Service Fanatics

by James Merlino

  In initial discussions, Boissy included Timothy Gilligan, a solid tumor oncologist who also had a passion for improving patient communication; V. J. Velez, a hospital medicine physician; David Taylor, an interventional cardiologist; David Vogt, a liver transplant surgeon; Saul Nurko, a nephrologist; and Amy Windover, a clinical psychologist and director of communication skills training at the Cleveland Clinic Lerner College of Medicine. The team members spanned different specialties, both medical and surgical, and had a range of practice experience from 7 to around 30 years. Each member of the team was a busy clinician, and not everyone believed a program was needed or would be successful. In fact, when Boissy recruited training facilitators, she chose several who were well respected within the organization and their fields, despite being unsure if they were interested in communication skills training. Their input was critical to understanding how both supporters and skeptics would receive and respond to the program.

  The team examined various communication models and programs but eventually focused on the Four Habits Model.7 Developed by Richard Frankel and Terry Stein, the Four Habits Model is empirically validated and creates a framework for the clinical encounter, particularly in outpatient settings.

  We hired a physician-trainer from the American Association for Communication in Healthcare (AACH) to train six clinicians to be facilitators, capable of teaching other physicians. Each clinician went through the equivalent of a full week of training, useful to kick off the effort and bond the core team.

  With trained facilitators on board, we evolved from using the Four Habits Model to a model that more closely fit our organization and providers and developed our own custom training program for future facilitators and physician participants.

  We designed a one-day course, Foundations of Healthcare Communication (FHC), to teach physicians the relationship-centered communication skills. A team of 2 trains a group of 8 to 10. The FHC course is learner-centered and focuses on one-on-one interactions and skills practice with standardized patients8 and each other. The complexity of the skills increases throughout the day, and facilitators adjust the training to individual physician needs. Doctors completing the course remark that it’s very applicable to clinical practice, and even the most skeptical walk away with new skills.

  From beginning to end of the daylong sessions, facilitators actively engage in learning opportunities relevant to their participants. A variety of educational strategies are used, including modeling, small- and large-group facilitation, video review, and skills practice with standardized patients and real-life scenarios. The course also leverages peer feedback and self-reflection for the majority of the learning, rather than a prescriptive approach.

  We select new facilitators carefully and deliberately to include an increasing variety of specialties, perspectives, and practice experience. We also consider who might eventually serve as a peer communication skills coach. We learned early that just because someone wants to be a facilitator or people like the person doesn’t mean he or she is right for the role. We often ask a leadership team member to meet with potential facilitators, as well as confer with their chairs and sometimes even their peers.

  Because the stakes are high, the facilitator pool must look like our physician population and reflect our learners. Some respond to a more authoritarian approach, while others prefer more nurturing. Seasoned physician facilitators command respect, while younger staff members have greater flexibility and enthusiasm. When possible, we pair teachers with like specialists—for example, surgeons teaching surgeons. We would never select a pediatrician just out of residency to coach a 20-year veteran cardiac surgeon on ways to improve communication. We’re fairly sure it would be a bad experience for both. Matching peers makes it much more difficult for an experienced clinician to dismiss the training. This was one of the brilliant ideas the team developed and is a critical factor in the program’s success.

  As we proceeded with the FHC course, our team identified important gaps and, as a result, designed and implemented a new proprietary framework, the Relationship: Establishment, Development, and Engagement (REDE) Model of Communication. It focuses explicitly on relationship building, with key components to drive physician engagement and satisfaction, as well as compliance and malpractice risk mitigation. The model recognizes the healthcare relationship as mutually beneficial to both patients and physicians, and knowing there was attention to their needs was critical to physicians. The REDE model encourages empathy throughout the clinical encounter and is flexible for both inpatient and outpatient settings. Mnemonics are employed to improve recall.

  Initially, there was pressure to train every house staff member before tackling the attending staff. Boissy pushed back, contending this was the path of least resistance and would not result in sustained change. She argued that sending trained house staff out with untrained attending staff who didn’t communicate effectively would undo the training. The role models had to be trained first, she maintained. Now, all new attending staff physicians and house staff members go through the one-day communication training as part of onboarding.

  Scholarship demonstrates that good communication between providers and patients improves patient satisfaction,9 patient emotional stress,10 treatment compliance and adherence,11 patient health outcomes,12 medical errors and malpractice,13 and, remarkably, physician satisfaction.14 The inpatient and outpatient communication scores of physicians who have taken FHC have seen significant and sustained improvement.

  Cleveland Clinic is self-insured for malpractice and has a very capable legal defense team, and medical malpractice and risk payout is very low. Physicians with high communication scores have even lower claim and malpractice risk than our overall profile, further supporting the importance of the training.

  The team has also been collecting self-reported quality-of-life data from physicians who have taken the program, and there’s emerging evidence that these scores are improving as well.

