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Involve patients in mistake prevention
How to overcome communication barriers
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Patients and their families play an important role in reducing adverse events. A growing number of news reports and federal and local initiatives are calling for more consumer involvement in the prevention of medical errors.
However, we cannot expect that patients and families will assume greater responsibility for the safety of health care services by merely telling them how to become more involved. Several factors inhibit the ability of consumers to serve as effective "safety watchdogs" during the delivery of health care services.
One inhibiting factor is our own professional attitude. The thought that case managers or any practitioners would perform in any way less than perfect does not mesh with our professional concept of infallibility. Yet, mistakes do occur. Our perception of what causes errors can actually prevent us from getting help from patients. We may believe that errors occur because the practitioner was not careful enough or because he or she didn't try hard enough.
If a patient asks the case manager to wash his or her hands, the subtle inference is that patient is challenging our professionalism. Such challenges can be uncomfortable and, thus, we may be reluctant to encourage patients to speak up. However, it's important that we admit human errors will occur despite everyone's best efforts. Overconfidence of our professional abilities can actually cause harmful mistakes.
Although patients can play an important role in preventing untoward events, there are challenges to getting them more involved. The patient may not understand the value of their role in the prevention of errors or be reluctant to participate. They may be hesitant to speak up, indifferent to the need for involvement, or disinclined to help out practitioners.
To engage the public in health care efforts to prevent errors, case managers and other caregivers need to understand what prevents patients and their families from becoming involved. The most common barrier is patient-practitioner communications. Ineffective communication can interfere with the patient's ability or willingness to help in reducing medical errors. If caregivers can help patients move past these barriers, their ability to act as system safeguards will be enhanced. Below are suggestions for addressing common communication barriers.
Bridging language barriers
If a patient does not speak English well, a bilingual staff member or an interpreter should be used so the patient can provide information about their history, their current condition and ask questions about their treatment. It is important to use someone other than the patient's family or friend as an interpreter, since the patient may not feel comfortable sharing personal information or expressing concerns about their care in front of a family member or friend. Interpreters should be instructed to not omit information related to sensitive issues about the quality of care or other concerns raised by the patient. An objective interpreter can help reduce the patient's reluctance to share their personal medical history, current symptoms, and concerns while maintaining their right to confidentiality.
Translate materials designed to educate patients about safety into the patient's language. This may seem an obvious suggestion for the non-English-speaking patient. But it is important to remember that many immigrants may not read English and, even if they do, they often are more comfortable reading in their own language. Bilingual materials should be made available for patients to use if they wish.
Patients who have low levels of literacy often feel ashamed and will go to great lengths to conceal their difficulties reading or comprehending information. Therefore, a literacy barrier is not always obvious and caregivers need to carefully screen for literacy problems. Case managers can do this by eliciting feedback from the patient and evaluating if the patient understands by asking questions and reiterating key points.
If it is discovered that the patient has difficulties in grasping or retaining information, case managers must be sure to simplify the information and verify the patient's comprehension in a respectful manner. Written materials about patient safety and the patient's role in reducing errors may need to be supplemented or replaced by verbal discussions and visual aids that illustrate key points. Eliciting questions and feedback from the patient will help practitioners assess their comprehension and engage them as willing participants in their care.
Know whom you're talking to
To ensure patient safety and reduce errors, case managers must understand the cultural beliefs and practices of different ethic populations. Knowing what to say is as important as how to say it. Case managers need a general understanding of how each culture defines health, views illness, and responds to death. The role of family, whether medications and pain treatments are acceptable in their culture, and how their religion or philosophy supports them in times of extreme stress also are valuable factors for practitioners to understand.
In some cultures, patients have preferred methods for how they wish to communicate and receive information. For example, 75% of cultures around the world are group-oriented. One of the many manifestations of this cultural value is that the extended family is extremely important. Family members want to be involved in the patient's care and, if educated along with the patient, can greatly increase the likelihood that information will be retained and recommendations practiced. The patient's cultural beliefs and practices become barriers when case managers fail to acknowledge and adapt practices accordingly.
Many health care organizations have developed resources for staff members to use when providing care to patients from different cultures. These guides help remind all caregivers of the patient's cultural perspectives and values and how nonverbal behavior should be interpreted. While not all members of one cultural group behave in exactly the same manner, it is helpful to have a basic understanding of the culture in order to engage patients in their care and effectively communicate.
Patients can gain a sense of control when case managers take the time to discuss the plan for their care, help them choose options, and educate them about their illness. Providing individualized attention to patients can have a dramatic effect on their willingness to disclose concerns about their care. When patients and their families trust their caregivers, they are better able to communicate effectively, cooperate in treatment, and cope with uncertainties. The trust of patients and family members depends upon the degree to which they see caregivers as competent, caring, and responsible. When case managers approach patients in an open manner, they are more likely to reveal personal thoughts and feelings.
Being proactive in providing information and anticipating questions is the first step in involving patients in error reduction activities. Case managers can actively seek patient participation by making a habit of asking them if they have questions, if there is anything that has been overlooked, and if there is anything else that needs to be done for them. Patients should be told what will be done before it happens. And most important, this conversation should be done without using medical terms and acronyms that will be unfamiliar to the patient. By offering explanations about post-discharge plans or other care coordination interventions, patients are given an opportunity to serve as "checks" in the system. The patient's request for clarification could easily help prevent a mistake from occurring.
Involving patients and families to a greater degree in the health care experience will only benefit the patient safety movement. When a patient asks questions about his or her plan of care, the patient is serving as a safeguard in the system. Such questions can help remind case managers to recheck or validate that the right thing is being done. We must welcome questioning patients and family members as vital partners in our efforts to prevent unintended mistakes.