Josh Miller, DO, Vice President of Regional Family
Health Center Operations, Cleveland Clinic
Lori Kondas, MBA, Senior Director, Office of Patient
Experience, Cleveland Clinic
Office of Patient Experience
The Cleveland Clinic Center for Medical Art & Photography © 2013 All Rights Reserved.
Photographer Stephen Travarca

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Leadership Communication:
Cultural Transformation and Alignment
Communicating Importance and Urgency:
Creating the Burning Platform:
Relationship Centered Communication
Strategies
Strategies for Sustainment and Improvement
Caregiver Engagement and Involvement
What is Your Corporate Culture?
Cleveland Clinic Experience
©2015 Cleveland Clinic Foundation All Rights Reserved
Engaged
Leaders
Patient
Feedback
Hire for
Success
Culture
of
Service
Service
Excellence
Recognition
Feedback
Caregivers
Engaged Leader:
Monthly Leadership Rounds
• Executive Attendance
• Pre-Rounding Presentation
– Special Topics
– Department Highlight
– Caregiver Celebration
• Round for one hour in teams of three
• Address Immediate Issues (service Xpress)
• Debrief/Share Stories & Findings
• Identify Opportunities
Leadership Rounding
https://www.youtube.com/watch?v=yLKaHi4f4Q
Audience
Says?
Why should leaders participate in rounding?
Engaged Leaders
Patient & Caregiver Rounds
•
•
•
•
Presence is a sign of commitment
Reinforce our mission for Patients First
Emphasize Expectations
Engage & Empower caregivers to own the
experience
Engaged Leaders
Enforce Transparency & Accountability
•
•
•
•
•
Doctor Scores
Service & Relationship-Centered Training
Scorecard Review Cadence
Appreciative Inquiry
Recognition
Transparency
©2015 Cleveland Clinic Foundation All Rights Reserved
Aggregators
Vitals.com
2 million visitors month
Healthgrades.com
7 million visitors month
*Source: Compete.com
Patient Ratings Transparency
ClevelandClinic.org
Hire for Success
Education
Experience
Technical Skills
? Patients First
Behavioral Based Interviewing
Talent Management Life Cycle
• The Power of
Everyone: New
Caregiver
Orientation
Transition
& Retire
• Leadership
Summit
• Cleveland Clinic
Experience
Promote
• Communicate with
H.E.A.R.T.®
Identify &
Attract
Select &
Hire
Hire to Retire
Develop
OnBoard
Talent Development
Global Leadership & Learning Institute
• Onboarding
• Personal Development
• Cleveland Clinic Leadership Experience
• Emerging Leader Program
• Leading in Healthcare
• Mentoring and Coaching
• Performance Management
Presentation Title l February 29, 2016
l 20
Accountability
Caregiver Recognition
Patients Choose Experience
“What factors influence your choice of hospitals?”
Location
18%
Patient
Experience
41%
Reputation
of Hospital
20%
Physician's
Decision
21%
CEOs and senior leaders at 35 U.S. hospitals that
place a high priority on patient experience:
• Lower staff turnover, higher retention, recruitment
of more highly qualified staff
• Greater patient loyalty
• Reduced costs from shorter lengths of stay
• Lower rates of re-hospitalization
• Better health outcomes, and fewer costly
procedures.
An Agenda For Improving Compassionate Care: A Survey Shows About Half Of Patients Say Such Care Is Missing . Beth A.
Lown*, Julie Rosen and John Marttila doi: 10.1377/hlthaff.2011.0539 Health Aff September 2011 vol. 30 no. 9 1772-1778
• In 2008, The Center for Medicare and Medicaid
Services (CMS) began publishing HCAHPS scores for
individual hospitals across the country on their hospital
compare website
• In late 2012, a portion of each hospital’s acute care
reimbursement from Medicare became tied to its
public performance on the HCAHPS survey, further
elevating the importance of patient experience as a
component of quality care.