  The most validating metric has been anecdotes from physicians who have gone through it. Skeptical and occasionally even hostile physicians have taken the one-day training and emerged as believers. Eric Klein, a seasoned urologist, chair of the Glickman Urological & Kidney Institute, leader in the patient experience, and excellent communicator, called after taking the class and said he had believed going in that there was nothing it could teach him. He was impressed with the depth and thoroughness of the program and immediately sent an e-mail to all institute physicians advising them to complete the course.

  At the 2012 Patient Experience: Empathy & Innovation Summit, Boissy moderated a panel including Edward Benzel, a neurosurgeon, and Thomas Rice, a thoracic surgeon, each with more than 25 years’ experience, that discussed the REDE model and communication training. They described how it changed the way they structure their encounters with patients and made them more efficient and effective.15

  The panel illuminated a very important characteristic of our physician communication training. True to Boissy’s original insistence, the program is not about improving patient perceptions, but rather about building physician skill. We spend enormous resources every year learning how to practice our skills through extensive continuing medical education (CME) coursework. But we spend no time learning ways to improve how we practice medicine. Physicians typically have no formal training in how to interact with patients and generally acquire their personal skills by watching mentors and other physicians. Just like any other medical skill, patient communication and interaction can be taught and learned, and practicing makes us better. We are not just teaching physicians how to communicate better; we are helping them learn better ways to practice. That’s an important differentiator that sets this program apart.

  We Must Help Private Practice Physicians

  In December 2012, we started releasing quarterly HCAHPS physician communication score data to private practice physicians privileged at our community hospitals. All data is unblinded. When we first discussed releasing the data, there
was concern that it would anger the physicians. But this is what patients are saying about them, not what we’re saying about them. It’s really no different than patients airing their gripes on social media. In addition, it’s what physician leadership and management teams are seeing. It seemed only fair to share the data with our private practice physicians rather than talk behind closed doors. We pushed this information to physicians in the community because we know what’s coming in the environment, and providers should not be blindsided once government mandates it. We have an obligation to help physicians who care for our collective patients improve. Surprisingly, there was barely a murmur of dissatisfaction. Many physicians still had no idea this data was collected and wanted information on how to improve.

  We’re answering that call and modifying the program to help private practice physicians. Taking care of patients is a partnership, and we all have responsibility to help each other. The messaging we’ve adopted for our private practice colleagues is that investing in improving communication and relationship skills is right for patients and ourselves and helps us do our jobs more effectively.

  Following the same principle of using peer physicians, we trained two private practice physicians to be physician facilitators. Using them and our staff doctors, we trained several groups of private practice physicians. As far as we know, this was the first time a healthcare system offered daylong physician communication training to private practice physicians. When employed physicians take a day off work, they still get paid. When private practice physicians take a day off, they lose income, so we needed to devise incentives for them to enroll. We’ve offered physicians CME credit and are exploring options such as starting late in the day and running courses in the evening and on weekends. Helping physicians enhance their communication skills will improve patient care, ultimately impacting safety and quality, so we’re determined to make the training readily available to as many community physicians as possible. We are just starting to roll the program out to our community hospitals. The medical executive committee of one of our large community hospitals has suggested the course be mandated as part of its credentialing and privileging process. Our team has worked with a group of private practice physicians to ensure that the content is applicable to their practice environment. Recognizing the importance and impact of improving physician communication skills, The Doctors Company, one of the largest malpractice insurers in the United States, had agreed to offer premium rebates to private practice physicians who take the course.

  Our communication training has been so overwhelmingly successful that we’ve established a Center for Excellence in Healthcare Communication (CEHC). The CEHC offers not only the FHC course but an entire interdisciplinary advanced communication curriculum, led by an intensively trained peer facilitator team. Our elite physician trainers are now sought by other healthcare institutions for training their physicians. One of our team’s greatest accomplishments is creating the facilitator training program led by Amy Windover, which trains physicians from a variety of different medical and surgical specialties, including neurology, hospital medicine, colorectal surgery, interventional cardiology, urology, general surgery, gynecologic surgery, pediatrics, and cardiothoracic surgery. We’ve also trained advanced clinical-care-provider facilitators to lead communication training for their peer groups. The training blends skills, theory, evidence-based literature, and group facilitation. Throughout our facilitator training, we treat our participating colleagues the same way we expect them to treat our patients and families. Windover also holds quarterly faculty meetings to further develop the facilitator skill set and ensure consistency of methods. This training and work is perhaps best summarized by a facilitator who wrote, “This is the best thing, by far, I have done in my entire career.”

  Cosgrove and Hahn, as well as the entire executive team, have gone through the program. Every metric we follow has improved, including HCAHPS, Clinician and Group CAHPS, and patient complaints. But most rewarding are comments from physicians who went into the course unconvinced that it would help and emerged believing that it would make a difference in their practice. Boissy was absolutely right. This is not about improving HCAHPS; this is about creating an experience for our providers that celebrates their expertise, builds their relationships with each other and with patients, and better equips physicians to provide amazing caregiving every time to every patient.

