Communication the Cleveland Clinic Way Read online

  We worked and consulted with Dr. Walter Baile, Rebecca Walters, Dr. Tony Back, Dr. Calvin Chou, and the AACH at various points in our development. Each brought valuable tools to the table. Baile and Walters have unique methods of deepening the teaching of empathy through action, born out of psychodrama and sociodrama. Back and his organization, Vital Talk (previously OncoTalk) have been teaching palliative care discussions for years. AACH worked with us early on in small group facilitation methods. Chou, an internal medicine physician at the University of California, San Francisco (UCSF), was pivotal in our initial efforts to evolve a program. He helped us understand that communicating effectively is a discipline and inspired us all to drive it forward.

  In working with these individuals, we recognized that strong content in the absence of a supportive culture is useless. You can build the best competency-based program with lists of references and train highly skilled facilitators, but if, at the end of the day, the chairs are empty, then the program has failed.

  Here are some key first strategic steps that you might consider as you get started.

  Initial Rollout, Recruitment, and Messaging

  As Merlino highlighted in his book Service Fanatics, we knew our own data. Communication accounted for 72 percent of our negative patient comments and was one of the lowest performing HCAHPS measures. Cosgrove himself drove transparency of patient satisfaction communication scores across the organization. We built a profile of a given physician based on his or her inpatient, outpatient, and ombudsman’s communication scores or issues (Table 2.1). This is critical to addressing some of the issues that clinicians raise about the scores. HCAHPS might not be a valid metric given its association with the discharging attending, but combining three sources of data for a given provider begins to build a story about how that provider communicates and is perceived by patients.

  * * *

  TABLE 2.1 Quarterly Individual Provider Reporting for Doctor Communication Across Data Sets

  Taussig Cancer Institute

  Patient Experience Physician Report

  (December 1, 2009 through November 30, 2010)

  HCAHPS

  Medical Practice

  Ombudsman

  Domain

  Recommend

  Patients

  N

  % Always

  N

  % V Good

  % V Good

  25

  77%

  20

  99%

  100%

  29

  63%

  34

  81%

  81%

  5

  48%

  40%

  3

  78%

  100%

  14

  71%

  5

  43%

  40%

  23

  86%

  16

  83%

  84%

  12

  88%

  82%

  1

  2

  100%

  100%

  29

  87%

  80%

  11

  73%

  82%

  5

  68%

  80%

  1

  8

  71%

  35

  74%

  83%

  1

  5

  73%

  14

  87%

  100%

  5

  68%

  80%

  1

  8

  71%

  35

  74%

  83%

  1

  5

  73%

  14

  87%

  100%

  * * *

  Transparency provides feedback to the individual provider, can fuel some healthy competition among clinicians who want to be the best at what they do, and generates some conversation among colleagues about what works and what doesn’t. But simply measuring performance is not enough to achieve improvement: physicians need opportunities to learn and to practice new, more effective skills and to begin letting go of bad habits.

  Calvin Chou trained an initial team of six clinicians: nephrologist Saul Nurko, cardiologist David Taylor, oncologist Tim Gilligan, hospitalist Vicente J. Velez, psychologist Amy Windover, and me. We were healthy skeptics. Chou was patient with all of our questions and moved us through the basics of facilitation. We developed a class using the Four Habit model as a foundation, with two facilitators for 8 to 12 participants.

  Communication skills training is a tricky business. We were intentional about highlighting the benefits of the training for individual providers and asking for help rather than making it one more thing they had to do. When engaging healthy skeptics, we knew that messaging mattered. So we invited colleagues to attend. We asked them for their help in building a program that would depend on their feedback. And we meant it. Here is an excerpt of the initial invite:

  I am asking for your participation in one of the upcoming courses. Our goal is to build upon communication skills you already have and to collect feedback before the program is rolled out to all CCF staff. For others, your chairs or center directors have expressed support for the program and want their staff actively involved in this process.

  This is no small challenge given the time pressures we all face in clinical practice. The Office of Professional Staff Affairs supports your time away from patient care to participate in this process.

  Once physicians attended (and they did), we asked them to recommend 10 of their colleagues, and the process repeated itself. Slowly, institute chairs began to reach out to us to train their physicians with the lowest HCAHPS communication scores. We nudged back, saying that the program leveraged the strength of everyone and wasn’t designed to be punitive or to be a rehabilitation program. Ineffective communicators giving feedback to ineffective communicators would be . . . ineffective. We required the participation of both effective communicators and less effective communicators for our model to work. Institute chairs were receptive to this, and many committed their entire staff on the spot.

