The Critical Role of Communication in Hospital Care: TJC PC.02.01.21 and the Risks of Malpractice

Communication about care isn't just between providers, patients and families must be at the center of it and driving care decisions.

Effective communication between healthcare providers and patients is fundamental to safe, high‑quality care. Misunderstandings, incomplete explanations, or failure to confirm patient comprehension can create critical gaps that lead to medical errors, adverse events, and malpractice claims. The Joint Commission’s Standard PC.02.01.21—“The hospital effectively communicates with patients when providing care, treatment, and services”—highlights the necessity of clear, patient‑centered dialogue at every step of the healthcare journey.

This blog explores:

1.      The requirement and rationale of PC.02.01.21.

2.      A compliant practice example illustrating best practices.

3.      Real‑world medical malpractice cases where lapses in communication violated this standard, with legal context.

4.      How EvaluCare (EvaluCare.net) partners with patients, families, and attorneys to review medical care provided to compliance with communication standards, reducing risk of error and litigation.

Throughout, we’ll emphasize how poor communication creates risk, while robust processes protect both patients and providers.

1. Understanding Standard PC.02.01.21

Requirement:“The hospital effectively communicates with patients when providing care, treatment, and services.”

In practice, this Standard requires hospitals to:

1. Assess and accommodate patients’ communication needs (language, literacy, hearing/vision impairments, cognitive status).

2. Provide information in a timely, accurate, and understandable manner—including diagnoses, treatment plans, medication instructions, and discharge instructions.

3. Engage patients and families in two‑way communication—inviting questions, confirming understanding (e.g., teach‑back), and documenting the interaction.

4. Use qualified interpreters or communication aids when patients have limited English proficiency (LEP) or sensory deficits.

5. Ensure consistency across settings (e.g., from the ED to inpatient units to discharge) in messaging about care plans, contingencies, and follow‑up.

While PC.02.01.21 does not enumerate formal Elements of Performance as some other standards do, its expectations are embodied in multiple performance elements and associated “EPs” dispersed through the Provision of Care (PC) chapter.

Key components typically include:

• EP 1: Identify patients’ communication needs (language, hearing impairment, cognitive status).

• EP 2: Use communication resources (interpreters, visual/hearing aids, written materials) to accommodate needs.

• EP 3: Provide information (diagnosis, treatment options, risks/benefits) in a way that the patient can understand.

• EP 4: Engage in shared decision‑making—ask open‑ended questions, encourage patient/family questions, and confirm comprehension.

• EP 5: Document all patient communication interactions, including use of interpreters or family members, details of teach‑back, and patient decisions.

Collectively, these EPs ensure that patients are not merely passive recipients of care but active participants. When hospitals neglect any of these components, they risk undermining patient safety, quality outcomes, and legal protection.

2. Rationale: Why Effective Communication Matters

A growing body of evidence links poor communication to adverse events, readmissions, and medical malpractice claims. Consider these facts:

• Miscommunication and Handoffs: Studies show that communication failures contribute to nearly 80% of serious medical errors. When transitions of care occur—such as between shifts, or from the ED to the ICU—vital information can be lost, leading to delays in diagnosis or therapy.

• Limited English Proficiency (LEP): Roughly 21% of U.S. residents speak a language other than English at home. LEP patients have higher rates of readmissions and longer hospital stays when interpreters are not used. 

• Health Literacy: Nearly 36% of U.S. adults have basic or below basic health literacy. Patients may misunderstand medication instructions, fail to recognize warning signs, or be unable to navigate follow‑up care without clear, tailored explanations.

• Informed Consent & Shared Decision‑Making: In complex cases—cancer therapy, major surgery, end‑of‑life decisions—lack of thorough discussion may lead to “uninformed” consent. Patients who feel they were not fully informed are far more likely to sue if outcomes are poor.

• Patient Satisfaction & Trust: Effective communication fosters patient engagement, adherence to therapy, and trust in the care team. Dissatisfied patients are more apt to file grievances or turn to litigation.

