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How to measure success of communication
Keys to knowing if you're making a difference
If anyone knows how difficult it is to measure something as ephemeral as "good communication," it is David Maxfield. He was the lead researcher on the Silence Kills study in 2005 on the dangers to patients of not speaking up, conducted for the Association of periOperative Registered Nurses (AORN) and the American Association of Critical-Care Nurses (AACN).
Maxfield says the first mistake that organizations make is that they do not measure how well their staff communicate frequently enough. "A lot of organizations know that they should measure it, and use good tools like the [Agency for Healthcare Research and Quality] one," says Maxfield. (See below for a list of resources, including AHRQ tools.) "But they use it once a year. If you have a webcam pointed at a freeway, you need to look at it fairly often to see if there has been an accident."
At a minimum, Maxfield says organizations with a good safety culture will measure their success and assess strengths and weaknesses three or four times a year.
Along with getting the frequency right, Maxfield says organizations need to determine how fine a grain their measurements should be. There can be very specific measures, such as end-of-day surveys that look at every single procedure done and assess whether there were good handoffs. Broader measures might be questions such as, "Was everyone respectful to you today?" The broader questions can help an organization determine patterns.
Those fine-grained measurements should be taken every so often, for a specific period, says Maxfield. The frequency during that duration should be high perhaps even daily over two weeks. That kind of data gathering is especially beneficial when you are implementing a new process or procedure to make sure it is working. "You'd do it every day for a few weeks, then do it weekly, then monthly," he says.
The broader measurements are best taken less frequently, but over a longer period because they are asking objective questions such as how you are treated over time.
"Certainly the number of incident reports is one metric you should look at," says Alan Rosenstein, MD. MBA, medical director of clinical efficiency and care management at Valley Care Hospital in Pleasanton, CA, and the medical director of Physician Wellness Services, a doctor employee assistance program based in Minneapolis. Rosenstein recently published an article on workplace safety and has often served as an expert witness in cases involving disruptive employees. "And you should also look at where the incidents are originated what department, what person."
There are other indirect measures that can give you a sense of how well staff communicate, too, such as turnover, says Rosenstein. Studying the times when an error almost happens is another way to get a sense of whether your staff talk to each other. If there was a near miss, it is likely a time when someone spoke up and was listened to. Each near miss might be a successful measure of your communication culture.
Lower numbers of adverse events is another indirect measure, Rosenstein adds, "because 70% of an adverse event is about communication."
Are there good measurement tools out there? Yes, says Maxfield, but every organization will have slightly different needs. In creating one for use in your organization, he suggests looking at what is available from organizations such as the Institute for Healthcare Improvement (IHI – ihi.org) or the AHRQ. Professional associations also often have tools you can use as a guide. "See what is out there first and use it as a template. Then ask yourself what is missing that you might need to add to make it relevant to your organization."
The goal is to measure things such as whether there are safety tools available in your facility, whether they are used every time, and whether they are used well. You need to measure whether people are frank and honest, whether they are encouraged to speak up, and whether they are heeded when they do. "The goal is that everyone talks and everyone listens," Maxfield says.
Don't expect your scores to be consistent all the time. Personnel changes, for instance, can influence the figures you get from your surveys. Someone who might feel unable to speak up during his or her first month of employment might be much more willing to after three months. Or a new physician who is gruff initially may adopt your organization's more collegial pattern of work. But know that if you keep seeing the same kinds of issues during the same shifts, or certain names popping up over time, then you have a pattern of problems that has to be addressed.
"You have to especially track those patterns. Look at how often something happens, look for patterns of people taking shortcuts, and look for comments about disrespect and incompetence," says Maxfield. What is the impact of those problems? How resolvable are they?
Tracking numbers is vital. After the Silence Kills original study, when only 12% of those asked said they shared their concerns with doctors, many were discouraged. But five years later, those rates have tripled. Other studies have shown that even if a small number speak up, they can have an impact, and behaviors can change, leading to a safer work environment.
"The breakdowns we focus on are when you know or suspect something is wrong and you do not say anything. Or if you do then no one listens. There are not a lot of elephants in the room in most organizations and on most teams. That gives you incredible leverage. If you can speak up and deal with the elephant, you can change the whole relationship."
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