It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. - Sir William Osler, MD (1849-1919)
Dr Osler, one of the founders of The Johns Hopkins Hospital (JHH), understood the importance of physicians connecting with their patients through dialogue. His advice is true and timeless, although so much has changed in health care since his bedside teaching of residents. Like many organizations working to improve the patient experience, JHH has implemented a myriad of "best practices," such as purposeful rounding and bedside shift report. In our experience and that of Dr Osler, none of this matters if care teams are not connecting at the most basic level of communication with their patients.
In 2014, The Johns Hopkins Health System added Patient and Family-Centered Care as one of its 6 strategic goals. As part of achieving this goal, it created a new position, a Chief Patient Experience Officer (CPXO). When the CPXO arrived (L.W.A.), she found that JHH performed well in certain patient experience metrics, but it had seen no real improvement in the last several years. In an effort to understand the stagnation, the JHH patient experience team did a deep dive into scores and patient comments from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) inpatient survey. We were looking for factors that had the greatest influence on a patient scoring a positive hospital experience.
Under the CPXO direction, the patient experience team reorganized to include patient experience coaches, data analysts, and senior program administrators. To support this project, the team convened subject matter experts in patient-provider communication from the School of Medicine and Bloomberg School of Public Health at Johns Hopkins University, a hospitalist researching patient experience, a fourth-year medical student, and the Director of the Armstrong Institute. Upon analysis of HCAHPS data, we found positive experience scores from patients linked to comments such as "I felt a true connection"; "I felt cared for"; "I felt like I was listened to;" and "I felt like I was involved and knew the next steps." The opposite types of comments came up when patients rated experience lower on the satisfaction scale.
The project team reviewed the literature on positive patient-provider communication.1-7 They assessed different models and sought input from the JHH patient and family advisory councils (PFACs) to determine key components of great communication in a health care setting. Next, the team worked with adult instructional designers to organize the concepts into a model that would be easy to remember and teach to others. To determine face validity, the model was distributed to the 6 PFACs, representing adult general, pediatrics, children and teens, oncology, emergency department, and ambulatory services. Each council confirmed the key components of the model and added its perspectives to strengthen the model.
We learned that it is easier to remember 3 rather than 5 things and that acronyms rarely make intuitive sense. Thus, we created a 3-step caring communication model-Connect, Partner, Reflect-and tested it throughout 2016. Each model component was modified on the basis of patient and provider feedback.
CONNECT, PARTNER, REFLECT: OUR CARING COMMUNICATION MODEL
1. Connect. Make a person-to-person connection with the patient and/or family to create positive communication. This includes an introduction, making it personal, and being prepared.Our earlier model was missing an important component raised by the parents in the Pediatric PFAC. They said, "Before you connect with me, connect with the previous caregiver rotating off shift." For parents, it was extremely frustrating when their child's plan of care changed from one provider to the next without acknowledging the prior plan. Showing the provider is prepared means acknowledging that there was communication with the previous nurse/physician.
2. Partner. Encourage patients and families to be a part of the care team. This phase involves listening to understand patient and family preferences and engaging them in shared decision-making. The partnership includes developing a plan to clarify needs, set expectations, and determine priorities. Part of this process includes teach back to clarify understanding and offer time for any questions.
3. Reflect. Conduct a check back to ensure understanding and determine the next steps. Summarize your interaction by reiterating what to expect next, and make sure there are no further questions. Finally, thank the patient and/or family for their time. If your shift is over, reflect on your patient interaction with the next provider or caregiver to help the next connection be positive for the patient/family.
While the original intention of this model was to improve patient-provider communication, we found it adapted well to other roles. We taught environmental care staff, front office staff, food and nutrition, and others to follow this model when interacting with patients and families. For environmental care staff, the interaction may go like this:
Hello, my name is Mary, I am here to clean your room (connect). Is there anything special you would like me to clean or stay away from (partner)? I have finished cleaning. Did I miss anything? Someone will be back to clean on the next shift around 3 p.m. (reflect).
IMPLEMENTATION
The JHH Children's Center was the first to adopt the model (2017) and teach it to providers, residents, and staff. In 2018, all adult inpatient units at JHH and the Johns Hopkins Outpatient Center adopted the model. The model is taught at new employee orientation, during our service excellence cohort training (a 3-hour program for patient experience champions), and at in-depth training sessions for clinical customer service coordinators and unit desk clerks. The patient experience coaches also take interactive trainings to faculty and resident meetings, staff meetings, and requested trainings for unit/clinic staff. Training materials include an online module to introduce the concepts and a workbook to make the trainings interactive and memorable. Connect, Partner, Reflect is now part of our everyday language, from leadership to frontline staff. We use these words at our recognition events and have made it part of who we are.
THE PAY OFF
Our efforts are paying off. Since introducing the model in 2017, our hospital HCAHPS scores have improved. Nurse communication scores increased from the 63rd percentile in 2017 to the 79th percentile in 2019, and physician communication scores rose from the 57th to the 74th percentile. Patients' "likelihood to recommend" JHH increased from the 93rd percentile to the 96th percentile, and overall rating of care increased from the 87th percentile to the 93rd percentile (Press Ganey Large Hospital Database Compare Group). Our biggest learning in this process was that one must teach all levels of the organization to use the same model. Make it part of daily practice and awareness and make it simple and meaningful. Once the basic building blocks of a shared communication approach are in place, other "best practices" can follow.
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