Improving Communication

Skills at a Large Academic

Medical Center:
Cleveland Clinics Experience

Timothy Gilligan, MD, MS

Co-Director
Center for Excellence in Healthcare Communication
Cleveland Clinic

Typical medical questions

Whats the best treatment for a heart attack?

Which drugs are most effective for metastatic lung
cancer?

For good risk metastatic testis cancer, is four cycles of

BEP chemotherapy better than three?

Key communication questions

How do you make someone feel important?

If a patient demands something inappropriate, how can
you form a strong relationship without giving it to him?

Whats the best way to give someone terrible news?

What is the most effective way to ensure adherence to
a treatment plan?

What is the most effective way to obtain informed

consent?

Key communication questions

What should you do if a patient starts to cry?

Or gets angry?

What if a terminally ill patient asks Am I going to die?

How can you show someone that you care?

Why should we care about communication skills?

Effective Communication
Improves patient satisfaction
Like et al., 1987; Kaplan et al., 1989; Ong et al., 1995; Weinman et al., 1998

Decreases patient emotional stress

Roter, 1995

Improves treatment adherence/compliance

DiMatteo et al., 1993; Squier et al., 1990; Brashers et al., 2000; Ciechanowski et al., 2001

Improves health outcomes

Woolley et al., 1978; Patrick et al., 1983; Stewart et al., 1995

Reduces medical errors and malpractice

Levinson et al., 1997; Lester et al., 1993; Beckman et al., 1994; Sutcliffe et al., 2004

Improves physician satisfaction

Suchman et al., 1993,Educ for Health, 2004

Communication
skills challenges

Communication
skills challenges
according The New Yorker

It must be for you my people love me.

Its the only treatment option he has under his current health plan.

Well, right now Im feeling a little uncomfortable

Dont freak out its just a save-the-date.

So what am I doing here knighting, beheading, or what?

Its a simple stress test I do your blood work, send it to

the lab, and never get back to you with the results.

What communication skills do clinicians

need to be able to implement?

How to connect with other human beings

How to listen without controlling the conversation
How to recognize, identify and respond to emotion
How to respond constructively to difference,
disagreement and conflict

How to communicate in such a way that the listener

understands and remembers

Benefits of better communication skills

Improved medical outcomes

Improved patient adherence
Improved patient safety
Improved patient satisfaction
Improved physician satisfaction
Reduced risk of malpractice litigation

HCAHPS & CG-CAHPS

Increasing accountability

HCAHPS Doctor Communication

During this hospital stay
how often did doctors treat you with courtesy and respect?
how often did doctors listen carefully to you?
how often did doctors explain things in a way you could
understand?

MD Communication
Domains of negative comments in 2012

Others
6%
Complaint
6%

DischargeBehavior
3%
4%

Skill
2%
Access / Time
34%

Listening
6%

Explain
18%
Coord /Plan of Care
21%

What have we done at Cleveland Clinic?

3-4 years ago, surveyed the current environment of

communication in healthcare

Reviewed the published literature, visited other

medical institutions and consulted experts in the field

Interviewed our top performers

Hired AACH to train a group of 5 physicians in
communication and facilitation skills

Developed a one-day (7 hour) course

Brought in outside experts to help us grow our skills

Communication
Curriculum

Foundations in
Healthcare
Communicaiton
(FHC)

Advanced Courses
Coaching
Center for Excellence
in Healthcare
Communication
(CEHC)

Faculty
Development

Research

Train the Trainer

Program

Evolution
Beginning (late 2011)
FHC one day a month

Now
6-7 times a month

Evolution
Beginning
FHC one day a month

Now
6-7 times a month

5 MD facilitators

23 MDs, 6 PhDs/CNPs

Evolution
Beginning
FHC one day a month

Now
6-7 times a month

5 MD facilitators

23 MDs, 6 PhDs/CNPs

Elective

Mandatory new staff

Evolution
Beginning
FHC one day a month

Now
6-7 times a month

5 MD facilitators

23 MDs, 6 PhDs/CNPs

Elective
External TTT

Mandatory for new staff

Internal TTT program

Evolution
Beginning
FHC one day a month

Now
6-7 times a month

5 MD facilitators

23 MDs, 6 PhDs/CNPs

Elective
External TTT
~50 MDs through first 3-

Mandatory new staff

Internal TTT program
>700 MDs trained, long

4 months

wait list

Evolution
Beginning
FHC one day a month

Now
6-7 times a month

5 MD facilitators

23 MDs, 6 PhDs/CNPs

Elective
External TTT
~50 MDs through first 3-4

Mandatory new staff

Internal TTT program
>700 MDs trained, long

months

Started with Four Habit

model

wait list

Designed new model

(REDE)

Structure of FHC Course

4 key skills presented

Brief didactic

demonstration

skills practice

Discussion of difficult cases from the participants practices

followed by skills practice exercises

Each session has 8-10 participants, is taught by two

facilitators and utilizes two standardized patients

Key strategies

Not about hugging

Doc to Doc
Safe setting with 8 to 10 participants

Focused on skills practice

Let MDs bring their own cases that haunt them
Dedication to model of supportive facilitation
Surgeons represented among facilitators
Leadership support verbiage, time
This is an investment in our staff

Facilitation, skills practice, small groups

Adult learners remember 10% of lectures

Re-enforcing effective behaviors results in more
behavior change than criticizing ineffective behaviors

If you want to be able to re-enforce success,

it helps if you prepare the learner to succeed

Treat clinicians the way we want them to treat patients

Increase buy-in by having learner identify goals
Having the learner discover something for herself is
more effective than telling it to her.

Most communication skills problems

fit in one of a few categories

Failure to express empathy effectively

Allowing unnecessary conflict to develop
Talking too much
Listening ineffectively
Communicating in a way that does not result in
increased patient understanding

Not allowing the patient to participate in setting the

agenda and negotiating a plan of care

Our Data

Doctor Communication
Main Campus Overall

Source: OPE Database

Date of data extract: 11/16/12

HCAHPS - Dr. Communication

Outpatient Survey

Dont forget that this is about culture change,

and therefore:

You will encounter resistance

Progress will be slow
You will need to cultivate internal and external allies
Consistent reinforcement will be needed
Can only be effective if part of a multi-pronged strategy

Key qualities/capacities to cultivate

Curiosity
Reflective practice
Openness
Empathy
Respect

Key unanswered questions

How do we reliably measure a clinicians

communication skills?

How do we reliably measure the impact of improving

communication skills?