Transcript Team-Based Patient-Centered Communication - PCMH e

Relationship, Communication and
Efficiency: Team-based, Patient-
centered Communication
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
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
SMS: problem solving
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
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
Estimating Panel Size in Primary Care
with Team-Based Task Delegation
Ann Fam Med 2012 10(5) 396-400
Transdisciplinary Functions and Roles in Primary Care
Role
PCP
Nurse
Medical
Assistant
Pharm
Behavioral
health
Care
Management
Relationship
5
5
5
5
5
5
Agenda setting
and activation
4
3
5
2
4
4
Self managementsimple
4
3
4
3
2
2
Self managementcomplex
3
4
2
3
4
5
Primary care
counseling
3
4
1
2
5
4
Plan confirmation
and care
integration
3
4
4
3
4
5
Proactive follow-up
and stepped care
3
5
4
3
3
4
Function
Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect
Larry Mauksch, M.Ed UW Family Medicine
Levels of MA/LPN(RN?) Activity
Warm
Engaged
Activating
X
X
X
X
X
X
Update Meds/ check refills
X
X
Agenda/Priority/Organize
X
X
Activate / Questions?
X
X
Limited
Relationship/Empathy
Vitals/ Visit prep
X
Prev/HCM/screening
X
Initial history (Scribe)
X
SMS: goal/action plan
X
Proactive f/u (registry mgmt)
X
Closure/navigation
Frequency
++
+++
X
X
++
+
The Patient’s Path
Patient uses
e-planning/
scheduler
Front
Office
Greets patient,
introduces form or
acknowledges
e-plan receipt
Warm greeting, MA/
elicits agenda, Nurse
activates patient, BH
may provide HBC
MD
ARNP
PA
Elicits questions,
provides education,
navigation
F/U support, behavior
change counseling
MA/
Nurse
BH
Makes connection,
elicits and negotiates agenda,
provides care, promotes
self management
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
TEAM COMMUNICATION TRAINING
Team members
reinforce use of
communication
skills in one
another
Shared learning
of skills builds
team function
Common Training Sequence
Introduction to
PCOF
Do the cycle again
to learn more skills
and achieve more
goals
Group rating and
discussion of C/B
Videos
Recurrent
observations and
team meetings for
reinforcement
Teamlet members
observe each
other using
extended
appointment slots
Groups meet to
share learning and
set goals
• Within teamlets
• Across teamlets
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Patient Template: Teamlet training
8:30-8;40 discuss needs of first three patients
8:40-8:45 MA bring patient to exam room and explains teamlet
training- at some point is joined by MD, ARNP or PA
8:45 -9:30
8:45 to 9:00 MA interview patient
and MD observes
9:00 to 9:30 MD interviews
patient and MA observes
9:30 to 9:40 debrief encounter
9:40 MA gets next patent and repeat cycle two more times
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Successful Transformation and Adaptive
Reserve: 15 years of research
Protected meeting time to reflect produces
mindfulness
A learning culture that supports efforts to make
sense of experience
Respectful interactions
Leadership
Teamwork
Crabtree BF, Nutting PA,, et al. Primary Care Practice Transformation Is Hard Work: Insights From a 15-Year
Developmental Program of Research. Med Care. Sep 17 2010.
Jaen CR, Crabtree BF, et al. Methods for evaluating practice change toward a patient-centered medical home.
Ann Fam Med. 2010;8 Suppl 1:S9-20; S92.
Nutting PA, Crabtree BF,. Journey to the patient-centered medical home: a qualitative analysis of the experiences
of practices in the National Demonstration Project. Ann Fam Med. 2010;8 Suppl 1:S45-56; S92.
Peer Feedback
Used for reciprocal coaching, problem solving and
support
Structured observation (checklists) important
Should not be used for high stakes purposes
Being the observer may be as valuable as being the
person being observed
Does not require much expert time
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Paired Observation and Video Editing (POVE)
Learners work in pairs They see 3-6 patients
alternating roles as
per day for 3 weeks
observer and “doctor” 40-60 patients in all
Students use
Visits videotaped:
an observation form to Students review tapes
structure their vision
regularly and learn
and feedback
video editing
Faculty review
Students get a series
tapes with students,
of mini talks on core
discuss and respond
communication topics
to questions
Student final
products:
1) Video essayshow baseline,
struggles,
growth and
mastery
2) Teaching VideoWrite, act, film,
Edit and teach
communication
skills
Please rate your skills
a) before, b) after, c) looking back prior to the start
1= very poor
2= some skill use but awkward
3= comfortable with skill use
4= strong and confident
5= highly competent and creative
Please rate your skills on…
Mean
Pre (Retro)
Post
Net % rating skills
higher post
course*
p*
Developing a
relationship
3.55
4.45
45
.002
Being present
3.50
4.09
2.55 (1.95)
4.27
27
.056
41
.004
2.50(2.14)
3.59
45
.000
Expressing empathy
3.64
4.27
32
.016
Eliciting family,
spiritual, cultural
influences on behavior
2.55
3.32
36
.029
n = 22
Agenda setting
Eliciting that patient’s
world view
Please rate your skills on…
Mean
Pre
Post
Net % rating skill
higher post
course*
p*
Helping patients with
health behavior change
2.32
3.45
41
.001
Creating a plan with
patient investment
2.36
3.68
45
.002
Help patients with Mental
health / substance abuse
2.32
3.23
41
.004
Helping patients with
relationship problems
2.18
3.36
45
.002
Time management
1.86
3.32
64
.000
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Faculty
Development
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Communication Training:
Why Faculty Development
Most physician faculty, including humanistic role models,
lack the vocabulary to describe how they communicate.