Value Based Purchasing
Source Legislation
Patient Protection and Affordable Care Act of 2010
• Implement VBP model beginning FY 2013
• Rewards “Value” defined by better outcomes, experience
& innovation
• Impact to acute Medicare reimbursement
90
Measuring Success
80
10,000
9,000
70
8,000
60
7,000
50
Percentile
Complaints
40
6,000
30
5,000
20
4,000
10
0
3,000
2008
2009
2010
2011
2012
2013
2014
©2015 Cleveland Clinic Foundation All Rights Reserved
Caregiver Engagement
HCAHPS Rating
HCAHPS Recommend
Complaints
Engagement and Safety by Direct Reports Group Trend Line
Enterprise Engagement, Safety
100
90
Percentile
80
70
60
50
40
30
20
10
0
Linear (Engagement %tile)
Linear (Safety %tile)
©2015 Cleveland Clinic Foundation All Rights Reserved
“At age 40, I was diagnosed
with advanced lung cancer.
In the months that followed,
I was subjected to
chemotherapy, radiation,
surgery and news of all kind,
most of it bad. It has been a
harrowing experience for me
and for my family.
And yet, the ordeal has been punctuated by moments of exquisite
compassion. I have been the recipient of an extraordinary array of
human and humane responses to my plight. These acts of kindness
– the simple human touch from my caregivers – have made the
unbearable bearable.”
From “A Patient’s Story” by Ken Schwartz, Boston Globe, July 16, 1995.
“I'm glad to see you are all still with me”
“THESE PATIENT
EXPERIENCE SCORES
ARE BOGUS. I HAVE A
WONDERFUL BEDSIDE
MANNER!!”
Picture of an angry doc.
“Dr. X was rude and
treated me like I was
stupid. He didn’t care
about me. I actually
cried in the office.”
Communication is the most common
medical procedure
• Over 200,000 times in an
average practice lifetime
• Communication skills
decline throughout
residency hojat et. Al .
Acad Med 84 (2009)
• Minimal physician
education in
communication skills
How many of you have had a formal
communication course?
Why Improve Physician Communication
 Board Exams testing skills
 Value Based Care incorporating patient
experience into their compensation
structures
 Pay attention now or pay later
RWJ Foundation; Good for Health, Good for Business, The case for Measuring Patient Experience 0f care
Why Improve Physician Communication
Malpractice
• 8% of docs account for over 85% of claim payouts
• Poor communication scores increased the likelihood of
being named in a malpractice suit by 21.7%
Fullam et al. Medical Care 47 (5)
• The most important factor in predicting who will sue…
– The quality of the relationship between the patient
and doctor
Medical Economics, July 2003
Age of Consumerism
Age of Consumerism
•
•
•
•
•
1/3 of patients use Public ratings
59% of patients think the ratings are imporant
Healthgrades.com 7 million hits/month
Vitals.com has 2million hits/month
Hospital Systems now posting ratings
– Larger N size and control of process
Hanauer DA, et al. JAMA 2014
The Communication Chasm
Physician Excellence
% of Physicians who
thought patients knew
their names
67%
% of Patients that
18%*
correctly identified
physician's name
0%
20%
40%
60%
80%
Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies
between physicians and hospitalized patients. Olsen, DP et al
The Communication Chasm
Physician Excellence
% of Physicians
believe patients
know diagnosis
77%
% of Patients
that know
diagnosis
57%
0%
20%
40%
60%
80%
100%
Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies
between physicians and hospitalized patients. Olsen, DP et al
The Communication Chasm
Physician Excellence
% of Physicians
stated they
sometimes
discussed…
98%
% of Patients that
said physicians
NEVER did this
54%
0%
20%
40%
60%
80%
100%
Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies
between physicians and hospitalized patients. Olsen, DP et al
R.E.D.E. to
CommunicateSM
Facilitator
Training
R.E.D.E. to
CommunicateSM
Skills Training
R.E.D.E. to
CommunicateSM
Advanced Topics
Center for Excellence in
Healthcare Communication
Research &
Scholarly
Dissemination
Est. 2009
Coaching
Consultation
© The Cleveland Clinic Foundation. All Rights Reserved.
