Practice Management

Communication tools improve patient experience and satisfaction


 

 

How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”1 a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”

“Studies2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.

Dr. Vincent Velez
Dr. Vincent Velez
In an effort to improve communication among clinicians and patients, the Cleveland Clinic’s Center for Excellence in Healthcare Communication (CEHC) created the Relationship Establishment, Development and Engagement (REDE) model. Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC, said the model is based on decades of studies on health care communication.

“It places a special focus on empathy in relationships, and in our case, the provider-patient relationship rather than patient-centered care. The former acknowledges that the thoughts and feelings in both sides of a relationship are important. We know that clinicians, too, can suffer as a result of the care they provide,” Dr. Velez wrote in “Communication the Cleveland Way.”1

“Healthy relationships are based on balance and mutual respect,” Dr Velez said. “Courses made a strong point to practice empathy in order to teach empathy. Clinician participants were gifted with a safe space, an opportunity to share their own skills and expertise, and a chance to be appreciated for what they already do effectively. Most of all, activities were designed to be fun and engaging.” For example, CEHC encouraged and fostered an attitude of exploration, experimentation, and adventure. Various warm-up activities effectively helped the participants enter a more playful space and get into character portrayal.

Dr. Velez credits the CEHC model’s sustainability and success to the early realization that an appreciative approach is effective. In a study3 about the strategy, hospital-employed attending physicians participated in the 8-hour experiential communication skills training course on REDE. The study compared approximately 1,500 “intervention” physicians who attended and 1,900 “nonintervention” physicians who did not attend.

Following the course, scores for physician communication and respect were higher for intervention physicians. Furthermore, physicians showed significant improvement in self-perceptions of empathy and burnout. Some of these gains were sustained for at least 3 months. “This is especially important because in the current health care climate, physicians experience increased burnout,” Dr. Velez notes.
 

How it works

Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”

Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”

Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”

One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
 

Study focuses on comportment and communication

In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.

To perform the study,4 chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.

Dr. Susrutha Kotwal
Dr. Susrutha Kotwal
The most frequently observed behaviors were physicians washing their hands after leaving the patient’s room in 170 (94%) of the encounters and smiling (83%), according to the study’s results. Behaviors that were observed with the least regularity included using an empathic statement (26% of encounters), and employing teach back (13% of encounters). “Teach back” refers to asking patients what they have learned during their visit. They use their own words to explain what they should know about their health, or what they need to do to get better. A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients’ personal histories and their interests.

Noteworthy is the fact that the distribution of HMCCOT scores were similar when analyzed by age, gender, race, amount of clinical experience, the hospitalist’s clinical workload, hospital, or time spent observing the hospitalist. But the distribution of HMCCOT scores was quite different in new patient encounters, compared with follow-ups (68.1% versus 39.7%). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes versus 8.7 minutes). The physicians’ HMCCOT scores were also associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might also translate into enhanced patient satisfaction.

As a result of the study, a comportment and communication tool was established and validated by following clinically excellent hospitalists at the bedside. “Even among clinically respected hospitalists, the results reveal that there is wide variability in behaviors and communication practices at the bedside,” Dr. Kotwal said.
 

Employing the tool

Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.

A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”

Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.5

The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
 

The effectiveness of care team rounds at the bedside

Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.

Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.

Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.

“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”

Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.

Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.

Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”

The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.

Karen Appold is a medical writer in Pennsylvania.

References

1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.

2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.

3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.

4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.

5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.

6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.

 

Bonus Content

Clinicians wary of course's worthiness

Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.4 “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”

Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”

Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
 

Why empathy is preferred over patient-centered care

The Cleveland Clinic intentionally puts a focus on relationship-centered care.

“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”

Dr. Kathleen Neuendorf
Dr. Kathleen Neuendorf
The development of a relationship between the patient and the physician has benefits for the physician, such as decreased rates of burnout, as well as better health outcomes for the patient, according to the results of several studies.3,5 Given these benefits, in 2014, two physicians advocated for a Quadruple Aim to replace the standard Triple Aim.6 “The Quadruple Aim recognizes that improving health care providers’ work life is imperative in keeping health care functioning,” Dr. Neuendorf said.

The Cleveland Clinic’s Relationship Establishment, Development and Engagement (REDE) course helps clinicians to see the individual that exists beyond a diagnosis. “Having empathy, or putting yourself in the other person’s shoes, is a key step in that process,” Dr. Neuendorf said. “Once a physician understands the patient’s perspective, the treatment for the diagnosis is more meaningful to both the patient and physician. Finding meaning in their work addresses the Quadruple Aim.”
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