Given these realities, the Joint Commission has long emphasized communication as a core component of safe, high‑reliability organizations. PC.02.01.21 crystallizes this in the hospital setting: every clinician—not just physicians—must prioritize clear dialogue.

3. A Compliant Example: Best Practices in Patient Communication

Scenario: “Mrs. Patel’s Education on Heart Failure Management”

Background:Mrs. Patel, a 68‑year‑old woman with newly diagnosed congestive heart failure (CHF), is admitted to a tertiary hospital after an ED visit for shortness of breath. She speaks limited English and has only a 5th‑grade reading level.

Communication Process Compliant with PC.02.01.21:

1. Assess Communication Needs (EP 1)

   • Upon arrival, the admitting nurse asks Mrs. Patel about her primary language and literacy. Mrs. Patel states, “I speak Gujarati. English is hard.”

   • The nurse flags “Gujarati” in her EHR profile and notes “Limited Health Literacy” under “Patient/Caregiver Needs.”

2. Deploy Appropriate Resources (EP 2)

   • The hospital uses a 24/7 remote video‑interpretation service that provides Guajarati‑English interpreters within 2 minutes. For bedside teaching, an in‑person interpreter is requested for morning rounds.

   • Printed CHF education materials (diet, medication, daily weights) are provided in Gujarati, written at a 4th‑grade reading level with pictograms.

3. Provide Information Clearly (EP 3)

   • On day 1, the hospitalist visits Mrs. Patel with the interpreter. The physician and nurse introduce themselves, explain what “heart failure” means (comparing the heart to a “pump that is slowing down”), and describe next steps (diuretics, low‑salt diet).

   • The interpreter uses simple phrases; the clinician pauses every 2–3 sentences to ask Mrs. Patel for questions.

4. Engage in Shared Decision‑Making (EP 4)

   • The cardiologist presents two diuretic regimens: high‑dose furosemide with inpatient monitoring vs. lower‑dose diuretic with close outpatient follow‑up.

   • Mrs. Patel, through interpretation, expresses fear of readmission due to transportation difficulties. The team acknowledges this, and they agree to start the higher dose in‑hospital with an urgent referral to a home health nurse who can visit twice weekly.

   • The plan is documented: “Discussed options; patient chooses regimen A for close monitoring at hospital; home health nurse order placed; transportation resources for follow‑up arranged.”

5. Confirm Understanding and Document (EP 5)

   • Before discharge, the nurse performs a teach‑back: “Mrs. Patel, show me how you will take your water pill when you get home.” Mrs. Patel demonstrates the timing and dosage correctly.

   • The interpreter notes in the EHR: “Patient demonstrated correct pill dosing; states understanding of low‑salt diet with teach‑back. Copies of Gujarati diet sheet placed in binder.”

   • Discharge instructions include a return‑demonstration of daily weights (weighing herself on the bathroom scale in her clothes) and what to do if her weight increases more than 2 pounds in 24 hours or if she develops worsening shortness of breath.

Why This Meets PC.02.01.21:

• Mrs. Patel’s communication needs were identified upfront (EP 1).

• Qualified interpreter services and appropriate materials were provided (EP 2).

• All medical information, risks, benefits, and follow‑up were explained in her preferred language, at an appropriate literacy level (EP 3).

• Decision‑making incorporated Mrs. Patel’s transportation and home circumstances (EP 4).

• Understanding was confirmed via teach‑back and documented thoroughly (EP 5).

As a result, Mrs. Patel was able to manage her CHF safely at home, had no medication errors, and did not require readmission within 30 days—illustrating the real impact of effective communication.

4. Malpractice Examples: When Communication Breaks Down

Despite best intentions, communication failures persist and frequently lead to malpractice claims. Below are two illustrative cases where lapses in patient communication violated PC.02.01.21, resulting in tragic consequences and legal liability.

Case 1: Martinez v. Regional Medical Center (2018)

Background: Mr. Martinez, a 54‑year‑old man with poorly controlled type 2 diabetes, was admitted for an infected foot ulcer. He only spoke Spanish. The hospital had a remote interpreter service, but nursing staff attempted to use his adult son as an ad hoc translator. Further, discharge instructions were provided only in English.

