Introduction

Inaccurate or untimely communication and ineffective teamwork in healthcare are consistently reported as leading causes of preventable adverse events, including medication errors and misdiagnosis.¹ It is widely recognized that communication, which can be defined as “the verbal and nonverbal processes by which information is clearly and accurately exchanged among team members,” is an essential tool for reliable, safe, efficient, and patient-centered care. In healthcare, communication includes information exchanged among healthcare professionals, across healthcare organizations, and with patients, families, and caregivers. Effective communication is critical to patient safety and has been shown to improve health outcomes and increase patient trust and engagement.

While effective communication is essential at all points of care, the nuanced nature of care transitions associated with the intricate network of individuals, healthcare professionals, and systems involved poses unique challenges as well as opportunities to improve patient safety. The Centers for Medicare and Medicaid Services defines transitions of care as “the movement of a patient between different healthcare settings,” such as from ambulance to emergency department, from intensive care unit (ICU) to medical ward, or from hospital to home. These transitions increase risk of adverse events or missed patient care by opening up opportunities for miscommunication or lapses in communication between responsible parties. However, with increased risk of adverse events comes an opportunity to recognize, recover from, and learn how to minimize these risks.²

With the ever-evolving healthcare landscape and larger societal changes in the ways people exchange information, communication during transitions of care was a major focus of articles published on PSNet in 2023. This essay showcases these articles, which discussed strategies for healthcare professionals and organizations to mitigate challenges and improve communication during transition of care, highlighted updates to communication and teamwork training and stressed the importance of organizational emphasis on safety culture, and emphasized the importance of engaging patients, families, and caregivers. Although articles highlighted several types of care transitions, much of the research focused specifically on hospital discharge.

Communication Strategies for Healthcare Professionals and Organizations

Transitions of care are vulnerable times for patients and associated with increased patient safety risks such as adverse events, medication errors, and misdiagnosis or delays in treatment. One study conducted at five home health agencies in the United States found that 70% of observed hospital-to- home health transitions included at least one safety issue, with the most frequent being unsafe home environments, medication issues, incomplete information, and lack of understanding of care plans.³ Another study published in 2023 identified ineffective communication as a key contributor to high rates of medication errors when transitioning patients from the ICU to the general medical ward.

Although risks are associated with transitions of care, these transitions present opportunities to detect and recover from such risks, such as opportunities to mitigate diagnostic errors and conduct medication reviews.² Effective communication among healthcare professionals and across organizations can both prevent risks and increase the opportunity to detect and mitigate risks by promoting consistent and shared understanding of information related to patient care. Research published in 2023 identified and built on the following established communication strategies to reduce risks, increase resilience through timely detection and mitigation of these risks, and avoid patient harm during care transitions.

Checklists and Structured Handoffs

Ineffective communication during handoffs, or the transition of patient care from one healthcare professional to another, has been associated with an increased risk for medical errors. Tools and checklists that facilitate standardized, structured handoffs, such as I-PASS (i.e., illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver), may contribute to efficient handoffs and promote consistent communication of patient information. One study published in 2023 found that after implementing a modified I-PASS tool, pediatric emergency department staff reported a decrease in perceived loss of key patient information during handoffs from 75% to 37.5%. Healthcare professionals implement checklists and tools like I-PASS to facilitate communication among healthcare professionals within an organization or unit. However, healthcare professionals can implement these checklists and tools across healthcare organizations to communicate key information during transitions of care, either via a shared electronic health record (EHR) or in a written format attached to the patient’s discharge summary. It is important to consider that while standardization, checklists, and structured handoffs can help facilitate effective communication, these tools alone are not “silver bullets” and do not guarantee safe transitions. Healthcare occurs in complex systems, and simple solutions such as checklists are limited in improving communication in care transitions.⁴

Shared and Standardized Documentation

Documentation, such as discharge summaries and the patient’s EHR, are important tools for communicating patient information such as medication and follow-up care plans. Unclear discharge summaries that omit important follow-up plan details or include unclear language such as abbreviations contribute to misdiagnosis or delays in treatment, particularly for patients with complex medical conditions. Establishing a process for maintaining clear, accurate, standardized, and patient-centered discharge summaries facilitates patient safety during transitions of care when the discharge summaries are made available to admitting healthcare facilities, primary care physicians, and patients in a timely manner.

