Patient Experience and Relationship Centered Communication

Patient Experience and Relationship Centered

Communication

Patient Experience and Relationship Centered

Communication

Josh Miller, DO, FACPCleveland Clinic

October 3, 2013

Picture of an angry doc. Picture of an angry doc. “THESE PATIENT EXPERIENCE SCORES ARE BOGUS. I HAVE A

WONDERFUL BEDSIDE MANNER!!”

“THESE PATIENT EXPERIENCE SCORES ARE BOGUS. I HAVE A

WONDERFUL BEDSIDE MANNER!!”

“Dr. X was rude and treated me like I was

stupid. I actually cried in the office.”

“Dr. X was rude and treated me like I was

stupid. I actually cried in the office.”

Today’s ObjectivesToday’s Objectives

• Patient Experience and Healthcare Reform

• The Clinical and Business effects of Patient Experience

• Relationship Centered Communication improves patient and physician experience

The National PictureThe National Picture

• The Affordable Care Act

Value = Quality / Cost

• CMS uses the CAHPS surveys for standardization of patient experience

What is CAHPS?

Consumer Assessment of Healthcare Providers and Systems

What is CAHPS?

Consumer Assessment of Healthcare Providers and Systems

• Funded by U.S. Department of HHS

• Promotes assessment of patients’ experiences with health care

• Program Goals

- Develop standardized surveys- Publicize & Compare results

CAHPS SurveysCAHPS Surveys

Environment SurveyHospital HCAHPS

Home Health HH-CAHPS

Health Insurance Health Plan CAHPS

In-Center Hemodialysis ICH CAHPS

Nursing Home Nursing Home CAHPS

Medical Practice CG-CAHPS

CAHPS BackgroundCAHPS Background

CMS CAHPS Goals

Allow objective comparison on topics important to consumers

Use public reporting to create an incentive to improve quality of care

Enhance accountability by increasing transparency

HCAHPSHospital Consumer Assessment of

Healthcare Providers & Systems

HCAHPSHospital Consumer Assessment of

Healthcare Providers & Systems

• First national and standardized report of hospitalized patient experiences

• Publically reported by Medicare in 2008

• Survey assessment areas:Doctor Communication Nurse Communication

Pain Management Staff Response (Call light, bathroom)

Medication Communication Discharge Communication

Cleanliness Quiet at Night

Hospital Rating Hospital Recommendation

Value Based PurchasingValue Based Purchasing

Beginning in FY 2013,

up to 1% of each hospital’s CMS

acute care reimbursement at risk

partially based on HCAHPS

survey performance

Transparency of ResultsTransparency of Results

• Hospital survey scores are published to Medicare’s hospital compare website and updated quarterly

• Game Changer in 2008• www.medicare.gov/hospitalcompare

What’s Driving CG-CAHPS?What’s Driving CG-CAHPS?

Affordable Care Act

Population Management

Greater Transparency

Greater Accountability

A new model of health care delivery & financing

Timeline for CG-CAHPSTimeline for CG-CAHPS

• 2014- 2015 Practice level only

• 2016 Pay for performance (proposed)

• 2017 All physicians use CG-CAPHS

2014 2015 2016 2017

CG CAHPS Survey DomainsCG CAHPS Survey Domains

• Access to Care

• Doctor

• Front Desk

• Coordination of Care

Why should you improve your patient experience?Why should you improve your patient experience?

Why Should We Pay Attention to Patient Experience?

Why Should We Pay Attention to Patient Experience?

• Patient Experience: a component of certification and compensation

- American Board of Medical Specialties MOC exams include core CG-CAHPS items

- Private and public payers incorporating CG-CAHPS into their compensation structures

- Pay attention now or pay later

RWJ Foundation; Good for Health, Good for Business, The case for Measuring Patient Experience 0f care

Malpractice LitigationMalpractice Litigation

• 8% of docs account for over 85% of claim payouts

• With every drop along a 5 point scale from very good to very poor, there is an increased likelihood of being named in a malpractice suit by 21.7%

Fullam et al. Medical Care 47 (5)

• The most important factor in predicting who will sue…

The quality of the relationship between the patient and doctor

Medical Economics, July 2003

The Clinical and Business Benefits of Patient Experience (PE)


• A patient experience-centered practice is linked to lower physician turnover and greater employee engagement

• Communication and Relationship quality is a major predictor of patient loyalty

• Patients are 3 times more likely to leave a practice that they report poor quality relationships with their physician

Safran DG et al. Journal of Family

Practice; 2001 50 (2)

“People place more importance on

doctors’ interpersonal skills than their

medical judgment, and doctors failings in

these areas are the overwhelming factor

that drives patients to switch doctors.”

