Cheshire Medical Center Improves Provider Communication in the Exam Room

Added on Dec 5, 2019

MD_doctor with one womanObservational Study Helps Cheshire Medical Center Improve Provider Communication in the Exam Room
By Lauren Keeley

A warm greeting, reassuring words, and open body language go a long way in the exam room, but it takes more than these behaviors to master the art of patient–provider communication. It also takes careful and compassionate education, process efficiency, and teamwork, among other considerations, according to a study out of Cheshire Medical Center/Dartmouth-Hitchcock in Keene, New Hampshire.

In an effort to enhance the insights derived from its patient experience data, Cheshire Medical Center—one of five facilities affiliated with Dartmouth-Hitchcock Health—conducted an observational study to determine how often its physicians practiced the following key behaviors that are known to impact excellent patient experience:

■ Warm acknowledgment and introduction of oneself
■ Asked open-ended questions such as “How are you feeling today?”
■ Addressed concern of patient and explained process of visit
■ Explanation of care and confirmation of patient understanding
■ Efficiency and good workflow/technology and proper hand hygiene
■ Closed the conversation with caring and compassion
■ Created a pleasant environment with other team members

The study was modeled on earlier research out of Johns Hopkins.

“As soon as I read this study, I started thinking about how many doctors have been practicing medicine for over 25 years and have never had someone in the room to observe their interpersonal skills,” explained Jason Vallee, vice president of patient experience at Cheshire. “They’ll choose a communication style and process for the visit, then stick with that style for every appointment.” 

Vallee was already managing a group of provider coaches within the systemwide Patient Experience Provider Ambassador Program—a peer-to-peer intervention in which provider coaches observe, talk through, mentor, and suggest behavior changes to providers who either have been referred by a department leader or chose to participate in the program on their own. He saw an opportunity to extend the reach of this effort through the observational study. “I thought the findings could help us improve existing communication processes while also serving as a catalyst for new initiatives,” he said.

Identifying Communication Gaps

Realizing that Cheshire’s culture as well as the needs and expectations of the community it serves influence its patient experience outcomes, Vallee was curious how providers within the health system thought they were meeting patients’ communication needs and expectations, so in 2015 he showed the findings to a group of Dartmouth-Hitchcock Keene physicians.

The response he heard most often was, “Well, that’s Johns Hopkins. We’re different,” according to Vallee. At the time, however, Cheshire’s top box score for Overall Rating of Provider was 57.1%. Vallee realized that although the providers understood the importance of communicating effectively during patient interactions, they thought they were doing it. By replicating the Johns Hopkins study, they would be able to see whether their perceptions were accurate.

With the Patient Experience Provider Ambassador Program already in place, Vallee and his colleagues chose two provider coaches to be their trained observers for the communication study. The observers followed 31 providers on 154 scheduled outpatient office visits across multiple locations during the months of June, July, and August 2018. Participants were randomly selected and blinded to the content of the assessment tool, which was based on Press Ganey’s patient experience survey questions cross-referenced with those of the Johns Hopkins study. Observers followed each doctor for two to four hours, looking for the seven key behaviors, and then offered verbal reports to the providers.

Upgrading Hardwired Habits for Process Improvement

Vallee and his colleagues found that all seven behaviors were observed together 21% of the time. Individual results for each behavior were as follows:

■ Warm acknowledgment and introduction of oneself: 96%
■ Asked open-ended questions such as “How are you feeling today?”: 98%
■ Addressed concern of patient and explained process of visit: 21%
■ Explanation of care and confirmation of patient understanding: 71%
■ Efficiency and good workflow/technology and proper hand hygiene: 83%
■ Closed the conversation with caring and compassion: 76%
■ Created a pleasant environment with other team members: 83%

Certain behaviors, such as warm acknowledgment and use of open-ended questions, appeared hardwired in most providers, whereas explanation of care and process of visit lagged, Vallee noted. It is important that providers perform all seven behaviors with each visit, because neglecting even one has the potential to erode trust between the physician and the patient, he said.

For example, a virtual outlier at 21%, process of visit refers to the provider explaining to patients what is going to happen with their care, in what order, and why. Knowing, and verbally expressing, a patient’s medical history is a facet of this skill that doctors often overlooked in the process of the visit, said Vallee. Yet patients “trust doctors with their most important information, so it is important that the patient feels their doctor is not a complete stranger,” he said. Cheshire’s patient experience data showed that physicians were not doing a good job with this communication skill, and this deficit was reflected in the study, Vallee said.

Turning Obstacles into Inspiration

Results in hand, Vallee and his colleagues turned their attention to interventions. Prior to conducting the study, Dartmouth- Hitchcock Keene’s Patient Experience Provider Ambassador Program proved to be a highly successful improvement tool: A five-year lookback conducted in 2017 revealed that 127 physicians had increased their overall rating by more than 20%. Additionally, patient complaints decreased while positive comments streamed in. The increase in patient experience scores has enhanced providers’ satisfaction with their work at Cheshire, Vallee stated.

Today approximately half of the physicians who participate in the coaching program are self-referred, reflecting an ongoing culture shift that emphasizes personal accountability and responsibility in transforming the patient experience. To further champion the program, Vallee started hosting breakfasts for new physicians in the Dartmouth-Hitchcock Keene system, finding that the majority of them are interested in getting a coach in their first year.

Next, Vallee collaborated with the clinicians. In fact, an initial barrier to this collaboration became the inspiration for one of the most effective improvement tools at Cheshire.

“We can’t pull physicians out of their practice and put them in a room for a training day, like you might be able to do in other fields,” explained Vallee. “Instead, I decided to show 75 doctors the observational protocol from the study and asked each one of them: ‘If these elements make for a great visit, why wouldn’t you do them?’” Then he compiled their responses and the study results and turned them into topics for a series of Quick Learn video modules. These videos help illustrate best practices and techniques for providers, and they position communication as a priority in every patient visit. In addition to their instructional value, they facilitate dialogue between caregivers.

For example, while conducting the study, the observers noticed a bimodal distribution with technology use during the visit. “Providers either had their heads stuck in the computer or weren’t even using the one in the room and would backlog everything at the end of the day, which ultimately led to safety and quality issues,” Vallee recalled. Many of the physicians Vallee spoke with also expressed frustrations about EHR hindering meaningful communication. Noting these trends, Vallee and his colleagues created the Quick Learn video Using Technology as a Relationship Builder: The Computer in the Exam Room, which has garnered almost 5,000 views on YouTube.

Finally, to propel meaningful behavior changes, providers at Cheshire are urged to take time on a regular basis to review their patient experience reports. To help them derive insights from the reports, Vallee and his colleagues developed an education program they call Metrics Masters to teach providers how to access and best use their performance data.

To date, the communication interventions have helped propel the organization’s top box Overall Rating from 57.1% to 81.7% and, according to Vallee, have reinvigorated the provider staff at Cheshire.

With sights set on sustaining improvement, Vallee plans to implement a “Chief First Impression” program to activate and engage the teams surrounding the providers. The idea was founded on the notion that everyone who comes in contact with the patient needs to have a shared understanding of Cheshire’s commitment to service excellence, he explained. The program will include universal tips and techniques for creating personal connections with patients every day. In the same vein, Vallee wants to develop an “Ambassador 2.0” program that includes outreach and presentations to the entire medical staff, setting into motion a cascade of all-staff engagement.