“The End Is Where We Start From”: Clarity & Orientation as Foundations of Safe Healthcare
"What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from."
— T. S. Eliot, Four Quartets
In modern healthcare’s complex “fourth-quarter,” T. S. Eliot’s words remind us that every conclusion must truly start with understanding. Yet too often, patients and providers find themselves piecing together fragmentary information as if scrambling to read the final chapter of a book they never began. Communication breakdowns and fragmented care are not abstract problems – they have real human costs. Studies consistently show that gaps in orientation (what the patient knows about their care plan) undermine outcomes. For example, a Joint Commission report found that communication failures contributed to 30% of malpractice claims in U.S. hospitals and were linked to 1,744 patient deaths over five years. In one survey, 59% of resident physicians reported that at least one of their patients was harmed during a recent shift due to poor communication (JCI, 2018). As a result, “clarity” is not optional – it’s a form of safety.
Healthcare is inherently fragmented. A hospitalized patient may see multiple teams, and an ambulatory patient may visit a dozen specialists in a year. Every handoff or referral is a potential disconnect. A large Danish cohort study illustrates the stakes: patients with higher care fragmentation (many providers, many transitions) had significantly higher mortality and more potentially inappropriate medications (Prior et al., 2023) Another systematic review of fragmented hospital readmissions found such fragmentation predicts longer hospital stays, higher readmission rates, and increased mortality (Snow et al., 2020). These data underscore the clinical consequences: when no single clinician “owns” the patient’s story, errors multiply. “Care fragmentation produces adverse consequences,” the Danish authors note, including wasted resources, health inequities, and depersonalization, and it is explicitly linked to “more hospital admissions, inappropriate medication use, and increased mortality.”
For patients and families, the human impact is profound. Imagine completing a clinic visit but feeling lost about what comes next: was that lab test done? Who fills the prescription? Confusion can lead to delayed diagnoses or missed treatments. When a patient leaves the hospital without truly understanding discharge instructions, they may skip needed follow-ups or misunderstand medications. Indeed, research confirms this danger: patients with limited understanding often struggle to follow medical advice or even attend their follow-up appointments. One study found that only half of hospitalized patients had adequate health literacy – and those with low health literacy were markedly more likely to return to the emergency room within 90 days of discharge (Shahid et al., 2022) In short, if the patient does not “get it,” the end result is often worse outcomes… be it readmission, progression of illness, or worse.
What We Call the Beginning is Often the End
Every healthcare visit or referral carries the risk of ending a thread rather than advancing a story. When care is “diffusely spread across many physicians,” no single provider has the full narrative of the patient. The patient is left to reassemble the tale from scraps. A Joint Commission (2018) analysis described how a patient must piece together communications of varying quality to assemble a picture of their health status… and that incomplete picture can have serious consequences. For example, poor handoffs between primary care and specialists can mean that vital test results or allergy warnings never make it into the next provider’s notes. Indeed, at least two-thirds of communication errors occur during transitions of care.
Fragmentation is not just inconvenient; it drives clinical risk. When care is disjointed, critical information may fall through the cracks. Consider a patient with multiple chronic diseases: dozens of appointments each year, in different clinics and sometimes different hospitals. A nationwide Danish study of 4.7 million people found that patients with ≥20 healthcare contacts in one year had an incidence rate ratio of 2.83 for receiving an inappropriate medication, and a hazard ratio of 10.8 for mortality, compared to those with no contacts (Prior et al. 2023). In other words, each new referral or test adds complexity and risk unless it is carefully managed and explained.
The systemic result is inequity and inefficiency. Patients who happen to be system-savvy – who “know the unspoken rules,” have help from family, or live near clinics – may scramble through the maze. But the less-advantaged suffer most. A World Health Organization safety brief highlights that “limited health literacy” and “communication breakdown” are key factors leading to preventable patient harm (WHO, 2023). Low-literacy or non-English-speaking patients, in particular, often receive poorer information about their own care, compounding the risk. Fragmentation thus particularly endangers those who are already vulnerable, reinforcing health disparities.
