TeamSTEPPS for Office-Based Care: Communication

Instructor's Guide

Contents

Introduction
Communication
Importance of Communication
Communication Considerations
Standards of Effective Communication
SBAR
Handoff
Handoff
Handoff Exercise
Check-Back
Check-Back Technique Example
Communication Video
Communication Video
Communication Exercise
Front Office Scenario
Front Office Scenario
Barriers - Tools - Outcomes


Introduction

TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety for Office-Based Care Communication.

Say: Communication is the first of the four main components of TeamSTEPPS. It is "the process by which information is clearly and accurately exchanged between two or more team members in the prescribed manner and with proper terminology and the ability to clarify or acknowledge the receipt of information" (Cannon-Bowers, et al., 1995). There is a tremendous body of evidence to support the efficacy of good communication skills for effective teamwork.

Time icon. Module Time: 30 minutes
Materials icon Materials:

  • Flipchart and markers.
  • Copies of Handouts.
  • Video of Office-Based Team.

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Communication

The first of the four main TeamSTEPPS components, 'The process by which information is clearly and accurately exchanged between two or more team members in the prescribed manner and with proper terminology and the ability to clarify or acknowledge the receipt of information.' The lifeline of any team. In health care, the lifeline between patients and any team member.

Say: Cannon-Bowers et al. (1995) found that communication comprises two critical skills: exchanging information and consulting with others. Information exchange is defined as such behaviors as closed-loop communication, which is the initiation of a message by a sender, the receipt and acknowledgment of the message by the receiver, and the verification of the message by the initial sender. Other behaviors include information sharing, procedural talk, and volunteering and requesting information.

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Importance of Communication

Joint Commission data continue to demonstrate the importance of communication in patient safety: 1995-2005: Ineffective communication identified as root cause for nearly 66 percent of all reported sentinel events; 2010-2013: Communication among top 3 root causes of sentinel events reported.

Say: The continued importance of effective communication in care teams cannot be understated. According to sentinel event data compiled by the Joint Commission between 1995 and 2005, ineffective communication was identified as the root cause for 66 percent of reported errors. More recent Joint Commission data from 2010 to 2013 show that communication has remained among the top three root causes of sentinel events. As these data illustrate, failure to communicate effectively as a team significantly increases the risk of error. Additional information about sentinel events and root causes can be found on the Joint Commission Web site: http://www.jointcommission.org/sentinel_event.aspx

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Communication Considerations

Things you should consider when communicating: The audience, The mode of communication, Standards associated with the specific mode of communication, The power of nonverbal communication.

Say: Communication is the lifeline of any team. In health care, it is the lifeline between patients and any member of the team. By history, medical plans of care were developed and shared with the patients for consents to the plan. In the Joint Commission 2008 publication Guiding Principles for Development of Hospitals of the Future, health care practitioners are expected to "share complete, unbiased information with patients and families in ways that are affirming and useful. Patients and families are to receive timely, accurate information in order to effectively participate in care and decision-making." For this commitment to be effective, information must flow freely through excellent communication processes that permeate every aspect of an organization.

Some things to consider include the following:

  • The audience—How might your interaction with a receptionist be different from that with a primary care provider?
  • The mode of communication—Verbal, nonverbal, written, email.
  • Standards associated with the specific mode of communication—Nonverbal communication requires verbal clarification to avoid making assumptions that can lead to error. The simple rule is, "When in doubt, check it out, offer information, or ask a question."
  • The power of nonverbal communication—The way you make eye contact and the way you hold your body during a conversation are signals that can be picked up by the person with whom you are communicating, although powerful, nonverbal communication does not provide an acceptable mode to verify or validate (acknowledge) information. For safety to exist, the message must be verified orally or written.

Here are some examples of nonverbal communication:

  • The nonverbal cues a primary care provider gives when looking at an EKG would quickly tell the nurse the severity of the situation and might lead to proactive action.
  • The nonverbal cues from the nurse's face communicate the urgency of a situation and the need to interrupt a doctor who is with a patient's family members.

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Standards of Effective Communication

Complete: Communicate all relevant information. Clear: Convey information that is plainly understood. Brief: Communicate the information in a concise manner. Timely: Offer and request information in an appropriate timeframe, Verify authenticity, Validate or acknowledge information.

Say: When sharing information with the team, which can include other providers, patients, or family members, communication must meet four standards to be effective.

Effective communication is:

  • Complete:
    • Communicate all relevant information while avoiding unnecessary details that may lead to confusion.
    • Leave enough time for questions, and answer questions completely.
  • Clear:
    • Use information that is plainly understood (layman's terminology with patients and their families).
    • Use common or standard terminology when communicating with members of the team.
  • Brief:
    • Be concise.
  • Timely:
    • Be dependable about offering and requesting information.
    • Avoid delays in relaying information that could compromise a patient's situation.
    • Note times of observations and interventions in the patient's record.
    • Update patients and families frequently.
    • Verify authenticity, which requires checking that the information received was the intended message of the sender.
    • Validate or acknowledge information.

