Safety, not satisfaction

1. Safety, not satisfaction • Patient-centered communication training in a new medical era • Pål Gulbrandsen & Bård Fossli Jensen • Oslo Communication in Healthcare Education and Research group (OCHER) • University of Oslo and Akershus University Hospital • International Forum on Quality and Safety in Healthcare • Paris, April 11, 2014 • www.ocher.no

2. Bård Fossli Jensen • Pål Gulbrandsen Conflict of interest • Received an innovation support grant from Norwegian national and regional health authorities, to initiat the company Somsagt. • Somsagt aims to train doctors to become qualified teachers of communication skills. • No conflict of interest • www.ocher.no

4. Two questions: • Why did I not demand intensive care, rather than ask gently? • Why did the nurse not listen to my plea? • www.ocher.no

5. We’re focusing on systems. • We want to change systems. • We do it to reduce shaming and blaming. • That’s fine • But..... • we also need to change people. • www.ocher.no

6. www.ocher.no

8. It is a system issue to improve our personal communication abilities • www.ocher.no

9. N= 58 • r = -0.162 • p = 0.224 Insight • Behaviour • Self confidence • Gulbrandsen et al, Patient Educ Couns 2013 • www.ocher.no

10. Poor associations between self- and other assessments • Gordon, Acad Med 1991 • Davis et al, JAMA 2006 • Lipsett et al, Arch Surg 2006 • Colthart et al, Med Teach 2008 • Blanch-Hartigan, Patient Educ Couns 2011 • Lanning et al, Patient Educ Couns 2011 • www.ocher.no

11. Patient satisfaction measures are always skewed heavily towards the maximum • Sitzia, Int J Qual Health Care 1999 • Epstein et al, Soc Sci Med 2005 • Garratt et al, Qual Saf Health Care 2005 • Makoul et al, Patient Educ Couns 2006 • Roland et al, BMJ 2009 • www.ocher.no

12. Association patient and observer reports • Patient ratings • Correlation .42 (p<.01) • Actual communication skills • www.ocher.no • Fossli Jensen et al. BMJ Qual Saf 2011

13. General satisfaction score Patient rating of behaviour • 0.80 • Satisfaction contamination • 0.42 • Actual behaviour • www.ocher.no

14. Spill-over effect from general satisfaction to behaviour rating • Fossli Jensen et al. BMJ Qual Saf 2011 • www.ocher.no

15. Ability to identify emotions • Satisfaction .22 (poor) • Positive affect .24 (poor) • Negative affect .38 (moderate) • www.ocher.no • Gulbrandsen et al, Med Care 2012

16. Elicit patient perspective score • 2.4 • 0 = not done done very efficiently = 10 • www.ocher.no

17. Patient-centredness • Patient-centredness ≠ consumer orientation • Pseudo-patient-centredness • reduces trust • brings patient-centredness and shared decision making into discredit. • www.ocher.no

18. How can I identify compromised communication? at my workplace? • www.ocher.no

19. Be curious

21. ”We took steps to lower the hierarchy of our teamto actively protect and seek out the insights of the quietest voiceson our team…”…” • Paul Uhlig, heart surgeon, Concord, NH, USA • In Flin & Mitchell, eds, Safer Surgery, 2009 • www.ocher.no

23. What can we do? • www.ocher.no

24. Durable change • 3 years after intervention: • 60% said the course had changed their practice • www.ocher.no • Gulbrandsen et al, Patient Educ Couns 2013

25. He doesn’t look well at all. What’s his haemoglobin? • 6.8. I’m not sure if my answer makes sense to you… • Oh, yes, I’m a doctor. He has deteriorated quickly, and he has had a myocardial infarction earlier. Please look carefully after him. • I can see you’re concerned. Thanks for telling us. What is it that makes you particularly concerned about the heart condition? • Well…I thought you would realize. A sudden anemia is life threatening when he has a coronary disease. • Oh yes, of course. I should know. Thank you. I’ll consult the attending doctor immediately. • Thank you. I really appreciate that. • www.ocher.no

26. He doesn’t look good at all. What’s his haemoglobin? • 6.8. I’m not sure if my answer makes sense to you… • Opens up for patient’s input • Oh, yes, I’m a doctor. He has deteriorated quickly, and he has had a myocardial infarction earlier. Please look carefully after him. • Recognizes feeling. Appreciation of initiative • I can see you’re concerned. Thanks for telling us. What is it that makes you particularly concerned about the heart condition? • Explores patient perspective more • Curious about patient understanding • Well…I thought you would realize. A sudden anemia is life threatening when he has a coronary disease. • Realizes that nurse might not be familiar with risk • Oh yes, of course. I should know. Thank you. I’ll consult the attending doctor immediately. • Receives information, • does not react negatively to possible critique • Clear plan. • Thank you. I really appreciate that. • Appreciation. Feels safer. • www.ocher.no

27. Conclusions • We must improve people • Communication skills training is a system issue • Several years of training and supervision should be organized • Champion doctors must be trained to teach and supervise communication skills • In the long term, this will create a patient safety culture that includes skilful communication • www.ocher.no

28. Conclusions • We must improve people • Communication skills training is a system issue • Several years of training and supervision should be organized • Champion doctors must be trained to teach and supervise communication skills • In the long term, this will create a patient safety culture that includes skilful communication • www.ocher.no

29. Thank you for your attention • pal.gulbrandsen@medisin.uio.no • bfj@somsagt.no • www.ocher.no