Relationship-Centered Communication (RCC)
• Communication with the goal of establishing
an authentic relationship
- Relationships are therapeutic
- Partnership and shared decision making
- Research shows Relationships are the
“game changer” in patient and physician
experience
CEHC Foundations of Healthcare
Patient outcomes of RelationshipCentered Communication
• Comprehension & recall 4,5
• Trust & loyalty 4,6,7
• Sense of self-efficacy &
support 4,8,9
• Satisfaction with care 6,8,10,11
• Treatment adherence 5,12
• Self management of chronic
disease 4
• Symptom improvement
or resolution 4,13-15
• Functional
improvement 13,15
• Health status & quality
of life 5,11,12
• Safety 5,10
CEHC Foundations of Healthcare
Provider outcomes of RelationshipCentered Communication
Improves
• Diagnostic accuracy 17
• Efficiency 18-20
• Self confidence 21
• Job satisfaction &
engagement 22
Reduces
• Professional burnout 23
• Malpractice claims 14, 24-26
• Cost of providing care 17
Doctor Communication
Nat’l
%ile
% Yes Definitely
100
95
90
Doctor Communication: R.E.D.E.
Pre and Post CGCAHPS
*
*
*
Pre
*
Post
*
*
85
80
Spend
Know
Explain
Listen Respect Clear Info
DR
Time
Hist
(p=.004) (p=.001) (p=.342) (p=.000) Comm
(p=.009) (p=.002)
(p=.000)
Center for Excellence in Healthcare Communication
Our Facilitator Team
• We feel we developed the
“secret sauce”
 59 Clinician Facilitators
 > than 1,000 years of
experience
 Home Grown
What does REDE Training look like?
Roadmap
• Overview

3 series of
–Brief didactic
–Demonstration
–Skills practice
• Integrative cases
• Wrap up
The R.E.D.E. Model of Healthcare
Communication
R elationship:
E stablishment
D evelopment
E ngagement
© The Cleveland Clinic Foundation. All Rights Reserved
Phase 1: Establish the relationship
Skills:
A. Convey value & respect with the welcome
B. Collaboratively set the agenda
C. Introduce the computer, if applicable
D. Demonstrate empathy using ‘SAVE’
© The Cleveland Clinic Foundation. All Rights Reserved
How to Convey Value & Respect
•
•
•
•
Review chart in advance
39 milliseconds
Introduce self & team
Introduce computer. Position at patient’s eye
level
• Recognize & respond to immediate signs of
distress
• Make a brief patient-focused social comment, if
appropriate 30
© The Cleveland Clinic Foundation. All Rights Reserved
B. Collaboratively Set the Agenda
• Use an open-ended question to initiate survey
“What concerns brought you in today? Before I ask you
some questions that I have, what questions do you
have for me?
• Ask “What
else?” until concerns exhausted
(5, 21)
© The Cleveland Clinic Foundation. All Rights Reserved
“What Else!?”
• “ Patients have too many presenting concerns per
visit.”
– The average outpatient has 1.7 concerns. (34)
– Eliciting a list takes ~ 32 seconds & significantly
reduces frequency of “doorknob” questions. (32, 60)
– Saves time
• “ It takes away from vital time for assessing & treating
the chief complaint.”
– The first concern usually not main concern. (6, 11)
– The “door knob” questions are more common
when an exhaustive list is not elicited early on. (32)
Empathy: The Human Connection to Patient Care - YouTube
Recall a positive experience with a
healthcare provider that you or a loved one
had as a patient …
What did you appreciate most?
EMPATHY
‘SAVE’
D. Demonstrate Empathy
Support
“I’m here for you. Let’s work
together…”
Acknowledge
“This has been hard for you.”
