About David McGrath, CPHRM

Dave-McGrath-right
David McGrath, CPHRM, has been with Physicians Insurance A Mutual Company since 1996. As a Healthcare Risk Management Consultant he provides advice and guidance to policyholders regarding healthcare risk management issues. David is based in the Seattle office and provides risk management services primarily in Western Washington.

Avoiding Errors with Better Inter-provider Communication

Dr on phone -low resYou might think that you’ve been doing a great job of communicating with other providers and specialists and you’re ready to close this page and read something else. But before you do that, consider this:

A study published in the Journal of the American Medical Association (JAMA) found that there’s a big discrepancy in reports of successful communication between primary care physicians and specialists. While 69.3% of primary care providers report that they “always” or “most of the time” pass along crucial patient information to specialists, only 34.8% of specialists say that they “always” or “most of the time” receive the information. Additionally, although 80.6% of specialists say that they “always” or “most of the time” send the results of a consult back to the primary care provider, only 62.6% of providers report receiving the results.1

Clearly, there’s a problem here.

Do you know how many other providers each of your patients currently sees? Are any of them specialists? More importantly, how many of them have you had the opportunity to speak with yourself? Do you ever feel your missing important information?

There’s a lot of discussion around care coordination, but unfortunately, in the fast-paced medical environment, care coordination tends to be one of the first things to fall through the cracks. On the surface, this seems understandable. You’re busy. Your colleagues are busy. You’d rather not disturb them if at all possible, and you’d prefer not to be disturbed yourself.

But what if another provider holds the key to improving your patient’s outcome? Without the information from the other provider, you might be trying to solve a jigsaw puzzle with several missing pieces. This doesn’t do your patients any favors, and it increases the likelihood of missing a crucial diagnosis, resulting in patient harm. Good communication with other providers also sends a clear signal to patients that you are invested in their health, which improves patient satisfaction. Studies have shown that satisfied, happy patients who feel that their provider cares are less likely to sue in the event that something does go wrong.

So, what can you do to improve inter-provider communication and patient outcomes?

1. Adopt appropriate health information technology (HIT). If you don’t have up-to-date HIT, you are missing out, and even worse, so are your patients. HIT makes it easy to update patient charts quickly as well as deliver reports and results and send messages to colleagues. If you already have HIT in place, take a look at it. If it’s an obscure brand, you may want to consider replacing it with a more commonly used program that will connect you with more specialists.

2. Standardize note formats. When you send written communication, are you using a standard format, or one of your own devising? Regardless of how simple you may consider your own format to be, if it isn’t in common use, it’s an error waiting to happen. Whether you’re based in an inpatient facility or in private practice, you will need to communicate with other medical professionals, and it’s essential that they understand what you are trying to tell them. HIT may resolve formatting issues, but if you are delivering an email or hard-copy orders, use a standard format with recognizable abbreviations (or, better yet, no abbreviations at all) and codes.

3. Create a care coordinator position. Your time is valuable – no question about that. When you find yourself constantly trying to coordinate communication with other specialists, it may be helpful to create a new position and hire a care coordination specialist to manage these details. The person in this position can keep close track of incoming and outgoing communication and keep you informed so you can tend to other duties.

However, take note of two key points here. First, people get sick, and vacations are necessary, so you need to have more than one person in this position. That way, balls don’t get dropped just because a person wasn’t able to come in to work one day. Second, this isn’t a “set it and forget it” type of scenario. Your patients don’t see what happens behind the scenes, and if a communication gets missed, they won’t want to hear that it’s the fault of the care coordinator. Occasional auditing to make sure that communication is happening smoothly will be necessary.

4. Pick up the telephone and call. How quickly should communication take place? If you need results from a specialist right away, it makes no sense to send an e-mail or other electronic note and then sit back and wait. You don’t know if the message was received or if it’s stuck in some kind of limbo.

Call.

Need a response right away?

Call.

Aren’t sure you understand what the specialist is saying?

Call.

Have further questions about the results?

Call.

In an urgent situation, a phone conversation or face-to-face meeting can save a life – or at least prevent serious injury. Yes, it takes more time, but the information you gather from an actual conversation with a colleague could save you a great deal of time further down the road, improve patient outcomes, and ultimately help prevent a costly error.

You can achieve better inter-provider communication by adopting appropriate HIT, creating a care coordination position, and using the phone to communicate with specialists. The improved communication you experience will benefit you and your patients in many ways.

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1 Ann S. O’Malley and James P. Reschovsky, “Referral and Consultation
Communication Between Primary Care and Specialist Physicians: Finding Common Ground”, Archives of Internal Medicine, January 1, 2011, Vol.171, No. 1 :56–65, doi:10.1001/archinternmed.2010.480.

