1. No category

2012 Minnesota Alliance for Patient Safety Conference
Breakout Session #3
Tools for Identifying
Emotional Intelligence
Thursday, Oct. 25, 2012
11:10 a.m. – 12:10 p.m.
Presenter: Timothy B. McDonald, M.D.
Session Objectives:
1. Understand the methodology for addressing communication styles.
2. List differences in communication styles.
3. Appreciate the importance of emotional intelligence in communicating patient harm events.
Timothy McDonald, M.D., J.D.
Timothy McDonald, M.D., J.D., is a physician-attorney who has been involved in quality and
patient safety efforts at the University of Illinois Medical Center for the past decade. Until his
recent promotion to assistant vice president for quality and safety for the entire University of
Illinois, he served as the chief safety and risk officer for health affairs and the program director for
the pediatric anesthesiology residency program. His focus has been on the principled approach to
quality, medical liability and patient harm with an emphasis on the robust reporting of patient
safety events, near misses and unsafe conditions. He has helped pioneer the medical center’s
learner reporting process as a means of engaging learners from all professions and all specialties
in safety and quality education. The principled approach to patient harm also includes a
commitment to communicate within the health care team and with patients and families
throughout the therapeutic relationship. It also involves a promise to investigate and by working
with quality management create systems improvement following the detailed analysis of harm or
near miss events or other gaps in quality metrics. His federally funded research has focused on
all of these domains and their impact on improving the quality of care while mitigating medical
liability issues, including the establishment of teaching methodologies for all levels and
professions in health care.
Tools for Assessing Communication
Competence and Emotional
Intelligence
Timothy B McDonald, MD JD
Professor, Anesthesiology and Pediatrics
Chief Safety and Risk Officer for Health Affairs
University of Illinois College of Medicine at Chicago
University of Illinois Hospital and Health Science System
Overview
• Importance of Communication
• Individual Differences in Communication
Competence
• Cognitive Complexity
– Impressions of Liked and Disliked Others
• Message Design Logic
– Responses to Hypothetical Scenarios
• Discussion/Q&A
2
Importance of Communication
Conveying information
Providing emotional support
Coordinating and regulating behavior
Minimizing malpractice risk
Managing our own identities and those of
others
• Defining and redefining contexts, roles,
identities, meanings, relationships
•
•
•
•
•
3
Some more background
Institute of Medicine:
1999 report that
shook the medical
world
Some more background: the negative power of poor
communication after harm occurs
Institute of Medicine:
1999 report that
shook the medical
world
Making Matters
Worse
More issues related to communication
Part of the issue
• February 2012, Volume 31, Issue 2
• Impact on the medical malpractice community
Adding to the equation
• Journal of Trauma, September, 2010
• 8% of physicians generate 34-40% of unsolicited patient
complaints
• Same 8 % generate 50% of risk management expenses
• Physicians in bottom q-tile of patient satisfaction have 110%
malpractice risk
More value to communication
• July 2011, Volume 30, Issue 7
• 50-60 of claims dropped once information shared
12
Creating a communication consult
service
Communications assessment tool
Measures emotional intelligence
Assesses cognitive complexity
Identifies highly skilled communicators in
complex social situations
• Balances out the “special colleague” issue
•
•
•
•
Individual Differences in
Communication Competence
• Some people are more skillful communicators
than others.
• Some communication tasks/situations are
much more difficult than others
– Easy: describe your apartment
– Hard: disclose a medical error to a grieving family
• Differences in skill most visible in hard
situations
14
Disclosure Requires High Level of Skill
• Disclosure situations are hard
– Multiple, conflicting goals
– High level of emotional arousal
– High ego-involvement
– Highly consequential
• Critical to identify organization’s best
communicators for Patient Communication
Consult Service
• Communication skill predicts malpractice risk
15
Our Approach to Assessment
• The tasks you completed allowed us to make a
preliminary assessment of your
communication competence
• We will explain how we analyzed your
performance and how you performed
• Measures we used have a long history
• So first, a quick course in communication
theory!