- The Wall Street Journal 2004



• Good patient experience has well documented relationship to clinical quality

• Patients with better care experiences have better health outcomes- Research shows better sugar control with

better provider-patient relationship*- Good outpatient experiences mediate poor

inpatient experiences*Robert Woods Johnson, The

Case for Measuring patient experience

Patients are more engaged and adherent

Patients are more engaged and adherent

- Adherence rates were 2.6 times higher among primary care patients whose providers had “whole person” knowledge of them (95%ile) compared to patients of providers without that familiarity.

Safran DG et al. Journal of Family Practice 1998; 47

TransparencyTransparency

Physician TransparencyPhysician Transparency

“In accordance with section 10331 of the Affordable Care Act, we intend to utilize Physician Compare to publicly report physician performance results.”

So Much of Patient and Physician Experience is Based

on Communication

So Much of Patient and Physician Experience is Based

on Communication

The Chasm for Physician Excellence

The Chasm for Physician Excellence

• 74% of patients are interrupted by physicians giving the initial history

• 91% of patients did not participate in decisions regarding treatment plans

JAMA 1999 281; 283-287;

JAMA 1999 282:2313-2320

Physician Communication When Prescribing Medications

Physician Communication When Prescribing Medications

- 26% failed to mention the name of a new medication

- 13% failed to mention the purpose of the medication

- 65% failed to review adverse effects

- 66% failed to tell the patient duration of treatmentArch of Int Med, 2006

Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies between physicians and hospitalized patients. Olsen, DP et al

Patient Knowing Physician NamePatient Knowing Physician Name


Patient Knowing DiagnosisPatient Knowing Diagnosis


Physician Discussing Patient FearsPhysician Discussing Patient Fears

We can do so much better!We can do so much better!

Relationship-Centered Communication (RCC)Relationship-Centered Communication (RCC)

• Communication with the goal of establishing an authentic relationship

- Relationships are therapeutic

- Patient perspective & psychosocial context is vital

- Partnership and shared decision making

CEHC Foundations of Healthcare I

The Healthcare RelationshipThe Healthcare Relationship

Does not require• Friendship• Agreeing on

everything• Unlimited time • Acceptance of

boundary violations• Practicing outside

your scope of practice

Does require• Personal connection• Mutual respect• Genuine interest in the

patient• Shared understanding of

pt. illness• Shared commitment to

patient health & wellbeing

Evidence-Based Patient Outcomes of RCC

Evidence-Based Patient Outcomes of RCC

• Symptom improvement or resolution (2, 16, 23, 54)

• Functional improvement (2, 54)

• Health status & quality of life (38, 44, 55)

• Safety (38, 42)

• Comprehension & recall (20,

38)

• Trust & loyalty (20, 46, 50)

• Sense of self-efficacy & support (16, 20, 56)

• Satisfaction with care (16, 42,

44, 46)

• Treatment adherence (38, 55)

• Self management of chronic disease (20)

• Diagnostic accuracy (40)

• Efficiency (32, 33, 58)

• Self confidence (37)

• Job satisfaction & engagement (45)

• Reduces professional burnout (60)

• Fewer malpractice claims (2, 10, 25, 31)

• Lower cost of providing care (40)

Evidence-Based Physician Outcomes of RCC (continued)

Evidence-Based Physician Outcomes of RCC (continued)

Communication is the most common medical procedure Communication is the most common medical procedure

• Over 200,000 times in an average practice lifetime

• Minimal physician education in communication skills

• Communication skills decline throughout residency

Communication Skills Can Be TaughtCommunication Skills Can Be Taught

• Like medical procedures, skills can be learned

• Must be practiced

• Mastery requires deliberate practice and feedback

Ericsson, 2008

Main Campus Ambulatory Provider Questions

FHCC Physician Participants

Main Campus Ambulatory Provider Questions

FHCC Physician Participants

The REDE Model The REDE Model

Relationship EstablishmentRelationship Establishment

• Review chart in advance• Knock & inquire before entering room, if possible• Greet patient formally with smile & handshake (4, 13)

- No pressure. First impression forms at 39 milliseconds

• Introduce self & team• Position self at patient’s eye level• Recognize & respond to immediate signs of

physical or emotional distress• Make a brief patient-focused social comment,

if appropriate (41)

• Introduce the computer

Collaboratively Set the Agenda Collaboratively Set the Agenda

• Orient patient to elicit a list of presenting concerns (9)

“I’d like to get a list of all the things you’d like to address today…”

• Use an open-ended question to initiate survey

“What concerns brought you in today? Before I ask you some questions that I have, what questions do you have for me?

