How to Achieve a Win-Win-Win: The PatientPhysician Dialogue and CAHPS Wendy Leebov, ED.D., Leebov Golde Group www.theberylinstitute.org Texas Health Resources Center for Learning and Career Development is an approved provider of continuing nursing education by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. DISCLOSURE TO PARTICIPANTS How to Achieve a Win-Win-Win: The Patient-Physician Dialogue and CAHPS To receive contact hours for this continuing education activity you must attend the entire program, complete the evaluation form, and turn in the yellow copy of the “Certificate of Successful Completion”. This activity is 1.75 contact hours. The purpose of this activity focuses on helping attendees understand the importance of communication in the healthcare setting and on how subtle changes in wording and behavior of medical staff can have great impact on patient satisfaction. RN leaders can utilize this information to make behavior changes to significantly improve their relationships with patients. The Objectives of this activity are: 1. Identify the benefits of the quality patient-physician relationship for the patient, the physician and the organization. 2. Identify specific physician communication skills key to high ratings on HCAHPS and CG-CAHPS as well as positive clinical outcomes 3. Identify organizational strategies for engaging physicians in improving their relationships and outcomes with patients and families The planning committee members and faculty/content specialists of this CNE activity have disclosed no relevant professional, personal or financial relationships related to the planning or implementation of this CNE activity. Approved provider status of Texas Health Resources Center for Learning and Career Development (THR C4L) refers only to the continuing nursing education activity and does not imply a real or implied endorsement by THR C4L, the American Nurses Credentialing Center (ANCC) or the Texas Nurses Association (TNA) of any commercial product, service, or company referred to or displayed in conjunction with this activity, nor any company subsidizing costs related to this activity. This CNE activity does not include any information about off-label use of any product for a purpose other than that for which it is approved by the U.S. Food and Drug Administration (FDA). The ANCC COA is interested in the opinions and perceptions of participants at approved CNE activities, especially in the presence of actual or perceived bias in continuing education. Therefore, ANCC invites participants to access their “ANCC Accreditation Feedback Line” to report any noted bias or conflict of interest in the educational activity. The toll free number is 1 (866) 262-9730. WENDY LEEBOV, ED.D. HOW TO ACHIEVE A WIN-WIN-WIN: THE PATIENT-PHYSICIAN DIALOGUE AND CAHPS Wendy has been a passionate advocate for the exceptional patient and family experience for more than 30 years. Through Leebov Golde Group, Wendy provides high-impact consulting services, training and tools that enhance the patient and employee experience. Wendy received her B.A. in Sociology/Anthropology from Oberlin College and her master’s and doctorate from the Harvard Graduate School of Education. A communication fanatic, Wendy has written twelve books for health care and produced the powerful, video-based Language of Caring Skill-Building System for health care. Wendy also issues a free, monthly, tool-packed e-newsletter HeartBeat on the Quality Patient Experience. www.theberylinstitute.org www.theberylinstitute.org How to Achieve a Win-Win-Win: The Patient-Physician Dialogue and CAHPS Wendy Leebov, Ed.D. President and CEO Leebov Golde Group 215-413-1969 Study by Beryl Institute and Catalyst “State of Patient Experience in American Hospitals” April 13, 2011 25% of respondents (executives and strategy champions) said physicians are a major roadblock to improving the patient experience. Patient experience strategies have largely engaged leaders and employees. With physicians, most of us have walked on eggshells. Engaging Physicians: Now is the Hour—for Your Organization! Forces at Work Impact? Physician impact on clinical outcomes • Mission fulfillment • Factor in Value-Based Purchasing • Factor in ACO payment Physician performance on HCAHPS • Public scrutiny and reputation • $$$: Factor in VBP and ACO payment Accountable Care Organizations (ACOs) • More employed physicians • Key to success: Alignment/teamwork • Patient experience: Payment factor Nursing shortage by 2020 • 50%+ soon to retire; People over 65 • Reforms giving millions access • Need to improve physician-nurse relationships for nurse retention Need for anti-blame “Just Culture” for patient safety • Need to engage physicians as accountable team players Reported decline in physician quality of life • Recruitment, retention, morale When providers buy into patient experience strategy--- • Outcomes improve! For Physicians: Now is the hour! Factors Physicians feel: Accountable Care Organizations (ACOs) • More employed physicians • Must work as a team, not independents HCAHPS and CG-CAHPS: • Public reporting • Public scrutiny • Transparency • Unsettled • Apprehensive • Anxious Pay-for-performance MOTIVATED! Stress, quality of life MOTIVATED! • Self-conscious • Accountable Patient Experience Strategy with Physicians: Objectives Help physicians join and contribute to positive culture Help physicians be optimally effective with patients and families Help physicians build relationships and collaborate Key Mindset Shifts Paternalistic Patient-Centered Expert and Fixer Partner Captain of the Ship Team Leader/Coach Independent Entrepreneur Good Citizen in Caring Community ThreePronged Strategy 2. Skill-building to improve the patient-physician relationship 1. Engage physicians as partners in strategy planning. 