16
Constructivism: A general theory of
communication competence
• Represent the social world in terms of bipolar
dimensions known as “constructs”
• Cognitive complexity refers to the degree of
differentiation, integration and abstractness of
one’s interpersonal constructs
• Cognitive complexity is correlated with
communication skill/competence
– More constructs => higher level of competence
17
Personal Constructs
• Construct is a bipolar dimension for
representing the social world
– kind/cruel, fair/unfair, happy/unhappy,
considerate/inconsiderate, genuine/fake
• Quality of social perception increases as
constructs increase in number, level of
abstractness, and level of integration
• Social skill increases similarly
18
Analogy #1: Image Resolution
http://en.wikipedia.org/wiki/Image_resolution
19
Analogy #2: Color Depth
1 bit (2 colors)
8 bit (256 colors)
2 bit (4 colors)
http://en.wikipedia.org/wiki/Color_depth
4 bit (16 colors)
16 bit (16,777,216 colors)
20
Analogy #3: Dimensionality of Data
Increasing the number, level
of abstractness, and level of
dimensionality in scientific
data has many benefits.
21
Benefits of Increasing Dimensionality
•
•
•
•
•
•
More acute perception
Greater insight
Improved predictions
Greater strategic understanding
Greater success in achieving goals
More effective action
22
Interpersonal Cognitive Complexity
The number, level of abstractness,
degree of integration of one’s
dimensions for representing the
social world
23
Benefits of Interpersonal
Cognitive Complexity
• Same benefits as increased dimensional data,
plus:
– More organized and integrated impressions of
others
– Greater ability to:
• recognize others feelings and dispositions; integrate
inconsistent information about others; understand
others thoughts, feelings and motivations; produce
effective messages, accurately and completely interpret
others messages, structure conversational interactions
(Burleson & Waltman, 1988)
24
Benefits (cont’d.)
• More differentiated, abstract and organized
system of constructs enables greater skill at:
– Social perception
– Impression organization
– Information integration
– Social evaluation
– Social perspective taking
– Message production
25
Measuring Interpersonal Cognitive
Complexity
• The Role Category Questionnaire (Crockett, 1965)
• Thought to elicit a representative sample of
respondent’s interpersonal constructs
• Describe one liked and one disliked other
– In as much detail as possible in 5 minutes each
– Focus on habits, beliefs, mannerisms, not physical
appearance
• Impressions can be scored for:
– Number of constructs (“differentiation”)**
– Abstractness of constructs
– Level of integration of constructs
26
Caveats
• Only measuring interpersonal cognitive
complexity (not measuring perception in other
realms)
• It is an imperfect measure
• Not measuring you IQ or value as a human
being!
• Interpersonal cognitive complexity continues
to develop over the entire lifespan.
27
Frequency Distribution of Number of Constructs
(i.e. Cognitive Complexity)
25
23
Frequency
20
15
10
4 standard deviations
above the mean!
8
7
4
5
2
0
10
20
30
40
50
0
0
0
60
70
80
1
90
0
0
100
More
Number of Constructs
28
Frequency of Construct Distribution
MHA Volunteers
Constructs
3.5
3
2.5
2
Constructs
1.5
1
0.5
0
10 thru 20
20-30
30-40
40 and >
29
Comparison of Construct Frequency
25
20
15
Co
Min
10
5
0
10 thru 19
20 thru 29
30 thru 39
40 thru 49
50 thru 59
60 thru 69
70 thru 79
80 thru 89
90 thru 99
30
Highly Complex Impression
(liked other)
• intelligent, intellectual, relaxed, down-to-earth,
approachable, genuine, humble, caring, kind,
thoughtful, loving, free spirited, respectful,
hilarious, insightful, discerning, intuitive,
composed, deferent, patient, deep, pensive,
considerate, multifaceted, complex, worldly,
ambitious, dedicated, shy, inspirational, friendly,
reliant, trustworthy, talented, infectious,
comforting, faithful, motivational, introspective,
pondering, committed, loyal, fun, bohemian,
adventuresome, generous, articulate (47
constructs)
31
Moderately Complex Impression
(liked other)
very positive, easy to get along with, has great
organizational skills, has a great sense of
humor and can make people laugh, is very
polite to others, has good manners, is a caring
person, is very giving, enjoys life, is very
creative, is a good writer, follow through with
was she sets out to do, is never late, likes good
food and good wine, will give you the shirt off
her back, knows how to love, loves animals, is
not self centered, most always looks on the
bright side, willing to be of service to others, is
very generous and laughs a lot. (23 constructs)
32
Average Complexity Impression
Funny, well read, thoughtful of others, a good
selector of gifts of gifts for others, a very
attentive father and grandfather, committed,
very goal directed, personally able to sustain an
effort in his work - self-motivated, a bit
opinionated, has some hold over of self worth
issues from his childhood which cause him to
take things personally that he shouldn't, tends
to project some of those type feelings to others.
