Best Practice Recommendations: Teaching residents patient-centered communication Pita Adam, MD, MSPH Keri Hager, PharmD, BCACP Mary Dierich, PhD, RN, C-GNP Courtney Murphy, PharmD Student

Participants should be able to: List the pros and cons of using the Patient Centered Observation Form (PCOF) to teach patient-centered communication. Modify their teaching of patient-centered communication curriculum based on data from our Best Practice Recommendations. Balance local resources required to teach patient- centered communication through observation.

Why Communication? Why Observations? IOM 2001: Patient Centered Care ACGME/milestones: Communication: Subcompetencies and milestones Push to include observations 2018: CMS reimbursement for quality and satisfaction Family Medicine has been doing this for awhile and can teach our healthcare colleagues

UMN Residency Programs Core Affiliated UMMC- Smiley’s Clinic NorthMemorial – Broadway Clinic St. Joseph’s – Bethesda Clinic St. John’s – Phalen Clinic Mankato (rural) Duluth (semi-rural) St. Cloud (semi – rural) Methodist (Twin Cities) Collaboration: Departmentally supported monthly meetings of different groups to share curricular and clinical best practices.

About Us Program Number of residents Number of FM Faculty Number of BH Faculty BH Fellows UMMC 18 8 1 (plus 10% Community) 2 (each 50% FTE) B 24 7 1 C 5 1 (intermittently) D 30 10 1.3 E 15 3

Our Experience 2009: Department started focusing on patient satisfaction scores Invited Larry Mauksch to our Integrated Behavioral Health conference Introduced Patient Centered Observation Form (PCOF) Trained audience Attendees: Beh Health, PDs, Med Directors, Clinic Mgrs Departmental mandate: 6 PCOFs/resident/year

PCOF Creator: Larry Mauksch, University “We have a tool” – Called the PCOF (Patient Centered Observation Form) . Derived by Larry Mauksch from the Essential Elements of Medical Communication: Kalamazoo Consensus Statement 1999 What this form does is break down the patient-physician visit in the outpatient setting into its’ component behaviors, starting with “Establishing Rapport” and ending (on the other side) with Closure. It follows a typical visit: So - first thing you do – is establish rapport. It then goes on to Maintaining relationship, which is something you start doing at that time and continue throughout. You then do Agenda setting. And so on. The columns on the right are how you are rated. The one on the left is …. The one in middle… The one on right … The more the clinician is on the right the more patient centered they are. How do you know which column the resident is in? By the number of behaviors they exhibit. These behaviors are listed on the left. What is so great about this is that you can be very clear when working with the resident in instructing them how to do this. How often have you seen a resident interact with a patient, realized it wasn’t great, but then really didn’t know what it was they needed to do better? Usually you know what they SHOULDN’T do but not always what they should. The developer of this tool (Larry Mauksch) has been using it for many years, so have we, and has modified it continuously to improve it. There is some data on its effectiveness as a teaching tool. Creator: Larry Mauksch, University of Washington Dept of Family Medicine Larry Mauksch, M.Ed University of Washington Department of Family Medicine

PCOF – what is it? One page observation tool Patient visit broken down into discrete components (Skill Sets) Each component is defined by discrete behaviors (Elements) Observer notes number of elements witnessed More elements = more patient centered

Our Experience Behavioral Health faculty are local champions of the observation curriculum Each residency’s curriculum is locally tailored Culture of Integrated Behavioral Health The health system continues to collect patient satisfaction data and publish it

Data collection Focus group (n=7) and interviews (n=3) of BH faculty Qualitative analysis with verification to derive themes Family Medicine faculty survey regarding the BH themes (n=27/33) Coordinator survey to collect curricular data

Video Review & Observation Curriculum Program # VR/resident/y # Obs/resident/y # PCOF/resident/y Where UMMC 4 7 12 14 11 Inpatient and Outpatient B 1 5 6 Outpatient C 3 D 2 8 E

Family Medicine Faculty Results (n= 27) Question % Yes Sub-question Do you know what PCOF is 85% Were you trained with PCOF as resident 30% Was it effective? 100% - yes Were you trained as a faculty to use the PCOF? 39% Have you completed a PCOF on a resident? 83% How comfortable are you using PCOF with resident? 84% Very comfortable or comfortable Does PCOF improve your effectiveness in teaching patient centered communication? 68% - yes 26% - not sure 5% - no

FM Faculty Survey: PCOF …

FM Faculty Survey: PCOF …

Our definition of success (culture shift) BH faculty believe our curriculum over time has improved our residents’ patient – centered communication skills Observations with feedback are happening routinely Language of patient - centered communication: Universally shared language Accepted as important by all Incorporated by many in their practice

Why successful culture shift Before After Home grown observation tool Tool varied from residency to residency No “high level decree” Departmental ACGME No system push (“satisfaction”) FM faculty less integral Standard, validated tool that works Residencies can share curriculum Departmental mandate with training Metric established (6/resident/y) FM faculty embraced Used it on themselves Made videos of themselves Participated in video review PCOFs incorporated into RMS/CCC

PCOF – why it works Requires “limited” training Behavioral anchors make sense, are clear Feedback no longer about “being bad” but learning “how to say things better” Not grade based – learners listen to the feedback Can “agenda set” the review Flexible – can be adapted to inpatient, only parts can be used

Barriers Time! Both BH and FM faculty must value and practice patient-centered care New hires need training no how to use the form PCOF Long form Cross cultural: behaviors not universally patient centered Templated visits/EMR: not as easy to use form

Barriers Logistics of video taping/observations Learner barriers: Dislike/avoidance of observations (FM faculty disagree) Summative perspective of learner Stage of learner: “don’t want to kill anyone” PCOF does not help learners debrief a difficult encounter

Time Introduce the form during Orientation (BH and FM) Self PCOFs Groups, role plays, watching videos, creating videos Self PCOFs Shadowing FM faculty Inpatient, focusing only on areas of overlap Community preceptor: build skills in one session Longitudinal: short, frequent observations

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