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Doctor Patient CommunicationImproving patient and physician satisfaction

Ron Hofeldt MDMedical Director

Wellness Develop Groupwww.WellnessDevelopmentGroup.com

855-205-4932

Ron Hofeldt MD

DISCLOSUREDISCLOSUREWe would like to disclose that

have no financial interests in any organizations that have a direct interest in the subject matter

of this CME presentation.

Objectives• Identify communication issues within the doctor-patient

relationship contributing to malpractice litigation• Discuss mutual value of improving doctor patient

relationship/communication• Describe common barriers to effective communication

following an adverse clinical eventfollowing an adverse clinical event• Highlight important considerations to preserving or restoring

the doctor-patient relationship when discussing adverse events or delivering bad news to patients or families

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Agenda• Discuss the impact and frequency of adverse events• Present factors contributing to lawsuits• Describe the value of effective physician patient

communication• Discuss apology and disclosure: types, style and content

MedicineA combination of complex science and intricate art

• Made in real time• No do overs

Decisions in medicine

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Modern Medicine• Characterized by:

– High volume– High acuity– High level of technology – High demandsHigh demands– High pressure– Lack of professional support– High complexity

Bad things happen

Survey results for Serious AEs•66% increase in anxiety re future errors•51% loss of confidence•48% decreased job satisfaction•48% sleep difficulties•15% harm to their reputation

Near misses56%36%34%

33%9%

Minor51%31%32%34%10%

Impact of adverse events

81% reported at least one of the above

Second victim

Gallagher, T. The Emotional Impact of Medical Errors on Practicing Physicians in the US and Canada, Joint Commission Journal on Quality and Patient Safety, August 2007

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• The Organization is deeply impacted, too- Excessive demands on staff: time and emotions

• Claims and Risk Management Departments • Administration and leaders

- Toll of responding to patients’ needs

Impact of adverse events

- Public relations issues

Third Victim

Impact of adverse events on clinicians

Relive the event

Anxiety

Guilt

Fear of litigation

Depression

Sleeplessness

Fear of judgment by colleagues

Emotional impact of adverse events

0 20 40 60 80

Anger

Professional self-doubt

Defensiveness

Loss of reputation

Consider career change

Use of substance

Percent of respondents who experienced symptomSymptom

The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey/Adverse Anesthesia Events F. Gazoni, Intern. Research Soc. Mar 2012. V 114. No 3

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• Avoidance/Withdrawal• Guilt• Anger• Fear • Overcompensate

Emotional impact of adverse events

• Overcompensate• Shame

• 92% of the physicians had been involved with a near miss, minor or serious error

Frequency of adverse events

Gallagher, T. The Emotional Impact of Medical Errors on Practicing Physicians in the US and Canada, Joint Commission Journal on Quality and Patient Safety, August 2007

Adverse events are common• 2010 Inspector General study of hospitalized Medicare pts.

– Hospital Medicare beneficiaries: • 13.5% experienced an adverse event resulting in Temporary

Harm• 1.5% had an event that contributed to their deaths

– ~15,000 patients/month• 44% of in-patient adverse events were preventable

Tax Relief and Health Care Act

Levinson D, et al. Adverse Events in Hospitals Among Medicare Beneficiaries.OIG for DHHS Nov. 2010

• 44% of in-patient adverse events were preventable

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When an adverse event occurs, how is it viewed?

• Was the incident a–Wrongdoing, a blameworthy event, or a mistake

vs.–Unfortunate incident, unexpected event, unanticipated

outcome

The outcome of an adverse event• Strongly influenced by perception

–Perception of the event–Perception of the care providers, team, clinic and

facility• Therefore, perception is crucial

• Communication breakdown- 82%– 35%

Factors contributing to lawsuits

Provider attitude

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Provider attitude• Following an adverse event, patients perception

of their physician–32% of patients felt deserted–29% of patients felt devalued–26% thought the information was presented poorly–13% of patients felt their perspective was devalued