-or- “I’m sorry for the wait. I value your time.”
-or- “I wish there were better alternatives.”
Validate
“Most people would feel the way you do.”
“Anyone in your position would feel upset.”
Emotion naming
“You seem sad.”
© The Cleveland Clinic Foundation. All Rights Reserved
Be Authentic
Be authentic!
“Well, right now I’m feeling a little uncomfortable”
Demonstrate Empathy
Throughout the Visit
• Shows how much we care
• Verbal and non-verbal
• Declines throughout
training or with time
& task pressure (15, 24)
• Saves time
- OP medical visits save 2 minutes & surgery
visits save 1.5 minutes with use of 1 empathic
statement. (30)
© The Cleveland Clinic Foundation. All Rights Reserved
Phase 2: Develop the relationship
Skills:
A. Engage in reflective listening
B. Elicit patient narrative
C. Explore the patient’s perspective using
‘VIEW’
CEHC Foundations of Healthcare
Reflective Listening
Skills Practice
• Pair up with someone you don’t know
• Determine a speaker and listener
• Speaker: Take 3 minutes to describe a
recent stressful situation
• Listener: Practice reflective listening,
refrain from asking questions of any kind
CEHC Foundations of Healthcare
Engage in reflective listening
• Listening in such a way as to understand &
acknowledge what is being said
• Allow patient narrative to unravel without
provider interruption or re-direction 42
© The Cleveland Clinic Foundation. All Rights Reserved
Are we opening Pandora’s box
allowing our patients to talk more?
• How soon do physicians interrupt patients after asking a
question?
18-23 seconds (9, 32)
• How long will a patient talk if uninterrupted?
90 seconds (28)
• What are the risks of not allowing patients to tell their
story?
– Most important concern won’t come out! (11)
– 75% never finish what they were saying (28, 32)
– Difficulty diagnosing 50+% of these cases (61)
Beckman & Frankel, 1984; Marvel et al, 1999; Weston, Brown & Stewart, 1989; Langewitz et al, 2002
Engage in reflective listening
Shown to:
 Enhance the therapeutic nature of a
relationship 42, 43
 Increase openness & disclosure of feelings
42, 43
 Improve listener’s recall 43
 Enhance patient & provider satisfaction 37
© The Cleveland Clinic Foundation. All Rights Reserved. l 67
Exploring the Patient’s
“VIEW”
• Vital activities
“How does it disrupt your daily activity?” or “How does it
impact your functioning?
• Ideas
“Often people have a sense of what is happening. What
ideas do you have about it?”
• Expectations (42)
“What are you hoping we can do for you today?” or “What
outcome do you hope to achieve with treatment?”
• Worries (concerns, fears)
“What worries you most about it?” © The Cleveland Clinic Foundation. All Rights Reserved
Phase 3: Engage the relationship
Skills:
A. Share diagnosis & information
B. Collaboratively develop treatment plan
C. Provide closure
D. Dialogue throughout using ‘ARIA’
© The Cleveland Clinic Foundation. All Rights Reserved
CEHC Foundations of Healthcare l February 29, 2016 l 69
Dialogue Yes, Monologue No
ARIA
ASSESS - using open-ended questions
REFLECT – patient meaning & emotion
INFORM – use understandable language &
visual aids
• Visual aids ↑ recall by ~ 60% (26)
ASSESS - patient understanding &
emotional reaction
© The Cleveland Clinic Foundation. All Rights Reserved
A. Share diagnosis & information
• Orient patient to the education &
planning portion of the visit
• Present a clear, concise
diagnosis
• Pause if necessary
• Provide additional education, if
desired & helpful
• Frame information in the context
of the patient’s perspective
© The Cleveland Clinic Foundation. All Rights Reserved. l 71
Are we speaking the same language?
• How much medical information is forgotten by
the end of a visit?