And to Make an End is to Make a Beginning
Every appointment, test, or hospital stay is only as useful as the clarity it delivers for what comes next. The end of one encounter must begin the next step of care. If a patient finishes chemotherapy without understanding the follow-up plan, the cure may slip away. If discharge paperwork lands on the doorstep unread, a short hospital stay can trigger a readmission.
Healthcare leaders have emphasized handoff communication precisely because its failure costs lives. The Joint Commission’s National Patient Safety Goals include strict standards for transition summaries and patient education, yet many gaps remain. In practice, even “thorough” discharge summaries often overwhelm patients. The JCI 2018 guide warns that every patient has different literacy skills; without tailored communication, “substandard communication and mistakes that could have been avoided” become routine. In one survey, nearly three-quarters of adverse events linked to discharge were due to missing or misunderstood information. Real patients have suffered: a missed instruction about wound care can lead to infection; a garbled medication list can cause overdose. Each “end” – discharging a patient, closing a clinic note – must therefore launch a new narrative of care with the patient fully oriented.
Health literacy is central to this transition. If a patient does not understand the “ending,” they cannot start the next chapter effectively. Research confirms that inadequate health literacy is a stronger predictor of poor health than age, income, education, or race. Patients with limited literacy have trouble deciphering prescription labels, grasping medication schedules, or following up on referrals (Shahid et al., 2022) In practice, this means fewer preventive checks and more emergency visits: one study noted that low-literacy patients had higher emergency department use and costs even after accounting for other factors. Importantly, about 43 million Americans have health literacy below the level needed to manage complex care. In effect, each discharge or referral can become a “break in the loop” if patients cannot “find, understand, and use” the information they are given.
The delay caused by confusion can be deadly. Patients who leave a doctor’s office uncertain may postpone seeking help when symptoms worsen. Delayed diagnosis is a known outcome of poor communication: patients with limited understanding often present with more advanced illness and face worse prognoses. This is not abstract: a systematic review found that diagnostic errors occur in 5–20% of physician encounters (WHO, 2023) often fueled by incomplete patient narratives and follow-up plans. On a systems level, the human consequences include not only individual suffering but lost productivity, higher costs, and preventable fatalities; precisely the kind of harm healthcare is pledged to avoid.
We Shall Not Cease from Seeking Clarity
If clarity is safety, how do we ensure every patient starts on firm footing? The answer lies in structured orientation – both by providers and by engaged patients. Clinicians must use plain language, teach-back, and checklists to verify understanding (CDC, 2024) But patients and caregivers can also take practical steps at every stage of care. For example, the CDC recommends encouraging patients to ask questions with open-ended prompts. In a survey of medical encounters, patients who posed questions (especially when invited with “What questions do you have?”) left visits with clearer understanding than those simply asked “Do you have any questions?”. This simple shift – from yes/no to open inquiry – reminds us that communication is two-way.
Patients can likewise prepare before and after visits. Practical orientation strategies include:
Before the appointment: Write down current medications (including over-the-counter drugs), symptoms, and questions. Locate prior test results or notes if available. Consider bringing a family member or friend to help listen and ask questions. Request interpreter services if language or hearing is a barrier. These steps ensure the patient begins the visit with a clear agenda and vital information on hand.
During the appointment: Take notes or ask permission to record key points. If something isn’t clear, ask the provider to “teach-back” – that is, ask you to explain in your own words what to do. Use phrases like “Can you please clarify” or “What should I do if...?” to prompt specifics. Confirm the name and role of each provider and the next steps (e.g. “Who will handle my follow-up care?”). Keeping a simple written or digital log of who said what – even dates of conversations – can bridge future handoffs.
After the appointment: Before leaving, ask for a summary of the visit or discharge instructions in plain language. Schedule follow-up appointments and request test referrals before you go. Review any new prescriptions with the pharmacist. At home, review and organize any printed materials or care plans. If uncertainty remains, call the clinic with clarifying questions or use the patient portal to follow up.
