Communication the Cleveland Clinic Way Read online

  You barely get the words out about what you’ve accomplished before questions about sustainability creep in (Table 2.4). We’ve approached this from every angle.

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  TABLE 2.4 Sustainable Communication Skills Training

  Curriculum Design

  Advanced communication courses

  Exclusive inpatient application of R.E.D.E.

  Online training

  “Booster shot” updates

  Peer coaching

  Leadership, quality, safety, and professionalism collaborations

  Integration into onboarding

  Accountability

  Report quarterly unblinded communication scores by individual.

  Show communication performance online.

  Hold regularly scheduled scorecard reviews with executive leadership.

  Make communication a factor in annual performance review.

  Facilitator Engagement

  Hold quarterly faculty development sessions.

  Promote opportunities to present outside the organization.

  Open access to a formalized Research Council.

  Start an e-mail newsletter with updates and training opportunities.

  Share resources with medical school.

  Promote Empathy + Innovation Summit track design and course offerings.

  Expansion to Specific Groups

  Offer malpractice discounts as incentive for course completion.

  Design a nursing curriculum.

  Design specialty-specific programs.

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  Advanced communication courses provide additional training for more in-depth topics and are readily available and taught by our same core facilitator team. We also offer individual peer communication skills coaching. Often, physicians will complete the FHC course but then look for more feedback, which individual coaching can provide. We review doctor communication measures in our annual professional staff reviews with a Board of Governors member, as well as with local leadership. Every quarter the entire institute leadership appears before the executive team and reports on their scorecards, which are a blend of experience, quality, and safety metrics. This also includes doctor communication as a target, so communication skills efforts are woven into our organizational fabric. We believe effective communication skills training must start in person and are exploring supplementing that with online training.

  We’ve also designed disease- and setting-specific training. Many of the communication models are geared for the outpatient setting, and not all providers naturally make the connection as to how these skills play out in the inpatient environment, so we built training specific to that space. In addition, there are nuances to conversations that are disease-specific. Discussing topics such as death by neurological criteria and end of life is done best when clinicians have a strong foundation of relationship-centered communication skills upon which additional skills can be layered.

  Data

  We thought about data a few different ways, and this was important to our success. If asked to build a communication skills training program, follow that invitation with a question about what you will be held accountable for. Spreading out the metrics helps capture the full impact of any training on a given clinician. We followed HCAHPS and CGCAHPS, but we knew that we also wanted to incorporate the clinicians’ perspective on their own empathy, resilience, and confidence to perform the skills. We assessed empathy and burnout using the Jefferson Scale of Empathy (JSE) and the Maslach Burnout Inventory (MBI) respectively. We used the 12-month visit-specific CGCAHPS survey because it maps directly to a given provider. In an early analysis, we asked 897 attending physicians about their confidence in performing certain skills before and after the course. The results appear in Table 2.5.

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  TABLE 2.5 Physician Self-Efficacy Pre- and Post-FHC Training: “Extremely Confident” Responses

  FACTOR

  PRE (N = 897)

  POST (N = 897)

  P-value

  Phase 1

  412 (50.2)

  587 (75.1)

  <0.001a

  Respect with Welcome*

  411 (46.0)

  572 (70.1)

  <0.001a

  Set Agenda*

  298 (33.6)

  468 (57.4)

  <0.001a

  Introduce Computer*

  175 (21.2)

  386 (49.6)

  <0.001a

  Empathy*

  418 (46.9)

  535 (65.6)

  <0.001a

  Phase 2

  407 (45.9)

  587 (72.0)

  <0.001a

  Reflective Listening*

  329 (36.8)

  506 (62.0)

  <0.001a

  Eliciting Patient Narrative*

  357 (40.1)

  511 (62.7)

  <0.001a

  Explore Patient Perspective*

  271 (30.5)

  457 (55.9)

  <0.001a

  Phase 3

  429 (49.2)

  609 (75.4)

  <0.001a

  Sharing Diagnosis*

  397 (44.6)

  544 (67.7)

  <0.001a

  Develop Treatment Plan*

  361 (41.1)

  506 (62.4)

  <0.001a

  Provide Closure*

  248 (28.1)

  464 (57.1)

  <0.001a

  Dialogue vs. Monologue*

  257 (28.9)

  439 (53.9)

  <0.001a

  *Data not available for all subjects. Values presented as N (column %).

  p-values: a = McNemar test

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  As for the provider perceptions of the course itself:

  88.2 percent were satisfied with R.E.D.E. duration

  98 percent appreciated the teaching methods used

  97.7 percent were satisfied/very satisfied with R.E.D.E. overall

  94.7 percent would recommend R.E.D.E. to a friend or colleague

  In the early analysis, empathy significantly increased according to the JSE from 116 to 124. Burnout significantly decreased as measured on the MBI from 65 to 62. And physician communication improved significantly in 6 out of 7 CGCAHPS questions.

