Results Oriented
Communication
Regina A. Casey, BSN, MSN, JD, CHC
Shareholder, Wroten & Associates
Marilynn W. Allemann, L.C.S.W., CPC
Owner/President Masters Executive Coaching
Georgia McCullough, RN, JD, CPHRM
Clinical Risk Manager, MemorialCare Health Services
Debi Witt, MBA, MHA, NHA
Director of California Field Operations, Golden Living
“The Greatest Problem In
Communication Is The Illusion That It
Has Been Accomplished.”
-- George Bernard Shaw
Styles of Communication
• Aggressive
• Passive
• Assertive
“When The Eyes Say One Thing, And
The Tongue Another, A Practiced Man
Relies On The Language Of The
First.”
-- Ralph Waldo Emerson
Methods Of Communication
• VERBAL: Speaking, the words we choose and how we
say them, tone of voice, intonation and volume.
• NON-VERBAL:
– Written: Electronic/email/texting.
– Body Language: Posture, gestures, facial expressions,
eye contact, positioning of arms and legs, and spatial
distance.
“If We Were Supposed To Talk More
Than We Listen, We Would Have Two
Mouths And One Ear.”
--Mark Twain
Listening - A Key To Effective
Communication
• PASSIVE LISTENING:
The basic level of listening.
• EVALUATIVE LISTENING:
Most of us do this.
• INTENTIONAL/ACTIVE LISTENING:
The most sophisticated level.
Case Study
• 86 year old female moves into assisted living facility, Shady Place
• Resident is wheelchair bound due to left sided weakness from a
stroke and self-propels her wheelchair around facility
• Mentally competent and capable of making own healthcare
decisions
• Resident is a smoker, no documentation of smoking assessment in
chart, but considered safe smoker by staff
• Spends every afternoon on patio in designated smoking area
• Shady Place does not have a written policy or procedure regarding
resident smoking nor uses a smoking contract
Facts of the Case
• Resident living at the facility for one year.
• Resident was alone on the patio and catches on fire.
• Another resident, who was in his room, smelled smoke, called for
help and went to the patio to assist.
• Tried to use the hose to put out fire but it did not reach.
• As resident was engulfed in flames she cried out “Help me! I am
going to die!”
• The daughter arrives at the facility and sees Mom being
transferred to a gurney to be taken to the hospital, where she dies.
Add Video
Scenario 1
What was wrong with this
scenario?
• Stop talking
First Listen
• Eye contact
• Don’t interrupt
• If you’re thinking about
what you’re going to
say, you aren’t listening
How to Respond
The right way…
• "I appreciate your
feelings."
• "This situation must be
very difficult."
• " I am so sorry that your
are going through this."
Not the right way
Human Release
• Listen
– without judgment,
– without apologizing,
– with compassionate
acknowledgment often
provides some measure of
catharsis and can diffuse
frustration and anger.
When Unexpected
Events Happen
• Using the Human Touch to
Avoid Litigation
Add Video
Scenario 2
Investigation
• Administrator needs to conduct/oversee an
investigation
• Interviews with residents, employees, family
may be conducted by the Administrator or
other assigned person(s)
• Root cause analysis
•
•
•
•
When Do You Investigate
Death
Missing resident
Abuse/neglect allegations
Serious accidental injury resulting from a facility
practice, action/inaction by staff, or circumstances
w/in the facility
• Hospitalization resulting from a facility practice,
action/inaction by staff, or circumstances w/in the
facility
• Exploitation allegations
Proactive Communication
• Meet EMTs at the door and prepare them for
anything unusual regarding the patient
• Contact ER staff and provide details or history
regarding patient (behaviors, wounds,
bruising, etc.)
• Involve the attending physician
Why Investigate?
• Statutory duty to investigate, both federal and
state
• Part of Quality Assurance Process to improve
quality of care
• Preserve evidence to use in defense if law suit
is filed
• Federal Law
Investigations
– Legal obligation to report under 42 CFR § 483.13
(c)(2)
– Legal obligation to investigate allegations of
neglect or abuse under 42 CFR § 483.13 (c)(3)
• State Law
– Title 22 CCR § 80061-SNF
– Title 22 CCR § 87211-RCFE
Investigation
• The facility must have evidence that all
alleged violations are thoroughly
investigated, and must prevent further
potential abuse while the investigation is
in progress.
Investigation
• Facility must attempt to identify cause of
injury
• Document its investigation
• Maintain its records in a way that will
enable third parties to review what the
facility has done or not done to
investigate the alleged abuse
Facts of the Case
The Investigation revealed:
• The outside video camera, which allows staff to monitor this area,
was broken.
• Incident occurred during lunch time, so staff was busy escorting
residents to the dining room – no staff member was on patio at the
time of the incident.
• Several residents interviewed report she frequently would take cat
naps on the patio with a lit cigarette.
• Staff reported finding holes in the Resident’s clothing and the
cushion of her wheelchair, presumably from ash or dropped
cigarettes.
Scenario 3
Disclosure Policy and Procedure:
Step One
• Legal: Triage and Assessment
– When it’s time to call Legal
– Investigation and Analysis of Risk and Value
University of Michigan
• Disclosure program
– Emphasis change from “Deny & Defend” to full disclosure
– Utilizes ombudsman mediator
• Claims
– 262 claims pending in 2001 (new program begins)
– 104 claims pending in 2006
– 100 claims pending in 2011 despite expanded practices
• Claim closure time reduced by half
• Loss rate reduced by third
Guarding Your Documents
• Incident Reports / Photos / Witness Statements
– The relevant inquiry is whether or not the document derives from an
investigation into the quality of care or evaluation thereof by medical
staff. Santa Rosa Memorial Hospital v. Superior Court (1985) 174 Cal.
