INTRODUCTION

By decree of the Ministry of Health of the Slovak Republic no. 444/2019 Coll. on the minimum requirements for the internal patient safety assessment system, health care providers were required to implement and comply with the internal patient safety assessment system.

After January 1, 2021, the provider had to demonstrate that it has an internal patient safety assessment system in place and is following the established requirements. If the patient safety system is not implemented, the Ministry of Health can fine the provider up to ten thousand euros. The first positive results in the area of patient safety were expected in the second half of 2021.

The internal patient safety assessment system is aimed at the identification, analysis, management and prevention of adverse events related to the provision of health care, as a result of which the provided health care may be negatively affected, the patient's health condition may deteriorate, or the patient's health may be damaged. The health care provider evaluates the fulfillment of the minimum requirements for the internal patient safety assessment system through an internal audit. With the help of an audit, the management of the medical facility monitors the implementation and compliance with legislative requirements, systematically checks individual procedures in order to prevent errors. The results of the audit also serve to create a strategy for preventing unwanted events. According to Kilíková et al. (2020), understanding the issue of safe health care and patient safety is of fundamental importance and impact on the quality of health care. A systemic approach in building safety management is a challenge for managers in healthcare facilities to increase the quality of care and overall patient satisfaction. In practice, however, many unresolved issues regarding patient safety remain. In our study, we focused on secure communication in an institutional healthcare facility. According to § 2 par. 11 of the Ministry of Health of the SR Decree No. 444/2019 Coll. on the minimum requirements for the internal patient safety assessment system, the institutional health care provider has met the minimum requirements for the internal patient safety assessment system in the field of secure communication, if it has developed a procedure:

a) uniform communication scheme for all healthcare workers, b) to ensure sufficient time for consultation with the patient, so that the patient can describe his health condition and its context and have the opportunity to ask questions to the attending health worker, c) the use of alternative communication techniques between the healthcare worker and the patient, including the provision of visual and written communication and instructional aids for patients, d) monitoring and analysis of detected deficiencies in communication with the patient, e) to ensure autonomy for people with mental disabilities and seniors, f) measures to eliminate identified deficiencies.

Communication is the main tool for our mutual understanding, and errors in communication can lead to misunderstandings and subsequent damage or deterioration of the patient's health. By implementing the requirements of the decree, clear and uniform rules for internal communication in the medical facility were to be introduced. Noviyanti, Ahsan & Sudartya (2021) emphasize that communication is part of the safety culture and building a safety culture in the organization starts with communication. According to Jang, Lee & Lee (2022), effective communication is a key factor contributing to patient safety.

Communication is an integral part of patient care. Communication in a healthcare setting is influenced by systems, processes and culture (Ross, 2018). Communication within the organizational culture should be characterized by openness, providing feedback and communicating about mistakes (Lee Sh et al., 2016). Communication in the organization includes the transfer of information in the organization, various patterns of communication for a large number of people - instructions, orders, conversations, meetings, phone calls, email communication, letters, manuals, directives, etc. Sedlák (2008) emphasizes that employees must understand the flow of information in communication, the purpose, essence and content in terms of the effectiveness of organizational communication.

Communication is important in all aspects of care. Every healthcare facility should regularly train its employees, especially those who come into direct contact with patients, in communication skills, but this rarely happens in our country (Klucho, 2017). Also according to Dimunová (2017), currently the biggest challenges in the healthcare sector are the safer provision of healthcare and the education of healthcare workers about the principles of safe care. Patient safety education focuses on acquiring the knowledge, attitudes and skills needed to promote behavioral change to deliver safer care. The WHO (2011) handbook is intended for patient safety education. Effective communication is one of the education programs for healthcare workers about patient safety. The basic topics of the educational program "How to communicate effectively" include, for example: Communication risk; How to communicate openly with a patient after an adverse event; Obtaining informed consent; Respect for cultures and awareness. The authors of the WHO guide were based on Australian and Canadian standards.