• Ask “What else?” until all concerns are identified (5, 21)

Beckman & Frankel, 1984; Marvel et al, 1999; Weston, Brown & Stewart, 1989; Langewitz et al, 2002

Are We Opening Pandora’s Box?Are We Opening Pandora’s Box?

• How soon do physicians interrupt patients after asking a question?

18-23 seconds (9, 32)

• How long will a patient talk if uninterrupted?90 seconds (28)

• What are the risks of not allowing patients to tell their story? - Most important concern won’t come out! (11)

- 75% never finish what they were saying (28, 32)

- Difficulty diagnosing 50+% of these cases (61)

• “Patients have too many presenting concerns per visit.

- The average outpatient has 1.7 concerns. (34) - Eliciting a list takes ~ 32 seconds & significantly

reduces frequency of “doorknob” questions. (32, 60)

• “It takes away from vital time for assessing & treating the chief complaint.”

- The first concern usually not main concern. (6, 11) - The “door knob” questions are more common when

an exhaustive list is not elicited early on. (32)

Recognizing & Responding to Fears of the Physician

Recognizing & Responding to Fears of the Physician


Relationship Development“VIEW”VIEW”

Relationship Development“VIEW”VIEW”

• Vital activities “How does it disrupt your daily activity?” or “How

does it impact your functioning?• Ideas “Often people have a sense of what is happening.

What ideas do you have about it?”• Expectations (42)

“What are you hoping we can do for you today?” or “What outcome do you hope to achieve with treatment?”

• Worries (concerns, fears) “What worries you most about it?”


Are we speaking the same the same language?


• How much medical information is forgotten by the end of a visit?

• How much of the information that is remembered is accurate?

40-80%

≤ 50%

• Doctors overestimate patients’ ability to understand medical information

• 88% of the country has intermediate to low health literacy

- Intermediate health literacy = able to determine when to take a medication with food from reading the label


(continued)


(continued)

Engage the RelationshipEngage the Relationship

• Use the process ARIA to:

- Share diagnosis and information

- Collaboratively develop the tx. plan

- Provide closure

Dialogue Yes, Monologue No Dialogue Yes, Monologue No

ASSESS - using open-ended questions

• “What do you know about Diabetes?”

REFLECT – patient meaning & emotion

• “I understand that this worries you”

INFORM – use understandable language & visual aids

• Visual aids ↑ recall by ~ 60% (26)

ASSESS - patient understanding & emotional reaction

ARIA

Collaboratively Develop Treatment Plan


• Describe treatment goals & options

• Elicit patient preferences & integrate into a mutually agreeable plan

• Check for mutual understanding (47, 48)

- “When you go home today, who will you talk to about today’s appointment? What will you say?”

• Confirm patient’s commitment to plan

- “How do you feel about committing to this plan?”

• Elicit potential treatment barriers & need for additional resources


(continued)


(continued)

Provide Closure Provide Closure• Alert patient that the visit is ending

• Affirm patient’s contributions & collaboration during visit- “I’m glad you came in today to get this

taken care of.”

• Arrange follow-up - “Let’s have you follow up again in 6

weeks. Meanwhile, I will let you know your lab results once I receive them.”

• Provide handshake & a personal goodbye with a handoff

• Provide After visit summary with instructions

Provide Closure(continued)

Provide Closure(continued)

Demonstrate EmpathyThroughout the Visit

Demonstrate EmpathyThroughout the Visit

• Shows how much we care

• Verbal and non-verbal

• Declines throughout training or with time & task pressure (15, 24)

• Saves time

- OP medical visits save 2 minutes & surgery visits save 1.5 minutes with use of 1 empathic statement. (30)

In ConclusionIn Conclusion

• Patient experience and health care reform

• Patient experience improves your practice

• Communication improves both the patient and physician experience

At the end of the day, Improving Patient Experience

and Communication is just the right thing to do.

At the end of the day, Improving Patient Experience

and Communication is just the right thing to do.

Documents

Patient Experience and Relationship Centered Communication