(13 constructs)
33
Low Complexity Impressions
• Genuine and sincere, taking people at face
value and giving them the benefit of the
doubt until they prove otherwise. Strong
work ethic and team oriented. (6)
• Accepts blame, Acknowledges others
achievements, Level headed, trustworthy (4)
• Good Listener (1) (liked other)
• Narcissistic moron (2) (disliked other)
34
Construct Abstractness
• In increasing order of abstractness (Burleson
& Waltman, 1988):
– Physical descriptions
– Role descriptions, e.g., name, age, gender
– Descriptions of general behaviors or specific
actions
– Reports of specific or general beliefs and attitudes
– Abstract dispositional and personality
characteristics
35
Abstract & Concrete Constructs
• Abstract
– Open to new ideas, spiritual, contemplative,
moral, bohemian, multifaceted, infectious,
discerning, territorial, linear thinker, patriarchal
• Concrete
– Average build, dark brown hair, middle aged, tall,
always on time, well groomed, nice, mean, hardworking
36
Highly Integrated Constructs
• Focused on outcomes, but considers the means to the
end equally important; not afraid to move forward,
but does so in a well-informed manner; ready, aim, fire
at a quick but calculated pace; earlier in career was
ready, fire, aim.
• He doesn't see the world as black or white but listens
to everyone to see and understand their views. Even
when he disagrees he is respectful and has a complete
understanding of the other person's view point…He
doesn't agree with me to just agree, he stands he
ground but does it with grace and ease.
37
Development of Constructs over the
Lifespan
• From concrete to abstract
• From few to many
• From isolated to integrated
• Life-long opportunity for
learning, growth, development
38
Person-Centered Messages
“…those which reflect awareness
of and adaptation to the
subjective, affective, and relational
aspects of communicative
contexts” (Burleson & Waltman,
1988, p. 15)
39
Cognitive Complexity and PersonCentered Communication
• As cognitive complexity increases,
people produce increasingly personcentered messages
• As person-centeredness of message
increases, others tend to perceive
the message as more effective,
comforting, persuasive, etc.
40
The Logic of Message Design
• People differ in the way they reason from
goals to messages
• Developmental progression in basic concepts
of language and communication
– Expressive: language a medium for expressing
thoughts/emotions
– Conventional: Communication is a game played by
social rules
– Rhetorical: Communication is the creation and
negotiation of social selves and situations
41
Expressive Design Logic
• Premise: language is for expressing
thoughts/emotions
• Evaluative dimensions: Clarity of expression;
openness; honesty; unimpeded signaling
• Key message function: self-expression
• Time orientation: reaction to prior event
• Little attention to context
• Subjective and associative; incoherent
• Pragmatically pointless content
• Message adaptation by editing only
42
Conventional Design Logic
• Premise: Game played by social rules
• Evaluative dimensions: Appropriateness; control
of resources; cooperativeness
• Message function: Secure desired response
• Temporal organization: Present
• Action and meaning context determined
• Intersubjective and rule-focused coherence
• Focus on rights and obligations
• Saves face using politeness
43
Rhetorical Design Logic
• Premise: creation of social selves/situations
• Evaluative dimensions: flexibility; symbolic
sophistication; depth of interpretation
• Message function: Negotiate social consensus
• Temporal organization: Movement toward
desired context
• Communication creates context
• Explicit context-defining clauses and phrases
• Focus on rights and obligations
• Saves face by redefining context
44
Development of Competence
• Increasing cognitive complexity
• Increasing mastery of higher-level message
design logic
• Rhetorical messages and message producers
tend to be evaluated more favorably than
conventionals, who in turn are evaluated
more favorably then expressives
45
30
Num. Constructs by Group Project MDL
29
18.0769
13.25
0
Mean Number of Constructs
10
20
One-way ANOVA, F(2, 41)= 4.25, p = 0.02
1
2
3
46
Num. Constructs by Disclosure MDL
One-way ANOVA, F(2, 41)= 5.19, p = 0.01
19.5161
9.75
0
Mean Number of Constructs
10
20
30
31.6667
1
2
3
47
Goals of Disclosure Task?
