way, that we would have the kind of problems that we do. And of course, as I said, we just leave patients almost completely out of the equation.

Bill Klaproth: Yeah, the siloed approach. It's a challenge and downfall, quite frankly, for many businesses. So the book contains over 40 original cartoons. Let me ask you this, Michael, why cartoons with such an important heavy topic at times?

Michael Grace: Well, it is heavy and it was for that reason that I thought one needs to lighten up the subject matter. Communication theory itself can be rather dense. I don't think it has to be, but it's often presented in sort of a mysterious dense academic fashion. And we know that if you're going to communicate effectively, especially to busy professionals and lay people, you've got to make it easy to read. You got to make it concise and, direct response to your question, it should be entertaining. Because we are all in our society expecting to be entertained. We're an entertainment-driven society. But on a communication theory level, we also know that people learn in multiple different ways. They learn from the printed written word, but most of us are also visual learners. And if you can add a reinforcement of the message through a visual cartoon, and maybe elicit a smile or a laugh from the audience, they're going to remember the message better than if those cartoons hadn't been there.

Bill Klaproth: Yeah. That's a good way to present this type of information to clearly state what you're trying to get across. So let's talk about the three participants in healthcare communication. You said doctors, nurses and patients. Let's take a look at the patients. What can patients do to protect themselves from miscommunication errors?

Michael Grace: I think they can do a lot. And the first is to realizes that in any communication scenario, you've got a sender, and you've got a message and you've got a receiver. And the patients at times are receivers of the doctors' and nurses' message. And at times, they're the senders of messages to the healthcare profession about their medical and physical condition. So first, I think we need to make patients aware that they all have, we all have within ourselves, certain barriers to understand, even a clearly delivered a message. And that's everything from healthcare illiteracy. The studies say about 80% of Americans are illiterate when it comes to healthcare. And then, you add to it a long laundry list of things such as our own personal biases. We're not going to hear the message as intended if we have a bias against say the sender of the message. What if it's a Muslim physician, for example? Or if we have a bias against the content of the message, say childhood vaccinations. Or against the specialty of the physician communicating the message, perhaps we have a bias against general practitioners in favor of internists or against chiropractic medicine and so on. So it takes that kind of self-awareness and then you add to that, of course, famous white coat stress, cultural and linguistic problems, fear of treatment, terror of death and dying and the impairments that can be caused by various kinds of medications in synergy with one another, so on and so forth. So I think we've got to bring an awareness to patients that they themselves may be experiencing and accounting for some of the barriers, even when a message is clearly delivered to them.

So, what should they do about that beyond awareness? I have several suggestions. First is always have a patient advocate. And that's somebody with your permission who can participate in meetings and then be a sounding board to you later on about what was actually said, to take notes during meetings, again, for the same reason. If you're hospitalized, keep a journal, either you or your advocate of every encounter, of every person you meet, their name, their specialty, the date and time and what was said. And that's the fastest way to break through any miscommunication before it gets amplified or repeated during the course.

Medication reconciliation is something that all physicians are encouraged to do on each encounter, but the patients have a responsibility to facilitate that. And I encourage everybody just take a cell phone camera picture of every medication label that you currently take and keep it updated. It's a lot easier than writing out in longhand and properly spelling the medication, the dosage, and so forth. And that's going to be an invaluable tool for either an office visit or hospital stay.

And then lastly, I would say patients need to hold providers accountable. And by that, I mean, providers have certain obligations, but often the patients are not aware of what those all entail. Let me give you a quick example if I may, the three patient identifiers. So we've got every hospital slaps a wristband on a patient in the hospital that has their full name, their date of birth and a medical record identification number. But patients aren't aware of really the purpose of that wristband or to make sure that no provider, even a transporter, gives them a treatment or even takes them out of their room without first asking them about the information on that wristband. I can tell you as a risk manager, unfortunately, every month, I had to investigate multiple examples of patients getting the wrong treatment that was not ordered for them or at least being taken to that location or having blood drawn by a phlebotomist who didn't go through that three person identifier drill first. Fortunately, it didn't account for a tremendous amount of patient harm, but we call this in the business of risk management near-misses. And of course, any near-miss can lead to serious and life-threatening consequences. So by educating the patients on things like that, they then become partners in their own care.

