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Picture the scene: A nurse whose third language is English checks in on an elderly patient. She's seen him every day for the past four and even though he's old and ill, he's different today. The nurse, a mother of three, knows in her gut something isn't right.

But the attending physician, an American-born male with four degrees, was just in the room and determined all was well. The nurse is worried, but she's learned to avoid approaching the attending physician because of his imperious manner. As a result, she keeps vital information to herself.

But he's already tangled with the senior physician once and been left bleeding, figuratively speaking, of course. He'll be damned if he challenges the more experienced doctor again, so he zips his lips.

In both of these fictional cases, because of poor communication, the patient ends up not getting the care they needed. You write the ending. Or really, you or somebody else writes the check, sometimes to the tune of millions of dollars in losses.

It's the kind of thing that keeps Shulamith Klein up at night. The senior director of Risk and Insurance Services for Atlanta-based Emory Healthcare says better communication, more than any other factor, is the key to reducing errors in hospitals and other medical facilities.

Klein says she pours over the post-trial reasoning of juries who decided for the plaintiffs in their malpractice claims against hospitals, and time after time, failures in how the hospital team communicated comes back to haunt medical providers.

The issue isn't reserved for how hospital teams communicate with each other. It also straddles how medical professionals communicate with patients' friends and families when a mistake occurs.

"I've heard people say, 'I had to sue because it was the only way I could find out what happened to my mother,' " Klein says.

But experts say creating better communication means undertaking a re-engineering of how people in the workplace, and not just the medical workplace, talk and interact. And it goes to the roots of our social differences, our psychological quirks, our prejudices and our fears.

In short, it's not easy work. But there are numerous organizations which are working to bring positive change.

Dr. Peter Angood is the inaugural chief patient safety officer for the Joint Commission on Accredited Healthcare, based in Oakbrook Terrace, Ill.The commission tracks what it calls sentinel events, incidents in which a medical error resulted in serious injury or death, as a way to help the industry study ways to reduce errors, and by extension, insurance premiums.

In his years as a clinician, Angood kept hearing the whisperings, and now that he's one of the drivers in the efforts to improve safety, he's come to an important conclusion.

"For years the word on the street was that if there is an issue in healthcare, it's communication, communication, communication," Angood says. "When organizations do a root-cause analysis of their sentinel event, that item is what comes up all the time."

CULTURE EATS STRATEGY

In his short story, "The Blue Hotel" Stephen Crane wrote that "every crime is a collaboration." A mistake, in other words, is usually the result of a network of human failures and can't fairly be pinned on one person.

Maureen Archambault, a vice president in Marsh's Los Angeles office who directs that office's healthcare practice, says researchers studying ways to improve communication in hospitals are focusing not so much on individual failures but on dysfunctional systems.

"Another emerging issue that is being addressed is the 'just culture,' " Archambault says.She says that means that reporting benefits everyone when it's the system that gets held responsible just as much as the last nurse or doctor that visited a patient whose condition later deteriorated.

The Joint Commission believes that the best way to focus on systems is to make reporting of errors voluntary. "If you're going to create a culture of fear where you drive this underground then people won't focus on improvement," says Elizabeth Zhani, speaking for the commission.

Archambault says new medical work culture strategies, taken from studies of the way crews on aircraft, submarines and other stressful environments interact, seek to find a way to hold the individual accountable and still improve the system.

The key, she says, to creating improvement in how hospital teams communicate and how they react to mistakes is winning the battle of culture. The best technology, the best strategy, the greatest management mind on the planet will lose out to an entrenched culture if there's not enough buy-in for change.

"Culture eats strategy every day," Archambault says.

Culture can also eat computers, electronic records systems, robotic pharmacies and a host of other technological improvements that are used to make patients safer.

"I don't believe that every human element can be managed by a process or a piece of equipment," Klein says.

For medical teams to communicate well, leadership has to recognize the importance of change and have the commitment to bring it about, Angood says.

"And that means putting the infrastructures in place so that there is accommodation of human factors, there is improvement in process design that facilitates and promotes an interactive approach and improved communication," he says.

WAYS TO IMPROVE CULTURE

Toward that end, many hospitals across the country are implementing simulation centers that give doctors and nurses an opportunity to work in staged, high-stress situations that can reveal the weak places in their communication and work process.