3. Develop and support physicians as team leaders and coaches. 1. Engage physicians as partners in strategy planning. • Plan with them, not for them. • Explore vision and “what’s in it for us?” • Physicians have to create, shape and OWN the strategy. Start with Champions/Allies. Find out: • Your vision • Suggested objectives • For you: Why this? Why now? • Force-field analysis: What’s working for us and against us? • WHO should we engage in the planning process? – Formal leaders – Informal opinion leaders? • HOW can we engage others Groundwork Plan Engage Formal Leaders. • Who? – CMO – Chief Hospitalist – Department Chiefs – Heads of Residency Programs – CNO • Need courageous conversations? – Example: Tex Landis, MD, asking CMO, “What legacy do you want to leave?” Engage informal leaders. • To ensure contagion, build on Gladwell’s Tipping Point • Identify and mobilize – Connectors – Promoters – Information Mavens Key Person Interviews and Recruitment by Champions Planning Process: Engagement Methods Planning Team: Formal and Informal Leaders Open-Door Focus Groups On-Line Focus Groups By Email Planning Team Agenda • Why this? Why now? – What’s in it for patients? – What’s in it for physicians? • Show scores: – Invite ideas on recognition for high-scorers – Invite interpretation and identification of opportunity • Invite and discuss strategy options What’s in it for physicians? Higher Scores Coworker Support Improved Outcomes Pride Personal Growth $$$ Performance-Based Pay • Increasingly, physicians are on pay-for-performance plans. – Hospital-based – Group-based 2009 2010 51% 63% 75% 92% • As of 2011, 50% of hospitals, health plans and medical practices use patient satisfaction/patient experience scores as significant factor in formula – Source: 2010 Physician Compensation: Prevalence and Planning Report, Hay Group Patients talk and other consumers listen. • Satisfied patients tell 3 others. • Dissatisfied patients tell 25+ via social media. • It takes at least 7 satisfied patients to offset one dissatisfied patient. • The grapevine affects patient recruitment and retention. Zimowski (HC Fin. Management, 2004 150 sites offer data about providers! VITALS.COM Communication problems are the cause of the vast majority of lawsuits. • Physicians in middle third on ratings have 26% more lawsuits than physicians in top third. • Physicians in lowest third have 110% more lawsuits than those in top third. – H Stelfox et al, 2005 – H Rodriguez et al.; 2008 Dissatisfied patients defect. On average, in a 6-month period: • 4% of satisfied patients switch physicians. • 16.8% of dissatisfied patients switch physicians. – H. Rubin et al., 1993 For every patient you retain, you tap into their lifetime value. 2. Skill-building to improve the patient-physician relationship Breakthrough Objective: Sharpen Physician Communication Skills There is hard evidence that effective COMMUNICATION AND INTERPERSONAL FACTORS are central to: • • • • • • Adherence to treatment plans Greater patient satisfaction and loyalty More appropriate medical decisions Reduced malpractice claims Better health outcomes Greater physician satisfaction Suarez-Almazor, Hughes,Stelfox, Press, McGlynn, Lussler, Levinson, Lohr, Sobel, Donabedian, IOM Crossing the Quality Chasm Report and many more CAHPS: “Doctor Communication” Questions in Every Version! HCAHPS CG-CAHPS Physician Communication Items Patient-Centered Medical Home Items on Physician Communication (tentative) • Explains things in a way that is easy to understand; avoids medical words that you don’t understand • Encourages questions and two-way conversation] • Gives you understandable and accurate information about tests, medications, etc. • Listens carefully to you • Gives you information about things that are important to you Special Item Sets for HCAHPS and CG-CAHPS: Cultural Competence Item Set • Providers are polite and considerate (3 items) • Providers are caring and inspire trust (5 items) • Patients’ rating of trust in provider (on a scale of 0 to 10) (1 item) Breakthrough Objective: Build Communication Skills How? Training and Tools • Behavioral Feedback • Group and Individual Kaiser Study Starting with Feedback: Beyond CAHPS HCAHPS • Delayed • Topically insensitive • Unit-based TruthPoint • Timely • Relevant • Personal Skill-Building Strategy: Components That Lead to Concrete Improvement Overview/ Jumpstart • Why this? Why now? • What’s in it for you? • Overview of skills Briefings • Short, digestible bytes • Tailored to time constraints/short attention