Connecting with Elderly Patients

Patty could tell that something seemed different about Frank. As they walked their favorite trail around the lake, she noticed that her father was moving more slowly and he seemed to be running out of breath faster than she had remembered. The buttons on his shirt seemed to be slightly strained, as if he had gained weight in his stomach, and he complained about having eaten something that must have disagreed with him.

“Have you seen Dr. Jones recently?” she asked her father.

Her father scowled. “I had an appointment last week. But you know how it is with these young kids—in and out and here’s a bunch of pills. I’m just getting old.”

Patty frowned. “He prescribed medication? For what?”

“I don’t know,” Frank said, shrugging his shoulders. “He talks too fast. All those big words. They make no sense.” He spied a nearby bench. “Can we sit down for a bit? I’m so tired.”

Worried, Patty sat with her father and they watched the ducks without speaking.

A week later, Patty received a call from the hospital. Her father was in the emergency room and appeared to have had a heart attack.

As she drove to the hospital, thoughts swirled in her head. What had gone wrong? Did the doctor miss a diagnosis? Had her father misunderstood the doctor’s instructions?

Most importantly, what could have been done to change this?

*****

What comes to mind when you think of your elderly patients? You might imagine a fragile person with thin white hair who is hard of hearing. Perhaps their mind has begun to slip and their memory isn’t what it once was. Maybe they walk with a cane or a walker. You might think first of the health complaints that become more common as people age—congestive heart failure, osteoporosis, arthritis, and dementia.

Do you bring these images to work with you? You might be inadvertently stereotyping your patients, forcing them to fit a mold they don’t necessarily belong in. It’s crucial to remember that each patient—including each elderly patient—is different and has different goals, different health concerns, and different needs.

Research has shown that patients who feel like they have a relationship with their health care provider are less likely to bring a lawsuit if a mistake is made or things go wrong. In today’s health care model, patient satisfaction is absolutely crucial.

Building relationships with your patients—including your elderly patients—can be challenging, but the payoffs are immeasurable and include improved health outcomes and happier patients.

*****

It might be helpful to take a step back and consider what your older patients expect from their health care providers. Many of these patients grew up with family doctors who provided care for each member of the family and were an active part of the community. They took their time getting to know their patients and may have even made house calls.

Over the years, the medical model has changed considerably. Many providers feel forced into spending less and less time with their patients, and the provider-patient relationship sometimes gets pushed aside because of the limitations imposed by third-party billing and the need to see a large number of patients every day.

But now the pendulum has begun to swing back in the other direction. We’re recognizing (again) the value of provider-patient relationships and the importance of taking the time to connect with and understand your patient. For your older patients, it may feel like coming back full circle, and it’s important to honor that.

While every elderly person has different needs, there are some concerns that, statistically, are more frequent in the elderly. For instance:

  • Only 3% of adults ages 65 and over are considered proficient in health literacy, according to the National Assessment of Adult Literacy.  Research has also connected lower health literacy with poorer physical and mental health.
  • 12.7% of adults ages 60 or over report increased confusion or memory loss.
    Approximately half of all adults over the age of 65 report that they have been diagnosed with arthritis.
  • Nearly half of Americans aged 65 and over have at least one major eye impairment.  Visual impairment often leads to other concerns, including increased risk of fall and fracture, increased risk of depression, difficulty identifying medications, and difficulty participating in daily activities such as bathing and dressing.
  • More than 80% of those diagnosed with lung cancer are over the age of 60,  and COPD prevalence in those aged 65 and over is estimated to be 14.2%.

These concerns may require you to adapt your conversation style. For instance a patient with low health literacy will require explanation of health conditions and medications, along with explanations of why and how things happen. Jargon will confuse this patient, and some patients may not admit to their confusion. A patient with hearing loss may require you to speak louder and more slowly or to write down instructions clearly (or type if your handwriting is hard to decipher). Patients with confusion or memory loss will also benefit from written instructions, and it may be helpful to ask them to bring someone else along, an adult child for instance, who can answer your questions more fully and help them remember your instructions. A person with lung disease may speak quietly, be difficult to understand, or become exhausted from a lot of speaking. It’s important to be patient and allow them to tell their story on their terms.

*****

What other steps can your office take to connect with your elderly patients? You may find that these steps go over well with all your patients, not just the older ones!