  A controlled study of the impact of the R.E.D.E. to Communicate: FHC course on burnout, empathy, confidence, and patient satisfaction has recently been published.2 We also created an IRB-approved registry for all clinicians who completed our course and are working to link communication and these scales to disease-specific outcomes and correlate it to patient complaints and cost.

  Getting Started

  Here are a few things to consider when thinking about embarking on training:

  Timing: If you train clinicians as facilitators and they don’t use their skills, those skills will atrophy and die. A meaningful investment in communication skills training must occur at the same time your organization is actually ready to make it happen. If you are still having conversations about whether you should unblind your individual communication scores to the caregivers, then you may not be ready to launch a program. Behavior change and appetite for communication skills training will be driven by unblinded transparency of communication scores.

  Cost: An eight-day TTT program—even one day of training—is a significant commitment of resources. People often ask about the cost. Our preferred response is, “What’s the cost of not doing it? How do you capture that?” We looked at how patients perceived their providers’ ability to communicate and mapped it to lawsuits and cost: physicians with the lowest communication scores have the highest number of lawsuits filed against them and cost our organization the most money. Multiple studies have confirmed the link of ineffective communication and malpractice risk.3 In addition, continuing medical education (CME) accreditation is an attractive benefit to factor in when considering cost.

  Consistency: Maintaining consistency in a program involves ongoing faculty development. We bring our facilit
ators together every quarter to discuss pertinent issues for our center and facilitation challenges and successes, as well as to expand their skill sets. We’ll bring in outside speakers with communication skills expertise or share skills we’ve learned from across the globe. We also observe our facilitators regularly to give them feedback on their facilitation skills.

  Program: We evolved external training in response to external demand. It wasn’t our intention when we started. There are many groups that offer Train the Trainer programs, some effective and some probably less so. We’ve had some organizations say, “We started with X, and it didn’t work. Can you come in and help us fix it?” This is tricky because if the audience is full of healthy skeptics and the program is not of high quality, then people develop “antibodies” and increased resistance to future training. Invest in getting it right the first time.

  Data: Ask for data. What evidence do you have that a training program worked? Anecdotal quotes are great, but where is the meat? Saying this is the right thing to do may work for some, but it won’t work for all. Meaningful impact must be demonstrated.

  Culture: Is your organization ready for communication skills training? Do you have leadership support both verbally and financially? What efforts have you tried already, and do you have antibodies to work through? What is the motivation to get started, and how has this been messaged to date? Would interprofessional or peer-to-peer training work better at your institution?

  Today

  We started with six people and ultimately grew a Center for Excellence in Healthcare Communication (CEHC) (Figure 2.1), which is within our Office of Patient Experience and sponsored by the chief experience officer. The CEHC runs the R.E.D.E. to Communicate: FHC course, the advanced communication curriculum, a peer coaching program, a consulting arm, a comprehensive Train the Trainer (TTT) program for facilitators, and research. Several of these pieces will be discussed in subsequent chapters.

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  FIGURE 2.1 The Center for Excellence in Healthcare Communication

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  Key programmatic accomplishments:

  Over four years, we trained 4,263 physicians and 840 advanced care providers in relationship-centered communication skills.

  There are 56 clinician facilitators who lead the FHC program and advanced courses, of whom a third are surgeons, a third are medical staff, and a third are advanced care providers.

  The R.E.D.E. model has been integrated into the medical school as a unifying curriculum across the professional continuum.

  The R.E.D.E. to Communicate: FHC course is mandatory for onboarding of new physician staff.

  When we first started to evaluate the course, we were not very sophisticated. We were most excited that it was rolling out the door. Perhaps the most powerful lesson we learned, which also transformed what we attempted to capture in the course, was that there can be two goals in teaching relationship-centered communication skills: (1) To deliver more or new content. Educators call this informative. A good analogy is adding water to a bucket. (2) To transform the bucket itself, perhaps into a boat. This is called transformative. We knew we were on to something when we started receiving feedback from participants:

  Really first rate and a game changer in terms of my practice.

  —NEUROSURGEON

  This course was a great tool for focusing on clarity and compassion in communication.