The Australian Commission on Safety and Quality in Health Care (2021) requires healthcare organizations to implement systems and processes to support effective clinical communication and documentation. The goal of the Communicating for Safety standard is to ensure timely, effective, and efficient communication and documentation that supports continuous, coordinated, and safe patient care. Communication is critical to providing safe patient care. Failure of communication, insufficient documentation of clinical information can lead to errors, incorrect diagnosis, inappropriate treatment. High-quality communication in a healthcare facility is also related to minimizing conflicts. In his contribution, Kutlík (2017) asks how healthcare workers are prepared to fulfill the role of communicators and communicators, i.e. providers and receivers of information. He particularly points to the communication between doctors and patients, which is currently in two extremes: either they talk to them in a too complex and professional manner, or they are not sufficiently empathetic. In the area of ​​patient safety, the importance of proper and timely communication is emphasized (Jang, Lee & Lee, 2022). According to Dimunová (2017), the introduction of information and communication technologies into healthcare practice is one of the key tools for making the provision of health care and the transmission of information more efficient.

The minimum requirements for the internal patient safety assessment system in the field of secure communication are established in the Slovak Republic by the Ministry of Health SR Decree no. 444/2019 Coll. on the minimum requirements for the internal patient safety assessment system.

For comparison, we present the legislative standard in the Czech Republic: "Minimum requirements for the introduction of an internal system for evaluating the quality and safety of provided healthcare services" published in the Journal of the Ministry of Health of the Czech Republic, issue 13/2021, p. 2-18. Although these requirements in the Journal, which contains Methodological Measures and Professional Guidelines are considered to be regulations of lower legal force with a recommendatory nature, they are mandatory for health care providers in the Czech Republic: "The internal assessment of quality and safety represents for all health service providers a set of mandatory minimum requirements for the provision of quality and safe care, the content of which will be updated and expanded as necessary." The minimum requirements for secure communication are contained in standard RBC 6 - Secure communication, which is one of the department's security goals. It contains five indicators/minimum requirements. The standard is met if the provider meets the quality and safety indicators:

  • "a unified system of used internal abbreviations was developed and implemented;
  • introduced standard procedures for cases of telephone surgeries of medicinal products;
  • developed a procedure for reporting critical examination values;
  • elaborated procedure for transmitting information by telephone to persons designated by the patient, state administration bodies, law enforcement agencies and other persons authorized to obtain information about the patient's condition and the media;
  • a method of verifying the implementation and efficiency/effectiveness of the standard in direct patient care (e.g. internal audit, reporting of adverse events) is established, and in case of deficiencies, corrective measures are taken".

From the comparative table no. 1, a significant difference in the established minimum requirements for secure communication in institutional health care facilities in both countries is evident.

Table 1 Comparison of minimum requirements for secure communication in institutional health facilities in the Slovak Republic and the Czech Republic

By introducing measures for safe internal communication in a medical facility, the risk of misunderstandings and subsequent harm to the patient will be reduced. Adherence to the rules for safe communication is a prevention of errors in patient care, communication barriers caused by age, language or cultural difference, level of education, sensory disorders, patient's health status, etc. are minimized. The patient must understand the information provided (Journal of the Ministry of Health of the Czech Republic, issue 13/2021, pp. 2-18).

In our opinion, requirements for effective strategic communication aimed at handling cyber security incidents are absent in both legal regulations, e.g. on the cyber security of medical records, which are also part of written communication. Medical facilities must take care to protect sensitive medical data of patients: medical documentation, personal data, etc. In the Czech Republic, cyber attacks on hospitals were recorded. They can cause loss of access to the reservation system, patient data, loss of access to technology, which can cripple the operation of the entire hospital. Dubovecká (2023) presents some challenges in the area of data security for modern health care from the Action Plan until 2025 "Cybernetic security of the health sector 2021-2025":

  1. Keeping information in medical records - protection against hacker attacks
  2. Electronic health records and information exchange
  3. Modernize technologies in hospitals
  4. Mobile applications - use of tablets in medical facilities (Dubovecká, 2023).

GOAL

Analysis of the safety of the health care provided in an institutional health care facility - evaluation of the minimum requirements for the internal patient safety assessment system in the field of secure communication.

FILE AND METHODOLOGY

Data collection was carried out in the months of January-April 2024 in sixteen institutional health facilities in the Slovak Republic - in selected departments and clinics. 25 nurses evaluated the fulfillment of the minimum requirements for the internal patient safety assessment system in the field of secure communication using a check list - Record of evaluation of the fulfillment of the minimum requirements for the internal patient safety assessment system in the field of secure communication at their workplace. The record included fifteen criteria evaluated using internal audit methods: nurse question, nurse observation, environmental assessment, device verification, documentation analysis. In the event that the evaluated department/clinic had developed a procedure - an internal guideline for safe communication, the nurses analyzed the contents of the document.