Beckman, et al. Arch. Int. Med. June 27, 1994

• Communication breakdown–Provider attitude 35%– 35%

Factors contributing to lawsuits

Communication failure

Communication failure• Root cause in

- 66% of all sentinel events* - 85% of maternal deaths and injuries*

• Considered the single largest source of patient *Communication Strategies for Patient Handoffs. ACOG, no. 367, June 2007

g g psafety threat**

**Communication in the Grey Zone- Perceptions about Emergency Physician-Hospitalist Handoffs and Patient Safety. Apkey, J. Soc. Acad.Emerg. Med. Oct 2007, vol. 14, no 10

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Root cause of sentinel events

The Science & economics of improving communication William T. ’Byrne, III, MD, LizaWeavind, MBBCh, John Selby, MD, JD Anesthesiology Clin 26 (2008) 729–744 doi:10.1016/j.anclin.2008.07.010 anesthesiology.theclinics.com

Percent of events

Percent of 3548 events

Hickson Study• Involved Individuals who filed birth injury claims n=127

–48% believed the physician was not honest or mislead the family–20% saw litigation as the only way to get information

Common causes of failure• Heuristics: mental short-cuts lead to solutions that are not optimal

• Errors in Perception• Confirmation bias

• Errors in Assumption• Errors in Communication

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Ineffective team communication• Most common cause cited for adverse events––Critical data is too often “lost”; hence, available Critical data is too often “lost”; hence, available information isn’t consideredinformation isn’t considered

–Missing vital information: the fumble/handnformation: the fumble/hand‐‐off error off error •• Lost in translationLost in translation‐‐ differing perceptiondiffering perception

Clinicians have a different “picture”Clinicians have a different “picture”–– Clinicians have a different  pictureClinicians have a different  picture

•• Lost in transition of careLost in transition of care–– When there’s a transfer of care When there’s a transfer of care 

Translation error• Classic translational hand-off error

–Recovery nurse remembers telling the podiatrist that s/he was concerned and the situation was urgent

–Yet, the podiatrist recalls the communication as routine

To avoid hand-off errors• Use closed-loop communication

–Use clear, concise and “standard” language–Verify that the sent message is both

• Received by the intended party and• Interpreted by the receiver correctly

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Transition handoff errors• Occurs across

–Disciplines–Shifts–Call coverage–Location

• Results in–Lost information–Breakdown in situational awareness

• Communication breakdown 82%–Provider attitude 35%–Communication failure 35%–Unrealistic pt expectations 5%

Factors contributing to lawsuits

Set realistic expectations• Value of the informed consent

–Establishes realistic expectations–Coupled with appropriate documentation

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• Communication breakdown 82%–Provider attitude 35%–Communication failure 35%–Unrealistic pt expectations 5%–Jousting 7%

Factors contributing to lawsuits

Jousting• Avoid off-handed comments regarding other

clinicians–Verbal–Non-verbal –Written

When medical errors occur• Do not

–Point fingers, blame, scapegoat or criticize–Speculate or guess as to who or what

• If you don't know, say it–Make off the cuff statements–Withdraw from the patient–Hide information

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• Influences the patient–Patients use the quality of communication to judge

competency–Enhances compliance–Promotes patient satisfaction

Value of effective communication

• Influences the patient• Influences the physician

–Creates a stronger physician-patient relationship–Promotes physician joy of medicine/satisfaction

• Less patient conflict

Value of effective communication

• Greater patient satisfaction• More fulfillment in medicine

• Influences the patient• Influences the physician • Promotes teamwork

–High functioning teams communicate more openly–Promotes collegiality

Value of effective communication

Promotes collegiality–Promotes situational awareness and error reduction

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Teamwork• Requires leaders to develop team building skills

–Empower team members–Encourage speak up and step up behavior

Key to a safe practice • Accept vulnerability• Everyone makes mistakes• All humans are fallible• Encourage speak up and step up behavior

Promote backup behaviorAnticipate the needs of team members

Error reduction

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Watch out for your teammate’s back

Situational awarenessCountermeasure to errors

•Workplacefactors- Interruptions, distractions, noise, chaos…- Human factors - Incomplete / inaccurate information- New and changing team membersAccelerated pace/time pressures

