Root Cause Statement: “If poor communication between the healthcare team and the patient/family had not occurred, then the unresponsive and ineffective postoperative care could not have happened.”
Goal: Enhance patient-centered care by ensuring effective and responsive communications between the healthcare team and patient/family.
Strategies to Address the Root Cause:
Give the family (wife) a means for obtaining timely information about a patient’s condition and for escalating concerns about the patient’s condition to obtain timely, effective treatment. These means could include:
Giving family members (not just healthcare team members) the ability to call a Rapid Response team to the patient’s bedside
Giving family members direct access to a Patient Care Liaison who can advocate for and elevate their concerns to appropriate senior leadership for immediate attention
Giving family members direct access to a hospital Ethics Hotline so they can report any concerns about potential ethical or professional issues
Providing family members with the means to request and participate in interdisciplinary patient care conferences to voice concerns and participate in treatment plan discussions.
Encouraging patients to designate a family member to be a key point of contact with healthcare team members and to share the information with other family members if requested by the patient.
Develop an educational program for healthcare providers on the importance of patient-centered care, including:
the importance of respecting patients’ autonomy and right to be fully engaged in their own healthcare decisions
the importance of delivering patient care/treatment that encourages and values patient/family engagement and input
the importance of paying close attention to family members’ observations and feedback on the patient’s condition (particularly since they may be best able to identify deviations from the patient’s baseline condition)
the importance of providing the patient/family with information they need to understand the patient’s condition, treatment options/alternatives, and risks/benefits and to make well-informed healthcare decisions
the importance of communicating effectively with other healthcare team members involved in the patient’s care to ensure coordination of care/treatment and consistent, transparent communications with the patient/family
Develop enhanced communication mechanisms among healthcare team members to strengthen the team’s ability to respond to patient needs and deliver coordinated, safe, timely, quality care. These mechanisms could include the following:
requiring formal handoff briefings when changing shifts or transferring patients from one team member or provider to another
requiring timely documentation in the EMR and in-person coordination among all healthcare team members involved in a patient’s care
establishing means for contacting healthcare team members and backups at any time of the day or night
establishing lines of authority to provide appropriate oversight for practitioners and to enable team members to seek upper-level support in addressing complex patient cases when needed.
Develop policies/procedures to help ensure that
all healthcare will be delivered in ways that respect the rights and autonomy of patients to be involved in and make decisions about their own healthcare
an Ethics Hotline is available to receive and investigate patient complaints of nonprofessional or unethical practices by healthcare professionals
a call to the Rapid Response team can be initiated by a patient/family if there are immediate concerns about a patient’s condition
doctors or their designated backups are required to respond to critical patient needs or changes in status at any time of the day or night (e.g., critical lab/diagnostic results)
patients can request interdisciplinary care conferences to share concerns and discuss potential treatment plans; and appropriate healthcare team members must participate
Patients can designate a family member to help communicate with healthcare providers (Jazieh et al., 2018).
Develop and implement technologies to ensure that
an EMR is available to document, exchange, and quickly flag/communicate critical data about a patient’s condition or lab/diagnostic results. .
an effective paging/phone backup system is in place to quickly reach physicians/backups any time of the day or night
an online patient portal is available to patients and designated proxies to facilitate their access to new patient data, lab/diagnostic results, and other information.
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