• Depends on timing!
• Task goals?
• Interpersonal/Relationship goals?
48
Error Disclosure Elements
• Apology
• Nature of error, harm
• When, where error
occurred
• Causes and results of
harm
• Actions taken to reduce
further injury
• Actions to prevent
recurrence
• Describe error review
process
• Who will manage ongoing
care
• How system issues are
identified
• Ongoing
communicator/patient
advocate
• Names and contact info
• Offer counseling/support
• Consider costs, patient’s
bill
Patient Communication Consult Service flyer, UIC Dept. of Safety and Risk Management
49
Four R’s of Apology
•
•
•
•
Recognition
Regret
Responsibility
Remedy
Woods, M. S. (2004). Healing Words.
50
Communicating with Patients:
Generic Do’s
Introduce yourself by name and role
Find a private/appropriate place to talk
Sit down
Frame the bad news with preliminary remarks
Proper nonverbal behavior (posture, gesture,
facial expression, volume, rate, distance)
• LISTEN (silence is not bad)
• Use plain language (no jargon)
•
•
•
•
•
51
Do’s for Initial Disclosure
• Do
– Provide emotional support and reassurance
• Acknowledge & name emotional states
• Express empathy and regret about bad outcome (apologize)
– Only provide solid facts
– Express uncertainty as appropriate about event, cause,
prognosis
– Offer assurances of follow-up and reassure they will not be
abandoned
• We will investigate
• We will be in constant communication
• Provide contact information
– Ask them questions about their current understanding
– Provide opportunity for them to ask questions
52
Don’ts
• Speculate or jump to conclusions or make
unwarranted inferences (about cause or
outcome)
• Offer unsupported opinions
• Prematurely admit fault or accept blame
• Make promises you can’t keep
• Finger-point
• Digress into medical jargon
53
Example
Bill and Beth? (As I sit down I say) My name is xxxx, I am a xxxxx here at MCR. I understand you are here
with your daughter Mary while she has her GI procedure, correct? (Leaning towards them, calm, steady
and caring/concerned eye contact) I realize you both have been sitting out here in the lobby while the
Code Blue was announced overhead and you may have seen members of our healthcare team go into
Mary's room. Please know that I can appreciate how you seeing that may have been quite alarming,
and I want to candidly share the information that I have at this moment regarding what transpired. (As
I put my hand on theirs keeping my body language and eye contact calm) First and foremost, please
know that she is resting comfortably in the recovery suite at this time, and the nurse will come out in a
moment to take you back to her. As you may be aware Mary was scheduled to receive moderate
sedation during her procedure, and we monitor her vital signs closely during these circumstances.
When the team determined she was not breathing adequately towards the completion of the procedure
they called the Code Blue. We are committed to keeping you and Mary informed about what we
unearth as we investigate this situation further. The involved provider will be speaking to Mary and you
in a moment, and once we know more about precisely what happened we want to coordinate a followup care conference with you, Mary and the involved provider and staff as appropriate so that we can
afford us with the opportunity to provide further information and answer any outstanding questions you
may have. Does this sound like an acceptable plan at this time? I also want to give you my business
card so that we may keep in touch throughout our review process. I want you both to know you can call
me at any time if you have any concerns or questions for me. I am here to support you and Mary. I
want you to know that we genuinely are dedicated to delivery world class care, and if there are any
improvement opportunities that merit our attention we absolutely want to identify them. Do you have
any questions for me at this time? Otherwise, let me check with the nurse and get you both back to see
your daughter.
54
Example
Mr. and Mrs ...., I'm xxxx a xxxx. I'm so sorry to tell
you that there were some complications during
Mary's procedure so that she was not breathing as
deeply as she should have been. We have been able
to get her breathing, heart rate and blood pressure
back to normal ranges, but do not know for sure
right now what her outcome will be. I know this
must be a terrible shock to you. I'll certainly try to
answer all the questions you undoubtedly have, but
there may be some questions that I won't have any
answers for right now. Is there anyone we can call
that you would like to have with you?
