Patient Experience and
Relationship Centered
Communication
Josh Miller, DO, FACP
Cleveland Clinic
October 3, 2013
“THESE PATIENT
EXPERIENCE SCORES
ARE BOGUS. I HAVE A
WONDERFUL BEDSIDE
MANNER!!”
Picture of an angry doc.
“Dr. X was rude and
treated me like I was
stupid. I actually
cried in the office.”
Today’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 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
• Funded by U.S. Department of HHS
• Promotes assessment of patients’
experiences with health care
• Program Goals
- Develop standardized surveys
- Publicize & Compare results
CAHPS Surveys
Environment
Survey
Hospital
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 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
HCAHPS
Hospital 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 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 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?
Affordable
Care Act
Population
Management
Greater
Transparency
Greater
Accountability
A new model of health care delivery & financing
Timeline for CG-CAHPS
2014
2015
2016
2017
• 2014- 2015 Practice level only
• 2016 Pay for performance (proposed)
• 2017 All physicians use CG-CAPHS
CG CAHPS Survey Domains
• Access to Care
• Doctor
• Front Desk
• Coordination of Care
Why should you improve
your 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 CGCAHPS 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 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
The Clinical and Business Benefits
of Patient Experience (PE)
• 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
- 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
Transparency
Physician 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
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
- 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
treatment
Arch of Int Med, 2006
Patient Knowing Physician Name
% of Physicians who thought
patients knew their names
% of Patients that correctly identified
physician's name
67%
18%*
0%
20%
40%
60%
80%
Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies
between physicians and hospitalized patients. Olsen, DP et al
Patient Knowing Diagnosis
% of Physicians believe
patients know diagnosis
77%
% of Patients that know
diagnosis
57%
0%
20%
40%
60%
80%
100%
Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies
between physicians and hospitalized patients. Olsen, DP et al
Physician Discussing Patient Fears
% of Physicians stated they
sometimes discussed
patients' fears and anxieties
98%
% of Patients that said
physicians NEVER did this
54%
0%
20%
40%
60%
80%
100%
Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies
between physicians and hospitalized patients. Olsen, DP et al
We can do so much better!
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 Relationship
Does not require
Does require
• Friendship
• Agreeing on
everything
• Unlimited time
• Acceptance of
boundary violations
• Practicing outside
your scope of practice
• 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
• Symptom
improvement or
resolution (2, 16, 23, 54)
• Comprehension & recall
• Functional
improvement (2, 54)
• Sense of self-efficacy &
support (16, 20, 56)
• Health status &
quality of life (38, 44, 55)
• Satisfaction with care (16,
• Safety (38, 42)
(20, 38)
• Trust & loyalty (20, 46, 50)
42, 44, 46)
• Treatment adherence (38,
55)
• Self management of
chronic disease (20)
Evidence-Based Physician Outcomes
of RCC (continued)
• 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)
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 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
The REDE Model
Relationship 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
• 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)
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)
Beckman & Frankel, 1984; Marvel et al, 1999; Weston, Brown & Stewart, 1989; Langewitz et al, 2002
Recognizing & Responding to
Fears of the Physician
•
“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)
The REDE Model
Relationship Development
“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?”
The REDE Model
Are we speaking the same the
same language?
• How much medical information is forgotten by
the end of a visit?
40-80%
• How much of the information that is
remembered is accurate?
≤ 50%
Are we speaking the same the
same language?
(continued)
• 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
Engage the Relationship
• Use the process ARIA to:
- Share diagnosis and information
- Collaboratively develop the tx. plan
- Provide closure
Dialogue Yes, Monologue No
ARIA
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
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?”
Collaboratively Develop
Treatment Plan
(continued)
• Confirm patient’s commitment to plan
- “How do you feel about committing to this
plan?”
• Elicit potential treatment barriers & need for
additional resources
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 Closure
(continued)
• Provide handshake & a personal goodbye
with a handoff
• Provide After visit summary with instructions
Demonstrate Empathy
Throughout 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 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.