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Physician Skill Building
Dan Smith, MD, FACEP
Medical Director
Studer Group
Physician-Patient Communication
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Execution Framework: Evidence-Based
LeadershipSM
2
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Why communicate better and deliver a great
patient experience?• Improves clinical effectiveness/treatment adherence
• Improves clinical outcomes and safety
• Increases loyalty and growth
• Improves CAHPS performance
• Reduces malpractice risk
• Improves physician/APP/staff satisfaction
Patients’ rating of quality is more predicted by their rating of the quality of communication than technical care. * Chang, Annals of Internal Medicine
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Outcome = Income
Volume Value
Past Future
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CAHPS® Family of Surveys
Consumer Assessment of Healthcare Providers and Systems
• Family of surveys designed to assess patient perception of care quality
• Allows comparisons of hospitals so that consumers can make choices
• Linkage to value-based purchasing reimbursement to hospitals
• CAHPS Survey Tools:
– HCAHPS
– CG CAHPS
– PCMH CAHPS
– In-center Hemodialysis CAHPS
– Home Health Care CAHPS
– ED PECS
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CG CAHPS Core Questions &Composites15 questions grouped in 5 composites
Getting Timely Appointments,
Care, and Information
(Access)
• Getting appointments for urgent care
• Getting appointments for routine care or
check-ups
• Getting an answer to a medical question
during regular office hours
• Getting an answer to a medical question
after regular office hours
• Wait time for appointment to start
Rating of the Provider (Doctor)
• Overall rating of your Provider
Provider (Doctor) – Patient
Communication
• Provider explanations easy to understand
• Provider listens carefully
• Provider gives easy to understand information
• Provider knows important information about
medical history
• Provider shows respect for what you have to
say
• Provider spends enough time with you
Courteous and Helpful Office Staff
• Clerks and receptionists were helpful
• Clerks and receptionists treat you with
courtesy and respect
Test Results
• Follow up on Test Results
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How we communicate predicts our patient’s
overall rating of care
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Chasm between consumer and physician
perception
98%
54%
0%
20%
40%
60%
80%
100%
120%
PhysicianResponse
PatientResponse
Physicians Discussed Patients’ Fears and Anxieties
77%
57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Physicians ThatThought Patient
Knew
Patients ThatCorrectly Identified
Patients Know Their Diagnosis
Olson, DP and Windish, DM; Communication Discrepancies Between Physicians and Hospitalized Patients” Arch Intern Med 2010; 170 (15): 1302-1307.
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Patient Experience is about High Reliability
There are standardized response options to the core CAHPS
questions and this is true for the communication domain
Always
Usually
Sometimes
Never
Yes
Definitely
Yes
Somewhat
No
9, 10
8 or less
ONLY THE TOP BOX RESPONSE COUNTS
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What are the skills to improve
communication and connection?
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Patient short list…
1. Who Are You?
2. Are You Any Good?
3. Do You Care?
What healthcare
consumers want to
know:
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Timely.
Team.
Effective.
Communicated.
Caring.
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Themes Portending a Positive Interaction
Relationshi
ps
Non-verbals Care Plan
and
Partnership
Care Team
and
TransitionsAcknowledge (A of
AIDET®) and 10-5
Rule
Seated Medical jargon
avoidance
Introduction (I of
AIDET®)
Introduction (I of
AIDET®)
Proximity Health literacy
alignment
Role Delineation
Appreciation or Thank
You
(T of AIDET®)
Warm tone Explanation (E of
AIDET®) is
understandable
Consultant
coordination
Empathy Eye contact Duration (D of
AIDET®) and
Timeline
Manage-up
Language specificity Hand wash Confirmed shared
agenda and invited
questions
Handover explanation
Cultural alignment Appropriate touch Care plan summary
and white board
updates
Biocard
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Narrate the Care
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With them…not to them
Shared Care Agenda
“Does that sound like a reasonable care plan?”
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Phases of a Patient Encounter and Key
Communications
• First impressions
• Tone and demeanor
• Non-clinical opener
• Awareness and alignment of “why” of the visit (Individualized Patient Care) and information
Beginning
• History and circumstances paraphrased
• P.E and share P.E. findings
• Informed of test results
• Explained working DX
• Explained meds
• Shared plan
Middle• Close the
loop/summarize
• Answer Q’s, Teach Back
• Care coordination/Handover
• Appreciation, admiration
• Lasting impressions
End
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Studer Group Five Fundamentals: AIDET®
A Acknowledge Eye contact, smile and acknowledge everyone in the room.
