Enhancing clinician communication skills in a large healthcare organization: A longitudinal case study
Introduction
Physicians in the US conduct 140,000–160,000 medical interviews during an average practice lifetime [1]. Recognizing that poor communication between clinicians and patients decreases quality and increases human and economic costs of care [2], organizations such as the Institute of Medicine, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Internal Medicine have identified communication as one of the core competencies required for good medical practice [3]. As a consequence, as of June 2004, graduates of American medical colleges are required to demonstrate competency in communication in order to receive certification from the National Board of Medical Examiners.
The importance of clinician-patient communication (CPC) is also drawing attention within organizations delivering healthcare. Consumers increasingly demand “doctors who listen” [4]. Likewise, medical educators have called for a shift in emphasis from biomedical to biopsychosocial and more recently from patient-centered to relationship-centered care [5], [6]. Research studies demonstrate the links between communication behaviors in the exam room and clinical outcomes [7], [8], [9], [10], [11], [12], [13]. Gaps in communication and relationship between patients and clinicians have been associated with switching doctors or disenrollment from health plans, poor adherence with recommended treatments, and propensity to sue for medical malpractice in the face of an adverse outcome [14], [15], [16]. Healthcare organizations wishing to address these gaps face the daunting challenge of assessing, enhancing, and supporting the communication skills of their clinicians.
The purpose of this article is to describe as a case study the approach taken over the past 16 years by one healthcare organization, Kaiser Permanente (KP), to optimize the clinical communication skills of their clinicians. Kaiser Permanente, with more than 11,000 physicians providing care to over 8 million members across eight regions (Northern California, Southern California, Northwest, Hawaii, Colorado, Ohio, Georgia, mid-Atlantic), is one of the largest health maintenance organizations (HMOs) in the US. This case study focuses mainly on CPC efforts within the Northern California region of KP, with over three million members served by the 5300 physicians of The Permanente Medical Group (TPMG). The centerpiece of this effort has been the creation and organization-wide dissemination of an integrated framework for teaching clinical communication and relationship skills called the Four Habits Model [17], [18].
Section snippets
Early stages of development
TPMG's focus on clinician-patient communication began not with an elaborate organizational strategy from senior leadership, but with a series of actions by a few people who thought the topic was important. In 1988, the Director of Staff Education for the Northern California region began a series of informal lunch hour conversations with physicians at several medical centers about research showing that the way doctors communicate makes a difference to patients. He found that audiences were
The Four Habits Model
Growing recognition of the importance of CPC skills and increasing requests for training highlighted the need for a simple cohesive structure or model that would enable clinicians to learn to communicate effectively and efficiently. In 1996, two of the authors (RMF and TS) addressed this need by designing the Four Habits Model (Table 1). The model is an evidence-based framework that connects and integrates skills to fit the real-time running organization of the clinical interview. A monograph
Expansion of the Four Habits Model within KP
Although the Four Habits Model was initially developed within the context of primary care practice, it has been adapted and used as the basis for teaching programs covering a wide variety of settings and specialties since 1996. These include:
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Strangers in crisis, a 1-day program for emergency department physicians and nurses (developed as a result of requests from ED physicians who attended Thriving and wanted a program addressing their unique challenges).
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Meeting point: hospitalists at work, a
Expansion of the Four Habits Model beyond KP
After being used widely for many years within Kaiser Permanente, the Model has now begun to be utilized outside the KP system. At the national level, the American Board of Medical Specialties is developing an instrument to assess physician communication from the patient's perspective. The items have been drawn from the SEGUE coding scheme [34], the Four Habits Model, and others. The instrument is currently undergoing preliminary field trials and appears to have acceptable psychometric
The Garfield Memorial Fund (GMF) research initiative
Developed initially for the purpose of teaching communication skills within KP, the Four Habits Model has more recently begun to serve as the springboard for empirical research. In 2000 the Board of the Garfield Memorial Fund, a grants giving unit within Kaiser Permanente, offered to sponsor a CPC research initiative. Following a needs assessment, a request for proposals focusing on five priority communication areas (technology, end of life care, physician satisfaction, best practices, and
Current and future CPC efforts in TPMG
Personalization of care: toward the end of 2003, the CEO and Executive Director of The Permanente Medical Group asked the Department of Physician Education and Development to train all 5300 TPMG physicians in skills to deepen personalization of care to members and patients. The purpose of this regional initiative was to ensure that members of KP in Northern California—even those who seldom or never come in for visits—would feel connected to a personal physician who knows their medical history,
Summary
This case study describes the history of clinician-patient communication education and research in KP. The KP experience and the Four Habits Model are examples of pedagogy and research informing each other in a cycle of continuous improvement. The story of the Model and its dissemination illustrates how organizational and scientific needs interact in practice to improve clinician satisfaction and ultimately the care delivered to patients.
Three major factors may help explain the steady growth of
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