  We invited like-minded peers to participate in the pilot phase to encourage attendance. This helped us learn how the course worked and how to improve it in the setting with interested participants who would be more forgiving of imperfections and more likely to recommend the course to others.

  We quickly realized that talking about HCAHPS isn’t very productive. We had included HCAHPS graphs in the slide deck, thinking that we would acknowledge the elephant in the room, and yet we found that invariably, the subsequent conversations drifted into “You are just doing this for HCAHPS” or “Just another flavor of the month.” We received comments like these with empathy and listening, rather than defense of the program, and removed the slide. Regardless of the realities of the healthcare environment, for the facilitators of the course, this became a more personal movement to honor the complexities and intimacies of caregiving, therefore, HCAHPS didn’t have a rightful place in that room.

  We recognized early on that people may have assumptions about who trains in communications skills. You may have your own. We wanted to flip those assumptions on their head. Surgeons participated from the very beginning. I recruited them by making an appointment, introducing myself, explaining what we were doing, and asking them to sign up. One of them said with a smile, “I knew you would come for me one day.”

  Clinicians who were highly respected by their colleagues and had some organizational longevity (and were not already involved in any communication efforts) were also identified and invited.

  This was a critical first step for us because there are many assumptions about the stereotypical surgeon and their communication style, just as there are assumptions about the type of person who may teach communication skills.

  The night before we trained our first group of surgeons as facilitators, we had tremendous anxiety about whet
her they would take it seriously. But our fears were unfounded; they quickly embraced the training. “Just tell me the best thing to say, and I’ll say it,” they kept saying. They debated the evidence for the skills less and were diligent about getting the language we suggested right. One of the surgeon facilitators we trained was renowned clinically and yet not always for his interpersonal skills. To his absolute credit, he became passionate about learning more and enhancing his own skills. He offered to mentor some of our residents in their research in communication skills training. He wanted to meet after class to discuss and review his facilitation. This example is worth noting because during every class we heard a participant say, “Well, I heard Dr. X has undergone a transformation, so I wanted to learn more about this work. If he can change, I can, too.” Never underestimate the power of one.

  Regroup

  After training 1,000 staff physicians over two years, we regrouped and redesigned the entire program into R.E.D.E. to Communicate™: Foundations of Healthcare Communication (FHC) (Table 2.2). We included competencies, checklists, pre- and postcourse evaluations, guides, and cue cards to make it clear to our facilitators and participants what was expected of them.

  * * *

  TABLE 2.2 R.E.D.E. to Communicate: Foundations of Healthcare Communication Outline

  * * *

  We realized that we wanted to own the training of our own facilitators. We designed a completely new Train the Trainer (TTT) model that built upon what we had learned, but now incorporated video with feedback, pairing to-be facilitators with more senior facilitators, creative moments that got people out of their chairs and interacting with each other, more opportunities for reflection, comprehensive evaluations, data collection processes, and narratives. We built a database of everyone who completed the training. Our TTT program runs for eight days (Table 2.3). Three days are spent showing what will be the final product, discussing evidence for communication skills training, explaining the educational theory behind it, and practicing. Then facilitators in training have a two- to four-week break. When we reassemble, we move on to videotaping presentation skills and giving feedback, more skills practice of how to run and orient learners to skills practice, and weaving in improv and action methods. One day is then spent at their home institution cofacilitating with them, and another day is spent watching them facilitate their own people with our feedback.

  * * *

  TABLE 2.3 R.E.D.E. to Communicate: Train the Trainer

  Topics Covered

  Location

  Stage One (Days 1–3)

  Complete R.E.D.E. to Communicate: FHC

  Evidence-based communication

  Learning theory

  Small group facilitation

  Goal setting

  Cleveland Clinic or locally

  Stage Two (Days 4–6, two to four weeks later)

  Reflective practice

  Presentation skills with video feedback

  Co-facilitation

  Integrative cases (improv and action methods)

  Challenging scenarios in facilitation

  Cleveland Clinic or locally

  Stage Three (One Day) Co-facilitation

  All of the above

  Home institution

  Stage Four (One Day) Observed facilitation

  All of the above

  Home institution

  * * *

  Within these Train the Trainer sessions, we foster relationships by having a cocktail hour so that newer facilitators can meet experienced facilitators and be welcomed into our facilitator family. We also have a congratulatory dinner for them at the end, and we present them with an inscribed gift based on what we have learned and admired about them during the training. During many of the sessions, we have an executive leader come to talk with them about how much leaders value this effort. Cosgrove came to one of these and told a powerful story about serving as a surgeon in Vietnam and not having much time to spend with hundreds of patients. He articulated that the one thing he did to let patients know that he was there was to touch them. He made a conscious effort “to touch a foot, a toe, a shoulder—anything” to let the person know he was connected to them. This was an unscripted and unplanned moment that made many of us personally believe that our CEO and organization supported the work we were being asked to do.

