Improving Communication Skills at a Large Academic Medical Center: Cleveland Clinic s Experience

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1 Timothy Gilligan, MD, MS Co-Director Center for Excellence in Healthcare Communication Cleveland Clinic Improving Communication Skills at a Large Academic Medical Center: Cleveland Clinic s Experience

2 Typical medical questions What s the best treatment for a heart attack? Which drugs are most effective for metastatic lung cancer? For good risk metastatic testis cancer, is four cycles of BEP chemotherapy better than three?

3 Key communication questions How do you make someone feel important? If a patient demands something inappropriate, how can you form a strong relationship without giving it to him? What s the best way to give someone terrible news? What is the most effective way to ensure adherence to a treatment plan? What is the most effective way to obtain informed consent?

4 Key communication questions What should you do if a patient starts to cry? Or gets angry? What if a terminally ill patient asks Am I going to die? How can you show someone that you care?

5 Why should we care about communication skills?

6 Effective Communication Improves patient satisfaction Like et al., 1987; Kaplan et al., 1989; Ong et al., 1995; Weinman et al., 1998 Decreases patient emotional stress Roter, 1995 Improves treatment adherence/compliance DiMatteo et al., 1993; Squier et al., 1990; Brashers et al., 2000; Ciechanowski et al., 2001 Improves health outcomes Woolley et al., 1978; Patrick et al., 1983; Stewart et al., 1995 Reduces medical errors and malpractice Levinson et al., 1997; Lester et al., 1993; Beckman et al., 1994; Sutcliffe et al., 2004 Improves physician satisfaction Suchman et al., 1993,Educ for Health, 2004

7 Communication skills challenges

8 Communication skills challenges according The New Yorker

9 It must be for you my people love me.

10 It s the only treatment option he has under his current health plan.

11 Well, right now I m feeling a little uncomfortable

12

13 Don t freak out it s just a save-the-date.

14

15 So what am I doing here knighting, beheading, or what?

16 It s a simple stress test I do your blood work, send it to the lab, and never get back to you with the results.

17 What communication skills do clinicians need to be able to implement? How to connect with other human beings How to listen without controlling the conversation How to recognize, identify and respond to emotion How to respond constructively to difference, disagreement and conflict How to communicate in such a way that the listener understands and remembers

18 Benefits of better communication skills Improved medical outcomes Improved patient adherence Improved patient safety Improved patient satisfaction Improved physician satisfaction Reduced risk of malpractice litigation

19 HCAHPS & CG-CAHPS

20 Increasing accountability

21 HCAHPS Doctor Communication During this hospital stay how often did doctors treat you with courtesy and respect? how often did doctors listen carefully to you? how often did doctors explain things in a way you could understand?

22 MD Communication Domains of negative comments in 2012 Complaint 6% Others 6% Discharge Behavior 4% 3% Skill 2% Access / Time 34% Listening 6% Explain 18% Coord /Plan of Care 21%

23 What have we done at Cleveland Clinic? 3-4 years ago, surveyed the current environment of communication in healthcare Reviewed the published literature, visited other medical institutions and consulted experts in the field Interviewed our top performers Hired AACH to train a group of 5 physicians in communication and facilitation skills Developed a one-day (7 hour) course Brought in outside experts to help us grow our skills

24 Communication Curriculum Foundations in Healthcare Communicaiton (FHC) Advanced Courses Center for Excellence in Healthcare Communication (CEHC) Coaching Faculty Development Train the Trainer Program Research

25 Evolution Beginning (late 2011) FHC one day a month Now 6-7 times a month

26 Evolution Beginning FHC one day a month 5 MD facilitators Now 6-7 times a month 23 MDs, 6 PhDs/CNPs

27 Evolution Beginning FHC one day a month 5 MD facilitators Elective Now 6-7 times a month 23 MDs, 6 PhDs/CNPs Mandatory new staff

28 Evolution Beginning FHC one day a month 5 MD facilitators Elective External TTT Now 6-7 times a month 23 MDs, 6 PhDs/CNPs Mandatory for new staff Internal TTT program

29 Evolution Beginning FHC one day a month 5 MD facilitators Elective External TTT ~50 MDs through first 3-4 months Now 6-7 times a month 23 MDs, 6 PhDs/CNPs Mandatory new staff Internal TTT program >700 MDs trained, long wait list

30 Evolution Beginning FHC one day a month 5 MD facilitators Elective External TTT ~50 MDs through first 3-4 months Started with Four Habit model Now 6-7 times a month 23 MDs, 6 PhDs/CNPs Mandatory new staff Internal TTT program >700 MDs trained, long wait list Designed new model (REDE)

31 Structure of FHC Course 4 key skills presented Brief didactic demonstration skills practice Discussion of difficult cases from the participant s practices followed by skills practice exercises Each session has 8-10 participants, is taught by two facilitators and utilizes two standardized patients

32 Key strategies Not about hugging Doc to Doc Safe setting with 8 to 10 participants Focused on skills practice Let MDs bring their own cases that haunt them Dedication to model of supportive facilitation Surgeons represented among facilitators Leadership support verbiage, time This is an investment in our staff

33 Facilitation, skills practice, small groups Adult learners remember 10% of lectures Re-enforcing effective behaviors results in more behavior change than criticizing ineffective behaviors If you want to be able to re-enforce success, it helps if you prepare the learner to succeed Treat clinicians the way we want them to treat patients Increase buy-in by having learner identify goals Having the learner discover something for herself is more effective than telling it to her.

34 Most communication skills problems fit in one of a few categories Failure to express empathy effectively Allowing unnecessary conflict to develop Talking too much Listening ineffectively Communicating in a way that does not result in increased patient understanding Not allowing the patient to participate in setting the agenda and negotiating a plan of care

35

36 Our Data

37 Doctor Communication Main Campus Overall Source: OPE Database Date of data extract: 11/16/12

38 HCAHPS - Dr. Communication

39 Outpatient Survey

40 Don t forget that this is about culture change, and therefore: You will encounter resistance Progress will be slow You will need to cultivate internal and external allies Consistent reinforcement will be needed Can only be effective if part of a multi-pronged strategy

41 Key qualities/capacities to cultivate Curiosity Reflective practice Openness Empathy Respect

42 Key unanswered questions How do we reliably measure a clinician s communication skills? How do we reliably measure the impact of improving communication skills?

43

44

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