App. 3d 711, (1985)
– "Nothing in section 1157(a) limits the privilege to records that are
generated by a medical staff committee, and nothing in the statute
supports the suggestion that materials submitted to a committee for
review are not protected "records" of the committee.” Alexander v.
Superior Court 5 Cal. 4th 1218. (1993) (Overruled on other grounds).
Incident Reports / Witness Statements /
Photographs
 Witness should report event to a CQI committee member.
 Witness should include factual information only in the incident report.
 As part of ongoing analysis, CQI member should describe the incident and include any other
information that might be helpful, including:
 Evaluation of the witness' actions.
 Evaluation of responsible party's actions.
 Analysis of how this incident may be related to other incidents, etc.
 CQI member’s report should be reviewed and discussed by CQI committee.
 CQI committee members should be free to add more comments to the incident report, if necessary.
 Once the entire committee has had an opportunity to review and discuss the incident report and
add any comments, each committee member should sign the report.
 The report should be presented at the next QA Committee Meeting.
Disclosure Record
• Maintain separate disclosure file as part of
Quality Assurance Process
• Document
– Meetings and discussions
– Patient updates to family/patient
– Objective
– Facts Only! No conjecture, blame, accusations
Disclosure
• Disclosure
– communication of information regarding the results of a
diagnostic test or medical treatment.
– Factual
– Not an Opinion
– Not an Apology
• Adverse Event
– a negative result stemming from a diagnostic test or medical
treatment.
• Unanticipated Outcome
– a result that differs significantly from what was anticipated
to be the result of a treatment.
Disclosure
Policy and Procedure
• What should I disclose?
– Facts not opinion
• When should I disclose?
– As soon as possible
– Set expectations for more information as
investigation proceeds
Provide Information
• Results of investigation
• Not peer review or employee discipline
• Establish contact for ongoing communication
Disclosure Policy and Procedure:
Step Two
• Engage Patient/Family and Share
Information
– Just the facts ma’am!
– use Ombudsman as mediator as needed
Disclosure Policy and Procedure:
Step Three
• Mistake and Injury determined
– Engage educational opportunities
– Engage clinical quality improvement
now what?
Scenario 4
When & How to Say
I’m Sorry
Two Categories of Apology
• An expression of sympathy or remorse without
an admission of fault, mistake or error causing an
injury suffered by a patient ("I'm sorry that you
are hurt.") and;
• An expression of sympathy or remorse with an
admission of fault, mistake or error causing an
injury suffered by a patient ("I'm sorry that what I
did caused your injury.”
Historical Perspective
I’m Sorry Laws
• 1999 Institute of Medicine report: To Err is Human
• 2001 JCAHO releases standard re: disclosure
• 2001 University of Michigan
– “I’m sorry” and transparency becomes policy
– A decade of success in reducing litigation
State Review of Admissibility
• Washington
– Statements or benevolent gestures not admissible
– Admissions of fault are admissible
• Oregon
– Any expression of regret/apology not admissible
– Admissions of fault may be admissible
• California
– Statements or benevolent gestures not admissible
– Admissions of fault may be admissible
• Nevada
• Idaho
– Statements of sympathy/apology/benevolence/fault
– Not admissible
• Montana
– Statements or benevolent gestures not admissible
– Admissions of fault may be admissible
Apology in Court
• “I would never introduce a doctor's
apology in court. It is my job to make a
doctor look bad in front of a jury, and
telling the jury the doctor apologized and
tried to do the right thing kills my case.”
President of South Carolina's Trial Lawyers Association
http://www.sorryworks.net
“Mistakes are an inevitable part of everyone’s
life. They happen; they hurt—ourselves and
others. They demonstrate our fallibility.
Shown our mistake and forgiven them, we can
grow, perhaps in some small way become
better people. Mistakes, understood this way,
are a process, a way we connect with one
another and with our deepest selves.”
-David Hilfiker, M.D.
Mistakes
Jury Opinions
• Forgive providers who:
– Try their hardest
– Cared about the patient
– Honest explanation
Summary of Communication Tips
• Always maintain your professionalism within the confines of your role
• Follow the policies and procedures in your organization
• Do not avoid speaking with family, silence interpreted as insensitivity, lack of
concern or hiding something
• Be empathic and sincere
• Explore the issue/event prior to your conversations whenever possible
• It’s not personal. Don’t take the other person’s reaction or anger personally
• Always speak in a non-threatening, calm manner
Summary of Communication Tips
• Engage with person by making eye contact and positive body language
• Be aware of your “non-verbal” cues
• Keep client/family informed and updated
• Give the other person a chance to speak and actively listen
• Suspend judgment and try to see things from their perspective
• Use inquiry
• Ask for clarification and summarize what you hear
Summary of Communication Tips
• Avoid making excuses - You don’t have to have all the answers.
• Look for alternative explanations (increases empathy and
decreases judgment)
• Pay attention to and validate the person’s feelings/frustration
• Apologize, sincerely without accepting or assigning blame