Bill Klaproth: Absolutely. Great tips, Michael. Thank you. Number one, always have a patient advocate. Take notes, even keep a journal. Number two, medication reconciliation. Take a picture of all of your medication labels, easier than writing them down. And then, hold providers accountable. So that was patients in our trioka here, doctors, nurses and patients. Let's move to doctors now. What are some examples of what doctors can do to prevent the linguistic mumble jumble that we all hear? We've all been to the doctor. We've all heard it. What can doctors do to prevent that?

Michael Grace: Well, they've got to become aware that they need to speak in a different language than that comfortable language that is appropriate when they're talking to their medical colleagues. Not to talk down to a patient ever, but to explain to patients in plain language what they're talking about. And encourage patient questions and use teach back. "Repeat back to me, please, what you understand you're supposed to do when you're released from the hospital," "What's the medication you've been given and how often are you going to take it?" and so forth to make sure that the patient in fact has understood what the physician has said. I think that's really important.

My own family is no different than anybody else's. Just a quick reference my father was diagnosed with lung cancer. And I and my mother went with him to meet with the surgeon for the very first time. Somebody we've never met before. And the surgeon, after greeting us, said this to my father, "Mr. Grace, your tumor in the upper bronchus is not resectable," and then he stopped and thought that he had effectively communicated it. My dad turns to me and says, "Mike, what's he saying?" Well, I've represented lots of doctors in hospitals at this point as a med mal defense lawyer, and even I was struggling, like "Not resectable? Oh, like resection? Oh, like not capable of resection." "Oh, my God. They're saying that my dad's tumor is not operable and can't be removed by surgery." So it's then myself in the encounter explaining to my dad what was really the duty and obligation of the physician to do in plain language. So that's one thing.

The second thing, if physicians listening to this hear one message, I would say informed consent. It's the most frequently charge allegation against a doctor. And that often derives from the physician's lack of understanding of what a legal informed consent involves and that's a nondelegable duty. It's not a document. It's not that consent form signed by the patient. It's the interactive process between doctor and patient, where the doctor explains the procedures, the alternatives, and the risks and entertains all the patient's questions. And then the patient agrees or decides not to agree. I describe this to doctors as the low-hanging fruit in the orchard at the plaintiff's med mal attorney. And it's the easiest claim to prove, because unlike most other med mal claims, you don't need an expert witness. And unlike other med mal claims, there doesn't even have to be harm. If you fail to mention a material risk and it occurs, and the patient hadn't been told and wouldn't have agreed had he have been told, even if that harm occurs in the most skilled hands, the surgeon, for example, is going to be legally liable. Too often doctors don't understand that and then don't accurately document, communicate in the medical record what they have said. And it causes so much litigation and so much heartache both for patients as well as frankly, for physicians.

Bill Klaproth: Some more great tips, Michael. Thank you for those. So speak in a language that's suitable for a patient, plain language, layman's terms. Make sure you do the repeat back. And then you talked about informed consent. So just so I have this right, informed consent is the interactive process between doctor and patients, that's where the doctor goes over all the procedures the alternatives, the risks and entertains all the patient's questions. Is that right?

Michael Grace: Exactly. And even when a physician does that by the book, too often as a risk manager, I heard, and as a trial lawyer representing doctors, I heard, about their impatience if a patient revoked consent or why they'd ask more questions and be it second time with the doctor. And of course, that's completely within their right to do. And again, the physician has to answer all of those questions and again, get the patient's consent or that procedure should not legally go forward.

Bill Klaproth: Right. So if the physician doesn't adequately explain the risks and something goes wrong, the patient says, "You didn't explain this to me," the physician is liable, right?

Michael Grace: Exactly right.

Bill Klaproth: And then Michael, finally, what can nurses and allied healthcare providers like medical assistants and technicians do to prevent harm from miscommunication?

Michael Grace: Well, they have the lion's share of contact with patients, more so than the physicians who are often tightly booked on schedules and have so many patients to see. So it's really important for them to be aware of that important role. And to take solace in the fact that nurses are still held in the highest esteem of any professional group. Gallup Surveys the past couple of years have shown that their popularity is undiminished, whereas doctors have fallen about 20 percentage points and we lawyers are right down at the bottom along with used car salesmen. So when they understand how important the role is, they need to take the time to listen. So much communication education is how to talk, when in reality to become an effective communicator means you're spending more time listening than talking; listening, not interrupting, which is a huge problem in healthcare, particularly by doctors, but also by nurses. In fact, the first interruption by a physician, according to the surveys, occurs in less than 10 seconds, even after the patient has been asked a question by the provider.