  —ANONYMOUS

  Just a big shout-out from me on your teaching at the course today. I have been so curious as to the content/delivery of the communications course, having discussed it from so many perspectives all year. FYI: it clearly exceeded my expectations.

  —RHEUMATOLOGIST

  This has been so far one of the best things in my career I’ve done.

  —CICU INTENSIVIST

  Power Points

  Complete an inventory of what already exists in your organization as a critical first step.

  Identify relevant stakeholders who will impact your success or failure.

  Unblinded and public transparency of patient satisfaction scores highlights opportunities for improvement, but be cautious about how you use them. Scores alone typically don’t inspire people.

  Choose facilitators who reflect the composition of your actual organization and who have a sphere of influence and are passionate about the initiative.

  Changing the behavior, through your training, of even one person who has a large sphere of influence can have a powerful ripple effect throughout your organization.

  Chapter

  3

  Keys to Launching a Successful Communication Skills Training Program

  Two of the underlying challenges facing anyone developing a healthcare communication skills training program for clinicians are legitimacy and credibility. A polarity exists in medicine between the positions that quality medicine is about technique and biomedical understanding, on the one hand, and that quality medicine is a humanistic endeavor in which emotional intelligence and communication and relationship skills are important, on the other. Although these two positions are not mutually exclusive, they are often posed as if they were, as though we had to choose between having an airline pilot who knew how to take off or one who knew how to land. During training, physicians primarily receive feedback on medical knowledge, decision making, and procedural skills. Suddenly holding them accountable for communication and interpersonal skills can feel like changing the rules halfway through the game.

  A different version of these challenges comes from clinicians who believe that they are excellent communicators who do not need communication skills training. They may have strong interpersonal skills and great charisma and have warm relationships with their patients. They may have been practicing medicine for over a decade. Who are we to tell them how to do their jobs? How safe is it for them to consider that there is room for improvement in how they communicate with patients?

  Resistance is to be expected. Be prepared for skepticism and pushback, and make a genuine effort to respond to resistance empathically from a perspective of curiosity and understanding. After all, skepticism is a prized quality in scientists, whom we expect to question and challenge ideas as a way of testing their validity. We show our colleagues respect by empathizing with the stress caused by both the changing measures of what represents high-quality healthcare and by the perception that their skills are being questioned. We show respect by welcoming their skepticism that communication skills can be taught effectively. A key to the success of our program was our expectation that very few clinicians would want to take our communication skills course and that many of those attending the course would reject what we were trying to teach. We will discuss later in this chapter why we made the choices we made and detail our various attempts to respond to this challenging environment.

  How We Structured Our Course

  Our basic framework for the course was to present a brief didactic on one of three phases of the medical interview followed by a brief demonstration of the skills for that phase and a longer period for skills practice. The didactic was given to provide a cognitive framework so that we could set up participants to succeed during the skills practice. For the first two phases, participants played both the patient and the clinician, whereas for the third phase, we originally employed standardized patients. At the end of the course, we spent 90 minutes practicing the skills on challenging cases that participants described from their own practices. The goal of this final component was to create an opportunity for participants to discover how the skills we had practiced could be applied in their specific practices and to highlight to participants that the model applied to challenging cases—new skills were not necessary to navigate most of these conversations. Because we could only practice a couple of cases in the time we had, we elicited a case from each participant and then had the group vote on which ones they wanted to recreate, with the person who supplied the case playing the role of the patient and a volunteer playing the clinician. This was important be
cause the patient was played by someone who had spent time with him or her and because it encouraged the clinician to develop a more empathic understanding of the patient. We would later change this format to make the case more universal and enhance group buy-in.

  Each session of the course, both in its initial Four Habits structure and subsequently using the R.E.D.E. model, had 8 to 12 participants and two facilitators. For the skills practice exercises for each phase, participants were divided into two groups of four to six, so that each participant would be able to practice at least two of the phases during the course. For the final session using cases supplied by and voted on by the group, we brought all the participants together again.

  The participants in each course were drawn from a variety of specialties. We intentionally avoided having sessions that were dominated by a single department or subspecialty due to our concern that a tribal dynamic might develop that would strengthen resistance. We discovered that participants expressed great appreciation for the opportunity to meet colleagues whom they had not known previously, so we had little incentive to change this policy of diversity. In fact, we decided that no more than four physicians from the same specialty could attend at any one time. There was also diversity with regard to communication skills. Having some highly skilled communicators as participants helped us because they served as unofficial cofacilitators and modeled skills for others. In addition, we avoided creating the impression that the course was remedial.