By Laura M. Cascella, MA

Improving communication among healthcare providers is a topic that, without doubt, is familiar to most physicians and dentists. Although this concept may seem to receive a disproportionate amount of emphasis, research continues to show that poor communication contributes to many medical errors and is “a top reason for team mishaps and subsequent lawsuits.”¹,²

With the increasing focus on collaborative care, communicating effectively becomes an even higher priority. The Institute of Medicine’s 2012 Core Principles & Values of Effective Team-Based Health Care discussion paper lists communication as one of five major principles guiding new models of care delivery.³

Doctors and advanced practice providers (APPs) — e.g., physician assistants, nurse practitioners, certified registered nurse anesthetists, and advanced dental therapists — are critical members of the team-based approach to care. Their working relationships often require close collaboration and coordination; thus, successful communication is vital to ensure patient safety and reduce the risk of errors.

This article suggests ways to establish an environment that supports sound communication strategies and collaborative efforts, shared accountability and responsibility, and mutual understanding and acceptance of each provider’s role within the practice.

Establishing the Foundation for Success
The foundation for successful collaboration can begin as early as the hiring process. When adding an APP to your team, consider not only the qualifications evaluated as part of credentialing (e.g., education, experience, training, etc.), but also whether the provider seems compatible with your team. For example, you may want to consider the following: ⁵, ⁶, ⁷

• Has your practice specifically determined what it is looking for in an APP and how the provider will complement, expand, or enhance practice services? Clearly defining expectations and accountabilities up front can help prevent conflict and misunderstanding later.
• Does the APP’s training and expertise match the practice’s patient population (e.g., pediatric, adult, specialty-related, etc.)?
• Is the APP committed to the goals and mission of the practice?
• Does the APP have a firm understanding of his/her proposed scope of practice and practice limits?
• Do the APP and supervising doctor have consistent expectations for oversight and autonomy?
• Does the APP communicate well during the interview and hiring process, and does he or she seem flexible and capable of learning and assimilating?

Including these considerations in your evaluation process for potential candidates can help lay the groundwork for effective working relationships and a shared vision of quality patient care. Working through the above questions also can help ensure that the practice has thoroughly considered the nature of the APP’s role and the dynamics of having multiple provider types on staff.

Creating a Collaborative Environment
The crux of the doctor–APP relationship rests on the ability of both practitioners to clearly understand roles and expectations and to participate in open and respectful dialogue. As Dr. Graham Billingham, MedPro Group’s Chief Medical Officer, explains, “Superior communication is essential to successful risk management. Communication among providers must be addressed, as it is frequently identified as the cause of errors in patient care.”

For APPs, failure to refer, delayed referral, and other communication issues are primary risk areas, pointing to the need for better information sharing and communication pathways.⁸, ⁹ To address communication risks, practices can establish reliable and efficient communication processes that take into account key risk areas, such as documentation and patient handoffs.¹⁰

Doctors, APPs, and other staff members should be active participants in these processes, and all individuals on the team should have a clear understanding of each member’s role and responsibilities for patient care and other practice functions.

Additionally, as part of a culture of safety, practices should promote a nonhostile, noncritical environment in which APPs are valued and respected members of the team who are encouraged to provide input and suggestions. A 2013 American Medical News article explains that “In negative work environments, some team members can feel they lack the status to share their view . . . .”¹¹ As a result of this perceived negativity, communication failures can occur, potentially leading to medical errors or poor outcomes.

The practice culture should empower APPs to ask questions, request consultations with their supervising doctors, contribute to conversations about patient management and care issues, and proactively participate in the practice’s knowledge network.

Equally important is the need for doctors to commit to providing regular consultation time, reliable contact information, and timely response to APPs’ questions or concerns. It’s essential that both the doctor and the APP “recognize the collaborative nature of the relationship and eliminate any apprehension.”¹²

Supporting Advanced Practice Providers Through Training and Education
Although educational programs provide the basis for clinical knowledge and skills, APPs — like other practitioners and staff members — will require further training from the practices that employ them, as well as opportunities for ongoing education and professional development.

One important consideration is the time and commitment required to incorporate an APP into the practice. Each office setting is different, and the specific nuances and characteristics of a practice can be learned only through on-the-job experience. Being realistic about the time it will take for an APP to learn practice policy and fully acclimate to the position is important, and creating a supportive and collaborative environment — as discussed previously — will facilitate the integration process.¹³

Practices should have formal orientation programs for APPs (as well as other new hires) that introduce and provide details about practice policies, procedures, and operations — as well as expectations for collaboration and communication. Similarly, APPs should be included in routine trainings and educational opportunities offered by the practice, such as training for new technologies, corporate compliance, and safety.