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SBAR

A framework for team members to effectively communicate information to one another. Communicate the following information: Situation - What is going on with the patient? Background - What is the clinical background or context? Assessment - What do I think the problem is? Recommendation/Request - What would I recommend? What do I need from you?  SBAR's adaptability is encouraged - make this work for your team! Remember to introduce yourself.

Say: SBAR is a framework that team members can use to effectively communicate information about a patient's condition to one another. SBAR stands for situation, background, assessment, recommendation, an easy-to-remember mechanism useful for framing any conversation, especially a critical one requiring a clinician's immediate attention and action. SBAR is one technique that can be used to standardize communication, which is essential for developing teamwork and fostering a culture of patient safety. It creates a consistent format for information to be sent and creates an expectation for information to be received.

SBAR originated in the US Navy submarine community to quickly provide critical information to the captain. It provides members of the team with an easy and focused way to set expectations for what will be communicated and how. Standards of communication are essential for developing teamwork and fostering a culture of patient safety.

In phrasing a conversation with another member of the team, you should consider the following:

  • Situation—What is happening with the patient?
  • Background—What is the clinical background or context?
  • Assessment—What do I think the problem is?
  • Recommendation—What would I recommend? What do I need from you?

SBAR provides a vehicle for individuals to speak up and express concern in a concise manner.

Also, never forget to introduce yourself. You should not assume that everyone knows who you are.

Finally, SBAR is adaptable and it 's adaptability is strongly encouraged! Try to think of SBAR as a menu. The parts you choose to use and the order in which they are used depend on your team's unique needs. Determine which parts you need and use those when communicating critical information among your team members.

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Handoff

The transfer of information (along with authority and responsibility) during transitions in patient care. It includes an opportunity to ask questions, clarify, and confirm. Both authority and responsibility are transferred.

Say: A handoff is a standardized method for transferring information (along with authority and responsibility) during transitions in patient care. When a team member is temporarily or permanently relieved of duty, there is a risk that necessary information about the patient might not be communicated. The handoff strategy is designed to enhance information exchange at critical times such as transitions in care. It maintains continuity of care despite changing caregivers and patients.

Handoffs include the transfer of knowledge and information about the degree of uncertainty (uncertainty about diagnoses, etc.), response to treatment, recent changes in conditions and circumstances, and the plan (including contingencies).

In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision-making has often been a major contributor to medical error (as identified in root cause analyses of sentinel events and poor outcomes).

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Handoff

A proper handoff includes the following components: Responsibility: Person is aware of assuming responsibility;  Accountability: You are accountable until both parties are aware of the transfer; Uncertainty: Clear up all ambiguity before the transfer is complete; Communicate verbally; Acknowledged: Ensure that the handoff is understood and accepted; Opportunity: Evaluate the situation for both safety and quality.

Say: A proper handoff includes the following components:

  • Responsibility—When handing off, it is your responsibility to know that the person who must accept responsibility is aware of assuming responsibility.
  • Accountability—You are accountable until both parties are aware of the transfer of responsibility.
  • Uncertainty—When uncertainty exists, it is your responsibility to clear up all ambiguity about responsibility before the transfer is completed.
  • Communicate verbally—You cannot assume that the person obtaining responsibility will read or understand written or nonverbal communications.
  • Acknowledged—Until it is acknowledged that the handoff is understood and accepted, you cannot relinquish your responsibility.
  • Opportunity—Handoffs are a good time to review and have a new pair of eyes evaluate the situation for both safety and quality.

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Handoff Exercise

Develop a handoff checklist based upon needs of your particular office: How is your team unique? Keep in mind core components, Share your handoff checklist with the rest of your team, Discuss how it could be used in your practice. Handoff Checklist: Responsibility, Accountability, Uncertainty, Communicate Verbally, Acknowledged, Opportunity.

Say: We're now going to work as a group to develop a handoff checklist based upon the needs of our own medical office team.

Note icon Instructor Note: Refer participants to the handout titled Creating a Handoff Checklist and ask them to form a small group (if their team members are in attendance, with their own teams) and develop a handoff checklist based on the needs of their particular medical office. Ask participants to think about how their team is unique and to keep in mind core components of TeamSTEPPS. Allow 10 minutes for this activity and then sample responses from the group.

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Check-Back

A closed-loop communication strategy used to verify and validate information exchanged.

Say: A check-back is a closed-loop communication strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received. This can be described as similar to placing an order at a fast food counter or drive-through window—the sender of the information places the order, the receiver accepts the message and repeats the order to ensure that he or she has the correct information, and the sender verifies that the message was received and confirms that the order is accurate.

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Check-Back Technique Example

A team member was asked by a provider to: 'Administer the influenza vaccine to Mrs. Green who is in Room 6.' 'So you want me to give Mrs. Green, who is in Room 6, an influenza vaccine?' 'Yes, that is correct.' 'O.K., I will prepare the vaccine.'

Say: Typically, when a team member calls out information, he or she anticipates a response on any order that must be checked back. For example, if a team member was asked by a primary care provider to administer the influenza vaccine to Mrs. Green in room 6, upon hearing this, the team member should check back to the primary care provider. The team member should confirm by saying, "So, you want me to give Mrs. Green in room 6 the influenza vaccine? I will prepare the vaccine. Please provide the follow on order."