1.    Train your team.
Before you even come into contact with each patient, they will have already met with several members of your team—your front desk, a medical assistant, and perhaps an RN. What impression is your team making? Are they being compassionate to the needs of your patient or are their own biases showing? Problems interacting with the team may cause the patient to be less, well, patient, and will feel misunderstood before you even begin speaking.

2.    Schedule extra time and avoid interruptions.
Your patient may need more time to tell their story or you might need more time for explanation and instruction. Either way, allow more time for the appointment and train your team not to interrupt you when you are with patients. This will help you communicate more effectively and build a patient-provider relationship.

3.    Use decision aids such as anatomy models, images, and written instructions.
Make your discussion as memorable as possible by using decision aids to help explain. A model of a mobile joint, an image of the circulatory system, and instructions that are printed in a larger size font will go a long way toward increasing patient understanding and improving compliance.

4.    Check your nonverbal communication.
Speaking is only one aspect of communication. What is your body saying to your patients? You might think you’re ready to listen to your patients’ concerns, but if you are looking at a computer screen, checking the clock on the wall, or sitting in a closed-off position, your patients may pick up on the fact that you are feeling impatient. They may feel like they are bothering you and will be less likely to share important information.

5.    Document your communication.
Make sure that your chart notes include the communication you had with your patient, everything from the patient’s health history to the instructions you gave and the medication you prescribed.

*****

Let’s go back to Patty and Frank. What happened at Frank’s appointment with Dr. Jones that could have been done differently?

Listen to what Frank had to say:

“You know how it is with these young kids—in and out and here’s a bunch of pills.”

It’s clear that Dr. Jones missed an opportunity. Frank did not feel valued or listened to. He felt rushed and didn’t feel comfortable expressing his discomfort. He was provided with a prescription for medications and he didn’t understand why he needed them.

“He talks too fast. All those big words. They make no sense.”

Dr. Jones likely hit Frank hard with a lot of jargon. Frank may also be having hearing difficulties, but Dr. Jones didn’t take a moment to find out. His rapid-fire speech delivery likely frustrated Frank.

Simply by slowing down the appointment, checking to see if Frank was understanding, and discussing the diagnosis and recommended medication, an unfortunate outcome might have been prevented.

_________________________________

  1.   Kutner, Mark, Elizabeth Greenberg, Ying Jin, and Christine Paulsen. The Health
    Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (National Center for Educational Statistics, 2003). Accessed 5/20/15.
  2.   Wolf, Michael S., Julie A. Gazmararian, and David W. Baker. “Health Literacy and
    Functional Health Status Among Older Adults.” Archives of Internal Medicine 165, no. 17 (2005): 1946-1952. doi: 10.1001/archinte.165.17.1946.
  3.   Adams, Mary L., Angela A. Deokar, Lynda A. Anderson, and Valerie J. Edwards.
    “Self-Reported Increased Confusion or Memory Loss and Associated Functional Difficulties among Adults Aged ≥60 Years—21 States, 2011.” Morbidity and Mortality Weekly Report 62, no. 16 (2013): 347-350. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6218a1.htm.
  4.   Barbour, Kamil E., Charles G. Helmick, Kristina A. Theis, Louise B. Murphy, Jennifer M. Hootman, et al. “Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation—United States, 2010 – 2013.” Morbidity and Mortality Weekly Report 62, no. 44 (2013): 869-873. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a1.htm?s_cid=mm6244a1_w.
  5.   Lee, Paul P., Zachary W. Feldman, Jan Ostermann, Derek S. Brown, and Frank A.
    Sloan. “Longitudinal Prevalence of Major Eye Diseases.” Archives of Opthalmology 121, no. 9 (2003): 1303-1310. doi: 10.1001/archopht.121.9.1303.
  6.   Howlader, N., A. M. Noone. M. Krapcho, J. Garshell, D. Miller, S. F. Altekruse, et al.
    (eds). SEER Cancer Statistics Review, 1975 – 2011. National Cancer Institute: Bethesda, MD. Based on November 2013 SEER data submission, posted to the SEER website April 2014. Retrieved from http://seer.cancer.gov/archive/csr/1975_2011/.
  7.   Hanania, N. A., Gulshan Sharma, and Armin Sharafkhaneh. “COPD in the Elderly
    Patient.” Seminars in Respiratory and Critical Care Medicine 31, no. 5: 596-606. Retrieved from http://www.medscape.com/viewarticle/730813_2.

Communication Is Critical to Your Success: 5 Changes Your Organization Can Make Today

doctor explaining info to patientWhat key factors lead to improved clinical outcomes?

Skill and knowledge, of course, are obviously necessary. But communication is also vital and fundamental to developing good rapport and helping patients become engaged in their own health care. Experience has shown us that when patients are engaged, they are more likely to speak openly and honestly about their health issues, better understand their treatment options, and follow through with recommended care.

