1.  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

2. 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.

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. FM Faculty Survey: PCOF …

14. FM Faculty Survey: PCOF …

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Your experiences