55
Example
Mary is doing well and is resting comfortably.
She had a bit of struggle toward the end of the
procedure, however, she received the care
necessary to keep everything on the right track.
We will give her a few minutes to get settled and
you can go in and see her.
56
Example
I regret that Mary had a bad cardiopulmonary
event, and she had to be resuscitated because
she was not breathing and her heart rate
decreased to a very low level. Mary is OK now.
This problem may have had something to do
with the sedation given to Mary for the
procedure.
57
Example
Hello, are you X? I am X. I would like to update
you on the procedure. Toward the end of the
procedure Mary breathing stopped and her
heart rate was very low. Currently her vital signs
are in the normal range.
58
Example
Bill and Beth, I need to discuss the outcome of the procedure that we just
completed. And I'm afraid that I need to deliver some bad news. During the
procedure Mary stopped breathing at one point and her heart rate dropped
down to 30 beats per minute, which is well below what it should have been.
We had to perform CPR on your daughter and we did get her breathing, pulse
and blood pressure back to normal. We've transferred your daughter to the
ICU and will have to wait to see what impact this will have on her brain's
functioning. Our team, and I'm guessing you as well, have a lot of questions
about what may have occurred during the procedure that led to this
occurring. We'll be looking at the monitoring during the procedure as well as
the amount of sedation given and any other factors that may have
contributed to this happening to your daughter. And I want you to be assured
that as we find out all of the facts, we'll be letting you know exactly what
happened. This would be hard news for anyone, and I can only imagine how
hard it is for you to hear this. How are you feeling right now? What can I do
fo you? What other questions do you have for me?
59
Example
…I'm sorry that this happened. It was my
responsibility to manage the sedation and I
administered too much of the sedative
medication. I don’t know the extent of the
damage if any from the sedation but I want
assure you that I will be involved in helping
her recovery and the hospital will assist with
any recovery, including medical care and
expenses, if need be…
60
Example
I have made a mistake in caring for your mother. She received too
much sedation during the case.…I am sorry for everything that has just
occurred. I know that it is going to be difficult to process now and as we
move forward. However, I would like to get your input and have you be
a part of the process for change in the future. It may be too early to talk
about this now, but my hope is that we can create a plan for change to
avoid this in the future. Patient and family input is very helpful. Please,
when you are ready, let me know if you would like to be a part of this
change. I am going to discuss the case with other members of the
team including the nurses, other physicians, and staff. I will ask for
their input and advice as well. We will discuss what went well, what did
not, and what is needed for future situations such as these. Again, I am
very sorry for my mistake. I want to prevent this in the future and hope
that you will be a part of the process of making that happen. Here is my
contact information if you would like to talk about this further or have
other questions.
61
References
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complexity. Central States Speech Journal, 33, 333-338.
Burleson, B. R., & Waltman, M. S. (1988). Cognitive complexity: Using the role category questionnaire. In C. H.
Tardy (Ed.), A handbook for the study of human communication: Methods and instruments for observing,
measuring and assessing communication processes. Westport, CT: Ablex.
Burleson, B. R. (2006). Constructivism: A general theory of communication skill. In B. B. Whaley & W. Samter
(Eds.), Explaining communication: Contemporary theories and exemplars. Mahwah, NJ:Erlbaum.
Burleson, B. R. (2003). Emotional support skills. In J. O. Greene & B. R. Burleson (Eds.), Handbook of
communication and social interaction skills (pp. 551–594). Mahwah, NJ: Erlbaum.
Crockett, W. H. (1965). Cognitive complexity and impression formation. In B. A. Maher (Ed.), Progress in
experimental personality research (Vol. 2, pp. 47–90). New York: Academic Press.
Delia, J. G., O’Keefe, B. J., & O’Keefe, D. J. (1982). The constructivist approach to communication. In F. E. X.
Dance (Ed.), Human communication theory: Comparative essays (pp. 147–191). New York: Harper & Row.
O’Keefe, B. J. (1988). The logic of message design: Individual differences in reasoning about communication.
Communication Monographs, 55, 80–103.
Woods, M. S. (2004). Healing words: The power of apology in medicine. Oak Park, IL: Doctors in Touch.
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