It is, perhaps, a no-brainer that improving clinical outcomes is a primary goal for all providers, and multiple studies have found that a positive patient experience is correlated with better outcomes. Ultimately, it comes down to patient experience of care.

Patients value quality service on a par with excellent clinical outcomes. This means that to achieve a quality patient experience of care, you need to successfully deliver both superior customer service and quality clinical care.

It’s also been demonstrated that physician compensation is increasingly connected to a patient’s experience of care. Both public and private payers are coming to understand that how a patient perceives their care is a direct indicator of quality.

Historically, providers have tended to focus on the quality of clinical care and left customer satisfaction initiatives to administration. But today, with the prospect of improved patient outcomes and significant financial incentives on the line, everyone in your organization should have the same goal of promoting and improving the quality of patient service.

So which changes can your organization make today that will mutually benefit both you and your patients?

  1. Minimize distractions and interruptions. Your time with the patient should be free of any unnecessary distractions. Allow patients to share their story regarding their health issues without interruption. Do not communicate to the patient that you are in a hurry even though you may be. Interrupting the patient to “get to the heart of the matter” is disconcerting and aggravating to the patient and does not promote rapport.
  2. Sit at the same level as the patient and maintain eye contact. Maintaining eye contact can be a challenge when using computer technology in the exam room to record the patient encounter. Devise strategies so that you can complete documentation but also give the patient uninterrupted time where you can maintain eye contact. This communicates to the patient that they have your undivided attention. Consider carefully the placement of technology in the exam room so you are not turning your back to the patient during the interview process.
  3. Listen actively and effectively. Concentrate on what the patient is telling you both verbally and nonverbally, noting both objective fact and emotion. When the patient has finished talking verbally, summarize the information they shared with you and ask the patient to confirm your understanding. Be aware of the nonverbal messages you are communicating to the patient. Avoid crossing your arms or appearing distracted with administrative duties. Leaning in, maintaining eye contact, and nodding at appropriate moments are all strong indicators that you are interested and receptive to what the patient is telling you.
  4. Keep it simple and assess the patient’s understanding. It is important to develop an understanding of the patient’s ability to process and understand the information that you provide. Your patients have varying degrees of education and healthy literacy, which may affect their ability to understand the information that you provide. In general, using lay terminology that is easily understood by the patient and their family will ensure that the important elements of medical care are understood. Certain patients may request additional or more detailed discussion to which you can then respond. Using the teach-back method requires the patient to repeat the information you have provided in their own words. This is a valuable tool to help you gauge the patient’s comprehension.
  5. Encourage questions. Encourage patients to ask any questions they may have about their medical concerns and the information you provided during the exam and interview. Patients are often intimidated and fearful about asking questions, thinking they may be asking a “stupid question.” Efforts to reduce the patient’s anxiety about asking questions are important. Let patients know that you have provided them “with a lot of medical information today and that this information can be confusing.” Then encourage your patient to ask anything they like regarding today’s exam.

Making a conscious decision to implement these techniques can yield significant improvement in your patients’ health care experiences. When you take the time to build rapport and engage the patient, you and your patient are likely to find a number of benefits, including compliance with recommended care and improved clinical outcomes, which in turn, lead to an enhanced overall patient experience of care.

Dealing with a patient’s noncompliant behavior

iStock_000012115736SmallWebAll health care providers, regardless of specialty, encounter patients who are noncompliant with medical advice or treatment recommendations. In many cases, the patients are not being deliberately noncompliant, and their providers can help them become more compliant.

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A patient’s right to informed consent or informed refusal

iStock_000017741056MediumblogInformed consent is a process that can lead to the best possible medical care for a patient. A good consent discussion can improve patient compliance, patient satisfaction, and clinical outcomes.

What are the key elements of informed consent?

Informed consent is more than a form; it’s a communication process. It begins with a provider’s recommendation of a treatment plan or procedure and a sharing of all material facts. This discussion should therefore include the details of the procedure, alternatives, benefits, risks, and complications (PABRC). For most procedures, a written consent form is important, and for significant procedures, a procedure-specific consent form is best.

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Communicating with the older patient

Nurse assisting older patientOlder patients suffer from a greater number of complex, chronic conditions requiring correspondingly complex medical treatment. As the complexity of medical treatment increases, so does the probability for adverse outcomes or medical errors.

Age-related decline in physical conditions such as hearing loss, poor vision, memory loss, and difficulty processing information all impact a senior patient’s ability to communicate.

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