1. Mount Auburn Practice Improvement Program (MA-PIP)
Community Learning Session #3
Improving Communication: To Improve Care and Patient Satisfaction While Reducing Malpractice Risk Yvonne Cheung, MD, MPH, CPPS Chair, Department of Quality and Patient Safety Mount Auburn Hospital
December 4, 2015
This project is funded through a Commonwealth of Massachusetts - Health Care Workforce Transformation Fund Grant (#54038)

2. Learning Objectives
As a result of participating in this activity, learners will be able to:
Describe strategies and tools that improve communication with patients and patient safety
Use small tests of change to make it feasible to improve care while providing care
Identify and employ strategies for engaging patients in improvement work.

3. Disclosure Statement
All Presenters and Content Developers have no significant financial interest/arrangement with any organization(s) that could be perceived as a real or apparent conflict of interest with the subject matter of the presentation.

4. Mount Auburn Practice Improvement Program (MA-PIP): Why now?
Purpose: Improving patient safety in office practice/ambulatory care
Enabling your practice to improve your work while you do your work- “see problems and solve problems”
Build on a proven model – federally funded PROMISES program
Build infrastructure, integrate with current ambulatory patient safety program
Enabling your practice to improve without disrupting patient care
- Skills to be a learning organization
- Engaging all practice staff to “ see problems and solve problems”
- Same approach can improve patient safety, quality, patient experience, efficiency
- Makes work more manageable
Accelerating Improvement in Healthcare &
“ Leader-led Learning: the great differentiator”
Steve Spear

5. Key Concepts For Safety Focus on systems, not people
Work on a culture of safety
For improvement:
Define a clear aim
Use measurement and data for decision making
Remember that improvement requires change
Keep testing using PDSA cycles – keep tests small
For everything:
Remember that customers are key 5

6. Science of Patient Safety
Systems thinking
Most problems do not result from individual workers; but from the design of work processes/system
Safety culture
Leadership & values
Teamwork & communication
Trust, psychological safety
What if you started your staff meetings with the question: “Do you have any patient safety concerns we can talk about?”
We don’t blame the people, we improve the system in which they work
Every system is perfectly designed to get the results it gets; if we want to improve results we need to improve system
Insanity is doing the same thing over and over and expecting different results
Safety culture starts from the top, as defined by leadership beliefs and core values
What if you started your staff meetings with the question: “Do you have a patient safety concern we can talk about?”
Requires teamwork and communication
And atmosphere of trust, where individuals feel safe to share information about unsafe or potentially hazardous conditions so that we can identify strategies for improvement

7. Model for Improvement PDSA = Aim Measures Changes Test of Change
Developed by: Associates in Process Improvement
Test of Change
The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance, 2nd Ed. Gerald J. Langley et al. Jossey-Bass April 2009
Builds on Deming’s Theory and the scientific method
Based on the development, testing and implementing of changes
Heavily focused on learning from small scale tests – “trial-and-learning

8. Patient Safety Priorities in Ambulatory Care
Reliable processes - 3 key areas:
-Test result management
-Referral Management
-Medication Management
Communication
– With patient, among staff, across settings
What keeps you up at night?
From the literature – the most common contributing problems 8

9. Why Focus on Communication
Physician-Patient Communication: The
Relationship with Malpractice Claims Among
Primary Care Physicians and Surgeons
Study identified specific communication behaviors among Primary Care physicians with no malpractice claims vs. those who had experienced malpractice claims Levinson, et al., JAMA (7):
From the literature – the most common contributing problems
Study identified specific communication behaviors associated with malpractice history for primary care physicians (though not in surgeons)
Multivariable model improved prediction by 57% above chance 9

10. Those Without Claims:
Used statements of orientation (educating the patient about what to expect/flow of the visit)
Used more facilitation (soliciting patient’s opinion, checking understanding, encouraging patient to talk)
Spent longer in routine visit – 18.3 vs minutes (independent effect in predicting claims status)
Summary question: Did it build a positive relationship, or lead to fewer errors, or both?

11. From latest IOM Report: To Improve Diagnosis and Reduce Diagnostic Error
Goal 1 - Facilitate more effective teamwork in the diagnostic process among health care professions, patients and their families
Recommendation 1B:
Partner with patients and families as diagnostic team members
Facilitate patient and family engagement in the diagnostic process
Align with their needs values and preferences
23% of MA residents Involved in Medical Error Situation (HSPH/BLC/Health Policy Commission, Sept 2014 )
Review of closed malpractice claims in Primary Care: 72% are diagnosis-related (397/551) – (data from Crico, Coverys)

12. Communication Issues for Today’s Discussion
For today’s discussion – not focused on patients with “additional” communication challenges -
health literacy,
language barriers,
cultural literacy etc.
Focus is communication with patients without barriers, but still have symptoms not addressed, unanswered questions, unclear understanding, concerns with the treatment etc.

13. Brief Small Group Discussion
What are some examples in office practice of how poor communication results in harm to a patient?
Invite comment – list on flipchart

14. Feedback and large group discussion

15. Examples of Suboptimal Communication That Can Lead to Safety Risk:
With the clinician:
Interrupting the patient and not hearing all the symptoms
Not asking about concerns with the treatment plan
Not assuring correct understanding of instructions
Not acknowledging uncertainty about diagnosis
Incomplete communication about danger signs
Interrupting the patient and not hearing all the symptoms, leads to wrong diagnosis (Osler)
Not asking about concerns with the treatment plan, patient does not follow through
Not assuring correct understanding of instructions – unclear explanation, or just asking “ do you have any questions”
Not acknowledging uncertainty about diagnosis and explain the expected outcome and need for the patient to call and let the office know
Incomplete communication about danger signs to watch for with new medications, what to do
Didn’t check to see that all health issues were raised and discussed, left a problem unaddressed

16. Examples of Suboptimal Communication That Can Lead to Safety Risk:
Not checking to see that all issues were addressed
Not making it safe to admit lack of adherence to prior treatment plans
Not using structured communication formats (missing new information on family history)
Clinician doesn’t make it safe to admit where there was not adherence to prior treatments ( side effects from medications, stopped taking)
Not using structured communication formats (missing new information on family history)

17. Examples of Suboptimal Communication That Can Lead to Safety Risk:
With other office staff
Front desk didn’t get information to assess urgency of the need
Not checking at the front desk – do they understand the next steps, have barriers or concerns
Not checking to make sure they got all their questions answered

18. Overlap With Those Working on Patient-Centered Medical Home
Patient Safety brings added dimensions and focus on communication.
Moving beyond non-compliance (“Why don’t they do what I tell them to?”)
Some similar issues – shared decision making, motivational interviewing, effective teaching
Some additional nuances - missed diagnosis, safety issues in other staff communications