Communication the Cleveland Clinic Way Read online

  Praise for

  Communication the Cleveland Clinic Way

  “At our very core, we are people caring for people. In order to excel, we need to make sure our caregivers know how to care. In Communication the Cleveland Clinic Way, Boissy and Gilligan provide an incredible how-to care guide as their team took on the challenge of ensuring empathy in over 5,000 caregivers. This book is really a journey that reveals the pitfalls and pearls of such a monumental undertaking and why every health system needs to do the same.”

  —David Feinberg, MD, MBA, President and CEO, Geisinger Health System

  “Reengaging and enabling physicians in an increasingly challenging work environment, Boissy and Gilligan are spot on. Enhancing communication builds the physician-patient relationship in a way that creates a superior patient experience and a superior physician experience.”

  —Vivian S. Lee, MD, PhD, MBA, CEO, University of Utah Health Care

  “Communicating effectively with patients is not an innate skill, and the emotional detachment we learn in medical training prevents us from building rapport and establishing solid relationships with our patients. Recognizing that there needed to be a better way, this book is a comprehensive road map created by a group of physicians who set out to transform the doctor-patient relationship and build the new gold standard for relationship-centered care. It is a must-read for every clinical provider.

  —James Merlino, MD, President and Chief Medical Officer, Strategic Consulting Division, Press Ganey and author of Service Fanatics

  “Caring for people—body and soul—is the heart of healthcare. Boissy and Gilligan demonstrate how improving communication enables better experiences for patients and for caregivers. Their actionable insight on relationship-centered care is invaluable for achieving cultural transformation in healthcare delivery that supports both professionalism and patient success.”

  —Elizabeth Teisberg, PhD, Professor of Community and Family Medicine, Dartmouth Geisel School of Medicine, and coauthor of Redefining Health Care

  “This invaluable book details the processes that Cleveland Clinic has used to boost its patient experience scores, which are associated with enhanced patient outcomes. Medical centers across the country would be well advised to replicate these programs in service of their patients and their staff.”

  —Calvin Chou, MD, PhD, FAACH, Professor of Clinical Medicine, University of California San Francisco

  “What an inspiring, important, myth-busting book! It shows that human relationships are the real heart of healthcare, and the skill of building those relationships can be trained. Cleveland Clinic knows how.”

  —Geoff Colvin, bestselling author of Talent Is Overrated and Humans Are Underrated

  “This book tells the story of a large and remarkably successful institution-wide program on physician communication skills. Told from a variety of perspectives—including senior executives, physician participants, and educators—it describes the important contributions this program is making to quality, strategy, and the professional meaning and well-being of the physician workforce.

  Beyond the inspiring story, the book offers a wealth of detail on instructional content and design that will be an enormous resource for others seeking to create their own communication programs. And it describes with great clarity the single most essential feature of a successful program: the informal curriculum or learning environment. We see the intentional effort to treat participants with the same kind of respect and engagement that they are being taught to show to patients.”

  —Anthony L. Suchman, MD, MA, Senior Consultant, Relationship Centered Health Care

  “Today, external demands and pressures have left many dedicated clinicians and healthcare providers struggling to find meaning in their work. This essential book, drawing upon a deep understanding of human relationships and educational principles, illuminates a pathway by which those who are involved in patient care can develop more effective and satisfying partnerships with their patients, patients’ families, and colleagues.”

  —Walter F. Baile, MD, Director, Program for Interpersonal Communication and Relationship Enhancement (I*CARE), University of Texas M. D. Anderson Cancer Center

  “Within the context of top-rated clinical and service excellence and the Patients First strategy, leaders at Cleveland Clinic have launched an innovative approach to enhance physicians’ human-centered communication skills to nurture the ongoing development of empathetic and compassionate interactions with the patients in their care. This practical yet profoundly transformational approach provides opportunities where physicians can reflect upon communications with their patients and family members, gain insights from dialogue with peers, and receive coaching and mentoring from experts to enhance and build new competencies. In addition, this program provides opportunities for clinicians to focus upon the ultimate purpose of healing not only the body but also the mind and soul of all in their care. And while doing so, many may find greater insight into their own human experience, build more resilience, and enhance or restore the joy in their professional careers. This book is an invaluable asset for all who strive to achieve a human-centered approach to healthcare and superior patient experience.”

  —Pat Rutherford, MS, RN, Vice President, Institute for Healthcare Improvement

  Copyright © 2016 by Adrienne Boissy and Timothy Gilligan. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

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  ISBN 978-0-07-184534-2

  MHID 0-07-184534-8

  e-ISBN 978-0-07-184535-9

  e-MHID 0-07-184535-6

  R.E.D.E., R.E.D.E. to Communicate, and Communicate with H.E.A.R.T. are trademarks of The Cleveland Clinic Foundation.

  Library of Congress Cataloging-in-Publication Data

  Names: Boissy, Adrienne, editor. | Gilligan, Timothy, editor.