The other thing that nurses in particular, I think, can do is to feel empowered to speak up. And that means they should, of course, be not hesitant to, in the counting of sponges, make sure a second person in the pre-op area is counting with them, even if the other person says, "You go ahead without me, you know, we're in a rush today." To speak up to the strong important surgeon in the room, "No, we have to enforce the universal protocol of a timeout to verify in front of the whole team the identity of the patient, the surgery, the surgical site, and so forth."

And how do nurses feel empowered? I think this is really a pivotal role of risk managers and all members of ASHRM. And that is to be there and support your nurses. You've got to develop that level of trust with them, go to the standup meetings, you know, in the OR. Let the them behind them if they stand up to an important physician, no matter how much revenue he's bringing into the facility by the number of surgeries that he's performing. I think that's important.

Bullying is another great example. Nurses often don't report it because they think they're not going to be supported. And if the risk manager takes the initiative to say, "I'll go to the mat for you. I investigate an incident and I believe what's going on here. I'll take it to the top, the administrative team if necessary, because no one wants to work in a hostile work environment." And it's hard to retain nurses. All hospitals are scrounging to find healthcare personnel. So we want to make as healthy working environment for everyone as possible. And I think that's something that risk managers can do really to help empower nurses to do the vital role and work that they do. And often it's to speak up. Those are some examples of what I think nurses can do.

And of course, lastly, best practice is to do your handoff communication that should change at bedside. Encourage the patient to correct you if you have misstated something rather than allow misstatements by a nurse privately to the oncoming nurse to be repeated. And then that sort of is like the telephone chain joke that by the end of it would be string of conversations that's unrecognizable to the first conversation.

Bill Klaproth: Michael, some other great points. And thank you for sharing those. As you say, nurses do perform the lion's share of communication with the patients. So make sure that the nurse feels empowered to speak up. Handoff communication should happen at bedside. And I love what you said here, to be an effective communicator, you need to listen, right? That's so important. I have a good friend of mine who's a DEI trainer, diversity, equity and inclusion. And he says to me, when it comes to listening, "Are you listening to try to understand? Are you listening waiting to speak?" It sounds like doctors are listening, waiting to speak, right? They're not really trying to listen to understand. They're listening waiting to speak. "Okay. I can talk now."

Michael Grace: Yes.

Bill Klaproth: So, yeah, really great points there. So Michael, let's turn to hospitals now. Is there anything hospitals and medical offices can do to make this situation better?

Michael Grace: Sure. I think there's a lot that both can do. Let's talk about medical offices first. When physicians who own medical practices realize they are legally on the hook for the actions of all their employees, they will spend more time and attention in the training of those people. And it's more than just a good first impression, which the front office always is. But that's also the place where a lot of malpractice occurs, particularly breaches of patient confidentiality. When I was practicing as a trial lawyer for all of those years in California, only one major insurance company that actually had a three-hour program that I taught on Saturdays, just for front office personnel. Now, all insurance companies periodically send people into practices and evaluate them and give them some feedback, but that's really no substitute for some in-depth training. So I would encourage all the doctors to inquire what their own professional liability carrier can do to help educate their staff. And if it's not much, then the doctor has to take that responsibility and emphasize things like patient confidentiality and make sure best practices are in effect.

With regard to hospitals, I'll share a personal situation. I was in the hospital this month for 10 days with a severe left leg infection. And I've been home now two weeks and I am still on daily IV antibiotic therapy that a home health nurse comes to administer. So I who've not had much experience on the patient side in hospitals before this, having remarkably good health that I probably didn't deserve, but I have good DNA. So this unexpected hospitalization that was so traumatic and so dramatic gave me an insider view again on miscommunication, in that setting lost opportunities. And I have to tell you, well, I had fantastic care by so many nurses and doctors especially the surgical team. My friends joke with me now that I have enough material for a second book. It's absolutely shocking. It's a bit disheartening, but it is the reality.

