Working to improve the quality of care delivery to nursing home residents.

“The single biggest problem in communication is the illusion that it has taken place”

- George Bernard Shaw




Communication is defined as the transfer or exchange of information from a sender to a receiver. More specifically, communication is a process whereby information is clearly and accurately conveyed to another person using a method that is known and recognized by all involved. It includes the ability to ask questions, seek clarification, and acknowledge the message was received and understood.

One critical result of effective communication is a shared understanding between the sender and receiver(s) of the information conveyed.

Why Communication is Important

Failure to communicate effectively as a team significantly increases the risk of error.

According to sentinel event data compiled by the Joint Commission between 1995 and 2005, ineffective communication was identified as the root cause of 66 percent of reported errors.

  • More recent Joint Commission data from 2010 to 2013 show that ineffective communication has remained among the top three root causes of sentinel events.
  • Team leaders require effective communication skills to convey clear information and to provide awareness of roles and responsibilities, as well as feedback.
  • Team members monitor situations by communicating any changes to keep the team informed and the resident protected.
  • Communication facilitates a culture of mutual support when team members request or offer assistance and verbally advocate for the resident.

Communication Challenges



Consider some of the challenges to successful communication that we face every day:

  • Language barriers
  • Distractions in workflow
  • Heavy workloads
  • Varying communication styles
  • Conflict
  • Lack of verification of information
  • Shift changes

How do we overcome these challenges?

Make communication a Priority

  • Clear, constant communication at all levels will help implement any changes you might be considering.
  • Improve the consistency of information and encourage it to flow among your facility's departments, staff, residents, family members and the public.
  • Communication of essential information cannot be left to chance.
  • When it is shared in a group through a shift huddle or with the management team, everyone hears EXACTLY the same information and can share what they know.
  • The group can problem-solve any issues on the spot. Staff members closest to the resident know the resident best. They have vital information and effective ideas. When they understand the problem, they have the best chance to implement an effective solution.

TeamSTEPPS Communication




TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to resident safety.

It is an evidence based program aimed at optimizing performance among teams of healthcare professionals, enabling them to respond quickly and effectively.

Teamwork has been found to be one of the key initiatives within resident safety that can transform

Resident safety experts agree that communication and other teamwork skills are essential for the provision of quality healthcare and for the prevention and mitigation of medical errors and resident injury and harm.

Consider these questions:

  • How does communication affect team processes and outcomes?
  • What is effective communication?
  • What are some communication challenges?
  • What are some strategies to improve communication?

Communication Tools/Strategies

Communication tools that can enhance teamwork include

  • SBAR,
  • Call­out,
  • Check back,
  • Handoff.

These tools facilitate effective and efficient communication within and across teams.


Provides a standardized framework for members of the healthcare team to communicate about a resident’s condition.

In phrasing a conversation with another member of the team, consider:

  • Situation—What is happening with the resident?
  • Background—What is the clinical background?
  • Assessment—What do I think the problem is?
  • Recommendation—What would I recommend?


A tactic used to communicate critical information, directed at a specific individual, during an emergent event. This information helps the team anticipate and prepare for vital next steps in resident care.


A closed loop communication strategy used to verify and validate information exchanged. This strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received.


As identified in root cause analyses of sentinel events and poor outcomes, lack of clarity about who is responsible for care and decision-making has often been a major contributor to medical error.

When a team member is temporarily or permanently relieved of duty, there is a risk that necessary information about the resident might not be communicated. The handoff strategy is designed to promote accurate information exchange at critical times such as transitions in care. More important, it maintains continuity of care despite changing caregivers.


TEAM STEPPS  Learning Series

TeamSTEPPS® Long-Term Care Version/AHRQ

Contact Us

New York

Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
Fax: (516) 326-0434

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458

IPRO Nursing Home Team


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