Enterprise Risk Management (ERM) Legal & Regulatory Patient Safety/Clinical Care

Risk looks at the art and science of effective communication

Communication is an art, a science and a core clinical and leadership competency. Communication competency is critical for a risk manager’s effectiveness. The Becker’s Hospital Review article1, “The chronic problem of communication: Why it’s a patient safety issue, and how hospitals can address it,” states that effective communication contributes to a culture of safety; however miscommunication remains a consistent and pervasive problem. The article provides two studies supporting the outcomes of poor communication. Citing a CRICO study, communication failures were linked to 1,744 patient deaths in five years and $1.7 billion in malpractice costs.2 A University of California, San Francisco study found that more than a quarter of hospital readmissions could be avoided with better communication.

It is clear that effective communication saves lives, improves patient safety, reduces costs and reduces financial reimbursement penalties. This article addresses the science of communication and examines the challenges of the communication process for the risk manager.

Science of Communication

Understanding the science behind communication is the first step in maturing communication competencies. Communication science is the processes of verbal and nonverbal communication in interpersonal relationships, group structures and social interactions. It includes types of communication, mechanics of communication, barriers to and saboteurs of communication. There are four types of communication. They are accidental, expressive, rhetorical, and interpersonal. Accidental or unintentional communication is when your listener attributes meaning to your spoken word, your nonverbal or your silence.

By contrast, expressive communication occurs when the speaker is expressing how they are feeling as they are talking. For example: if, as you are speaking, you reach out to take someone’s hand, you are expressing your sense of wanting a personal connection or that you care. Another example of expressive communication occurs when you blurt out how you feel in the spur of the moment. You may say, “Oh no” or “Oops,” which would convey that you made a mistake.

The third type of communication is rhetorical communication. This is one-way communication that removes the listener from the process. Here, the speaker communicates with a goal. An example of this is when discharge instructions are being provided by someone in a hurry.

By contrast, interpersonal communication is two-way conversation. The components of interpersonal communication form a feedback loop that is the basis for communication models. The SMCR (Source, Message, Channel, and Receiver) Model is recognized by communication scientists as the basic process of communication and is the dominant communication model used to understand interpersonal communication. In the SMCR model, the speaker (source) decides what to say (encodes a message). The speaker is affected by or influenced by “noise,” which refers to internal and external conditions and distractions. This includes the speaker’s internal dialogue, interest or disinterest, attitude, biases, life experiences, environmental conditions, hunger, fatigue, and wandering minds. Noise is a barrier to and saboteur of communication.

The speaker sends a message using verbal and nonverbal channels to the receiver to decode and encode the message back to the speaker. The receiver is also influenced by the same noises. This model illustrates just how easy it is for a message to go off track. Noise as a barrier or saboteur can obstruct or truncate messages. In fact, noise can create a feeling that subjugates the actual message. When this occurs, the message may not be able to be recalled, but the feeling will be readily available for recall.

This model can be examined in a risk management context. For example, when a provider is disclosing an error, adverse event or preventable harm to a patient, the noise might be defensiveness. Noise can also influence nonverbal communication. The accepted formula is 7% of communication is verbal. This means that 93% of communication is nonverbal, which includes body language, paralanguage, silences and pauses.

When risk managers are coaching providers in communication and resolution programs, or are engaged in disclosure and apology communication, it is imperative that risk managers listen to what is being said, as well as what is not being said by the providers. There are three levels of listening: non-listening, passive listening and active listening. Risk managers watch for each, allowing the ability to hear and understand effectively what the other party is communicating.

Communication Competencies

Communication competencies are essential in health care. Effective communication is necessary to build and sustain relationships, to enable patient engagement to optimize patient understanding of treatment plan and to optimize patient adherence. Communication is the key to patient satisfaction and has a direct impact on patient outcomes. Communication is measured on patient surveys to assess patient satisfaction. The HCAHPS3 (Hospital Consumer Assessment of Healthcare Providers and Systems) survey contains 25 questions about the hospital. Fifteen of these questions (60%) relate to communication.

The Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey4, known as OAS CAHPS survey, contains a total of 37 questions, of which 24 relate to the patient perception of care, meaning that 54% of the survey questions relate to communication.

Communication competencies rarely are a set of natural skills. For most people, communication competencies are learned and strengthened through practice, metacognitive exercise and solicited feedback.