The EHR is another important communication and documentation tool that facilitates information transfer and care coordination between healthcare organizations. However, inaccurate or incomplete input of information and technical issues can contribute to patient safety issues related to the EHR. In one case study published in 2023, providers did not flag a critical echocardiogram result populated in the patient’s EHR after discharge from the hospital to a skilled nursing facility, resulting in missed care and the patient’s readmission to the hospital. Implementing processes to regularly enter information into the EHR, flag critical information requiring follow-up, and notify admitting care facilities helps to mitigate these risks. Although electronic transfer of healthcare documentation has become standard, issues such as a lack of interoperability of EHR systems across different healthcare organizations still pose challenges for effectively communicating follow-up plans for patients and necessitate more direct communication between healthcare professionals and with patients.

Coordinated Care and Patient Follow-Up

Coordination of follow-up care before discharge and direct follow-up with patients after discharge can help bridge the gap between hospital and home care. Several studies published on PSNet in 2023 highlighted the importance of patient navigation and care coordination when transitioning from one care setting to another. A systematic review of interventions for transitions from hospital to home healthcare found that establishing contact with local healthcare services before discharge and following up via telephone with patients after discharge to identify patient needs and connect them with additional resources increased both patient safety and patient satisfaction. One case study, which examined a patient who experienced sepsis due to treatment delays, identified that follow-up after discharge to coordinate care at other facilities or at home, including direct communication between services, can improve care coordination and reduce readmission rates. This study noted that patients seen in follow-up after discharge are less likely to be readmitted, and proactive coordination of care can reduce risks of patients being lost to follow-up.

Combined Strategies

Although each of these individual strategies is useful in improving communication during transitions of care, the 2023 research emphasized that combining multiple strategies can positively affect patient safety during transitions of care. One study found that implementing bundled transition strategies that included a post-discharge telephone call, restructured discharge summary, and structured handoff communication to the outpatient provider was associated with a reduction from 15.8% to 10.2% in 30-day readmissions for children with medical complexity after hospital discharge, and was associated with a 36.4% decrease in the rate of incidents per discharge.

Additionally, a systematic review published in 2023 highlighted five studies that combined systematic patient education before discharge, establishment of contact with local healthcare services before discharge, and nurse follow-up after discharge as strategies to increase patient safety and satisfaction associated with hospital discharge. The review found varying impacts of these strategies on patient satisfaction and patient safety, and recommended tailoring specific combinations of discharge communication strategies to the needs of each patient. Although several strategies can be implemented to improve communication during transitions of care, healthcare environments are complex, nonlinear, sociotechnical work systems, and there is no cure-all solution.

Communication Training and Organizational Emphasis on Safety Culture

Communication and teamwork are key components of organizational safety culture. When healthcare professionals trust they operate in an environment where they can safely and effectively communicate with their colleagues, this assurance can help facilitate better communication in challenging scenarios, reduce patient safety risks, and increase staff perceptions of team performance.

The 2023 literature published on PSNet emphasized communication and teamwork training as a strategy to improve both communication during transitions of care and to foster an overall culture of safety within an organization. Communication training in healthcare has been shown to strengthen resilience, improve teamwork, and reduce risk of adverse events among healthcare teams. One intervention study in a hospital obstetrics department found that in the year following the implementation of a teamwork-focused communication training program, preventable adverse events decreased from 13.5% to 8.83%. Another study found that healthcare professionals’ perceived patient safety risks decreased following communication and teamwork training.

TeamSTEPPS, or Team Strategies and Tools to Enhance Performance and Patient Safety, is an evidence-based framework for communication and teamwork training in healthcare. In 2023, AHRQ launched TeamSTEPPS 3.0, which builds on the foundation of the original TeamSTEPPS curriculum while incorporating additional virtual resources and a focus on patient and family engagement. TeamSTEPPS Module 1: Communication teaches communication strategies for healthcare professionals including SBAR (situation, background, assessment, recommendation, or request), closed-loop communication, call-out, check-back, teach back, and structured handoffs, and specifically calls out the application of these strategies to transitions of care. Implementation of TeamSTEPPS training within an organization can improve patient safety, reduce clinical error rates, improve patient satisfaction, and emphasize a wider culture of safety within an organization.

Engaging Patients, Families, and Caregivers

In addition to communication strategies that focus on healthcare organizations and professionals, the 2023 literature further emphasized the importance of communication with patients, families, and caregivers in care, particularly during care transitions. A report published in 2023 highlighted 53 AHRQ-funded patient safety projects related to increasing patient and family engagement, two of which specially focused on transitions of care. The 2023 TeamSTEPPS 3.0 updates incorporated patients and family caregivers as essential members of care teams. Involving patients, families, and caregivers in care improves patient safety, patient satisfaction, and quality of care.

