The Doctor’s Advocate | First Quarter 2021
Perspectives from the CMO

Universal Masking Calls for More Structured Communication in Healthcare

David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company, and for the TDC Group of Companies

When Captain Chesley “Sully” Sullenberger and copilot Jeff Skiles emergency-landed Flight 1549 on the Hudson River, they had met just once before. Medical teams, like flight crews, sometimes work together over years, and sometimes have just met. Either way, when things go wrong, teams need agreed-upon systems for communication and procedures already mastered.

During COVID-19, many medical teams, some redeployed into areas of their hospitals where they have never worked before, must communicate well in spite of not knowing each other—or ever having seen each other’s faces.

The Joint Commission has identified communication failures as contributing to more than half of sentinel events, as well as to various significant adverse outcomes.1 Many medical malpractice lawsuits (whether deriving from medical error or patient dissatisfaction) can be attributed to communication failures. Because most communication is nonverbal, multilayered personal protective equipment (PPE) presents an obstacle to patient safety and a liability risk, even as it reduces infection risks.

For years, structured communication systems have helped surgical teams communicate through layers of PPE to elevate patient safety and professionalism while lowering liability. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) offers many useful tools, and as medical professionals across the spectrum of care adopt universal masking for the long haul, it’s time to implement these tools across the spectrum of care.

The Checkback

The checkback is familiar to anyone who has ever ordered a pizza: You say what you’d like, and the person taking your order repeats it back. We should use this simple strategy much more often in healthcare.

Whether the checkback is with colleagues or patients, it is especially helpful when there are potential impediments to communication, such as masks, hearing loss, or lack of overlap in people’s first languages and/or accents.

Anyone can start making more frequent use of the checkback today with colleagues and patients. Better yet, any healthcare professional can request a process to institutionalize the checkback by requiring it for more types of clinical or consultative interactions.

The Brief, Huddle, and Debrief

TeamSTEPPS presents three tools critical to team leadership: briefs, huddles, and debriefs. The brief, often referred to as a time-out in procedural settings (see The Joint Commission Universal Protocol), occurs before a procedure or other clinical interaction and is a structured discussion of the plan of care. The huddle is an ad hoc team discussion to assess or adjust the care plan.2 In a debrief, often referred to as a sign-out in procedural areas like the OR, the team has a chance to review the work just performed, discuss how it might be improved the next time, and communicate about the patient’s next level of care.

Such steps make us more efficient, not less—and most briefs, huddles, and debriefs take just minutes. These tools recognize that each team member brings needed information. I once saw an anesthesiologist—a time-out skeptic—converted when a nurse asked, “Does everyone remember the patient is a Jehovah’s Witness?” The anesthesiologist had not known this—and it would have made a big difference if the need for a blood transfusion had occurred during the patient’s spinal procedure.

The first step in a brief, in which everyone on the team typically introduces themselves, also subconsciously gives team members permission to speak—and, crucially, increases the odds that they will later say something if they see something.

A favorite (and real) patient safety anecdote describes a near-miss incident that was averted because a medical student had felt empowered to speak: The student said, “I think you’re prepping the wrong knee,” and he was correct.

The Checklist

In structured communications, such as the brief and debrief, it is helpful to use a checklist, recognizing that we often don’t remember all the items to discuss. As pressure intensifies, so does the checklist’s value—surgical teams that performed simulations with checklists improved their management of actual operating room crises.3 To be effective, checklists must be created by the teams using them, and they must be seated within a comprehensive teamwork and/or patient safety program.

When Ontario, Canada, mandated the use of surgical checklists, rates of morbidity and mortality remained substantially unchanged,4 but renowned patient safety expert Dr. Lucian Leape observed that 90 percent of hospitals studied had used checklists taken directly from the World Health Organization (WHO) or Canadian Patient Safety Institute—unmodified from their original versions, and unsupported by training.5

To improve patient safety, the checklist must be owned by, modified by, even created by the care team, with implementation training.5 For instance, a Scottish study examined checklist use and saw steep declines in patient mortality following implementation of checklists “tailored to suit each hospital and specialty.”6 Checklist implementation was also part of a nationwide patient safety program.

Pandemic conditions have made checklists even more valuable—and more applicable to all clinical situations. This is especially true in areas in which typical communication has been changed due to masking and other pandemic-related requirements.

At your practice or institution, if you haven’t already, consider creating checklists. Checklists can cover day-to-day operations, such as during the team’s morning brief prior to a clinic session. They should also address critical medical interventions—both predicted, such as administration of chemotherapy, and sudden, such as when a patient faints in the office.

Standardized Communication Tools for the Healthcare System

Maimonides Medical Center in Brooklyn is implementing I-PASS across its system for all residents and much of its attending staff. Implementing this standardized communication system for handoffs has decreased medical errors and preventable adverse events at many other health systems.7 Using I-PASS, conversations for handoffs and transitions of care include:

Illness severity

Patient summary

Action list

Situational awareness and contingency plans

Synthesis by the receiver

Other structured communication systems include Situation-Background-Assessment-Recommendation (SBAR) and Situation-History-Assessment-Recommendations/Result-Questions (SHARQ).

Implementing any structured communication system promotes collaboration among team members who mutually support each other in offering care that fits a shared mental model. This protects patients while improving professional satisfaction and reducing liability.

Like checklists, structured communication systems are only as good as their fit within a team’s needs and their support through team-based training; they should be applied across the board by care teams. The hurdles imposed by COVID-19, especially those impacting how we communicate, require extra care—extra care that will benefit us all in a post-pandemic future.


  1. The Joint Commission. Sentinel event statistics released for 2015. Joint Commission Perspect. 2016;36:10.
  2. Use of structured communication tools to improve surgical patient safety. American Academy of Orthopaedic Surgeons. Published October 2015. Accessed December 1, 2020.
  3. Arriaga A, Bader A, Wong J, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368:246-53. doi:10.1056/NEJMsa1204720
  4. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029-38. doi:10.1056/nejmsa1308261
  5. Leape LL. The checklist conundrum. N Engl J Med. 2014;370(11):1063-1064. doi:10.1056/NEJMe1315851
  6. Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. BJS Society. 2019 Apr;106:1005-1011. doi:10.1002/bjs.11151
  7. Shah C, Sanber K, Jacobson R, et al. I-PASS illness severity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020 Oct:578-582. doi:10.4300/JGME-D-19-00755.1

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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