A series of developments now require health care workers to be skilled diagnosticians and interventionists, and be skilled in relationship-building and communication. In 2001, the Institute of Medicine's Crossing the Quality Chasm: A New Health System for the 21st Century report suggested a redesign of the health care system with patient-centered care as an essential dimension of high-quality care.1 Similarly, the Triple Aim2 identified "enhancing patient experience" and "improving quality" as 2 of 3 key contributors to optimize health system performance. Further, the health care reimbursement system has changed since the passing of the Patient Protection and Affordable Care Act,3 and reimbursements by federal insurance are increasingly tied to health outcomes and patient satisfaction.
Effective provider communication with patients is associated with higher patient satisfaction,4 better outcomes and treatment adherence,5 and more efficient health care utilization.6 In addition, effective communication is associated with fewer malpractice claims7 and higher health care worker job satisfaction.8 Despite these benefits, health care workers receive limited training in effective patient communication.
WHAT IS THE JOHNS HOPKINS PATIENT ENGAGEMENT PROGRAM?
The Johns Hopkins Patient Engagement Program (PEP) is a comprehensive communication training program intended for staff who have direct contact with patients, including physicians, nurses, and mid-level providers, medical assistants, community health workers, and front desk staff members. The PEP often engages complete teams so that interdisciplinary team members can "speak the same language."
The PEP teaches approaches described in the health literacy literature such as Teach Back,9 attitudes and skills emphasized in Motivational Interviewing10 (MI), and relationship-building processes from MI and shared-decision making. We chose MI as a foundation for the PEP because it is an evidence-based treatment for individuals who are struggling with health management for a wide range of conditions. MI is not considered a therapeutic practice and, therefore, can be taught to and used by any health care worker, including paraprofessionals or lay health workers. A systematic review of MI training for health care workers in primary care facilities showed more effective counseling of patients with lifestyle-related issues.11
The training methods used for the PEP are guided by adult learning theory. The PEP uses a multimodal teaching approach that includes asynchronous online learning and live skill-building workshops. During the workshops, learners watch videos, have discussions, and engage in live role-play with feedback from experts. This variety of activities increases opportunities for self-directed learning and reflection. The PEP uses clinicians as trainers to provide more opportunity for effective role modeling and addressing real-world problems.
The PEP is guided by the Standards of Quality Improvement Reporting Excellence12 guidelines. Thus, the PEP places heavy emphasis on an initial planning phase, which supports thoughtful creation of an often-customized intervention and implementation plan, as well as the assessment phase, which supports determination of whether or not the PEP was effective and how to improve effectiveness. In total, the PEP has 4 phases with a fifth optional phase:
1. Planning. PEP faculty consult with organizational leadership to clarify goals for training, assess readiness, identify groups to be trained, and develop an implementation plan.
2. Training. E-learning curriculum and live skill-building workshops are offered, with content including rationale, foundational MI attitudes that promote engagement, relationship-building processes, and specific communication skills that promote patient engagement. Workshop content can be customized depending on the audience.
3. Maintenance. We implement a one-year (minimum) program that includes identification of PEP Champions to lead the local practice of skills and a "PEP Tip of the Month" email, which is a monthly reminder of an important principle or skill and short video demonstration. Additional options include booster skills workshops and repeated completion of the online training.
4. Evaluation and assessment of outcomes. PEP faculty monitor and evaluate the program's effectiveness. Evaluation is accomplished through (a) pre- and post-training learner assessments of self-efficacy, knowledge and attitudes, and communication skills; (b) learner satisfaction; and (c) patient or institutional health outcomes.
5. Sustainability. PEP faculty provide a "Train-the-Trainer" program where on-site clinicians are trained as PEP trainers. These on-site trainers are able to carry out the PEP in ongoing years.
PROVIDER COMMUNICATION KNOWLEDGE AND SKILLS PEP OUTCOMES
Our data indicate that baseline learner scores on knowledge and attitudes that promote patient engagement and self-efficacy to apply this knowledge tend to be relatively high.13 These baseline scores may lead health care workers to believe that training is unnecessary. However, there appears to be a consistent gap between knowledge and attitudes scores and the demonstration of communication skills. Following PEP training, health care workers show significant improvement in communication skills. PEP training and maintenance phases have improved patient satisfaction scores related to nurse communication and education.
RECOMMENDATIONS
Improvement in patient engagement and satisfaction requires an organizational commitment. Thus, the choice to engage in a PEP must be mission-driven and backed by institutional leadership. Patient engagement cannot be considered a "flavor of the week." There has been recent movement to assess the organizational readiness to engage in change when considering a quality improvement initiative, such as the PEP.14 This formal assessment can be done during the PEP planning phase.
Given that health care workers seem to have weaker communication skills but high self-efficacy, they are unlikely to independently seek out such training. Therefore, it is critical that organizational clinical leaders participate in PEP training to model humility, recognizing that even experienced practitioners require ongoing training. It may be useful to conduct a baseline assessment of communication skills for all staff who interact with patients, provide feedback on scores, and then encourage or require low-scoring staff to attend training as an annual professional development goal. To fully incorporate patient engagement training as part of the organizational culture, inclusion of communication training during new staff orientation sends a clear message-patient engagement and satisfaction are central to our organization.
For more information about the PEP:http://www.hopkinspep.org
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