Practices also may want to consider mentorship opportunities for APPs as a tool to “foster collaborative, consistent practice and promote education between providers.”¹⁴ Mentors can answer questions about practice policy and guidelines, provide feedback on standards of care, and offer advice about patient care and management issues. Practices considering this type of training should develop mentorship programs that specify eligibility, duration, and expectations for the mentor and mentee.

Involving the Team
The importance of effective communication between doctors and APPs cannot be overstated; however, equally important is including APPs as part of a practice’s broad communication network. A 2011 Medical Protective article noted that APPs often are isolated from information sharing, communication, and feedback mechanisms within their organizations.¹⁵

Having routine team meetings with all office practitioners can help address this problem. APPs should be present at these gatherings and encouraged to provide insight, offer suggestions, make recommendations, and ask questions.

In the busy practice environment — and with an increasing emphasis on electronic communication — routine “touch-base” meetings present an opportunity for practitioners to discuss patient care issues, share expertise, and offer advice and support. These types of meetings “strengthen the education of the staff, provide for cohesiveness within the provider group, and help ensure consistency in patient care.”¹⁶

Some offices may choose to structure team meetings as open discussions about salient and current issues, while others may prefer formal presentations of research, case studies, etc. Regardless of the format of team meetings, these gatherings and discussions will help reinforce collaboration and information sharing among team members.

Conclusion
Communication among healthcare providers is a risk management topic that has received its share of attention over the years. Yet, it continues to represent a serious risk concern and present challenges for medical and dental practices.

As healthcare shifts toward collaborative and team-based care, and as the number and responsibilities of APPs continue to expand, the issue of communication takes on new complexities. Doctors who work closely with APPs must consider the various ways in which they interact with and support these providers.

Taking proactive steps to address communication gaps and enhance information sharing through establishing clear expectations, creating a supportive and nonhostile environment, providing ongoing training, and offering opportunities for team discussion can help facilitate interactions among practitioners and enforce a strong culture of safety within your practice.

Endnotes
¹ Gallegos, A. (2013, July 29). Physician liability: Your team, your legal risk. American Medical News. Retrieved from http://www.amednews.com/article/20130729/profession/130729942/4/
² ECRI Institute. (2005, June). Intervention methods improve physician-nurse communication. Risk Management Reporter, 24(3). Retrieved from https://www.ecri.org/Pages/default.aspx
³ Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., . . . Von Kohorn, I. (2012). Core principles & values of effective team-based health care. Institute of Medicine. Retrieved from http://www.iom.edu/Global/ Perspectives/2012/TeamBasedCare.aspx
⁴ Trilla, F., & Patterson, A. (1998, Winter). Physicians and nurse practitioners in collaborative practice. Harvard Risk Management Foundation, Forum, 18(5), 9–10.
⁵ American Academy of Physician Assistants. (2005, revised 2012). Competencies for the physician assistant profession. Retrieved from http://www.nccpa.net/App/PDFs/Definition%20of%20PA%20Competencies%203.5%20for%20Publication.pdf
⁶ Sattinger, A. (2007). Collegial relationships: Extending otolaryngology practice with other professional providers. ENT Today. Retrieved from http://www.enttoday.org/details/article/527241/Collegial_Relationships_Extending _Otolaryngology_Practice_with_Other_Professiona.html
⁷ Fitzgerald, M. A. (1998, Winter). Supervising nurse practitioners with prescriptive authority. Harvard Risk Management Foundation, Forum, 18(5), 11.
⁸ Page, A. E. (2010, March). Liability issues with physician extenders. AAOS Now, 4(3). Retrieved from http://www.aaos.org/news/aaosnow/mar10/managing6.asp
⁹ Medical Protective Closed Claims Analysis.
¹⁰ Gallegos, Physician liability.
¹¹ Ibid.
¹² Page, Liability issues.
¹³ Sattinger, Collegial relationships.
¹⁴ Trilla & Patterson, Physicians and nurse practitioners.
¹⁵ Medical Protective. (2011, Spring). Use of advanced practice providers increasing. Hospital Protector.
¹⁶ Trilla & Patterson, Physicians and nurse practitioners.

The information provided in this document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the regulations applicable in your jurisdiction may be different, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal statutes, contract interpretation, or legal questions.

The Medical Protective Company and Princeton Insurance Company patient safety and risk consultants provide risk management services on behalf of MedPro Group members, including The Medical Protective Company, Princeton Insurance Company, and MedPro RRG Risk Retention Group.

© MedPro Group.® All Rights Reserved.