  In summary:

  1. Effective physician communication is a critical component of the patient experience. It impacts not only satisfaction but patient safety and quality of care as well. Most physicians believe they are excellent at patient communication, but the data suggests otherwise. Like a new medical treatment or surgical skill, effective communication skills can be taught and require practice and maintenance for proficiency.

  2. Improving communication skills is not just about improving the patient experience; it is about developing essential physician skills. These are areas of development that physicians do not typically have an opportunity to work on and are skills that are not frequently valued by hospital leaders and healthcare organizations. Physicians are compensated through continuing medical education to drive more efficient, effective, and productive practices. Personal development of critical skills such as relationship building and communication style receives little attention. Recognize that these skills are important for physicians’ professional development as well as their medical skills development.

  3. Disseminating communication data to physicians is a critical first step in improvement so that they understand how they are measured and where they stand with patients. Many physicians have never seen this data and are quick to point out its deficiencies. Recognizing data limitations is important, but directionally, the data is generally accurate. If physicians repeatedly receive low scores, there is likely a problem with how the physician communicates with patients.

  4. The most effective physician communication improvement tactics are those driven by physicians. Improving a physician’s communication skills is very personal behavior change. Having critical conversations with physicians who have been in practice for a long time that what they have been doing may not be as effective as they have always believed is a delicate situation and requires care. To be effective, I believe only respected physician peers can initiate this conversation and get doctors to pay attention. Use physicians to drive behavior change among their physician colleagues.

  5. To improve communication and relationship skills with physicians, peer-based coaching in small-group learning sessions is a more effective tactic than didactic learning. Group participants can be leveraged to help teach their colleagues as they each participate in exercises.

  6. Many physicians have good practices to engage and communicate with patients. Collecting these best practices from physicians in your organization and sharing them with others is a quick way to help others improve their communication abilities and demonstrate that you are benchmarking your own organization to help drive improvement.

  Chapter 12

  Making Patients Our Partners

  If I’m helping to lead the patient experience from the top down, Dave deBronkart is leading it from the bottom up. DeBronkart is a cancer survivor diagnosed with Stage IV renal cell carcinoma in 2007. The disease had metastasized to his lungs and bone, and he was given a median survival time of just 24 weeks. He has an amazing story.1 Seven years later, deBronkart has gone from patient to crusader, working to drive patient empowerment across the world. DeBronkart believes in patients taking more control of their healthcare and advocates a shift in the balance of power from providers to patients. DeBronkart uses the nickname e-Patient Dave, with the e standing for “empowered, equipped, educated, engaged, and expert,” characteristics he believes critical for patients to be successful partners in their healthcare journeys.

  I first met deBronkart at the TEDMED 2012 event in Washington, D.C., when he and I participated in a joint interview, “What Makes a Doctor-Patient Partn
ership Flourish?”2 We were both asked, “Who’s really responsible for your healthcare? Is it you, the patient, or the doctor?” DeBronkart observed, “The vast majority of what people do to take care of themselves and their families is themselves, but I run out of skills and information sometimes, and I go to my doctor, so it really is a partnership.” I agreed, stating that the responsibility for successful patient care belongs to both doctors and patients.

  Only when this partnership is strong can we ensure that providers deliver safe, high-quality care in an environment where patient expectations are fulfilled and patients are satisfied. Patients need to become more involved, ask more questions, and understand what to expect. Patients need to become their own advocates, and if they are incapable or unwilling, family members or friends must step in to help.

  To some patient advocates, this idea is controversial; to others, it’s downright repugnant. They will argue that caregivers have a responsibility to provide knowledge, protection, communication, and education to patients because they simply are not prepared to be equal participants. I don’t completely disagree; the job of healthcare workers, especially doctors and nurses, is to be advocates for their patients, and we are all educators and caregivers. Yet while patients have a distinct disadvantage when it comes to healthcare knowledge, no one knows an individual’s history or body better than the patient.

  But healthcare delivery customarily has been quite unidirectional, an environment in which it is difficult for patients or families to function as successful advocates. Throughout history, physicians were healers, most likely elders, with almost mystical status. Doctors occupied an exalted, even royal, social position and possessed knowledge that was neither questioned nor challenged. Furthermore, hospitals are intimidating and unfamiliar places. Patients are anxious, worried, and, in some cases, terrified about their condition and whether they will survive. They fall into a pervasive submissiveness and become afraid that challenging their healthcare team will be reflected in the treatment they receive. Cleveland Clinic randomly interviewed 1,000 patients from across the United States and found that less than half ask questions and challenge their physicians, and an astounding third of all patients trust everything their doctors tell them. Eight percent said if they disagreed with the doctor, they would find a new one instead of raising a challenge.