Transcript Team Training Model - Larry Mauksch - PCMH e

Relationship. Communication
and Efficiency: A Team
Training Model
Larry Mauksch, M.Ed
Senior Lecturer
Department of Family Medicine
University of Washington
Consultant and Trainer
Goals
Promote team training to improve quality,
patient safety, skill learning, and skill retention
Describe communication skills at the
intersection of quality and efficiency
Promote direct observation to enhance
competency assessment and faculty
development
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Objectives: Participants will learn:
A model of communication, relationship and efficiency
based on a literature review and additional evidence.
To use the Patient Centered Observation Form (PCOF)
and be given access to free online training
To create teaching tapes that help learners master these
skills
Options for direct observation to maximize formative
competency assessment
Skills that should be mastered by other members of the
health care team
to maximize quality and efficiency
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Barriers To Learning
Patient Centered Communication
Focus on tangible
markers in health
care training
Stigma and hidden
curriculum
Limited team
development
to reinforce
skill use
Limited vocabulary
to describe
“intangible” skills
Fear loss of control
of time
US Prevalence (2001) of Multiple
Risk Factors in Adults ≥ 18
Am J Prev Med 2004 27(2S) 18-24
Number of Risk
Factors
Estimated US percent
0
10
1
33
2
41
3
14
4
3
Mean
1.7 per person
Mental Distress
High 2.03; Low 1.67
Chronic Disease
Yes 1.75; No 1.67
Stages of Activation
Hibbard et al Health Services Research 2007, 42(4) 1443-63
Level of activation
(age 45 or older, 2.9 chronic conditions)
diabetes, HTN, lung, cholesterol, arthritis, heart
May be overwhelmed and unprepared
to play an active role in their own health
Percent
(cumulative)
12
May lack knowledge and confidence
about self management
29
(41)
Taking action but may lack confidence
and skill to support self management
37
(78)
Mastered self management but may not
maintain behaviors at times of stress
22
Mental Disorders in Primary Care
J of Fam Practice 200150(1), 41-47
Any Diagnosis
Major Depression
Panic Dis
Other Anxiety Disorder
Bulimia
Other Depression
Binge Eating Dis
Prob Alcohol Abuse
0%
10%
PHQ-3000
20%
30%
40%
50%
Marillac 500
60%
Primary Care Realities
Primary Care patients average 3-6
problems per visit
Indigent primary care populations have
a greater illness burden
Half of adults have two or more chronic
illnesses
•75% of US health care dollars go to care for
chronic illness
Time Demands in Primary Care
Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:209-214.
Well controlled
Ten most common
2500 patients
Chronic illnesses
Conservative
time estimates
Preventive care
Level A and B
recommendations
3.5 hrs/day
Poorly controlled
10.5 hrs/day
7.4 Hours per day
Why Learn Communication Skills?
Time
management
and
organization
Promote self
management
Safety
Better
outcomes
Behavioral
health
What
patients
want
Health
Literacy
Decrease
litigation risk
Teamwork
The solution
Why Are High Functioning Teams
Essential To Primary Care
Too much work
for one person
Collaboration
produces better
outcomes
Effective teams
help sustain
healthy behaviors
in their members
Fewer errors
Hierarchy of Interactional Behaviors
Therapeutic
• Reflective listening
• Explores beliefs
• Strengthens coping ability
Self
management
support
• Goal setting
• Problem solving
• Confidence building
• Behavior change reinforcement
Communication
• Diagnosis
• Education
• Time management
• Anxiety reduction
Relationship
• Listening
• Empathy
• Patients feel known
• Building trust
Observation Form Purpose
and Training
The value
• Structures vision
• Creates and standardizes vocabulary
Primarily for formative assessment and to
strengthen the “observer self” (mindfulness)
Online training:
http://uwfamilymedicine.org/pcof
PCOF Use
Behavior in either of the columns to the right of
thick vertical line is in the competent range
Observers mark accurately and avoid giving
the benefit of the doubt
Feedback
is best:
When
solicited
Specific,
rather than
general
Curious, not
judgmental
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Relationship Communication and Efficiency
Mauksch et al, July 14 2008, Arch of Intern Med
Ongoing influence
Rapport and
Relationship
Mindfulness
Topic Tracking
Empathic
response to
cues
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Polite Interruption
Acknowledge and Apologize
Empathize with the problem that is being cut
off
Explain why you are interrupting, for example
• Planning time use
• Finishing an important topic (topic tracking)
• Stopping to explore an important cue
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Relationship Communication and Efficiency
Mauksch et al, July 14 2008, Arch of Intern Med