I Introduce
“Hello Mr. Clark. My name is Dr. Jones, good morning. I have been an
emergency physician for 10 years and I will be caring and coordinating
your care today. During this initial encounter, I want to verify the
information you provided to the ER up front, learn more about the
dizziness you have been having, do a good exam and then describe our
treatment plan…”
D Duration“I would anticipate that you will be here for 2 hours…this may vary
some depending on how you are feeling and the results of the
testing…”
E Explanation“Let me explain the plan with this new medication. It is designed to
reduce your dizziness. It can make some patients a bit drowsy and
perhaps lead to constipation…”
T Thank you“So I wish you all the best. Thank you for the opportunity to care for
you”
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Advantages of AIDET® & Key Words
Decreased anxiety with increased adherence
=Decrease
d Anxiety
Increased
Adherence+Improved clinical
outcomes, more
positive patient
experience and
greater
professional
fulfillment
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•Distance-based guide for interaction
•If you sense a need in a pt/family:
–10 feet: Make eye contact
–5 feet: Acknowledge them
10-5 Rule
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RECOMMENDATION: AIDET® + “The
Promise”
Tell the patient and family what kind of care
you plan to deliver
Excellent Great
Awesome
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When discussing matters of feeling and attitude, effective
communication is a function of:
Verbal Content: 7%
Vocal Expression: 38%
Visual Cues: 55%
What is important is "CONGRUENCE"
Common Sense Communication Skills
Albert Mehrebian
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Show Empathy
understand and
share the feelings of another
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Emotional Intelligence (EQ)
• Describes characteristics beyond technical skill and
cognitive intelligence
• Step one: be aware of your own emotional state/feelings
• Step two: recognize the patient’s
feelings/attitudes/emotional state
• Step three: modulate your response using key words and
empathic cues
• Example
–“I can imagine the frustration of being in the hospital for 2
weeks with this infection, getting home and now being
back in the ED…you have been through a lot recently…”
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Effect of sitting vs. standing on
perception of provider time
at bedside
0:01:28 0:01:40
0:03:44
0:05:14
0:00:00
0:01:26
0:02:53
0:04:19
0:05:46
Standing Sitting
Actual Time
Perceived Time
Conclusion:Simply sitting instead of standing at a patient's bedside can have a significant impact on patient
satisfaction, patient compliance, and provider-patient rapport, all of which are known factors in
decreased litigation, decreased lengths of stay, decreased costs, and improved clinical outcomes.Patient Educ Couns. 2012 Feb;86(2):166-71. doi: 10.1016/j.pec.2011.05.024. Epub 2011 Jun 30.
Effect of sitting vs. standing on perception of provider time at bedside: a pilot study.
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Adjuncts to Communication
•Patient communication
white boards
•Biocards
•Care cards
•PACS images
•EHR information
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Psychology of “Manage-Up”• Affirming statement which
forecasts positivity of an upcoming
experience, usually with an
individual or a process
• Sets a positive perception of the
care team or care process
• Example: “Dr. Hakim will be
seeing you shortly. He is an
experienced hospitalist who will
continue your inpatient care.”
• Example: “You are very fortunate
to have Judy as your nurse. She is
one of our finest and cares deeply
for her emergency patients…”
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High Impact Provider Handover
•Professional
•Cordial
•SBART
•The handover is
complete when the
patient and family have
been updated and
understand the care
transition
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Service Checklist
•Timely evaluation
•Warm demeanor
•Addressed concerns
•Narrated care plan
•Provided time estimate
•Comfort measures
•Empathy
•Closed the loop
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Deploying a Physician Training Program
29
How do we get this done?
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Slide 30
Educate Train Validate
Our approach (high level)
Why is this important? What are the skills ? How am I doing ?
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Studer Group-Partner Example
Physician Coaching Plan
2013 2014 2015
Focus Groups: ED and Hospitalist
ID’d focus groups
(ED and Hospitalists)
Core Communication Curriculum
Didactic training in 8 sessions
Relationships secured
Begin validation rounding
Intensive Shadow Rounding
with feedback to physicians
ID’d and trained ED champions
Champions begin validation
and training of colleagues
Physician Leadership core skill
training:
Physician Leader Rounding
Running an Effective Meeting
Phys CommunicationTexas, six-hospital system
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32
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33
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Healthcare Flywheel®
Connect
To
Purpose
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Purpose Worthwhile Work and Making a Difference
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LIVE
LEAD
LOVE
SERVE
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Wherever you go, no matter what the weather,
always bring your own sunshine.
Anthony J. D’Angelo
The College Blue Book
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Dan Smith, MD, FACEP
Medical Director
(850) 439-5882
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Next Presentation: See What Right Looks Like!
Physician-Patient Communication: Skills Lab
The Physician Coaching Team