Gilligan Talk for Mdacc 2013-05-14

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

Timothy Gilligan, MD, MSCo-DirectorCenter for Excellence in Healthcare CommunicationCleveland Clinic

Typical medical questions

Whats 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?

Whats 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 stressRoter, 1995

Improves treatment adherence/complianceDiMatteo et al., 1993; Squier et al., 1990; Brashers et al., 2000; Ciechanowski et al., 2001

Improves health outcomesWoolley et al., 1978; Patrick et al., 1983; Stewart et al., 1995

Reduces medical errors and malpracticeLevinson et al., 1997; Lester et al., 1993; Beckman et al., 1994; Sutcliffe et al., 2004

Improves physician satisfactionSuchman et al., 1993,Educ for Health, 2004

Communicationskills challenges

Communication skills challenges

according The New Yorker

It must be for you my people love me.

Its the only treatment option he has under his current health plan.

Well, right now Im feeling a little uncomfortable

Dont freak out its just a save-the-date.

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

Its a simple stress test I do your blood work, send it tothe 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

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?

During this hospital stay

HCAHPS Doctor Communication

Access / Time 34%

Coord /Plan of Care 21%

Explain 18%

Listening 6%

Complaint 6%

Others 6%

Discharge 4%

Behavior 3%

Skill 2%

MD CommunicationDomains of negative comments in 2012

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

Center for Excellence in Healthcare

Communication(CEHC)

Communication Curriculum

Foundations in Healthcare

Communicaiton(FHC)

Advanced Courses

Coaching

Faculty Development

Train the Trainer Program

Research

Evolution

Beginning (late 2011) FHC one day a month

Now 6-7 times a month

Evolution

Beginning FHC one day a month 5 MD facilitators

Now 6-7 times a month 23 MDs, 6 PhDs/CNPs

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

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

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

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)

Structure of FHC Course

4 key skills presented

Brief didactic demonstration skills practice

Discussion of difficult cases from the participants 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 staff

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.

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 CommunicationMain Campus Overall

Source: OPE DatabaseDate of data extract: 11/16/12

HCAHPS - Dr. Communication

Outpatient Survey

Dont 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 clinicians communication skills?

How do we reliably measure the impact of improving communication skills?