In 2009, Cleveland Clinic started a program to improve health care communication. At the time, their inpatient patient-satisfaction scores related to doctor communication was in the 24th percentile nationally, but within 5 years, they were in the 99th percentile.1 Communication accounted for 72% of their negative patient comments. In the book, Communication the Cleveland Clinic Way, Drs. Adrienne Boissy and Thomas Gilligan describe how they designed a successful communication program that engaged caregivers across the organization and led to these remarkable improvements.
They believe that the birth of this movement was with the conception of “Patients First” as Cleveland Clinic’s motto. “Patients First” came from the Cleveland Clinic CEO, Dr. Toby Cosgrove, and he made sure that “any strategic decisions or initiatives that the organization put forward had to involve improving the care and experience of [their] patients at their core.” Patients First led to redesigning care service lines to be physically aligned around the patient, introducing same-day appointments, and creating “Voice of the Patient Advisory Councils” throughout the health care system. This clear “True North” for the organization laid the groundwork to develop a robust communication strategy that would help caregivers provide empathetic care that focused on building relationships.
But before that communication strategy could be built, Boissey and Gilligan described a few key steps that they took to maximize the potential impact of the program. Along the way, they were sure to be mindful of what they discovered to be myths about communication training.
Before developing the structure of the program itself, the group first:
Acknowledge and listen to stress factors and causes of burnout
Ask physicians about what gives their work meaning—usually it’s time with patients
Discover what the physician does care about, and build from that
Explore real-world personal and professional challenges caused by basic skill deficits
Elicit the physician’s own stories––the cases that haunt them
Link basic skills to leadership development
Promote lifelong learning and sharing of best practices for a given scenario or population
Know and share the decades of evidence that you can
Stay curious about prior learning experiences with empathy and communication
Demonstrate that empathic behaviors can be taught through innovative design
Learning is lifelong for staff and trainees
Residents watch staff closely and learn from their behavior, including communication skills
By dedicating attention to communication skills, attendings message its importance and value
Caring for patients is a team sport, so everyone has a responsibility
cknowledge that changes in healthcare are difficult
Expand the discussion to how communication skills training benefits the individual clinician
Show how effective communication impacts outcomes, satisfaction, safety, and efficiency
“We aimed to model the behaviors that we thought would help [caregivers] in their work with patients,” said Dr. Boissy, Chief Experience Officer at Cleveland Clinic Health System.1(ppxvii-xviii) “If we wanted them to listen to their patients, then we needed to listen to them. If we wanted them to express empathy with their patients, then we needed to express empathy with them. If we wanted them to work in a collaborative way with patients, we needed to work in a collaborative way with them. Lecturing physicians not to lecture patients is hypocritical.”
Through this groundwork, the team discovered that a communication program focused on relationship-centered care rather than on patient-centered care alone would resonate more with both clinicians and patients. (p72)
Aligning their mission and these relationship-centered values with the communication skills they wished to impact led to the development of a conceptual framework called R.E.D.E. to Communicate, which stands for Relationship Establishment, Development, and Engagement. This model aims to improve the experience of both the patient and provider.
This model laid the foundation for the communication training program that was eventually rolled out to every single Cleveland Clinic employee.
Source: The Cleveland Clinic Foundation. Read Communication the Cleveland Clinic Way: How to Drive a Relationship-Centered Strategy for Exceptional Patient Experience
Convey value and respect with the welcome
Collaboratively set the agenda
Introduce the computer, if applicable
This refers to the use of EHRs and health technology. Make it a part of the patient communication experience rather than allowing it to detract from it.
Demonstrate sympathy using S.A.V.E (Support, Acknowledge, Validate, Emotion naming)
With this, the Cleveland Clinic launched a successful communication training program that emphasizes relationship-centered communication. They did this by ensuring that their program was designed in a way that respected health care professionals and recognized that adult learners are self-directed, practical and goal-oriented. They made the learning primarily experiential with a focus on skills practice with facilitated feedback: “Like any skill, whether it’s playing tennis or the violin or building a wooden cabinet, it was necessary to break down the larger process into key core elements and practice them with opportunities for skilled feedback.”1(p49)
They purposefully did NOT focus on “patient satisfaction” (e.g., HCAHPS) scores as they felt this did not resonate with physicians and caregivers, so they simply left it out of the discussion. “…For the facilitators of the course, this became a more personal movement to honor the complexities and intimacies of caregiving, therefore, HCAHPS didn’t have a rightful place in that room.”1(p28)
Relationship-centered communication became the primary goal of their communication skills training. Relationship-centered communication is built upon mutual respect, where both provider and patient are recognized and appreciated for their unique perspectives, experiences, and expertise. “By using relationship-centered rather than purely patient-centered communication, your program values and honors the expertise of all stakeholders.”1(p86)
Cleveland Clinic also created an individualized peer coaching program for clinicians who wanted or needed more individualized attention.
1- Boissy A, Gilligan T. Communication the Cleveland Clinic Way: How to Drive a Relationship-Centered Strategy for Exceptional Patient Experience. 1st edition. New York: McGraw-Hill Education; 2016.