RESULTS AND DISCUSSION

After a summary analysis of the records, we present in tab. 2 results of compliance with § 2 paragraph 11 of the Decree of the Ministry of Health of the Slovak Republic no. 444/2019 Coll. on the minimum requirements for the internal patient safety assessment system. We evaluated fifteen criteria. Criteria no. are directly related to the said decree. 1 - evaluates letter a); no. 2 - evaluates letter b); no. 3 and 15 - evaluates letter c); no. 4 and 9 - evaluates letter d); no. 5, 11 and 12 - evaluates letter e) and no. 6 and 13 - evaluates letter f).

Table 2 Overall evaluation of meeting the minimum requirements for the internal patient safety assessment system in the field of secure communication

The average rating (35.2%) of all evaluated criteria points to significant non-compliance with the provisions of the decree. Overall, we can conclude that the minimum requirements for the internal patient safety assessment system in the field of secure communication were not met in the evaluated medical facilities. Not one of the sixteen evaluated institutional health facilities achieved a rating in the range of 99-81%, which we consider a partial fulfillment of the minimum requirements. The results shown in tab. 2 we consider critical with regard to communication security. The study by Holej (2012) confirmed the significant importance of communication in the hospital. Employees confirmed that communication has an impact on their work performance, behavior, actions and satisfaction. Communication is a neglected management tool in the organization, and Holeja's study, after analyzing communication in the hospital, pointed to the underestimation of the importance of communication by the management of the medical facility, to misunderstanding and ignorance of the content of internal communication. Managers in hospitals have to reflect on constant changes in the external environment and implement them in the organization, solve the lack of funds, etc., so communication is not a priority for hospital management. According to managers, the most common cause of problems in internal communication is a lack of time, and the author also adds that managers are not familiar with the issue. The combination of these reasons together with the lack of funds complicates the setting up of a secure and efficient communication system. However, an important aspect is the positive attitude of managers who are willing to deal with safety management (Holá, 2012).

Only seven institutional health care providers in our group out of the total number of 25 evaluated had developed a uniform communication scheme for all health workers in accordance with § 2 par. 11, letter a) decree of the Ministry of Health of the Slovak Republic no. 444/2019 Coll. on the minimum requirements for the internal patient safety assessment system. After the content analysis of this procedure, we note that there is considerable diversity between the communication schemes in the evaluated hospitals (tab. no. 3), respectively. we cannot consider some procedures as a communication scheme. The communication scheme serves to graphically express the communication process in the organization, it should be clear and understandable.

Table 3 Contents of the unified communication scheme for all healthcare workers

In their study, Sovariová Soosová, Zamboriová & Murgová (2017) focused on assessing the culture of patient safety in hospitals in Slovakia as perceived by nurses and assessing its impact on the perception of the level of patient safety. The authors used The Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. After analyzing the domains of the hospital's patient safety culture, they found that a score of 75% was not achieved in any domain. Achieving a positive response score of 75% and above is considered an optimal safety culture. The following results were achieved in the domains related to secure communication: Feedback and communication regarding errors - score 74.10%; Passing on information - score 53.20% and in the domain Open communication - score 50.06%. According to Ross (2018), the causes of ineffective communication in terms of safety in nurses are insufficient communication about the patient's condition with other health care providers, insufficient interpretation and documentation of clinical findings.

The second evaluated criterion was focused on compliance with letters b) in § 2 paragraph 11 of the Decree of the Ministry of Health of the Slovak Republic no. 444/2019 Coll., by which we determined whether the institutional health care provider has developed a procedure to ensure sufficient time for consultation with the patient so that the patient can describe his health condition and its context and have the opportunity to ask questions of the attending health worker. Only five institutional health care providers out of 25 evaluated have a time interval in minutes for consultation with the patient set in the internal regulation (table no. 4). On average, the time interval is limited to 15 minutes.

Table 4 Time interval in minutes determined in the patient consultation procedure

Another negative finding revealed in our study related to the practice of using alternative communication techniques between the healthcare professional and the patient, including the provision of visual and written communication and instructional aids for patients. Only three providers have developed this procedure. In practice, pictograms and other communication aids are absent. Nurses are forced to make some communication aids themselves to enable and facilitate communication with patients.