Key Failures:

1. Lack of Qualified Interpreter (EP 2):

   • The attending physician conducted rounds without requesting the formal interpreter, believing “his son can do it.” In reality, the son often “summarized” conversations rather than translating verbatim.

2. Inadequate Discharge Instructions (EP 3):

   • On discharge day, the discharge nurse handed Mr. Martinez a diabetic ulcer care sheet in English only and said, “Make sure you change the dressing daily and rinse with warm water.” No interpreter was present.

3. No Teach‑Back or Confirmation (EP 5):

   • Staff assumed Mr. Martinez understood English instructions and did not confirm comprehension.

Outcome: Within 48 hours of discharge, Mr. Martinez returned to the ED with spreading cellulitis and early osteomyelitis, ultimately requiring a below‑knee amputation. A Spanish‑speaking wound care nurse testified that Mr. Martinez had said he did not understand how to change the dressing and forgot to obtain the antibiotic refill—information that was never conveyed by his son.

The court found that by bypassing the hospital’s interpreter policy and failing to provide discharge instructions in Mr. Martinez’s preferred language, the hospital violated PC.02.01.21. The “ad hoc” use of the son as translator was deemed inadequate in light of Joint Commission guidance on interpreter use. Judgment was entered against the hospital for negligence, with damages awarded for the amputation, prosthesis, rehabilitation, and pain and suffering.

Why It’s Malpractice per PC.02.01.21:

• EP 1/EP 2: Communication needs were known (limited Spanish); a qualified interpreter should have been used at every encounter.

• EP 3/EP 5: Discharge instructions were not provided in Spanish; comprehension was never verified.

Case 2: Greene v. City Surgical Hospital (2020)

Background: Ms. Greene, a 42‑year‑old woman scheduled for elective laparoscopic cholecystectomy, had mild hearing loss and used hearing aids at home. At hospital admission, a nurse noted “hearing impairment” but did not document it on the pre‑op checklist. Operating room staff assumed she could hear fine. Post‑op, when providing pain management and post‑op care instructions, staff spoke quickly, often with masks obscuring facial expressions. No written supplements were provided.

Key Failures:

1. Unaddressed Hearing Impairment (EP 1):

   • Though the nurse noted “hearing impairment,” the care team did not ensure she had her hearing aids or offer a pen‑and‑paper alternative.

2. Unclear Post‑Op Instructions (EP 3):

   • Early on post‑op day 1, an order to ambulate “three times a day” was communicated verbally to Ms. Greene while she was sedated. She heard “rest in bed,” believing ambulation wasn’t yet needed.

3. No Confirmation of Understanding (EP 5):

   • Nursing staff assumed she understood because she nodded, but Ms. Greene was struggling to lip‑read due to her mask.

Outcome: On post‑op day 2, Ms. Greene developed a deep vein thrombosis (DVT) in her left leg. By the time staff recognized her leg swelling, she had not mobilized per orders, pulmonary embolism was appearing. She required ICU transfer for heparin infusion, extended her hospital stay by 5 days, and underwent an inferior vena cava (IVC) filter placement.

When she filed a lawsuit, her expert pointed to PC.02.01.21: because her hearing impairment was never adequately accommodated, verbal instructions were not effective. The hospital’s failure to identify this barrier (beyond initial note) and provide alternative communication methods (writing instructions, offering a hearing‑aid check) constituted negligence. The jury awarded damages for the extended ICU stay, filter placement, and post‑thrombotic syndrome management.

Why It’s Malpractice per PC.02.01.21:

• EP 1: Identification of hearing impairment was superficial—no follow‑through.

• EP 2: No use of alternative communication (written orders, pen‑and‑paper).

• EP 3/EP 5: No confirmation that Ms. Greene understood ambulation orders, leading to preventable DVT/PE.

5. Recognizing Communication Failures & Preventing Harm

Hospitals can often detect lapses in PC.02.01.21 compliance by watching for these “red flags”:

1. Frequent Readmissions or ED Returns:

   • A cluster of early return visits for conditions that should be managed at home (e.g., wound infections, medication mismanagement, fluid overload)—often indicating poor discharge communication.