Communication Challenges

Risk managers are faced with daily communication challenges. When effective communication occurs, risk managers must be slow to speak and quick to listen. This allows risk managers to fully understand the issue(s) at hand. Studies show that patients are less likely to file a complaint or lawsuit when they feel heard and understood. Likewise, it is important for risk managers to plan appropriately, allowing enough time for patient and provider conversations to take place. In doing so, those communicating do not feel rushed. Preventing interruptions also allows the conversation to flow smoother, creating more opportunity for success. Often, it is helpful for the risk manager to recap any conversation by saying…”What I heard you say….” This way, the patient has an opportunity to correct anything that was incorrectly stated or misinterpreted. Risk managers must communicate to the patient or representatives any options and choices that may be available. It is always wise to implement a timeline to ensure everything stays on track with an eye toward resolution. Keep in mind that these communication methods can also be used in provider-provider communication or risk manager-provider communication.


The communication process can become quite complex, especially when dealing with difficult patients, family representatives, etc. Risk managers must have a strong communication process established to ensure proper communication is exchanged. Making certain decision makers are at the table when a conversation begins is paramount to success. Anything less only adds frustration to all involved. Finally allowing those present during the conversation to express what they heard, along with any concerns aids an ultimate resolution and satisfactory outcome.

Risks of Poor Communication

When appropriate planning has not occurred for communication, things can go haywire. Patients may end up not “hearing” the intended message; assumptions may be made that are incorrect; confusion may be present; patient harm may occur; patients may lean toward or file a complaint; or patients may file a lawsuit. It is imperative to take the time to plan and create a safe, healthy environment for communication. In doing so, risk managers will set the stage for a successful outcome.   


  • Create a solid communication process
  • Secure a quiet private space to meet
  • Ensure the decision makers are at the table to answer questions (clinical, administrative, physician, nurse, risk manager, etc.)
  • Allow or create space for choices to be made
  • Make sure the patient/family understands by recapping what was said
  • Ask the patient/family what they have heard from the conversation
  • End the conversation on a positive note; thank the patient/family for attending
  • Follow up on execution of any resolution plan established during the meeting


Communication is tough. Effective communication is tougher. Understanding the science behind communication allows risk managers to dig deeper to understand what is required to ensure effective communication is exchanged between patients, staff, providers, clinicians, as well as other business partners. Establishing a strong communication process in the beginning not only saves risk managers time, but saves all parties involved the frustration of not having the right systems in place to create opportunities for a successful resolution.


[1] https://www.beckershospitalreview.com/quality/the-chronic-problem-of-communication-why-it-s-a-patient-safety-issue-and-how-hospitals-can-address-it.html Retrieved 10/23/2020

2 For 2020 hospital readmission penalties, see https://www.advisory.com/daily-briefing/2019/10/04/hrrp-map.  Retrieved 10/23/2020. More than 2,500 hospitals out of 3,129 hospitals (83%) evaluated by CMS will face penalties for FY 2020. Medicare estimated its payment penalties will cost hospitals a total of $563 million over a year. The penalties, which will apply to each affected hospital’s Medicare payments between Oct. 1 and Sept. 30, 2020, are based upon readmissions July 1, 2015 to June 30, 2018.

3 The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) created a national standard for collecting and publicly reporting information that enables valid comparisons to be made across all hospitals to support consumer choice. The HCAHPS sampling protocol is designed to capture uniform information on hospital care from the patient’s perspective.

4 The Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey, known as OAS CAHPS measures the experiences of care for patients who visited Medicare-certified hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) for a surgery or procedure. The survey measures patients’ experiences on topics that are important when choosing an outpatient/ambulatory surgery provider. The following types of patient experiences are included:

  • communication and care provided by health care providers and office staff;
  • preparation for the surgery or procedure, and
  • preparations for discharge and recovery


Deborah Lessard, JD, MA, BSN, CPHRM, FASHRM , has 30 years experience in health care strategy and operations. She is a nurse-attorney with a graduate degree in organizational communication and a focus in health care communication. Lessard has a certification in Strategic Decision Making and Enterprise Risk Management from Stanford University. She also serves as adjunct faculty in Georgetown University’s doctorate nursing program teaching health law and enterprise risk management.

Leigh Ann Yates, AIC, MBA, CPHRM, DFASHRM, is senior healthcare consultant at Hallmark Financial Services, Dallas, as well as president and CEO of Risky Business Consulting. She has been an active member of national risk management associations for 25 years. Yates served several years as ASHRM chair of the Social Media Committee, as well as currently contributing to the Forum Task Force Committee.  Most recently, she was a key contributor to ASHRM’s playbooks, as well as authoring several risk management Forum articles.  

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