A lack of training in [communication] assessment reduces
inter rater reliability and is confusing to trainees
There is a disconnect between communication skills taught
in early medical school and what trainees observe in
clinical settings
Faculty may be be reluctant to assess because they suffer
from evaluation PTSD
-Egnew TR, Wilson HJ. Patient Educ Couns. May 2009;79(2):199-206.
-Egnew TR, Wilson HJ.. Fam Med. Feb 2011;43(2):99-105.
Holmboe ES, Ward DS, Reznick RK, et al. Acad Med. 2011;86(4):1-8.
Weissmann PF, Branch, WT, Gracey, CF., et al Acad Med. Jul 2006;81(7):661-667.
TEACHERS AS LEARNERS:
THE IMPACT OF BEDSIDE TEACHING ON THE CLINICAL
SKILLS OF CLINICIAN-TEACHERS
Wenrich, MJ, Jackson, MB. , Ajam, KS. et al
Academic Medicine. July, 2011.
“Teaching foundational
clinical skills at the
bedside may be the
best form of education
and skills
maintenance/enhance
ment for clinicians”
• Expanded knowledge
and skills
• Deconstructing the
clinical experience
• Greater self reflectionmindfulness
Interdisciplinary Direct-Observation
Precepting Model (2x2)
--------------------------
Valerie Ross MS, Larry Mauksch, M.Ed
Mark Beard MD, Jane Huntington MD
(in press, May 2012, Family Medicine)
What topics were discussed in
precepting after being observed that
would not have been addressed in
traditional precepting?
Competency
Assessment
Larry Mauksch, M.Ed University of Washington Department of Family Medicine
Programmatic Competency Pathway
created by Judy Pauwels, MD and Larry Mauksch, M.Ed
Competencies
Milestones
• Patient Care
• Medical Knowledge
• Practice Based Learning and
Improvement
• Interpersonal and Communication
Skills
• Professionalism
• System Based Practice
• For each
competency,
every 6
months
Formative Assessment
• Direct Observation
• Structured tools
• Field Notes
• Surveys
• Guided Learning
Experiences
• Simulations
Consolidate Learning
Experience
Summaries
• Assessment language
is the same across
summaries, for each
milestone and
competency
Goals and
Objectives for
each
learning
experience
Summative
assessments
• Semi-annual reviews
• Goal setting
• Problem solving26
• Final Evaluation
Formative Competency Assessment
A series of observations
Determine trainee knowledge,
attitude and skill
Shaping the trainee’s ability to
apply skills in diverse contexts
Entrustable Professional Activities
Ten Cate, Medical Teacher, 2010, 32, 669-675
Atul Gwande, MD
New Yorker, Oct 2011 Annals of Medicine
Search: “Gwande Coaching”
Personal Best: Top athletes and singers have
coaches, should you?
Davidoff F.
Music lessons: what musicians can teach
doctors (and other health professionals).
Ann Intern Med. Mar 15 2011;154(6):426-429.
Toward Patient Centered Teamwork:
Promoting Cultural Change
Educational
Goal
Educational Strategy or Tool
Understand core
concepts
(Facts; Knowing)
Read to create
vocabulary
Skill learning
(Knowing;
comprehension )
Group discusses “Common” and
“Better” Video with vocabulary
tutoring
Rate video with PCOF,
Online training to increase
vocabulary and skill
recognition
Enhance self
awareness
(Doing; application)
Maximize structured direct
observation:
Observe others, be observed
Team ownership and
reinforcement (Doing;
analysis)
Team critique of
video
Follow patients
across team
encounter
Share learning
and establish
goals
Cultural change
(Synthesis)
Leaders as video
role models,
champions
System wide
training
Inter-clinic sharing
Video and rate self
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