  Title: Communication the Cleveland Clinic way : how to drive a relationship-centered strategy for exceptional patient experience / [edited by] Adrienne Boissy, MD and Timothy Gilligan, MD.

  Description: New York : McGraw-Hill Education, [2016]

  Identifiers: LCCN 2015051012| ISBN 9780071845342 (hardback) | ISBN 0071845348 (hardback)

  Subjects: LCSH: Medical personnel and patient. | Patient-centered health care. | Interpersonal communication. | Physician and patient. | Medical ethics. | BISAC: BUSINESS & ECONOMICS / Business Communication / General.

  Classification: LCC R727.3 .C665 2016 | DDC 610.7306/9—dc23 LC record available at http://lccn.loc.gov/2015051012

  McGraw-Hill Education books are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a representative, please e-mail us at [email protected].

  For my boys—

  I love you to infinity and beyond

  AB

  To my patients—

  who teach me and give meaning to my work

  TG

  Contents

  Foreword

  Thomas H. Lee, MD, MSc

  Preface

  Adrienne Boissy, MD, MA

  Acknowledgments

  Adrienne Boissy, MD, MA, and Timothy Gilligan, MD, MS

  Chapter 1 “I Already Know This” and “Patients Know I Care”: Designing a Culture That Is Ready for Communication Skills Training

  Adrienne Boissy, MD, MA

  Cha
pter 2 Leveraging Your Burning Platform

  Adrienne Boissy, MD, MA

  Chapter 3 Keys to Launching a Successful Communication Skills Training Program

  Timothy Gilligan, MD, MS

  Chapter 4 Birth of the R.E.D.E. Model

  Amy Windover, PhD

  Chapter 5 Making Communication Resonate with Experienced Clinicians

  Amy Windover, PhD

  Chapter 6 Conversations That Haunt Clinicians

  Vicente J. Velez, MD

  Chapter 7 Individual Peer Coaching: What to Do About Dr. Jones?

  Timothy Gilligan, MD, MS

  Chapter 8 Facilitating Staff Physicians Is Not the Same as Teaching Residents or Students . . . Or Is It?

  Katie Neuendorf, MD

  Chapter 9 Who Facilitates Whom?: Advanced Care Provider Training

  Susan Bowling, PhD, and Farzana Meyers, PA

  Chapter 10 Empathic Communication through the Loop Lens: A Surgeon’s Perspective

  Edward Benzel, MD

  Chapter 11 “Trust Me, I’m A Doctor!”: Building, Supporting, and Maintaining Professionalism

  J. H. Isaacson, MD, and Richard Frankel, PhD

  Chapter 12 The Awesome Power of Vulnerability

  Adrienne Boissy, MD, MA

  Notes

  Index

  Foreword

  Healthcare is inherently chaotic. Patients are heterogeneous, so their medical problems are complex and their needs variable. Because of this chaos, clinicians need frameworks and the discipline to use them. Yes, every patient is different, and every interaction unique, but structured approaches to interactions with patients enable clinicians to deliver better care and feel calmer while doing so. Clinicians can focus on connecting with the patient, rather than wondering what they should be doing.

  This book describes such a framework, along with powerful insights on how to implement it. Adrienne Boissy and her colleagues at Cleveland Clinic have driven remarkable improvements in the communication skills of caregivers, and they have also provided a superb example of how to build social capital. Although this term is not widely used in healthcare today, it is increasingly relevant as we enter a marketplace driven by competition on value—meeting patients’ needs as efficiently as possible. If financial capital refers to the monetary resources that enable organizations to build buildings and accomplish other goals that otherwise would be impossible, social capital describes how relationships within the organization allow it do things it otherwise could not do. Social capital explains how some organizations do a better job at meeting patients’ needs and why others fall short even though their personnel are just as hardworking and well trained. In higher-performing organizations, the whole is greater than the sum of its parts; in weaker organizations, the opposite is often the case.

  To increase value, clinicians have to work more effectively with each other, and with patients and their families. To do that, organizations have to be able to increase their social capital. University of Chicago sociologist Ronald S. Burt1 describes two basic ways to do this: brokerage and closure. Brokerage describes how organizations learn, and actually increase the variation in how they do things. Closure describes how they reduce variation, and achieve consistency in working together in an effective and efficient way.

  Organizations need both types of functions, as demonstrated by the work on healthcare communication skills at Cleveland Clinic. The Clinic was wise enough to give the responsibility and a blank slate to Boissy, who was well respected by her colleagues but honest and humble enough to admit that she did not know how to accomplish the goal, so she looked outside of her usual context and enlisted other colleagues with the same openness. They spent a year developing an inventory of what work was going on internally, at other healthcare organizations, and at organizations outside healthcare delivery.

