**4. Barriers to communication, collaboration, and care coordination**

Without effective communication between care providers, healthcare teams, and their patients, considerations given to safety measures are more likely to be insufficient, often creating adverse outcomes in both unexpected and unpredictable ways [6]. There are several important barriers to collaboration, coordination, and communication, as outlined in the current section. Within the highly complex and dynamic modern healthcare organizations, each individual must organize and coordinate the necessary care in accordance to their unique, specialized, and highly valued training, expertise, and patterns of practice [43]. Consequently, this inherent systemic heterogeneity is a strong determinant of breakdowns in team function, beginning with differences in the level and type of training and ending with vast and often non-overlapping skill sets that are neither universally understood nor well communicated across the involved group. For example, nurses and doctors are trained to communicate very differently. Nurses tend to be more detailed and emphasize gathering, collecting, and communicating highly granular facts [44, 45]. On the other hand, physicians are taught to interpret these facts, make a diagnosis, and communicate their conclusions without necessarily relating all of the details that led to the formulation of associated clinical plans [44, 45]. An important consideration in this general context is the potential difference in perceptions related to communication among different group members [45, 46].

**5. Overcoming barriers to communication, collaboration, and** 

a troubleshooting forum for any problems that may arise [53].

**6. The importance of organizational culture and leadership**

Much like effective communication, highly structured coordination is important to ensuring that established patient safety mechanisms continue to function properly. All team members should be "on the same page" in terms of their understanding of the group's function and purpose. Yet, as we discussed in previous sections, this can be challenging at times due to the abovementioned barriers. In this context, resistance to change may be responsible for the reluctance of both people and institutions to embrace better ways of doing things. Such resistance can persist within clearly dysfunctional teams despite unequivocal evidence demonstrating successful culture shift within other high-stakes industries such as aviation and banking [52]. Identification of problems in the current patient safety paradigm must begin with clear and unambiguous definitions. For example, there are different categories of suboptimal communication, including poorly timed, misdirected, incomplete or inaccurate information exchanges, as well as ineffective communication due to lack of follow-through [32]. The latter type is thought to be a leading cause of medical error and patient harm in the acute care setting [32]. As outlined throughout the *Vignettes in Patient Safety* cycle, the goal of effective communication should be to ensure that everyone's understanding of the situation at hand is clear and that all participants are communicating in an organized, methodical fashion. This can be accomplished by standardizing the approaches which we use to relate critical information within and between healthcare teams. Thus, efforts to disseminate universally agreed upon clinical communication tools across our organizations will be of pivotal importance (as well as the efforts to educate all stakeholders accordingly). Multidisciplinary rounds are a great platform for coordinating care, ensuring that "everyone is on the same page," fostering open communication and collaboration among different disciplines, and providing

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Standardized team training is important to ensuring a sustained ability of our institutions to function at high-performance levels. Such training programs increasingly take into consideration the human performance science and are designed to mitigate errors and patterns of errors that commonly occur when human beings operate under high levels of stress [54]. Targeted training in leadership, decision-making, briefings, and cross-checking, as well as monitoring, reviewing, and modifying plans under stress, is integrated into the curricula [54]. Simulation constitutes another important aspect of team training. It provides an opportunity to practice various techniques and scenarios in a controlled, highly structured environment. It facilitates real-time feedback and thus creates an opportunity to proactively improve team

Good leadership is paramount to organizational success. Rapidly evolving modern healthcare environment requires leaders to be highly flexible and well-versed in change management skills, with focus on the delivery of high-quality, safe patient care. The establishment

**coordination of care**

attitudes and behaviors.

Another barrier to effective collaboration and communication is the persistence of hierarchical systems that place various team members at different levels of the team decision-making process, often based on specialty, expertise, politics, and other arbitrary factors [47]. Instead, approaches that embrace the fact that each individual brings a unique perspective and breadth of knowledge to the team should be encouraged and appear to be of great importance to improving patient outcomes and promoting a culture of safety [3, 4]. Inviting input and open discourse from the entire team can both improve the delivery of care and reduce the possibility of critical safety steps being missed. Mutual respect, appreciation, acknowledgement, and constructive reflection within the team must be encouraged and should constitute the foundation of sound organizational culture [48, 49]. Great emphasis also needs to be placed on valuing different perspectives, regardless of how divergent individual views may be, through respectful discourse and acknowledgment of key differences. In health care, each member of the team inherently believes that he or she is doing what is truly best for the patient. Respect for differing opinions is an important part of avoiding unnecessary "ego contests" that may be detrimental not only to the team dynamic but also to patient safety and outcomes.

There are several other potential barriers to communication and collaboration that are worth mentioning. Intimidation and disruptive behavior both can interfere with effective coordination of care. There should be "zero tolerance" for these phenomena because they can lead to the development of a hostile work environment and result in fear of communicating or reporting medical errors (e.g., unwillingness to speak up). Any evidence of intimidation or retribution should be a basis for disciplinary action, up to and including termination of employment. Disruptive behavior has been associated with preventable adverse events and adverse patient outcomes [50], and it can distract team members from focusing on effective communication and the performance of essential functions of their job [32, 51]. In summary, it is critical that these two major, yet uncomfortably under-recognized barriers to effective team collaboration and communication be identified and aggressively addressed at all levels of healthcare institutions.
