Hospitals seeking accreditation from the Joint Commission, a nonprofit agency that accredits health care organizations, must now adhere to new and revised standards intended to ensure that health care providers communicate appropriately and effectively with patients.
The new patient-centered communication standards are designed to have a positive influence on patient-provider communication and on the quality of hospital care (Joint Commission, 2010a). They focus on all patients having their communication needs met. In particular, standards support communication for the most vulnerable patients: those who have no voice; have hearing, vision, or cognitive impairment; speak a language other than English; have limited literacy or knowledge about health care; or have sexual identity, cultural, or religious differences.
The Joint Commission's action is a direct response to research that links poor patient-provider communication with negative health outcomes and increased costs (Joint Commission, 2009; Bartlett, Blais, & Tamblyn, 2008; Joint Commission, 2010b). To help facilities implement these standards, which took effect Jan. 1, the Joint Commission developed a how-to guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (Joint Commission, 2010a; see sidebar at right).
Speech-language pathologists and audiologists have a unique opportunity to share their knowledge and skills by implementing communication strategies in hospitals for individuals who face communication barriers and breakdowns. Both professions need to join with compliance officers, risk-management teams, nurses, doctors, and other hospital staff and build collaborative relationships with interpreters, translators, clergy, and others who are being asked to support effective and appropriate patient-provider communication.
A case study illustrates many of the challenges to effective communication in hospitals:
Mr. G., 82, is a widowed Italian-American who emigrated to the United States 50 years ago to work in the steel mills. He has limited literacy skills and interacts primarily within the immigrant Italian community. He was recently hospitalized for an aortic aneurysm, which was successfully repaired surgically. Following surgery, Mr. G., a long-time smoker, developed respiratory complications and was transferred to the intensive care unit (ICU) and intubated with mechanical ventilation. Because Mr. G. was often combative when alert and frequently attempted to extubate himself, anxiolytic medications were prescribed to calm him. His visitors spoke to him only in Italian. He often became visibly upset after they left, refusing to take medications and attempting to get out of bed. Members of the medical staff tried to establish rapport with him, but were unable to discuss treatment options. Mr. G.'s daughter indicated that her father was hard of hearing, but he did not have hearing aids.
Clearly, appropriate care for Mr. G.'s current and potential health care concerns must address several issues: maintaining ventilation and medication to improve pulmonary health, decreasing anxiety about procedures to minimize the need for medication, and addressing end-of-life issues and discharge planning.
However, Mr. G.'s scenario presents several barriers to successful patient-provider communication:
- Language issues. Although Mr. G. understood and spoke some English, his primary language was Italian. The hospital staff spoke only English.
- Communication vulnerability. ICU nurses couldn't understand Mr. G. because of the barriers posed by intubation and limited English. Also, Mr. G. didn't understand the nurses because they spoke rapidly, did not look directly at him when speaking, and did not recognize his hearing difficulty. The room was very noisy. Anti-anxiety medication occasionally made him groggy.
- Health literacy. Mr. G. did not understand why he was in the ICU or what was happening to him. He was confused by the consent forms. Because he would not sign, some procedures could not be administered. Verbal attempts to inform him were not successful.
- Cultural supports. Discussing end-of-life issues with social workers, Catholic clergy, or family in culturally appropriate ways would be difficult given Mr. G.'s medical condition and treatment, as well as his speech, language, and hearing problems.
The new Joint Commission standards will help in the effort to remove barriers to successful patient-provider communication. The standards include the following provisions:
The medical record contains information that reflects the patient's care, treatment, and services (Standard RC.02.01.01). This information includes "the patient's communication needs, including preferred language for discussing health care." According to this standard, Mr. G.'s language and hearing issues must be identified at admission and documented in the medical record. For example, after asking Mr. G. to point to his preferred language on a pictorial admissions form, the hospital likely would provide a trained interpreter to obtain a valid health history.
The hospital communicates effectively with patients when providing care, treatment, and services (Standard PC.02.01.21). Under this standard, hospitals will identify and address oral and written communication needs—including cognitive, speech, hearing, and vision issues; preferred language; and health literacy—throughout the "course of care." Thus, a referral to the speech-language pathology/audiology departments could be initiated at admission. Following a brief assessment (Garrett, Happ, Costello, & Fried-Oken, 2007), an SLP might provide Mr. G. with simple AAC supports and training (e.g., a nurse call signal, a tablet and gel pen, a simple voice output device, or a low-tech communication board containing needs-based messages and questions in Italian and English). The SLP also might coach the ICU staff to speak slowly and directly to Mr. G., using visual supports to augment his comprehension. An audiologist might provide a temporary amplification device, marking the on/off switch and posting a chart explaining its operation. Medical instructions (consents, explanations of ventilation and tracheotomy, etc.) could be in plain language, with Italian and/or pictures to increase comprehension.
The hospital respects, protects, and promotes patient rights (Standard RI.01.01.01). This standard indicates that hospitals will allow for the presence of a support individual of the patient's choice, unless the individual's presence infringes on others' rights or safety or is medically or therapeutically contraindicated. At admission, Mr. G. could ask that his daughter be allowed to stay with him and talk to the doctors and nurses. Staff could use the "teachback" method—ask Mr. G. to retell information (via translators, if necessary) to ensure he comprehends consent forms and instructions (Weiss, 2007).
Audiologists, SLPs, and other health care providers can take several steps to help ensure that hospitals and providers advance the effort to enhance patient-centered communication:
- Become familiar with the new Joint Commission Standards and the accompanying Roadmap (search "patient-centered communication").
- Talk with your medical colleagues and find out how to get involved. Audiologists and SLPs can expand the influence of the field of communication sciences and disorders (CSD) while influencing policy and practice and improving the quality of health care and patient outcomes. Establish collaborative relationships with nurses, sign language interpreters, translators, and health care staff involved in implementing the new standards.
- Explain to hospital administrators that CSD professionals can help implement standards. Inform compliance officers, hospital administrators, and risk management teams of SLPs' and audiologists' specific expertise with a broad range of communication problems and disorders in children and adults. Assume responsibility for hospital-wide implementation of evidence-based practices that support communication with vulnerable patients.
- Take the lead in developing communication materials, brochures, and consent forms that use simple text, large print, and picture symbols. Offer to adapt communication techniques for patients with a variety of communication, language, cultural, and literacy challenges (for examples, visit www.patientprovidercommunication.org).
- Establish a pool of low- and high-tech equipment that hospitalized patients may borrow (for examples, visit the Patient Provider Communication website).
- Identify, modify, and/or develop continuing education or in-service modules for staff. Teach health care providers in your facility and community about communication access for patients. Incorporate direct instruction about techniques (e.g., look patients in the eye, write or draw instructions for people with limited auditory comprehension, provide materials) and role-play (Garrett, Paull, & Happ, 2007).
Finally, ensure that providers in your own practice settings "talk the talk" and "walk the walk" by providing a variety of services that address the communication and cognitive needs of communication-vulnerable patients in health care facilities. SLPs and audiologists are in a unique position to address the Joint Commission's improved communication strategies for people with hearing, speech, language, and cognitive issues; individuals who speak languages other than English; and those from diverse and different cultural backgrounds. CSD professionals can take the lead in promoting effective communication between patients and hospital staff in meaningful and effective ways that ensure respect for individual differences.