40-80%
• How much of the information that is
remembered is accurate?
≤ 50%
Kessels, R. (2003) Patients Memory for Medical
Information. Journal of Royal Soc. Of Med. ,96
B. Collaboratively Develop Treatment Plan
• Describe treatment goals & options (including risks,
benefits, & alternatives)
• Elicit patient preferences & integrate into a mutually
agreeable plan
• Check for mutual understanding
53,54
• Elicit potential treatment barriers & need for additional
resources
“I want to be sure I’ve explained everything clearly. What
Foundation.
are you going to do when you get home?” © The ClevelandAllClinic
Rights Reserved
CEHC Foundations of Healthcare l February 29, 2016 l
73
C. Provide Closure
Clinician Participant &
Facilitator Comments
• “I thought being an empathic sort & thorough in history
taking over 25 years, I would have little to learn. I was
wrong. Your course brings up some very useful ideas….”
• “Reminds me of why I became a doctor in the first
place...”
• “Thank-you for all you have done for me. I am a better
doctor because of your efforts.”
• "The training experience you created transcends any
prior work in communication skills and I am so grateful to
have participated. The relationships and development of
community among all of us cannot be overstated."
Service Philosophy & Objectives
1. Increase the awareness of the impact of every
patient, visitor and employee interaction
2. Understand the role of the employee is greater
than the tasks associated with his/her job
3. Empower employees to deliver world-class care
Training Courses
S.T.A.R.T. with Heart®
Expected Service Behaviors
Respond with H.E.A.R.T.®
Service Recovery Model
Answer with H.E.A.R.T.®
Service Excellence & Recovery by Phone
© The Cleveland Clinic Foundation. All Rights Reserved
Expected Service Behaviors
 Acknowledge the other person
 Introduce self and role
 Use person’s preferred name
 Clearly communicate expectations
 Offer to resolve concerns or forward to the
appropriate person
 Use active listening
 Communicate empathy
 Use common courtesy
 Offer to help
© The Cleveland Clinic Foundation. All Rights Reserved
© 2014 The Cleveland Clinic Foundation. All Rights Reserved.
Presentation Title l February 29, 2016 l 80
What Next?
Deep Dive courses:
 R.E.D.E. to CommuniateSM: How to Build Trust, Convey
Respect & Save Time
 R.E.D.E. to CommuniateSM: How to Improve Your
Listening and Diagnostic Skills
 R.E.D.E. to CommuniateSM: How to Enhance Patient
Comprehension and Collaboration
 R.E.D.E. to Round
© The Cleveland Clinic Foundation. All Rights Reserved. l 81
What Next?
Advanced Topic courses:
 Difficult Patient
Encounters
 Discussing Code Status
 Helping Patients Change:
An Introduction to
Motivational Interviewing
 Delivering Bad News
 Family Meetings
© The Cleveland Clinic Foundation. All Rights Reserved. l 82
What Next?
© The Cleveland Clinic Foundation. All Rights Reserved. l 83
Center for Excellence in Healthcare Communication
84
Opportunities
Patient Feedback
• 4,500 patient verbatims gathered from
75,000 surveys
© The Cleveland Clinic Foundation. All Rights Reserved
Presentation Title l February 29, 2016 l 86
Main Campus Cleanliness
100
80
Mayo (2)
Mass Gen (1)
Johns Hopkins (3)*
UCLA (3)*
CC (5)
50th
78
60
%ile
40
20
0
2008 2009 2010 2011 2012 2013 2014
Source: CMS and Press Ganey 1.25.16
Main Campus
Cleanliness
100
80
Mayo (2)
Johns Hopkins (3)*
CC (5)
Mass Gen (1)
UCLA (3)*
50th
78
60
%ile
40
20
0
2008 2009 2010 2011 2012 2013 2014
Source: CMS and Press Ganey 1.25.16
Questions?
© The Cleveland Clinic Foundation. All Rights Reserved. l 18