Table 5 Alternative communication techniques used in an institutional healthcare facility

With alternative communication, we temporarily or permanently compensate for the manifestations of a disorder or disability in persons with speech and writing disabilities. Alternative communication systems are used as a substitute for spoken language so that an individual with a communication disorder can express their needs and share their feelings or experiences. We use this method of communication in patients after a stroke, after a brain injury, with dysphasia, with dysarthria, in individuals with mental disabilities or autism spectrum disorder. Communication is facilitated by pictograms, use of sign language, finger alphabet, touch alphabet, pictorial communication system, etc. The management of institutional health care facilities in our study does not provide nurses and other health workers with alternative communication aids, which significantly threatens the safety of patients.

Five providers out of 25 evaluated have developed a procedure for monitoring and analyzing identified deficiencies in communication with the patient in accordance with letter d), § 2, par. 11 of the Ministry of Health of the SR Decree No. 444/ 2019 Coll. We were interested in the most common deficiencies found in patient communication and how deficiencies in patient communication are monitored. Among the most common negative aspects of communication are the lack of time to talk with the patient, the provision of a large amount of information or, on the contrary, insufficient information and instruction; use of professional terminology, the patient does not know who he is talking to; low level of empathy in healthcare workers; not using non-verbal communication.

Deficiencies during communication with the patient are monitored in several ways, but most often with the help of questionnaires. The second frequent way is to submit an initiative to the hospital's directorate, especially as a complaint about the unprofessional pro-client approach of the health worker towards the patient or family members. We found out whether the provider of institutional health care provides remediation when deficiencies related to secure communication are detected and what measures were implemented to eliminate the identified deficiencies. Based on the analysis of the questionnaires, specific suggestions are addressed immediately; addressed complaints are dealt with personally with a specific employee; educational activities focused on communication were carried out in some medical facilities; development of pictograms and other alternative communication aids. Lee et al. (2016) confirms that the level of patient safety in a hospital is influenced by feedback and error communication, effective information transfer and teamwork.

Five institutional health care providers out of 25 evaluated have developed a procedure to ensure autonomy for people with mental disabilities and seniors. To ensure the autonomy of people with mental disabilities, hospitalization with a family member/legal representative and their presence during examinations and interventions is used, which significantly facilitates communication with a patient with mental disabilities.

Ensuring the autonomy of seniors is key to supporting their dignity, independence and quality of life. The basic principles of safe communication with seniors in order to ensure their autonomy include: adapting communication to reduced sensory perception - hearing and vision impairments, sufficient volume, adjusting the font size in written documents, using simple words, without professional terminology and devaluing expressions; with respect for dignity; use non-verbal communication. Ross (2018) reports that a senior patient in the United States sees an average of seven different doctors. Only 40% of patients remember the information given to them by their doctors, and of these 40% of patients, only half knew how to correctly interpret the information provided.

Recommendations for practice

Recommendations for practice are addressed to the management of medical facilities.

  1. Implement and comply with the legislative requirements resulting from the decree of the Ministry of Health of the Slovak Republic no. 444/2019 Coll.
  2. Develop individual directives - procedures, continuously update and supplement them.
  3. To carry out regular internal audits aimed at meeting the minimum requirements for the internal patient safety assessment system.
  4. Educate employees about patient safety, safe communication.
  5. Provide a sufficient amount of alternative communication aids for healthcare workers

CONCLUSION

Communication security is neglected and underestimated in hospitals. Setting up a system of safe and effective communication also complicates the attitude of managers, for whom secure communication is not a priority.

The results of our study are alarming. They revealed non-compliance with legislative requirements regarding secure communication in practice. We expected a significantly better compliance score for the minimum requirements for secure communication. As positive, we can consider the partial interest of the head nurses at the evaluated workplaces in correcting, developing and ensuring at least some guidelines and procedures that are within their competence with regard to job classification; organizing or enabling the participation of nurses in educational activities aimed at safe communication.

Limits

The conclusions cannot be generalized, the results apply only to the evaluated institutional health care facilities, and due to the small number of evaluated health care facilities, the results serve to create a summary view of problems related to patient safety in practice.

Literary sources complemented our findings by providing empirical support. Despite the mentioned limits, the results can be considered acceptable and based on them solutions can be initiated in managerial practice. For us, the negative results of this study are a subject for further evaluations of compliance with the minimum requirements for the internal patient safety assessment system at the institutional health care provider in selected areas.

Author *** doc. PhDr. Viera Hulková, PhD., MPH** Department of Nursing, Faculty of Health Sciences, Alexander Dubček University of Trenčín* ORCID 0000-0003-2631-1803

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