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Communication Video

Let's watch this office demonstrate proper team communication.

Say: Let's watch the fourth primary care office demonstrate proper team communication.

Icon of film reels. Do: Play the video by selecting the director icon on the slide.

Time icon. Video Time: 3:32 minutes
Materials icon Materials:

  • Video.

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Communication Video

Now that you have watched the video, think about what went well in this version of the scenario. In particular:  Was proper communication demonstrated? Was this strategy effective? Why or why not? Did you see any other opportunities for better communication? Have you encountered situations similar to this with your team? If so, how did you overcome it?

Discussion icon.  Discussion: Discuss the video and what they did right this time . Ask participants if anything else could have been done to improve the situation.

Possible discussion points:

  • Was proper communication demonstrated in this video?
  • Was this strategy effective? Why or why not?
  • Did you see any other opportunities for better communication in this video?
  • Have you encountered situations similar to this with your team? If so how did you overcome it?

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Communication Exercise

Think about your office team: What do you think are the opportunities to improve communication in your office? If you had a magic wand what strategies would you use to overcome communication breakdowns?

Say: We're now going to take a few minutes and think about our team's communication. What are some areas for improvement? How are staff involved? How are patients and families involved? If you had a magic wand, what strategies would you use to address the communication breakdowns on your team?

Note icon Instructor Note: Allow them about 5 minutes to group with two or three other participants and share their experiences. Then ask if there are volunteers who are willing to share their experiences as well as their suggestion for a strategy that can be used to address the issue.

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Front Office Scenario

For some unknown reason the electronic health records system was not working and the staff had to write paper notes. Alice had an appointment for followup of labs and x rays. Since they could not access the diagnostic data, the provider asked the administrative assistant to call both the lab and the radiology service to get the results by phone. The administrative assistant called and gave the situation, background, and assessment, and requested the needed information. This method of communication expedited the transfer of information from the radiology technician to the administrative assistant. The provider could then see Alice on time and discuss her lab and x ray results.

Say: Now let's look at the following scenario and see how communication can be demonstrated in the nonclinical aspects of the primary care team:

Read The Scenario: For some unknown reason the electronic health record was not working and the staff had to write paper notes.  A patient had an appointment for followup of labs and x rays.  Since they could not access the diagnostic data, the provider asked the secretary to call both the lab and the radiology service to get the results by phone.  The secretary called and explained the situation, background, and assessment, and requested the needed information. This method of communication expedited the transfer of information from the radiology technician to the secretary. The provider could then see the patient on time and discuss her lab and x ray results.

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Front Office Scenario

Reflecting on what took place in the scenario, did you pick up the use of SBAR? You should have noted that the administrative assistant called and explained the situation, background, and assessment, and requested the needed information, As with all the other TeamSTEPPS concepts, good communication applies to everyone within the office. Remember, teamwork is everyone's responsibility.

Say: Did anyone pick up on the use of SBAR in this scenario? The administrative assistant called and explained the situation, background, and assessment, and requested the necessary information.

As with all the other TeamSTEPPS concepts, good communication applies to everyone within the medical office. Remember, teamwork is everyone's responsibility.

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Barriers - Tools - Outcomes

BARRIERS: Inconsistency in Team Membership, Lack of Time, Lack of Information Sharing, Hierarchy, Defensiveness, Conventional Thinking, Complacency, Varying Communication Styles, Conflict, Lack of Coordination and Followup With Coworkers, Distractions, Fatigue, Workload, Misinterpretation of Cues, Lack of Role Clarity. TOOLS and STRATEGIES: Communication, SBAR, Call-Out, Check-Back, Handoff. OUTCOMES: Shared Mental Model, Adaptability, Team Orientation, Mutual Trust, Team Performance, Patient Safety!!

Say: Communication skills interact directly with leadership, situation monitoring, and mutual support. These are the principles you will learn about in the following presentations.

  • Team leaders require effective communication skills to convey clear information, provide awareness of roles and responsibilities, and provide feedback.
  • Team members monitor situations by communicating any changes to keep the team informed and the patient protected.
  • Communication facilitates a culture of mutual support when team members request or offer assistance and verbally advocate for the patient.

Communication tools that can enhance teamwork include SBAR, call-out, check-back, and handoff. These tools facilitate effective and efficient communication within and across teams. Good communication facilitates the development of shared mental models, adaptability, mutual trust, and patient safety.

Note icon Instructor Note: This ends the Communication module and may be a good place to break again. The next module will begin the discussion on Leading Teams.

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Cannon-Bowers JA, Tannenbaum SI, Salas E, et al. Defining competencies and establishing team training requirements. In: Guzzo RA, Salas E, eds. Team effectiveness and decision making in organizations. San Francisco: Jossey-Bass; 1995. p. 333.


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Page last reviewed September 2015
Page originally created September 2015
Internet Citation: TeamSTEPPS for Office-Based Care: Communication. Content last reviewed September 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/teamstepps/officebasedcare/module3/office_comm-ig.html