We hear about ‘poor communication’ so often related to undesirable outcomes, that the term has become somewhat generic in nature. It has become meaningless in terms of implementing corrective action plans to prevent the risk of further miscommunication. How can we act on ‘poor communications’ without understanding what causes such miscommunication? This article will focus on applying key RCA principles to understanding what causes miscommunication.
The Application of ‘RCA” to Poor Communication
The term RCA has become just as useless as the term poor communications. This is because it has become so diluted due to a lack of a standardized, universally accepted definition. Therefore any approach someone uses to try and solve a problem is deemed to be their form of ‘RCA’.
This then assumes that approaches ranging from the less intensive troubleshooting, brainstorming or 5-Whys techniques are equally as effective as the more comprehensive cause-and-effect approaches like logic trees (supported by full evidence-based validation of hypotheses). This simply is not a valid comparison and will yield widely variable results.
This paper is not intended to focus comprehensively on effective RCA approaches but rather to express some key principles that can aid the reader in analyzing why poor communication exists.
The Case Study
As a career investigator, I was involved with a team exploring the decision-making process in AVF placement in hemodialysis patients. I was the lead investigator and the only non-clinician. As a layman, I can ask all the seemingly ‘stupid questions’ because I am not expected to know the answers.
In this case, the team was chartered to understand why dialysis patients were choosing catheters and grafts as their primary choice for access versus a fistula. CMS has deemed the fistula to be the safest and most preferred access for such patients, yet it is still not being used as often as it should be. Why?
Let’s explore this using what I referred to earlier as a ‘logic tree’. This will be our RCA tool of choice for this case.
Each block marked ‘H’ (Figure 1) is referred to as a ‘Hypothesis’. These are stemming from the block labeled ‘M’ which is a factual ‘Mode’. When at the Mode level, we simply ask ‘How Could?’, as we go down the tree. In our case above, we have two (2) hypotheses expressed by the team:
1) the Patient was inappropriate for AVF placement and/or
2) there was vessel non-preservation.
For the sake of our case and our focus on poor communication, we are going to follow the first hypothesis.
As each hypothesis is proven to be true, we continue asking the ‘How Could?’ questions as we drill down the logic tree. How could the patient be inappropriate for AVF placement? Our hypotheses are:
1) The patient’s refusal of AVF placement and/or
2) It was the physician’s decision
When we continue to drill down in this manner, we will eventually come to decision-makers. At the point we reach a decision-maker, we change our questioning to ask ‘Why?’ did they feel the decision they made at the time, was appropriate.
In our case we will continue down the path where the patient is making the decision to not use the fistula option. Why are the patients not using that option?
The four (4) hypotheses developed by the Subject Matter Experts (SME) on the team were (Figure 2):
1. Patient education issues
2. Patient fear (i.e. – needles, surgery, etc.)
3. Patient satisfied with current functioning catheter or graft
4. Negative patient experience and observation of others
For the sake of our ‘poor communication’ focus, we will pursue the potential patient education issues that led the patient to choose placement options other than a fistula.
It is at this point where many opinions were expressed by the SME’s on the team and many were related to the patient’s incompetence or inability to understand their access options. As a lead investigator, my charter is to remain neutral and focus only on the facts. While the team’s expressions were valid hypotheses, they did not express all of the possibilities related to how the patient’s make their decision(s).
I told the team that as a non-clinician, I was closer to the perspective of the patient in such a situation. If I had just been diagnosed with Chronic Kidney Disease (CKD), I would initially be in shock. As that shock wore off, someone would have to educate me about my access options from that point forward. I told my team this was the discussion we needed to dissect. If I was this patient, I would have no idea what a fistula was, much less a catheter or graft. So how does a patient learn about these options?
Whenever we educate anyone, it is a form of communication. In order to have effective communication, we need to look at it from a systems perspective.
We need to have a person delivering the message, the content of the message itself and a person receiving the message. This comprises the ‘educational system’ (Figure 3).
Remember, the team was focused mainly on the patient’s inability to understand. By looking at this from a ‘systems’ perspective, we have forced the team to look at themselves as educators/communicators as well as how they develop their message/content.
As we explored potential issues to related to our educational content, we found two (2) hypotheses (Figure 4):
1. The patient educational content was not provided in all the languages needed and/or
2. The availability of educational content was not known to the patient
Notice on these blocks they are labeled as ‘LR’. This stands for ‘Latent Root Cause’. These are simply systemic flaws (organizational system flaws) that need to be corrected in order to improve future communications.
Let’s look at the block labeled ‘recipient education issue’. We found two (2) hypotheses here as well (Figure 4):
1. Inadequate cognitive ability of the patient to understand message and/or
2. Patient health literacy was less than adequate
Again these are latent root causes because if we write materials written at the average grade level of the patients, they are more apt to understand them and make better, more informed decisions.
Now let’s explore the path associated with the potential deficiencies of the educator (physicians in this case). The potential deficiencies cited were (Figure 5):
1. Educator’s did not have enough time to properly communicate with the patients
2. Educator’s were poor teachers
3. Scarce human resources were available for such performing such education
4. Educator’s failed to use available materials for such education
5. Educator’s not culturally competent to communicate with some patients
It is much more difficult when we have to look at ourselves as potential contributing factors to poor communications, but it is absolutely necessary in order to promote effective communication.
Why would the educator’s have poor teaching skills?
1. Lack of proper supervisory oversight of such delivered training (no one is observing to see if such education/communication is effective or not)
2. Non-existent training processes and protocols to follow
3. Inadequate training processes/practices in place
Oftentimes education is not a high priority because it is viewed as a ‘soft’ (people) issue. It is hard to demonstrate an ROI on such soft issues so we tend to downplay it. However we can certainly demonstrate a cost when this lack of effective communication results in a poor outcome with a claim filed.
Lastly, when we look at having scarce resources to conduct such important training, we often find such training is not a priority because the clinician may not be getting reimbursed for it (Figure 6). This often puts the task at the bottom of the priority list in many cases.
I have tried to demonstrate a methodical approach to breaking down poor communication via a case study. If the Latent Root Causes are properly addressed, it will dramatically improve future communications and therefore effective decision-making. This can then be traced back directly to an improvement in patient safety.
This thought process itself (the logic tree) can be applied to any undesirable outcome.
We need to join together to defeat the following paradigm:
“We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again!”
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