Disclosures Receive consultation fees and honoraria for consultation and training provided to academic and health care organizations with a focus on communication, teamwork, competency assessment, self management support Co-owner of MedFAD.com, a competency assessment software company Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Objectives Learn a communication model blending skills that enhance quality of care and efficiency. Apply an assessment tool to learn rapport building, agenda setting, respectful interrption, and effective visit closure Plan how to incorporate skills into a team approach to care.

Observation Form Purpose and Training The value Structures vision Creates and standardizes vocabulary Primarily for formative assessment and to strengthen the “observer self” (mindfulness) Online training: www.pcof.us

PCOF Use Behavior in either of the columns to the right of thick vertical line is in the competent range Observers mark accurately and avoid giving the benefit of the doubt Feedback is best: When solicited Specific, rather than general Curious, not judgmental Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Relationship Communication and Efficiency: Creating a Clinical Model from a Lit Review Mauksch et al, 2008, Arch of Intern Med, 168 (13) 1387-1395 Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective 3. Co-creating a plan SMS: problem solving

EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA. 2017 March 14th Excuse yourself (acknowledge and/or apologize) Empathize with the problem that is being cut off Explain why you are interrupting Planning time use Finishing an important topic (topic tracking) Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Interruption: Important cue Mr. Fredricks, forgive me for stopping you. You just said something about wondering if your thigh pain was in your bones and perhaps serious. Can we go back to that? It sounds like you have some important concerns that I want understand further.

EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA EEE: Polite Interruption Mauksch. Questioning a Taboo…, JAMA. 2017 March 14th Excuse yourself (acknowledge and/or apologize) Empathize with the problem that is being cut off Explain why you are interrupting Planning time use Finishing an important topic (topic tracking) Stopping to explore an important cue Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting

Visit Organization Agenda collision Acute Chronic HM / Preventive SMS

Upfront Collaborative Agenda Setting Brock, Mauksch, et al Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst, Health, 2001 Identifies patient’s priorities Organizes the visit Decreases chance that patients or providers will introduce “oh by the way” items Screens for mental disorders Facilitates shared decisions about time use between acute, chronic, and health maintenance care Does not lengthen the visit; protects time for planning Decreases clinician anxiety

Agenda Creation Orient the patient: Ask, “what is most important” “I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will help us make the best use of time”. If the list is greater than three items, the patient is screen positive for depression or anxiety Ask, “what is most important” Listen (feel) for the most important concern Avoid premature diving by patient or yourself When needed interrupt the patient or yourself: Acknowledge, Empathize Share reasoning

Diving or Agenda Setting New What is on your list of concerns today? In addition to your ear pain is there something else? Let’s make a list of your concerns and then figure out how to make the best use of our time? Old What are we doing today? How are you? What can I do for you? What is going on? Tell me about your ear pain.

Agenda Setting Missteps and corrections Provider diving Interrupt your self: “ I am getting ahead of myself” Patient diving Interrupt with an apology, empathy, and reason “I apologize for interrupting. Your sleep is a concern but before we talk about it, is there something else?” No orientation to purpose of agenda setting Orient: “Lets plan the use of time before we use it” In “trying to do too little” : Add ? After …this plan.

Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Explore the Patient Perspective When: Promoting self management and behavior change Detecting clues about thoughts or feelings Family or cultural influences are suspected Psychosocial factors may be present There are unexplained medical symptoms You sense distrust in the health system Desired change does not occur Contemplating a major health care decision Discussing palliative care (PalCOF)

Exploring Patient Perspective: Core Skills and attitudes Curiosity Empathy Remembering, when patients do not do something, there is always a reason Cultural humility Skills Reflective listing Open ended, focused questions Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med Ongoing influence Rapport and Relationship Mindfulness Topic Tracking Empathic response to cues Sequential 1. Upfront collaborative agenda setting 2. Hypothesis testing and understanding the patient perspective 3. Co-creating a plan Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Co-creating a Plan Assess patient’s preferred decision role State clinical issue / decision to be made Describe options Discuss pros and cons Discuss uncertainties Assess patient understanding Ask for patient preferences Resolve decision differences Plan respects patient goals and values

Closing the visit Combine Teachback and AVS and share the screen Questions Teachback After visit summary Combine Teachback and AVS and share the screen

Links to Online Training Patient Centered Observation Form (PCOF) www.pcof.us Palliative Care Observation Form (PalCOF) www.palcof.com Family Centered Observation Form (FCOF) https://sites.google.com/view/fcof Larry Mauksch, M.Ed University of Washington Department of Family Medicine

TEAM COMMUNICATION TRAINING Team members reinforce use of communication skills in one another Shared learning of skills builds team function

Mastering a Skill Domain Practice Real situations Learned from expert: description demonstration Feedback Specific Sensitive Developmentally appropriate Reflection Promotes analysis Synthesis Integration

Common Training Sequence Introduction to PCOF Group rating and discussion of C/B Videos Teamlet members observe each other using extended appointment slots Groups meet to share learning and set goals Within teamlets Across teamlets Recurrent observations and team meetings for reinforcement Do the cycle again to learn more skills and achieve more goals Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Patient Template: Teamlet training 8:30-8;40 discuss needs of first three patients 8:40-8:45 MA bring patient to exam room and explains teamlet training- at some point is joined by MD, ARNP or PA 8:45 -9:30 8:45 to 9:00 MA interview patient and MD observes 9:00 to 9:30 MD interviews patient and MA observes 9:30 to 9:40 debrief encounter 9:40 MA gets next patent and repeat cycle two more times Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Observer Foci 1) Skills on the PCOF 2) Overlap with Lean approach Those done well Wonder about doing something differently 2) Overlap with Lean approach Going where the action is Value stream thinking- study the present, plan the future Standard work Raising skills to the ceiling of role capacity Work supported by coaching Reveal waste Change designed by folks who do the work

FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW Practice Reflection and Commitment to Change Tool JOUR OF CONTIN EDUC IN HEALTH PROFESSIONS, 35(3):166–175, 2015 The most useful information for me was: This highlighted the following gap in my practice: FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW I will change my current practice in the following way: Barriers I anticipate: What changes to my current practice am I considering? What would enable me to change What confirmed my current practice? What supports my current practice? I am not convinced there is a need to change my current practice because:

Networking Introduce yourself to the other occupants at the table; Provide your name and your role.   QUESTIONS FOR DISCUSSION: From what you have just heard are there skills and tools that you want to incorporate into a team approach to care?  How do you plan to incorporate these into your practice?