spans Mastery Tools • For use over time • Reminder cards, self-checks, peer observation, personal coaching, Decisions about Target Groups • Entire medical staff? • Targeted subgroups? – Hospitalists? – Residents, fellows and students? – Attendings vs. employed physicians? • A combination: Jumpstart for ALL, followed by skill application and mastery in homogeneous work teams Communication Skill Content: Seven Competencies Mindful Practice Engaging Patients as Partners Effective Openings and Closings Collaboration And Teamwork Effective Explanations Communicating with Empathy Hard Conversations Mrs. Fry Talks with Tex Landis, MD Mindful Practice • • • • Paying attention With purpose In the present moment Without judging Mindful Practice Mindful Practice • Quiet your mind. • Take a deep breath. Bring your full attention to the present moment and the person in front of you. • Sit. Lean in. Adopt an open, receptive posture. • While the person is speaking: Maintain eye contact. Be quiet. Don’t interrupt. Don’t think about what you’re going to say or do next. • Avoid multitasking (shuffling papers, taking notes, looking at computer). • Resist interruptions. • Tune in fully. Effective Openings and Closings • The Effective Opening: How to greet the patient to jumpstart openness and trust The Effective Closing: How to end so that the patient feels safe, cared for, and clear about their next steps. The Effective Opening Effective Opening s and Closings • Welcome the patient. • Personalize your care by showing knowledge of the patient. • Elicit all of the patient’s concerns. • Negotiate the visit agenda together. The Effective Closing • How to check for understanding using TeachBack • How to ensure closure • The last 6 seconds Effective Opening s and Closings Engaging Patients as Partners • • • • • • “Nothing about me without me!” Encourage the patient to speak up. Share control. Find out the patient’s perspective and theories. Use partnership language. Collaborate on goal-setting. Engage the family. Communicating With Empathy Communicating with the Empathy patient’s • Understanding experience, concerns and perspective • Acknowledging and validating the patient’s feelings Empathy Skills Communicating With Empathy • Communicate empathy verbally. – Acknowledge and validate the patient’s feelings. – Use Heart-Head-Heart Communication • Communicate empathy nonverbally. – Match your nonverbal behavior to theirs. – This is a form of listening or nonverbal attunement. Hard Conversations • Ahead of Time: Adjust your mindset. Adopt an outlook of appreciation and goodwill. Hardand conduct the hard • Use an effective model to plan conversation. E.g. Conversations 1: State your positive intent. 2: Tell the truth fast. 3: Listen and understand. 4: Find common ground. 5: Identify options and your action plan. 6: Express appreciation. ….with patients, family members and coworkers! Collaboration And Teamwork The Indicators • Everyone on the team values and respects every other person on the team---as an individual of importance, with something to contribute. • Everyone PARTICIPATES fully. • People communicate in an open and empathic way. • People help each other. • And everyone’s priority is the patient’s well-being. The Skills Collaboration And Teamwork • Acknowledge and appreciate everyone involved in the patient’s care. • Invite diverse perspectives and open your mind to them. • Communicate with empathy in strained interactions with coworkers. • Transfer TRUST during handoff • Ask for what you need or want in a clear and caring way. • Initiate relationship-building conversations. “But we don’t have enough time!” The Man with the Saw What happens when physicians refresh these skills? Peace Health Results Align Performance Management Practices to Support and Advance Excellent Physician Communication. Hiring Process Job Descriptions By-Laws Peer Feedback Process Pay-forPerformance Disruptive Physician Process 3. Develop and support physicians as team leaders and coaches. Help physicians step into their power. “But we don’t have any power!” • Few see themselves as managers of each other. Many feel little or no authority. • Help them reframe: – Replace “captain of the ship” with “team leader” – Remind them of the power they DO have---to set tone, be role model, engage everyone’s hearts and minds, encourage, coach, partner….as TEAM leaders. – Help them step into their informal power. How to Engage Physicians as Team Leaders and Coaches • Engage in strategy planning • Develop and train champions: – To facilitate skill-building – To coach peers • Equip ALL physicians to hold cup-of-coffee conversations with peers Recap: ThreePronged Strategy! 2. Skill-building to improve patient-physician relationship 1. Engage physicians as partners in strategy planning 3. Develop and support physicians as team leaders and coaches Physician Engagement in the Patient Experience: It’s a WIN-WIN-WIN! Patients/ Families/ Staff Sterling HCAHPS Performance Thank You Wendy Leebov, Ed.D., President and CEO Leebov Golde Group 215-413-1969 [email protected] www.quality-patient-experience.com BREAK Breakout Sessions begin at 2:45 pm www.theberylinstitute.org