Ongoing influence
Rapport and
Relationship
Sequential
Mindfulness
Topic
Tracking
1. Upfront collaborative agenda setting
Empathic
response to
cues
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Visit Organization
Chronic
HM /
Preventive
Acute
SMS
Agenda
collision
Upfront Collaborative Agenda Setting
Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst, Health, 2001
Identifies patient’s priorities
Organizes the visit
Decreases chance that patients or providers will
introduce “oh by the way” items
Screens for mental disorders
Facilitates shared decisions about time use between
acute, chronic, and health maintenance care
Does not lengthen the visit; protects time for planning
Decreases clinician anxiety
UW Family Medicine Residency
(Mauksch et al
Families Systems, Health, 2001)
Community RCT
Brock, Mauksch et al
JGIM, Nov 2011
10 Residents; 7 faculty 162 patients
48 physicians, 1460 patients; two systems
Brief reading, video, written learning
confirmation, skill reinforcement
2 hr training w/demo & practice;
handout, 2 hrs coaching/wk for 4 weeks,
no reinforcement for 6 months
•Higher patient satisfaction
•More MD prioritization
•EF MDs showed more upfront
elicitations (“something
else”*)
•MDs charted more
problems
•EF Patients more likely to say
“that’s it”
•More f/u requests
•EF Patients & MDs had fewer
“oh by the ways”
•No difference in visit
lengths
•Shorter visits 90 seconds (NS)
Agenda Creation
Orient the patient:
“I know you are here to talk about ____. Before we get into_____ is there
something else important to addresses today? Making a list will help us
make the best use of time”.
If the list is greater than three items,
the patient is screen positive for depression or anxiety
Ask, “what is most important”
• Listen (feel) for the most important concern
Avoid premature diving by patient or yourself
When needed interrupt the patient or
yourself:
Acknowledge, Empathize
Share reasoning
Agenda Setting
Missteps and corrections
Provider diving
• Interrupt your self: “ I am getting ahead of myself”
Patient diving
• Interrupt with an apology, empathy, and reason
• “I apologize for interrupting. Your sleep is a concern but
before we talk about it, is there something else?”
No orientation to purpose of agenda setting
• Orient: “Lets plan the use of time before we use it”
Relationship Communication and Efficiency
Mauksch et al, July 14 2008, Arch of Intern Med
Ongoing influence
Rapport and
Relationship
Sequential
Mindfulness
Topic
Tracking
Empathic
response to
cues
1. Upfront collaborative
agenda setting
2. Hypothesis testing and
understanding the patient
perspective
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Explore the Patient Perspective When:
Promoting self
management
and behavior
change
Detecting clues
about thoughts
or feelings
Family or cultural
influences are
suspected
Psychosocial
factors may be
present
There are
unexplained
medical
symptoms
You sense distrust
in the health
system
Desired change
does not occur
Contemplating a
major health
care decision
Exploring Patient Perspective:
Core Skills and attitudes
Attitudes
• Curiosity
• Empathy
• Remembering, when patients do not do something,
there is always a reason
• Cultural humility
Skills
• Reflective listing
• Open ended, focused questions
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Relationship Communication and Efficiency
Mauksch et al, July 14 2008, Arch of Intern Med
Ongoing influence
Rapport and
Relationship
Sequential
Mindfulness
Topic
Tracking
Empathic
response to
cues
1. Upfront
collaborative
agenda setting
2. Hypothesis
testing and
understanding
the patient
perspective
3.
Co-creating
a plan
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Co-creating a Plan
Informed
decision making
•Offer a plan
•Share evidence
•Examine
•Uncertainties
•Pros and cons
•Alternatives
Shared decision
making
•Addresses patients
values and goals
•Solicits patient
preferences or
input
•If needed, plan is
revised
The Decision Making Phase
Informing
• Providing
access to
decision
aids
Completing
• Questions
• Teachback
• After visit
summary
Sharing
Direct observation:
Logistics
Consenting
patients
Activity in
the room
Time use
between
patients
Direct Observation:
Methods, Time Demand, Pros and Cons
Faculty
Time Demand
Educational
Pros
Educational
Cons
Direct observation
in the room
High
Loss of income or
other activity
Clear view
Can teach on the
fly
Trainee initially self
conscious
Risk of upstaging
relationship
Video review
High
Loss of income or
other activity
Trainee self
observes, strong
educational
options
Delayed practice
Requires technical
expertise and
expense
Closed circuit
Moderate
Some income loss
or other activity
Fast practice
Faculty
development
Distraction,
time limitation,
Reliability?
Very Low
++Observations
++reflection
++Practice
Less depth
versatility
Reliability?
