Andrew Jager, MA
Featured Guest Bloggers: Andrew Jager, MA & Matthew Wynia, MD, MPH, FACP
- Do patients at your organization understand what doctors tell them?
- Are staff members adequately trained in using plain language with patients?
- Do leaders and policymakers know the range of patients’ literacy levels and so they create an environment in which patients of all levels feel comfortable asking questions?
Do you know the answers to these questions? The truth is, valid data on these issues aren’t easy to gather. Yet knowing the answers to these questions is increasingly urgent to practitioners and leaders in health care organizations.
In the Institute of Medicine’s landmark report, Crossing the Quality Chasm, there is a call for systems to be “designed to serve the needs of patients, and to ensure that they are fully informed, retain control and participate in care delivery whenever possible, and receive care that is respectful of their values and preferences.”
Clinicians are being encouraged to engage patients more in care decisions. And many patients expect this participation, as they should — and often must — to get good outcomes.
Matthew Wynia, MD, MPH, FACP
But what should organizations do to create an environment in which it’s easier to get patients involved in care decisions?
To help organizations get a handle on these questions, the AMA worked with leaders from hospitals, nursing, patient organizations, purchasers, employers and more to identify a set of practical performance expectations for high-quality communication and care, including factors such as health literacy and patient engagement in decisions. We asked a national panel of experts to come to consensus on what it would mean for a care facility like a hospital to fully support patient engagement in care decisions. To help in this work, we also went out to the field and visited hospitals that were doing an exemplary job, to see what steps they were taking.
These hospitals had programs to help communication-vulnerable populations navigate the health care system, they provided educational and notification materials at appropriate literacy levels, they trained their staff on use of teach-back, and, perhaps most important, they sought out and celebrated staff members who went out of their way to provide clear information to patients.
Our visits to hospitals also showed, however, that even top-performing organizations have opportunities for improvement. This is no surprise given the complexity of issues like shared decision making.
But building a better communication climate requires knowing where to start.
When valid data are collected in a baseline assessment of the communication climate, organizations can then decide where best to invest their resources. Sometimes the data suggest addressing deficient areas; other times it might make more sense to use an appreciative inquiry approach and build on areas of success. One tool for performing such an assessment is the Communication Climate Assessment Toolkit, or C-CAT, which was the result of the AMA-led work described earlier in this post.
While we believe the C-CAT is an especially good tool, the point of this post is not to promote it. Rather, the aim is to encourage health care facilities — whether hospitals, clinics, group practices, ACOs or others — to systematically collect data regarding organizational performance and processes, and use these data to work toward the creation of an organizational climate that makes it easier for professionals to consistently deliver high-quality care to all patients, including involving folks in decisions about their own care.
This table at the end of this post lays out some of key consensus performance expectations in the domains of health literacy and patient engagement that came from the AMA’s multi-stakeholder process, along with how these expectations have been translated into the different instruments that make up the C-CAT. You can find all the performance expectations behind the C-CAT measures in our full consensus report, Improving Communication—Improving Care.
Despite the challenges of doing a comprehensive organizational assessment of communication climate, we believe the outcome — improved patient understanding of health information and greater patient empowerment in their health decisions — makes the effort worth it.
About the Authors:
Andrew Jager, MA is a Research Associate at the American Medical Association’s Institute for Ethics. Mr. Jager’s research interests include looking at interventions to improve health care communication and reduce disparities and developing measures of the ethical environment in health care. Additionally, Mr. Jager manages the Communication Climate Assessment Toolkit (C•CAT) program, which provides health organizations with a 360-degree assessment tool for organizational performance on communication that is effective and patient-centered. Mr. Jager has worked on numerous research projects on topics ranging from teen obesity to corporate governance in Latin American and European markets. Mr. Jager is fluent in Portuguese and Spanish and holds an MA in Latin American, Caribbean and Iberian Studies from the University of Wisconsin-Madison and a BA from BeloitCollege.
Matthew Wynia, MD, MPH, FACP, Director, Institute for Ethics & Center for Patient Safety at the American Medical Association is an internist and specialist in infectious diseases. At the American Medical Association, he oversees projects on topics including learning from medical errors, physician professionalism, ethics and epidemics, medicine and the Holocaust, and inequities in health and health care. The author of more than 125 published articles and a book on fairness in health care benefit design, his work has been published in leading medical and health policy journals and he has been a guest on ABC News Nightline, the BBC World Service, NPR and other programs. Dr. Wynia cares for patients at the University of Chicago.
Footnotes:
- Do patients at your organization understand what doctors tell them? http://www.ama-assn.org/resources/doc/ethics/patient-survey.pdf
- Are staff members adequately trained in using plain language with patients? http://www.ama-assn.org/resources/doc/ethics/staff-survey.pdf
- Do leaders and policymakers know the range of patients’ literacy levels and do they create an environment in which patients of all levels feel comfortable asking questions? http://www.ama-assn.org/resources/doc/ethics/organization-survey.pdf
I agree that there are a number of disparities in physician-patient communication. I have not heard of the C-CAT program, and I am very interested in its goals as well as its potential. I recently became involved in a program at a local hospital working to improve patient understanding by using volunteers to review their medical instructions with them before they leave the hospital. In addition to engaging patients in doctor’s decisions as your post suggests, we also work to ensure that patients simply understand the decisions. If more hospitals could enact programs such as this, or C-CAT, I believe that improved patient care is very possible.
As a pre-medical sophomore student, I do not have extensive exposure to clinical doctor-patient relationships. However, I am currently enrolled in a Medicine and Media course at my university, which recently discussed this issue. It was suggested that the initial step to improving communication should be to increase the physician’s ability to understand the patient on a personal level, before engaging them directly. We read a particular article by Charon, which comments on the physician’s inability to fully understand his patient’s perspective. The author suggests that exposure to narrative medicine can aid the physician in adjusting his thought-process and relatability.