Threats to situational awareness

- Accelerated pace/time pressures- Rapid switching/fluctuations- Work overload and under-load- Compromised/disrespectful communication

Stress-Performance Correlation

Image

Optimal

PERFO

RM

AN

CE

STRESS The Yerkes-Dobson Curve

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• Influences the patient• Influences the physician • Influences teamwork• Reduces the risk of litigation

Value of effective communication

Medical error• Leaves patients confused• Disrupts the patient’s trust with the physician

When the trust is broken When the trust is broken the relationship must be rebuiltthe relationship must be rebuilt

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Trust is reestablished withTrust is reestablished with

an honest, an honest, and heartfelt and heartfelt disclosure and apologydisclosure and apologytransparent transparent

Rebuilding trust promotes forgivenessRebuilding trust promotes forgiveness

Truth Empathy+ + Forgiveness =Forgiveness formula: + SincerityApology

“Full disclosure is the right thing to do.

It is not an option; it is an ethical imperative.”

Lucian Leape

t s a et ca pe at e

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How to mitigate the impact of adverse events

A timely disclosure and a genuine apology

The disclosure and apology gap

Num

ber

ExcellentPoor

Preliminary data from T. Gallagher, MD

ExcellentPoor

Num

ber

Style

The Disclosure and Apology The Disclosure and Apology •A learned skill•Elements:

-Empathy, compassion, sincerity & vulnerability-Components of disclosure and apology

•A learned skill•Elements:

-Empathy, compassion, sincerity & vulnerability-Components of disclosure and apology Content

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•Desirable qualities: -Transparent -Organized -Thoughtful-Forthright-RemorsefulE thi

•Desirable qualities: -Transparent -Organized -Thoughtful-Forthright-RemorsefulE thi

Style counts! Style counts!

-Empathic-Pace: set by patient

•Style -Leaves a lasting impression -Helps to repair the broken trust-Involves trainable skills

-Empathic-Pace: set by patient

•Style -Leaves a lasting impression -Helps to repair the broken trust-Involves trainable skills

Shows you care!Shows you care!

•Type of apology: determines the content •Components of an apology•Type of apology: determines the content •Components of an apology

Content Content

•Statement of sorrow•Offered from one person,organization or country to another•When heartfelt, provides a salve that heals wounded relationships

•Statement of sorrow•Offered from one person,organization or country to another•When heartfelt, provides a salve that heals wounded relationships

An apology- definition An apology- definition

pp

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I.Expression (apology) of regret I.Expression (apology) of regret The Apology The Apology

II.Apology of remorse II.Apology of remorse

Commonly offered in our society Commonly offered in our society I.Expression (apology) of regret I.Expression (apology) of regret

•Expression of sympathy or consolation•Indicated when:

-Person was harmed, impacted or inconvenienced-The event not due to a wrongful act. “No fault”

•No system error or breakdown•Non-preventable adverse event

E l

•Expression of sympathy or consolation•Indicated when:

-Person was harmed, impacted or inconvenienced-The event not due to a wrongful act. “No fault”

•No system error or breakdown•Non-preventable adverse event

E l

I.Expression (apology) of regret I.Expression (apology) of regret

•Examples: -Patient experiences known side effect to medication-Caregiver is late for the appointment

•Examples: -Patient experiences known side effect to medication-Caregiver is late for the appointment

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Elements of an expression of regretElements of an expression of regret•Involves

-Expression of sorrow: •“I am sorry that you…”•“I am sorry you…”•“I am sorry it…”•“It must be difficult that…”“I t th t ( ) d ”

•Involves -Expression of sorrow:

•“I am sorry that you…”•“I am sorry you…”•“I am sorry it…”•“It must be difficult that…”“I t th t ( ) d ”

Apology Apology

N thN th •“I regret that (____) occurred.” -Name the wrong (if appropriate)

•“I regret that (____) occurred.” -Name the wrong (if appropriate)

Name theviolated

social norm

Name theviolated

social norm

“I’m sorry the door slammed on your foot. I didn’t catch it in time.

