It's good to talk

Risk managers must master many complex and important functions in their jobs—but this can mean they forget the importance of one of the simpler tools they have at their disposal: good communication, says Dan Groszkruger of rskmgmt.inc.

What’s an effective healthcare risk manager’s most important skill? Clinical expertise? Good leadership? Legal knowledge? Evaluating risk financing alternatives? While all of the above can be helpful—even necessary—for a risk manager, there may be another skill which rises above all the others: effective communication.

THE CHALLENGE

When speaking to physicians about avoiding involvement in lawsuits, I could always elicit some groans (and maybe even protests) by asking: “At what point, doctor, did your patient feel more comfortable talking to an attorney than to you?”

This question seemed to hit home with physicians, many of whom had stopped communicating with a patient or family after an adverse outcome, only to be shocked subsequently by receipt of a lawsuit alleging professional negligence. It’s awkward and uncomfortable to reach out to another human being at a time when sadness and anger prompt that person to look for someone to blame. Most of us have no trouble finding a reason to delay making contact. Eventually, lost among the busy details of caring for others, we forget about doing so altogether!

For a long time, risk managers, defense attorneys and insurers have urged their physicians to maintain regular contact with patients and families—especially after an adverse outcome. Although tough to measure, the shared belief was that patients and families are reluctant to sue a caring and attentive physician, even when errors and omissions have caused permanent serious harm. We’ll never know for certain exactly how many lawsuits were avoided because lines of communication were kept open.

How many times, during a post-event root cause analysis (RCA) meeting, has a nurse suddenly realized that a deceased patient might still be alive if she had simply made a different decision?

It might have been a spur-of-the-moment assessment regarding which call light to answer. The nurse decided to look in on the man in 603, recently transferred from the ICU, rather than the woman in 610 who, she knew, was scheduled for discharge. In retrospect, the nurse’s decision can be rationalized as appropriate allocation of scarce resources—except that the nurse probably would have made a different decision had she known that the woman in 610 was in sudden crisis (eg, an aspiration event).

It is likely that the nurse will feel guilty that calling a Code Blue team was delayed because of her decision. Somehow, rationalizing her decision cannot make up for the guilt, or the fear that another such life-or-death decision lurks right around the corner. Will she make a better/safer decision the next time? All this will occur regardless of whether the surviving family members sue the hospital for wrongful death—and, they probably will.

When the nurse testifies at a sworn deposition, or submits to cross-examination at trial, will her testimony persuade jurors that she made an intelligent, responsible decision? All witnesses are bound to tell the truth, under penalty of perjury. But most of us are not professional witnesses (as are, for example, medical experts) and our emotions can take over when our professionalism and dedication is challenged. Whose responsibility is it to support and coach that nurse, from the time of the adverse outcome through to the present, that her decision was unfortunate, to be sure, but not below the expected standard of care?

THE SOLUTION

All healthcare risk managers will acknowledge that education ranks high among their many responsibilities. But how many risk managers understand that skills in communication (both teaching and coaching) are perhaps the most important in order to be effective?

Many risk managers are employed in circumstances where unique responsibilities are assigned to the Risk Management department. However, relatively few risk managers have received formal education and graduate-level training in either the theory or the practice of effective communication.

In addition, they probably lack sufficient financial and staff resources to enrol in formal education and training in the future. So how can risk managers develop good communication skills and learn how to educate and coach others—in particular, our direct care physicians and nurses who are even less likely to have been exposed to formal education and training?

One principle that is central to good communication skills is audience awareness. As simple and straightforward as it sounds, knowing something about your audience is vital to effective communication. When a risk manager takes into account the attributes and circumstances of his or her audience, the content and the method of delivery of a message will both be directly affected. This may appear to be common sense, but the simple act of putting oneself in the shoes of the audience can only enhance and improve the effectiveness of communications.

Addressing all the circumstances in which audience awareness could be crucial is beyond the scope of this article. However, one illustration may suffice. Returning to the physician whose patient has experienced an adverse outcome, and where the physician is reluctant to initiate contact, how does the risk manager approach this physician? One way might be putting him/herself in the shoes of the physician by acknowledging defensive reactions and the likelihood of guilt and self-doubt.

Among the physician’s reactions may be the following:

• Did I make a mistake, or overlook something, that caused this adverse outcome?

• Will the patient and/or family blame me?

• Won’t everyone recognize that the patient’s failure to follow orders probably contributed?

• How will news of this patient’s adverse outcome be viewed by my professional colleagues?

• Am I facing a medical malpractice lawsuit?

Of course, the most common initial response is an outright denial that the physician’s judgment or skills could be faulted. The threshold to communication may well be acknowledging that the physician feels unfairly targeted by a malpractice lawsuit and accepting that anger and frustration are to be expected. But, if the risk manager is able to gain the physician’s trust, perhaps by employing empathy, the next hurdle will be learning and understanding what circumstances led to the physician’s acts or omissions. In other words, the next step is ‘audience awareness’.

The risk manager will need to ‘stand in the shoes’ of the physician in terms of making decisions pertaining to the patient’s best interests. While many risk managers probably lack the extensive education and training of physicians, all the circumstances affecting one patient at a particular time are often readily ascertainable. During the process of learning about one’s audience, the content and delivery of the specific communication often becomes apparent. Audience awareness will often dictate both the content and method of effective communication.