A second scientific article we read by Patel primarily focuses on increasing patient knowledge through access to digital records; however, it also touches on the issue of perspective. For example, the author notes the physician’s interpretation of disease as “the dysfunction of the body,” as compared to the patients who “bring not only their knowledge and beliefs about illness, but also particular personal experiences of the disease and how these affect their daily lives.” There is a clear difference between the analytical perspective of the physician, as compared to the emotive perspective of the patient. By taking the extra time to talk to their patients and make them feel valued, physicians can greatly improve the quality of care they provide.
Even with my limited experience, I am still aware of the need for better physician-patient communication. Through my shadowing experiences, I have seen a marked difference in the comfort level of patients being cared for by personable, engaging physicians, as compared to those who appear uninterested in their personal lives and who are very brief and ‘over-professional.’ I believe that if the physician-patient relationship is to be improved, more programs like C-CAT that work to bridge this gap are necessary. Hospital staff should be encouraged to engage with patients, making them feel both valued and involved. Whether this is through using “plain language” or adjusting to their literacy level as your post suggests, all methods of providing for the patient and not just for the disease are beneficial.
Charon– http://www.ncbi.nlm.nih.gov/pubmed/22373630
Patel–http://www.sciencedirect.com/science/article/pii/S1532046402000023
Hello Laura,
On behalf of my co-author, I’d like to thank you for your thoughtful comment!
You make excellent points in your comment, and I am glad that you see the importance of what we’re proposing in your practice. One of the greatest strengths of assessments such as the C-CAT is that by focusing on organizational performance (as opposed to performance of individual clinicians), tailored QI interventions can be implemented that help create the conditions in which communication is more likely to be effective and patient-centered. These interventions can be developed to either address an area that requires attention or can expand on areas of success. We have found through our research that improvement in the C-CAT domains is correlated with patient-reported quality of care and trust in organizations. Further, other research has pointed to correlations between improvements in the areas we are measuring and clinician satisfaction. Basically, we think that creating an environment that fosters effective communication makes it easier for physicians (and other health professionals, too) to do deliver the kind of high-quality care they want to. At the same time, organizations can develop and implement the sorts of programs that patients need to understand the information they receive and be partners in their care. I think you might find a recently published commentary piece interesting. The PubMed link is below, but if that doesn’t work please don’t hesitate to get in touch. In the commentary piece, Dr. Wynia makes some points that are similar to what I’m trying to say here, though he does so much more eloquently than I’m able to!
http://www.ncbi.nlm.nih.gov/pubmed/22818186
Kind regards,
Andrew
andrew.jager@ama-assn.org
Reblogged this on lava kafle kathmandu nepal.
Once of the largest challenges that many physicians face is being able to communicate effectively with patients of diverse backgrounds. I’m glad that you pointed out several ways that health organization can improve patient understanding and patient involvement in care such as training staff on teach-back and reviewing regular assessment on the effectiveness of communication possibly through a tool like C-CAT.
However, I have a two of questions.
You stated that patients should be more engaged in participating in care decisions and have a solid understanding of those decisions. When seeking an understanding, many patients turn not only to their doctor, but to social media. Whether they are reading the Wikipedia version of the disease, joining a diabetes online support group, or looking up forums on alternative treatments, many patients today walk into the doctor’s office with information they have sought out. How can physicians be more prepared to engage with these patients who have been doing their own research? Given that medical information fond on the internet might not be correct or up to date, and simply ignoring what a patient has researched definitely discouraged future patient participation in care decisions.
Also, you mentioned that some hospitals provided educational and notification materials to patients at appropriate literacy levels. How is this information conveyed? In paper copies, online forums, or an outreach setting? The avenue in which these materials are conveyed can make a big difference in what population is reached, and I would be interested to find out what health organizations are using.
Dear mer8ce,
Thank you for your comment and for your questions.
Your observation that patients are more often arriving with information drawn from sources including social media, Wikipedia and others is certainly correct. As you say, ignoring this information, even if it is out of date or erroneous, is likely to discourage patient participation. Given the increasing prevalence of (perhaps incorrect) health information, it is even more important that clinicians confirm patient understanding of health messages by using a technique such as the teach-back method. If a patient responds with incorrect information, the clinician then has an opening to explain why that information is wrong and correct any misunderstanding.
Regarding your question about the format that information was delivered in, organizations were most successful when they selected the best format for their particular patients. Which is to say, it varied by site. You can find in-depth descriptions of the promising practices that were identified in a report from a few years ago, “Promising Practices for Patient-Centered Communication with Vulnerable Populations: Examples from Eight Hospitals.”
http://www.commonwealthfund.org/Publications/Fund-Reports/2006/Aug/Promising-Practices-for-Patient-Centered-Communication-with-Vulnerable-Populations–Examples-from-Ei.aspx
Thanks again for your excellent questions!
Best regards,
Andrew
andrew.jager@ama-assn.org
thank you Andrew!
Hi Andrew,
Thank you for your reply! I’m happy to hear about the success of your program, and will definitely look at the PubMed link when possible. I really appreciate what you are doing, and I am sure the patients who benefit do as well.
Best wishes,
Laura
[...] Andrew Jager, MA & Matthew Wynia, MD, MPH, FACP: “What Should Health Care Organizations Do to Support Shared Decision Making? Consensus From Health… [...]
[...] Matthew Wynia and Andrew Jager asked what organizations can do to encourage and create an environment where shared decision making can occur. The Communication and Climate Assesment Toolkit identifies health literacy strategies like teach back and creating a space where patients feel safe and encouraged to ask questions. [...]