That approach is getting intense attention at the Stanford Medical Center in Palo Alto, Calif. Jeffrey Driver, the center's chief risk officer, says Stanford Medical has four simulation centers which it uses to expose doctors and nurses to situations which are so difficult that errors are inevitable.

"I believe the Holy Grail in healthcare risk management is to find unrevealed errors waiting to happen andcorrect them before an accident occurs that could lead to patient harm," Driver says.

Driver says the simulation centers have produced better communication in medical teams. As a result, Stanford has seen a drop in its real errors and a drop in its insurance premiums.

Stanford, Emory and others have also introduced rapid response teams that fill in the gaps when a patient in crisis can't reach their primary physician. Emory's Klein says that has led to better handoffs and a reduction in malpractice claims.

Klein says Emory Healthcare rolled out a board-mandated patient safety initiative 18 months ago and plans to follow up with a more focused effort that will give the health center more premium reduction credits from its underwriters for reaching specific patient safety goals. From 2006 to 2007, Klein says the Atlanta health system has seen a drop in its excess liability insurance premiums in the 8 percent to 15 percent range.

Stanford and Emory are among hundreds of hospital systems nationally that are seeing excess liability premiums drop due in part to improvements in patient safety.

Mike Shepperd, the director of insurance for the Oakbrook, Ill.-based University Health System Consortium, says data collected from the consortium's 200-plus members shows that academic hospital systems everywhere are seeing reductions in premiums and claims.

Shepperd says that an annual claims survey run by the UHC for its members indicates that loss expense per discharge, a figure representing the average insurance claim loss per patient discharge, has been stable since 2004. Frequency of claims is also down by a third system wide, from around three per 1,000 discharges in 2002 to two per 1,000 in 2007.

Shepperd says the very ambition and competitive drive that pushes someone to a career in medicine is what drives improvement. Physicians at the University of Chicago Medical Center don't want to be outdone by the UCLA Medical Center or some other competitor when it comes to patient safety, he says.

Klein says the leadership of Bermuda-based Endurance Specialty Holdings Ltd. and the Allied World Assurance Co. of the same Caribbean island also deserve a lot of credit for initiating patient safety report cards that reward healthcare providers for reaching specific initiatives.

Many state governments have now also gotten into the act and are trying to provide a bird's-eye view for healthcare providers on why hospital processes are producing errors.

Bill Marella, director of patient safety programs for the ECRI Institute, based in Plymouth Meeting, Pa., says as many as 20 state governments have developed medical error reporting systems, many of which are managed by nonprofits such as his.

In cutting down on medical errors, Marella cautions risk managers not to get caught up in the error of the moment, even though such things as electronic medical records maintenance are increasingly grabbing the attention of hospital risk managers.

He says such things as slips and falls, medication errors and complications from care have always been the most common errors his organization sees. "You can get caught up in this whack-a-mole mode but the truth is we are dealing with the same things we've been dealing with for the past generation," Marella says.

For the positive trends that experts cite to continue, they say traditional notions of who does what best are going to have to be discarded.

Angood is willing to admit that for all of his training and intellect, he and his fellow physicians are just one more piece in the system that need to make the same adjustments as every one else.

"We in healthcare as an industry are not equipped to take on the human factor engineering that facilitates communication. These traditions were based upon the tradition that the physicians were the depository of the knowledge and the science, and they aren't necessarily the depositories anymore," Angood says.

Risk managers should also keep in mind that the excess premium reductions they're seeing are a result of numerous factors, not just improvements in patient safety.

Tort reform and natural industry cycles like the distance in time from the hardening effects of Sept. 11, 2001, and Gulf Coast hurricane damage are also helping to bring reinsurance and excess premiums down.

A hard market in 2002 and 2003 that featured triple digit premium increases is now normalizing. "I think they priced things so high there was a lot of room to improve," Shepperd says.

Klein says patient safety and prompt disclosure of errors is crucial whether the market is hard or soft.

"The surest way to reduce your insurance premiums irrespective of the market is to reduce your claims. There is no way you are going to get around that connection and it's two-pronged. One, it's to improve patient safety and two, to disclose unanticipated outcomes immediately," Klein says.

DAN REYNOLDS is senior editor of Risk & Insurance®.

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