Low
Role modeling
Observer self
Faculty growth
Passive trainee
role
Peer
You are observed
Consenting patients
Can be done by receptionist, medical
assistant, nurse or physician
Should not be done with observer
present
Emphasize that the focus is on the health
care team member, not the patient
Consenting patients
“Hello, I am Dr/Ms. Mapleleaf.
Before we begin I want to ask if
it is OK with you if a colleague
sits in to observe. The focus is
on me. As part of our
professional development we
observe each other to maintain
excellence in patient care.”
Activity in the room- Entry
Person being observed
should introduce observer
Observer should greet
each person
Thank the patient and
others
“Hello, thanks for letting me sit in. I
am going to sit out of the way” (sits
down)
Position chair in place not in line of
sight between team member and
patient
Activity in the room-Seating
Counter
MA/RN
MD
B
A
Door
Observer behavior during
interview
Avoid upstaging interviewer with eye contact or non verbal
behavior, e.g., head nodding, non verbal empathy
If patient speaks to you, look at MD or at the floor, and then to your paper
to avoid reinforcing being included in the conversation
Never interrupt person being observed
• OK to plan ahead to invite observer in to help
If interviewer leaves the room:
• Engage patient in brief conversation or respond to patient questions
but be careful not to undermine the interviewer, or
• Leave with interviewer
If person you
are observing
requests
feedback then
spend a few
moments, but
be sensitive to
schedule
If person needs
to do other
work (phone
call, check
labs, see next
patient),
encourage
him/her to do it.
Make use of
“no show” time
and protected
time
Giving Feedback
It is timely
and
requested
About
something that
the receiver
can change
Kind
Not
judgmental
Honest
Specific
Provisional
and curious
1) What communication and relationship skills did you see
demonstrated that you do not use but would like to adopt?
2) What interpersonal skill weaknesses did you see that you
recognize in yourself?
3) What are the ways that this team worked well together to
maximize quality and patient satisfaction and eliminate
unnecessary redundancy or wasted time for the patient?
4) How might this team improve the quality of care for its
patients?
Common and Better Video:
Faculty development primer
Common
Missing core skills
• Should not be bad
caricature
• Better if observer
rates it and doesn’t
see much to
improve
Better
Re-create the
scenario but
with core skills
• Should be better,
but not perfect
• Make both videos
the same length
Bibliography
Arnold RW, Losh DP, Mauksch LB, et al. Lexicon creation to promote faculty development in
medical communication. Patient Educ Couns 2009;74:179-83.
Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS. Effectiveness of Intensive
Physician Training in Upfront Agenda Setting. J Gen Intern Med. Nov, 2011.
Egnew TR, Mauksch LB, Greer T, Farber SJ. Integrating communication training into a required
family medicine clerkship. Acad Med 2004;79:737-43.
Egnew TR, Wilson HJ. Faculty and medical students' perceptions of teaching and learning about
the doctor-patient relationship. Patient Educ Couns. May 2009;79(2):199-206.
Egnew TR, Wilson HJ. Role modeling the doctor-patient relationship in the clinical curriculum. Fam
Med. Feb 2011;43(2):99-105.
Epstein RM, Mauksch L, Carroll J, Jaen CR. Have you really addressed your patient's concerns?
Fam Pract Manag 2008;15:35-40.
Kim S, Spielberg F, Mauksch L, et al. Comparing narrative and multiple-choice formats in online
communication skill assessment. Med Educ 2009;43:533-41.
Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient communication skills to medical
students: an innovative strategy. Acad Med 2005;80:118-24.
Bibliography Continued
Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, Communication,
and Efficiency in the Medical Encounter: Creating a Clinical Model From a
Literature Review. Arch Intern Med 2008;168:1387-95.
Mauksch LB, Hillenburg L, Robins L. The established focus protocol: training for
collaborative agenda setting and time management in the medical
interview. Families, Systems and Health 2001;19:147-57.
Robins, L. Wittetborn, S., Miner, L. Mauksch, L. Edwards, K. Brock, D. Identifying
Transparency in Physician Communication, Patient Education and
Counselling, in press
Ross, V., Mauksch, L., Huntington, J., Beard, M. Interdisciplinary Direct
Observation: Impact on precepting, residents, and faculty, Family
Medicine, in press.
Schirmer JM, Mauksch L, Lang F, et al. Assessing communication competence:
a review of current tools. Fam Med 2005;37:184-92.
*Weissmann, P., Branch, W. Gracey, et al. Role Modeling Humanistic Behavior:
Learning bedside manner from the experts. Academic Medicine, 2006,
81, 661-667