I'm going to give you a couple of quick examples where I think hospitals are missing some opportunities and this has nothing to do directly with my own personal healthcare condition. One of them is going back to the three patient identifiers. Probably only about two thirds of my encounters with hospital staff did anyone do that, which was fairly disappointing to me because so much energy has been put into the education of people in that regard. I think all hospitals miss the opportunity when that band is slapped on the patient's wrist, whether it's in the ED, which is where most patients are admitted through the hospital. That person, whether they're secretarial or whatnot, in 10 seconds can explain "I'm putting a wristband on you that will remain with you throughout this hospitalization. As you can see, it has your full name, your date of birth and the medical record ID number. Please make sure that everybody you encounter here ask you to confirm this information." Well, that plants the seed of why it's there, why it's important. And then when the patient gets to the floor and meets the nurse for the first time, that should be part of the nurse's orientation as well. You know, "And please tell me now, what's your full name? What's your date of birth?" So they get used to the drill, because no one understands the message hearing it just the first time. It needs repeating and often by different people in different ways, in different media.

We know in this particular hospital, there was going to be a patient guide. Well, I looked for it when I arrived, but it was almost midnight before I got to the room. I didn't see it on the tray table next to the bed. It wasn't on the bed. It was only 10 days later on the day of discharge, I saw this 40-page booklet on a table behind my bed off in the corner. A lot of thoughts have been given to those 40 pages. It had important and useful patient safety information, but no one told me it was there. So that was a message that really was never delivered to me, the patient, as the intended recipient.

I think all hospitals either to make sure that's part of the orientation by the nurse, in my example, when she talks about the wrist band and also say, "Here's your booklet. It has important information such as, such as..." or here's something more innovative, but I think we should take a page from hotels. All good hotels, when you turn on the TV, you don't get the channel that you're hoping to find. The first thing you do is you will land on page or a small video about the amenities of the hotel and the services and so forth. That's a lost opportunity. All hospital beds and rooms have televisions. Why not have a rotating series of either dramatically portrayed or animated quick points, a 30-second message, to reinforce things such as the examples we've been given, the three patient identifiers, the wristband, best practice of nurse to nurse handoff communication at bedside, feel free to speak up and so forth. And that way, we're bringing that essential participant, the patient, into what will be a more effective healthcare communication process.

Bill Klaproth: A lot of this just seems like common sense, Micheal. Good customer service, trying to put yourself in the shoes of the patient, what they're going to go through and the explanations and information they may need. This just seems like it would be common practice in the healthcare industry, but i guess it's not

Michael Grace: It's not. And of course, it's always a challenge for risk managers. We have great ideas and, of course, very little power to enforce them. We have to create allies within the hospital system, up our chain of command, within the administrative team, within the medical staff, within all of the nurses who really run hospitals. And in my experience, the best way to initiate effective change is to use our powers of persuasion. Talk to each of them about what's in it for them. How is this going to make their life easier and their life better and their job more satisfactory. And once you get that buy-in, I think our chances of being effective as risk managers increases.

Bill Klaproth: Yeah, absolutely. Last question, Michael. And thank you so much for your time, this has really been informative. What else should we know when it comes to healthcare miscommunication? Anything else you want to add?

Michael Grace: I would just add that we cannot underestimate its importance. Aristotle, the famous Greek philosopher and rhetorician said 2,500 years ago, all good relationships begin with good communication. It's at the core of effective and healthy delivery of medical care. And unfortunately, despite a lot of attention, we slap posters on hospital walls with acronyms that are supposed to remind us of patient-centered communication to boost patient satisfaction scores, if we take such a passive approach or think we've done the job by putting up the poster over time and it becomes wallpaper, this is a message that we have to work with every single day. So it's in everybody's interest to take a new approach to healthcare communication include doctors, nurses, and patients get away from the silos and talk in a concise, uncomplicated, easy and entertaining way and avoid the mumbo jumbo and the tendency to make ourselves seem more important by obfuscating the meaning by using elevated language. We don't really have to do it that way.

Bill Klaproth: Right. Yeah. So get out of the silos, as you say. And the quote from Aristotle, all good relationships begin with good communication. And as you say, it's at the core of effective and healthy delivery of medical care. Everybody write that down, attribute it to Michael. Michael, this has really been a pleasure. It's been great talking with you. Congrats on the book and thank you for all that you do to try to counter the miscommunication happening in healthcare. Thank you again.

Michael Grace: Thanks, Bill. It has been a pleasure.

Bill Klaproth: And once again, that's Michael Grace. And to join as a member of ASHRM, go to ASHRM.org/membership. And the ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth.. Thanks for listening.