It is widely understood that poor coordination resulting from silos within the healthcare system reduces the quality of care and increases healthcare costs. But there is another serious, but often overlooked effect for physicians— the increased risk of malpractice allegations.

During a typical hospital stay, the average surgery patient is shuttled between numerous departments, eventually seeing up to 27 different medical professionals. Ideally, the patient’s records, medical history and treatment plan are shared seamlessly between the surgeons, anesthesiologists, nurses, and other medical staff who coordinate their care.

In reality, inefficient communication patterns often make for a disjointed experience, with providers working separately toward different objectives, cobbling together disparate pieces of data, and sometimes operating with missing information.

This type of miscommunication is probably one of the biggest contributors to costly and dangerous medical mistakes. Conservative estimates put the number of deaths related to medical error at more than 250,000 each year — and that number is likely much higher.

Dr. Zeev Kain reviewed this topic within the context of orthopedic surgery during our January 2017 VBC conference and indicated many of these medical errors could have been prevented with better communication between providers and better care coordination.

Part of the problem lies with the fragmented healthcare system in the United States, which hinders effective coordination between providers, insurers and patients.

Even in a single hospital, where teams of physicians and nurses work together to treat patients, poor interpersonal relationships and ineffective communication often inhibit the effective coordination of care.

Now, medical teams have become larger and more specialized, forcing nurses to communicate with many more people in order to care for a patient.

At the same time, advances in electronic record-keeping has transformed the way we manage and share information. While this can help improve coordination, it also means a single mistake or a failure to record a key piece of data can lead to errors in treatment that often go unnoticed until it’s too late.

According to a landmark study in Mayo Clinic Proceedings, the demands of electronic record keeping also contribute heavily to “physician burnout,” which more than half of doctors experience. CMS regulatory demands, as well as complicated compensation schemes such as MACRA and MIPS, are likely to make this an even bigger problem. One of the underlying issues is that most EMRs in the US today were originally designed to be utilized for billing purposes rather than to enhance clinical care or the coordination of care.

Add to this a toxic work environment created by the high-stakes settings found in hospitals and you’ve got a recipe for disaster. When factors like long shifts, constant rotations, time constraints, administrative burden, and life-or-death situations combine, medical staff may take out their frustrations on each other.

The Nurse-Physician Relationship

Several studies have shown that poor relationships between hospital staff, especially physicians and nurses, can affect patient outcomes negatively.

In 2008, the Joint Commission, which accredits healthcare organizations, found that disruptive or unprofessional behaviors, including shouting at colleagues, throwing objects and berating each other were common among hospital staff.

Not surprisingly, the frustration, lack of concentration, increasing workload, physician burnout and fundamental mistrust created by such incidents actually led to errors in administering treatment.

Complicating matters further is the power dynamic between doctors and nurses, a holdover from earlier days when nurses functioned more like assistants to the “all-knowing” physician. It’s not uncommon for a doctor to ignore nurses’ suggestions for patient care and resent what they see as overstepping. Nurses may feel powerless to report harmful behaviors because they fear retaliation or simply believe hospital administration is complicit.

In a 2015 study published in The Online Journal of Issues in Nursing, 55 percent of nurses said their care decisions were impacted by the way physicians behaved, such as whether doctors treated nurses with respect and how well they communicated about patients’ care plans. What’s more, the nurses and doctors perceived their relationship differently, suggesting a fundamental disconnect between both sides’ values and expectations.

But poor communication between medical staff is not just a problem for workplace morale: it can lead to patient injury and death. In fact, miscommunication is one of the biggest contributing factors in malpractice claims brought against hospital staff.

The Role of Communication Errors in Medical Malpractice

While most hospital visits end positively for patients, medical errors are still a big problem.

In fact, medical error may be the third most common cause of death in the United States, behind cardiovascular disease and cancer. What’s worse, most of these mistakes go unreported, according to a 2016 study published in BMJ.

Even the most careful physicians make honest mistakes, but among the complaints that come up frequently, many are preventable. Consider the numbers:

• A recent analysis of data from a national database of paid malpractice claims found that between 1992 and 2014, the top three allegations were related to incorrect diagnoses, surgery-related errors and incorrect medication.
• Analyzing 25 years of paid malpractice cases, the BMJ Quality and Safety reports that “among malpractice claims, diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.” Between 1986 and 2010, malpractice cases related to diagnostic errors cost $38.8 billion payouts, and that’s just for the most severe cases.

So what causes medical errors like incorrect diagnoses and can they be prevented?

It turns out miscommunication is the second most common contributing factor in malpractice lawsuit cases, according to MedPro, a liability insurance company for physicians and dentists owned by Berkshire Hathaway.

In many cases, it’s a lapse in communication between doctors and patients. But poor communication between healthcare providers often leads to medical error as well. And the more providers involved, the greater the risk for this kind of breakdown.

Perhaps the most common area where avoidable communication errors take place is during handoff — when responsibility for a patient, including their history and care plan, is transferred between caregivers. Ineffective handoff can result in lost records, incorrect medication, delays in treatment, and in the most severe cases, permanent injury or death.

Within a single hospital, this can happen when staff change shifts without relaying critical information, like a patient’s allergy to a certain medicine, to the incoming nurse before signing out.

But the problems are even more rampant when you zoom out to look at the entire continuum of care. Take for example, a surgery patient who must deal with their referring doctor, the surgeon, an anaesthesiologist, lab technician, and various other specialists. In most cases, each clinician operates within individual silos, rarely talking to each other directly.

As Harvard Law Professor Einer Elhauge points out in his book The Fragmentation of U.S. Health Care: Causes and Solutions, it’s often the patient that is responsible for coordinating the efforts of the various doctors — a task which is not only time-consuming and costly, but also requires professional experience.

Without a proper system in place to improve communication between the growing number of people involved in a patient’s care, it can be difficult to tell just who is responsible for following up when things fall through the cracks.

Reducing risk through patient-centered integrated care

One key solution for breaking down the existing silos and improving patient outcomes is an integrated care model, which has received a lot of attention recently with the push toward value-based care under the Affordable Care Act.

Specifically for surgery-related care, the Perioperative Surgical Home (PSH) and enhanced recovery models have tackled many of the inefficiencies and barriers to communication that results from the current fragmentation in the system.

Under the PSH model, surgeons, anesthesiologists, nurses, hospital administrators and everyone involved in a patient’s care work together toward a single set of predetermined objectives. The underlying theme of this clinical model is significantly enhanced communication across the entire surgical journey from booking the surgery until 90 days after discharge. That is, communication will be improved both cross-sectionally as well as longitudinally.

An important component in radically transforming the problematic organizational structures in hospitals is greater transparency among various stakeholders. For example, different departments can increase data sharing to understand things like how many times patients are asked to provide the same information. The increased collaboration also reduces the kind of “tunnel vision” that can lead to dangerous diagnostic errors when a clinician focuses only on their area of specialty and ignores the potential consequences of a method of treatment in other areas.

Studies have already shown that this evolving model reduces costs and improves patient outcomes in health care facilities that have implemented it. And this approach, which is rooted in value-based healthcare, promotes greater alignment not just at the hospital level, but between insurance providers and policymakers as well. In other words, it’s a win for everyone.