Partnering with patients and families and incorporating their input when planning for discharge from hospital to home is associated with increased patient safety and fewer hospital readmissions. This may include identifying the patient’s support systems, clarifying roles and responsibilities, making sure they have needed equipment at home, and identifying any barriers to their care. When communicating with patients and families during care transitions, it is important to approach communication through a health equity lens. Historically minoritized patients report that their interactions with and trust in healthcare professionals are important determinants in their experience of safety.

Following transition from hospital to other care settings, patients report being unprepared for their roles in the next healthcare setting, lacking understanding of the steps involved in their care, and being unsure how to contact the appropriate healthcare professionals for assistance. Patient understanding of care decreases readmission rates and improves patient satisfaction; however, 2023 research shows that patient retention of information following hospital discharge remains poor. Communication strategies such as verbal, written, and video-based patient education and counseling before discharge, as well as patient follow-up after discharge, facilitate patients’ understanding of their care and adaptation to transitions.^5,6

Producing patient-centered documentation and ensuring patient access to documentation can improve patient safety during transitions of care. One study published in 2023 identified that 774 patients who reviewed their after-visit notes reported 962 “blind spots,” which the study defines as “safety hazards that are difficult for clinicians and organizations to see.” These blind spots included inaccurate descriptions of symptoms, inaccurate patient history, and omission of main concerns or next steps. The study pointed out that because patients are the connecting thread across different healthcare professionals and systems, their unique perspectives can be critical in identifying errors in documentation during transitions of care that may have otherwise gone undetected. Providing patient access to documentation and ensuring the documentation is patient-centered and uses language that makes sense to both patients and healthcare professionals facilitates common understanding, which in turn improves patient safety, particularly during care transitions.

Conclusion and Future Directions

The 2023 research showed that communication is an essential and multifaceted tool during transitions of care. Predischarge interventions, such as patient education, discharge planning, and patient-centered discharge instructions, combined with post-discharge interventions, such as follow-up phone calls and care coordination, have been shown to reduce adverse events and improve patient safety. Communication interventions at an organizational level, such as implementation of I-PASS and TeamSTEPPS, can foster a culture of safety and improve communication skills among healthcare teams.

Further research on this topic may explore Safety II approaches, which seek to understand safety through successes rather than failures, to identify what strategies or tactics care professionals use to ensure reliable transfer of key information and integrate resilience into care transitions. The growing role of technology in healthcare presents a need for further research into the role of technology in supporting communication, such as the role of artificial intelligence (AI) and technological design characteristics that support distributed cognition across professionals and with patients, families, and caregivers. Although the importance of patient engagement is clear, further research is needed on how to better engage patients and families coming from disadvantaged populations in care transitions.

References

1. The Joint Commission. Sentinel Event Data 2022 Annual Review. The Joint Commission; 2023. Accessed February 6, 2024. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/03162023_sentinel-event-_annual-review_final-(002).pdf

2. Wears, RL, Perry, SJ, Shapiro, M, et al. Shift changes among emergency physicians: best of times, worst of times. Proc Hum Factors Ergon Soc Ann Mtg. 2023;47(12):1420-1423.

3. Arbaje AI, Hsu Y, Keita M, et al. Development and validation of the hospital-to-home-health transition quality (H3TQ) index: a novel measure to engage patients and home health providers in evaluating hospital-to-home care transition quality. Qual Manag Health Care. 2023. doi:10.1097/QMH.0000000000000419

4. Perry SJ, Wears RL, Patterson ES. High-hanging fruit: improving transitions in health care. In: Henriksen K, Battles JB, Keyes MA, et al, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Agency for Healthcare Research and Quality; 2008. https://www.ncbi.nlm.nih.gov/books/NBK43656/

5 Sun M, Liu L, Wang J, et al. Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: a meta-synthesis of qualitative studies. Front Public Health. 2023;11. https://doi.org/10.3389/fpubh.2023.1047723

6 Gillespie BM, Thalib L, Harbeck E, et al. Effectiveness of discharge education for patients undergoing general surgery: a systematic review and meta-analysis. Int J Nurs Stud. 2023;140:104471. https://doi.org/10.1016/j.ijnurstu.2023.104471