These patient actions mirror evidence-based navigation: they create redundancy and verification so information is not lost. Importantly, they also help patients “arrive where they started and know the place for the first time” – echoing Eliot – by closing the loop of understanding. In practice, studies show that systematic patient navigation interventions can dramatically improve outcomes. For instance, a recent overview of reviews found that patient navigator programs “were shown to expand access to screenings and health services for vulnerable patients” and improve transitional care outcomes including readmissions (Budde et al., 2021). In other words, giving patients support and information at each transition actually reduces the fragmentation risk that otherwise drives harm.
The End of All Our Exploring
The journey through healthcare should not feel like an endless maze with no exit. At every step, patients need orientation so the next chapter can begin safely. Failure to provide clarity is not merely an inconvenience – it is an error of omission that can cause real harm. As the Joint Commission notes, inadequate communication “can lead to malpractice claims, patient harm, and/or death”. The opportunity cost is high: confusing a patient about follow-up can easily lead to a preventable emergency visit or worse.
A compassionate, effective healthcare system must therefore prioritize transparency and continuity as fiercely as it prioritizes treatments. This means training clinicians in health literacy techniques, tracking handoffs, and measuring patient understanding. It also means empowering patients with tools and resources so they can navigate care confidently. Simple systems like written visit summaries, appointment trackers, or support lines can make the difference between a patient feeling lost and a patient feeling secure.
In sum, the evidence is clear: clarity and orientation are not “nice-to-haves.” They are indispensable to safe, effective care. Putting patients and families in the driver’s seat of their health journey dramatically improves outcomes. Services that bring structure to patient navigation exemplify this principle. For example, Storyline Health Navigation uses a clinician-guided framework to organize records and guide patients through each step of care, turning fragmented information into a coherent story. Storyline’s approach is rooted in the same evidence: giving people tools and guidance to understand when and where they are in their care dramatically reduces missed steps and confusion.
Ultimately, the health system must never forget Eliot’s wisdom: each end is a beginning. By starting every interaction (first visit, referral, or discharge) with clear, patient-centered information, we begin safely. In the end, clarity is safety. It ensures that when we close one chapter of care, we have truly set the stage for the next. For healthcare leaders, clinicians, and patients alike, embracing orientation as mandatory rather than optional is how we protect everyone’s health. Tools like Storyline Health Navigation offer a model for making that real: organized, evidence-based support that helps every patient finish the story of their care and know where to start the next one.
Reference List
Eliot, T. S. (1943). Little Gidding. In Four Quartets. Faber and Faber.
CRICO Strategies. (2015). Malpractice risks in communication failures: 2015 annual benchmarking report. The Risk Management Foundation of the Harvard Medical Institutions.
The Joint Commission. (2018). Transitions of care: Handoff communications (Sentinel Event Alert, Issue 58). The Joint Commission.
Prior, A., Laursen, T. M., Fenger-Grøn, M., Larsen, F. B., Pedersen, H. S., & Søndergaard, J. (2023). Care fragmentation and mortality: A nationwide register-based cohort study. BMJ Quality & Safety, 32(3), 197–208. https://doi.org/10.1136/bmjqs-2021-014316
Snow, R., Ambler, G., Burke, S., & Baldwin, H. (2020). Hospital readmissions and care fragmentation: A systematic review. BMC Health Services Research, 20, 444. https://doi.org/10.1186/s12913-020-05424-2
Shahid, R., Thomas, S., & Jani, A. (2022). Health literacy, hospital readmission, and outcomes: A systematic review. Journal of Patient Safety, 18(7), e1180–e1188. https://doi.org/10.1097/PTS.0000000000000943
World Health Organization. (2023). Global patient safety action plan 2021–2030: Towards eliminating avoidable harm in health care. WHO. https://www.who.int/publications/i/item/9789240032705
Centers for Disease Control and Prevention. (2024). Health literacy: Strategies for clear communication. U.S. Department of Health and Human Services. https://www.cdc.gov/healthliteracy
Budde, H., Williams, G. A., & Kluge, H. (2021). Patient navigation and care coordination: An overview of systematic reviews. International Journal of Environmental Research and Public Health, 18(21), 11186. https://doi.org/10.3390/ijerph182111186