2. Unexpected Patient Behavior:

   • Patients who appear frustrated, confused, or disengaged, even after routine explanations, may be signaling unaddressed comprehension gaps.

3. High Interpreter Service Usage but Poor Outcomes:

   • If a hospital provides interpreters yet still has high complication rates for LEP patients, the issue may be in how information is conveyed or if proper interpreter protocols are followed.

4. Staff Reports of “I Told Them, but…”:

   • When clinicians claim they “explained it,” yet families file grievances, it typically indicates a breakdown in EP 5: patient confirmation of understanding.

5. Discrepancies in Documentation:

   • EHR notes showing “patient education provided” but no notes on teach‑back or patient questions signal a box‑checking culture rather than meaningful communication.

Early identification of these signals can trigger rapid cycle improvement—preventing avoidable adverse events and malpractice exposure.

7. Conclusion: Communication as a Shield Against Error and Malpractice

As the healthcare system grows more complex—and as patient populations become more diverse—hospitals must remain vigilant about how they communicate. Standard PC.02.01.21 is not a box‑checking exercise; it is a lifeline that connects clinical expertise to patient understanding, ensuring safety and reinforcing trust. Each time a provider presumes “the patient knows” without verifying, or treats interpreter services as optional, the risk of error balloons. Conversely, when communication is intentional—assessing needs, deploying resources, confirming comprehension, and documenting diligently—hospitals fireproof themselves against common sources of adverse events and malpractice claims.

8. EvaluCare: A Partner in Communication Compliance Evalution

EvaluCare (EvaluCare.net) is a specialized clinical review service that partners with patients, families, and attorneys to assess compliance with Joint Commission standards, including PC.02.01.21. Here’s how EvaluCare helps stakeholders:

For Families & Patients: Expert Opinion in Grievances and Lawsuits

• Independent Case Review: If a family suspects that communication failures led to harm, such as a missed cancer diagnosis, medication error, or surgical complication, EvaluCare will review records and point out deficiencies. They assess whether communication met PC.02.01.21 and identify where breakdowns occurred.

• Patient Advocacy: By objectively evaluating records, EvaluCare can also uncover systemic issues, such as absence of interpreter services or missing consent forms, that help families understand what went wrong and manage direct settlements.

  
  

For Attorneys: Strengthening Malpractice Cases

• Document Analysis:Attorneys use EvaluCare’s nuanced insights to bolster claims. For example, in Martinez v. Regional Medical Center, an EvaluCare review could show exactly where interpreter services were bypassed, linking that to breach of PC.02.01.21 and the resulting complications.

• Benchmarking Against Standards: EvaluCare’s reviewers can compare the hospital’s practices to national benchmarks.

• Settlement & Trial Strategy: Armed with data on how local hospital performance deviates from standard, attorneys can negotiate from a position of strength, sometimes avoiding protracted trials. When cases do go to court, EvaluCare experts provide credible analysis.

Learn more at EvaluCare.net:🔗 https://www.EvaluCare.net

References (Selected):

1. The Joint Commission. Comprehensive Accreditation Manual for Hospitals (CAMH), Provision of Care Chapter—PC.02.01.21.

2. Martinez v. Regional Medical Center, No. 2:17‑cv‑555 (E.D. Ca. 2018).

3. Greene v. City Surgical Hospital, 430 F. Supp. 3d 123 (S.D. Ohi. 2020).

4. Agency for Healthcare Research and Quality (AHRQ). Health Literacy Universal Precautions Toolkit.

5. Levine DM, Landon BE, Linder JA. Trends in Patient‑Reported Experience and Clinical Outcomes in English versus Non‑English‑Proficient Patients. JAMA Intern Med. 2019;179(1):47–53.

6. Divine HR, Lin SY. Interpreters and Medical Malpractice. J Gen Intern Med. 2018;33(1):23–28.

7.  EvaluCare. Communication Standards Audit Module, 2024 Edition. (Internal Quality Improvement Reference.)