“I’m sorry the door slammed on your foot. I didn’t catch it in time.

“I’m sorry.”“I’m sorry.”vs.vs.

Expression (apology) of regret Expression (apology) of regret

I am very sorry.”I am very sorry.”

•Indicated when-An injury/harm that is clearly caused by an error or system failure

•Delivered by-The individual directly responsible

•If capable!

•Indicated when-An injury/harm that is clearly caused by an error or system failure

•Delivered by-The individual directly responsible

•If capable!

II. Apology of remorse

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II. Apology of remorse•Following an error, patients want:

-What happened. The KNOWN FACTS•The facts told succinctly

-An apology -Clear explanation of the impact of error on health-Why it happened-How injury will be treated/corrected-Prevention of future similar errors

•Not every apology requires a full apology•Every apology is unique•Not every apology requires a full apology•Every apology is unique

•Illinois Public Act 094-0677 Sec. 8-1901, 735 ILL. Comp. Stat. 5/8-1901 (2005)

•Arizona A.R.S. 12-2605 (2005)

•Montana Code Ann.26-1-814 (Mont. 2005)

•Louisiana R.S. 13:3715.5 (2005)

•Missouri Mo. Ann. Stat. 538.229 (2005)

•New Hampshire RSA 507-E:4 (2005)

•Virginia Code of Virginia 8.01-52.1 (2005)

•Vermont S 198 Sec. 1. 12 V.S.A. 1912 (2006)

States with apology laws•Revised Statute 13-25-135 (2003)

•Oregon Rev. Stat. 677.082 (2003)

•Massachusetts ALM GL ch.233, 23D (1986)

•Texas Civil Prac and Rem Code 18.061(1999)

•California Evidence Code 1160 (2000)

•Florida Stat 90.4026 (2001)

•Washington Rev Code Wash 5.66.010 (2002)

•Tennessee Evid Rule 409.1(2003)

•Ohio ORC Ann 2317.43 (2004)•Connecticut Public Act No. 05-275 Sec.9(2005) amended (2006) Conn. Gen. Stat. Ann. 52-184d

•South Carolina Ch.1, Title19 Code of Laws 1976, 19-1-190 (2006)

•Delaware Del. Code Ann. Tit. 10, 4318 (2006)

•Indiana Ind. Code Ann. 34-43.5-1-1 to 34-43.5-1-5

•Idaho Title 9 Evidence Code Chapter 2 .9-207

•Iowa HF 2716 (2006)

•Utah Code Ann. 78-14-18 (2006)

•Nebraska Neb. Laws L.B. 373 (2007)

•North Dakota ND H.B. 1333 (2007)

( )

•Georgia Title 24 Code GA Annotated 24-3-3.1(2005)

•Wyoming Wyo. Stat. Ann. 1-1-130

•Oklahoma 63 OKL. St. 1-1708.1H (2004)

•Maryland MD Court & Judicial Proceedings Code Ann. 10-920 (2004)

•North Carolina General Stat. 8C-1, Rule 413

•Hawaii HRS Sec.626-1 (2006)

•Maine MRSA tit. 2908 (2005)

•South Dakota Codified Laws 19-12-14 (2005)

•West Virginia 55-7-11a (2005)

35 states and the District of Columbia

Call to action!• Transformation of medicine is occurring

–Clinicians are losing autonomy–Administrators are “telling” clinicians how to practice–Clinicians are becoming dissatisfied and disillusioned

• Further contributing to burnout and medical errors

•Yet clinicians must play step up and engage•Yet, clinicians must play step up and engage

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Physicians must• Become leaders

–If not, no one will follow–Help to create teams with situational awareness

• Address the impact of stress in our lives & practices• Maintain life-work balance

A leader is one who knows the way, goes the way and shows the way

Questionsand

Comments

Doctor Patient CommunicationImproving patient and physician satisfaction

Ron Hofeldt MDMedical Director

Wellness Develop Groupwww.WellnessDevelopmentGroup.com

855-205-4932