  The second major change involved an advanced structure that fostered relationships among participants. We noted that many staff appreciated having an opportunity to come together and spend some time not just sharing communication challenges and tactics, but also engaging with each other. Given the size of our organization and the pressure we felt clinicians were under, we took notice. We also believe that there cannot be a meaningful patient experience without a meaningful clinician experience. Subsequently, building relationships among the team members became a strategic hidden curriculum for the program. In the new course we developed, informal and formal relationship-building opportunities were created, and the relationship-centered strategy became a parallel process—in other words, the facilitators were deliberate about forging relationships with participants at every moment. Key revisions included building in networking time at the beginning of the course and layering in more creative ways of building engagement.

  Most important, it was at this point that we developed our own model of communication that is explored in Chapter 5. This was a critical step in our growth and expansion as a program. Dr. Windover initially presented this idea to me in 2013. I had asked her to collect the data and build a new program and model. When she first presented it, I wasn’t so sure. Revise the course to emphasize first and foremost building relationships with patients? Did I even think about that in my own role? Yet as I reflected on it, I saw her brilliance.

  A few years earlier, I had inherited a very large multiple sclerosis (MS) practice. I had no extra time with patients whom I was meeting for the first time, and I was intent on making sure I took good care of them. As I reviewed their records in advance, to my surprise, I found that some of the patients didn’t actually have MS. That was odd. They had been coming to a MS center for years. At the same time, I realized that this wasn’t a mistake or misdiagnosis. These were patients who had been labeled with MS for one reason or another, and yet we knew they didn’t have it. I would later call this “therapeutic mislabeling.”1

  I would go into the examination room, introduce myself, and ask them about themselves: “Tell me something about yourself outside of your diagnosis.” Then I would say, “Thanks for sharing a bit of yourself with me. So, I looked through all the records, and the great news is you don’t have MS.” What a relief. I had “fixed” their diagnosis and been honest about what they didn’t have. I was stunned then when patients became angry and made comments like, “I’d like my old doctor back” or “If it’s not MS, what is it?” or “I know that’s what I have.” What happened? I was honest, I gave accurate information, I asked them about themselves, and yet they were mad. Really? As Windover described why she was advocating for a relationship-centered approach, it hit me. Of course patients didn’t hear what I was saying. I was giving what I thought was good news, which patients perceived as bad news and did so in the absence of a trusting relationship. It was an aha moment that would shape the rest of my career.

  We rolled out our new R.E.D.E. to Communicate: FHC program in 2013, and shortly thereafter, we announced that completion of the course was “encouraged.” That may be another word for “mandated” you might want to try. Persuading physicians to enroll was facilitated by the fact that our entire executive team completed the training and unblinded transparency had already been in place for several years at that point. As we worked with the executive team, we were struck by their own experiences as patients themselves or as caregivers to their loved ones. Training the executive team also bolstered the R.E.D.E. model because relationships are universal and the skills applied to our CFO and administrators as much as they did to clinicians. Relationship-centered communication skills ar
e helpful in all human interactions.

  We ramped up our ability to provide more frequent training as we were on an aggressive timeline. We were asked to train the entire attending staff population and all the residents in about seven months, an estimated 3,076 caregivers. We asked facilitators to teach three times a month, three times their original expected commitment. We needed to train more facilitators, for a critical mass of about 60. We mapped out each department and institute and sent them weekly reports on their registrations and completions of the course. When people said they couldn’t or didn’t want to complete the training, we responded with, “Thank you for sharing your thoughts. Dr. Cosgrove and our executive team have completed the training. Please consider attending so others may learn from you. If you still feel you would like not to come, please discuss directly with Dr. Cosgrove or the chief of staff.” We didn’t hear much after that.

  We also wrote letters of appreciation to department administrators, department chairs, and institute chairs to thank them for their continued support of the effort and the facilitators. Here’s an excerpt:

  John Smith is one of the 18 trained physician facilitators for this program.

  His role in this program has been invaluable, and the commitment that he has made to help our colleagues improve their skills is having an important impact on changing the culture of this organization.

  As of December, this group of 18 physicians has trained 509 staff members in this daylong, behavior-based communication training curriculum. This is an important achievement that we should all be proud of.

  Thank you for the contribution of your staff member to this very important program for our organization.