  In this brokerage phase, Boissy and her colleagues understood that their work was to learn from others, not start from scratch. To learn, and successfully bring ideas from outside into an organization, information brokers have to create what Burt calls “bridges” over which information can traverse, and “holes” through which the information and new practices can enter. Within any large and complex organization, there are suborganizations, and creating bridges and holes among them is an important function of the learning process.

  Organizations that are too inwardly focused are at high risk for missing out on new and better ideas that have developed elsewhere. The temptation is always great in any large and well-regarded organization such as Cleveland Clinic to discount work done elsewhere. Fortunately, the Clinic’s leadership was willing to confront data suggesting weak performance and then create the imperative to learn and to improve.

  But just learning (idea brokering) is not enough to realize actual improvement; organizations also need “closure,” to make the better ways of doing things the new local norm. Here again, Boissy and her team sensed that clinicians need a structured framework for approaching interactions with patients, and that this framework could only be spread via trusted colleagues.

  One of my favorite parts of this book is the description by Dr. Edward Benzel, then chair of Neurosurgery, of his initial reaction to the request that he become a trained facilitator for the communications initiative. Benzel’s response was to try to get the work assigned to a young woman who had recently been recruited to the neurosurgery group. Boissy and her colleagues knew that the framework they were advancing would spread much faster if well-known and trusted authority figures were pushing it. Benzel relented, as did many of his more senior colleagues, and the Clinic avoided one of the most common mistakes in dissemination of best practices—which is to take the path of least resistance and focus efforts on clinicians who have less influence on their colleagues.

  When it comes to making a new and better way of doing things a social norm, the accumulation of social capital blurs into social network science. Here, organizations may benefit from the work of researchers such as Yale’s Nicholas Christakis, author of Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives.2 They have shown how values (e.g., good communication being essential to professional excellence) can spread from person to person to person. Financial incentives can capture clinicians’ attention briefly, but to achieve real and sustained improvement, social norms must be strong enough to exert peer pressure upon clinicians to be reliably excellent with every single patient.

  It is worth noting that the Cleveland Clinic experience demonstrates that brokerage and closure are not two sequential phases. Both must go on continuously and indefinitely. The Clinic has been modifying its program right from the start, and we can expect it to have evolved a year or two from now. The learning will never stop, nor should the work to achieve closure by standardizing best practices.

  Thomas H. Lee, MD, MSc

  Chief Medical Officer, Press Ganey

  Professor of Medicine (part-time), Harvard Medical School

  Professor of Health Policy and Management, Harvard School of Public Health

  Preface

  My pager went off before I even made it through the hospital doors. Returning the call, I was greeted with “Hey, good morning. It’s Joe in the ER. Your patient in Bed 5 is asking for Dilaudid. I don’t want to give it to her, but it’s up to you.” I didn’t know the patient in Bed 5 and communicated that as soon as I met her, I’d be happy to treat her pain with something else. Shortly thereafter, I was rounding on the neurology inpatient service, and the residents told me about a young woman, “the patient in Bed 5,” who had been admitted overnight for two months of head pain with innumerable requests for Dilaudid. Their frustration and annoyance were palpable. They described treating the patient with IV steroids, magnesium, Compazine, Toradol, morphine, and Dilaudid in a span of a few hours since her admission, as well as starting prophylactic medications to prevent her head pain. I could see the costs compounding in my head. In addition, she had been admitted to our hospital for three months the yea
r prior. I took a deep breath and entered the room.

  “Good morning, Ms. Hide. I’m Dr. Boissy, the neurologist in charge of your care while you are here. I’m so sorry you spent the night in the ER and are here.”

  “Thanks.” A somewhat groggy young woman with multiple tattoos rolled onto her back to speak with me. She had her forearm over her eyes and wouldn’t look at me.

  “I’m wondering if you can tell me about yourself.”

  “My pain is ten out of ten, mainly on the right side . . .”

  “Thank you for telling me. What I meant was about you as a person.”

  “Oh.” She shot me a surprised look as her arm came down from her face. “OK, well, I live at home with my parents. It’s not that great because we don’t really get along. They don’t think anything is wrong with me.”

  “I’m sorry to hear that.”

  “It’s OK, I’m used to it. I also work as a pharmacy tech.”

  “That must be interesting. Have you had to miss work because of everything going on?”

  “Yeah.”

  “I bet you miss it. This pain that you’re having seems to be really impacting you. Most people have ideas about what’s happening with them. What do you think?”

  “Well, I think I either have MS (multiple sclerosis) or parasites. I read about them online.”

  “I’m glad you told me. The good news is I’m an MS specialist, and we can easily check your stools for parasites.”

  “That’s good to hear.”

  “How are you hoping I can help you?”

  “I don’t think you’re going to fix my pain.”

  “I think you might be right about that. Sounds like we have been trying a lot of different things without much success.”

  Fast forward two minutes. “Any history of verbal, physical, or sexual abuse?”

  She looks down. “I was raped twice as a teenager. No big deal though. Same thing happened to my best friend, and we worked through it by talking about it with each other.”