Improving Communication Skills at a Large Academic Medical Center: Cleveland Clinic's Experience - Timothy Gilligan, MD, MS Co-Director Center for ...
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Improving Communication
Skills at a Large Academic
Medical Center:
Cleveland Clinic’s Experience
Timothy Gilligan, MD, MS
Co-Director
Center for Excellence in Healthcare Communication
Cleveland Clinic
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?
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?
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?
Why should we care about communication skills?
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
Communication skills challenges …
Communication skills challenges … according The New Yorker
“It must be for you – my people love me.”
“It’s the only treatment option he has under his current health plan.”
“Well, right now I’m feeling a little uncomfortable”
“Don’t freak out – it’s just a save-the-date.”
“So what am I doing here – knighting, beheading, or what?”
“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.”
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
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
HCAHPS & CG-CAHPS
Increasing accountability
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?
MD Communication
Domains of negative comments in 2012
DischargeBehavior Skill
4% 3% 2%
Others
6%
Complaint Access / Time
6% 34%
Listening
6%
Explain
18%
Coord /Plan of Care
21%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
Foundations in
Healthcare
Communicaiton
(FHC)
Communication
Curriculum
Advanced Courses
Coaching
Center for Excellence
in Healthcare
Communication
(CEHC)
Faculty Train the Trainer
Development Program
ResearchEvolution Beginning (late 2011) Now • FHC one day a month • 6-7 times a month
Evolution Beginning Now • FHC one day a month • 6-7 times a month • 5 MD facilitators • 23 MDs, 6 PhDs/CNPs
Evolution Beginning Now • FHC one day a month • 6-7 times a month • 5 MD facilitators • 23 MDs, 6 PhDs/CNPs • Elective • Mandatory new staff
Evolution Beginning Now • FHC one day a month • 6-7 times a month • 5 MD facilitators • 23 MDs, 6 PhDs/CNPs • Elective • Mandatory for new staff • External TTT • Internal TTT program
Evolution Beginning Now • FHC one day a month • 6-7 times a month • 5 MD facilitators • 23 MDs, 6 PhDs/CNPs • Elective • Mandatory new staff • External TTT • Internal TTT program • ~50 MDs through first 3- • >700 MDs trained, long 4 months wait list
Evolution Beginning Now • FHC one day a month • 6-7 times a month • 5 MD facilitators • 23 MDs, 6 PhDs/CNPs • Elective • Mandatory new staff • External TTT • Internal TTT program • ~50 MDs through first 3-4 • >700 MDs trained, long months wait list • Started with Four Habit • Designed new model model (REDE)
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
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 staffFacilitation, 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.
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
Our Data
Doctor Communication Main Campus Overall Source: OPE Database Date of data extract: 11/16/12
HCAHPS - Dr. Communication
Outpatient Survey
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
Key qualities/capacities to cultivate • Curiosity • Reflective practice • Openness • Empathy • Respect
Key unanswered questions • How do we reliably measure a clinician’s communication skills? • How do we reliably measure the impact of improving communication skills?
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