Patient/provider communication critical — Pick the best method

Avoid misdiagnosis, inappropriate treatment, and med errors

A series of patient testimonies videoed for a new initiative launched by the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, this fall shows the benefit of two-way communication between clinicians and patients. For one patient, the conversation resulted in a correct diagnosis and a reduction in medications. Another realized that if he had discussed with his physician the side effects he was experiencing from his high blood pressure medicine, he would not have ended up in the emergency department.

Called "Questions are the Answer" (, this effort one of many initiatives and tools introduced in recent years to improve communication. With The Joint Commission evaluating institutions to determine if they are working to improve patient/provider communication, it's time to make sure plans are in place. What steps might you take to enhance patient/provider communication?

Choose tools that have been identified as a best practice or promising practice, says Jen Kimbrough, PhD, executive director of the Guilford Coalition on Adolescent Pregnancy Prevention in Greensboro, NC, a faculty member at the University of North Carolina at Greensboro, and a founding member of the Guilford Health Literacy Forum and NC Health Literacy Council in Greensboro, NC. Best practice is something that repeatedly has been shown to be effective in any setting where promising practice is supported by emerging evidence.

Kimbrough recommends the Health Literacy Universal Precautions Toolkit for primary care released by AHRQ. It contains some proven communication strategies, such as teach-back and information on how to do a brown bag medicine review. In that review, providers request that patients bring all their medications and supplements to medical appoints for patient/provider discussion on their purpose and how to take them correctly. (To download a copy, visit

At WellSpan Health, a healthcare system in York, PA, the discussion about tools to improve patient/provider communication within physician offices took place within the Health Literacy Task Force set in place by the Healthy York County Coalition, which is affiliated with the healthcare institution. The work is part of the Aligning Forces for Quality grant funded by the Robert Wood Johnson Foundation. Input also came from the patient advisory councils at WellSpan Health. The interventions selected include brown bag medication education and teach–back, says Christine Hess, MEd, patient and family education coordinator at WellSpan Health.

It is always good to include the people impacted by communication tools in the discussion, says Cindy Schlough, director of Strategic Partnerships for the Wisconsin Collaborative for Healthcare Quality (WCHQ). in Middleton. Therefore, when discussing communication strategies that impact clinicians and patients, include them in the process, she says.

Do the research

When committees are assembled to examine communication tools, it is important for members to gather as much information as possible, says Schlough. Before implementing the "Ask Me 3" program at local clinics, the group Schlough worked with performed a literature search to find research on the tool, which they listed in their report on the project. Also, they held conference calls with clinics that had implemented the program.

"We need to look at each program to determine where it has been successful and then what made it successful," says Schlough.

Also important is an assessment of your facility to determine what you do well and where there are weaknesses, says Kimbrough. Create a plan based on the evaluation, she advises. She recommends "The Health Literacy Environment of Hospitals and Health Centers" produced by The National Center for the study of Adult Learning and Literacy in Boston. (To obtain a copy, see list of resources at the end of this article.)

Schlough says the research on "Ask Me 3" revealed that patients did not feel comfortable asking questions of the physician. One physician realized early on that regardless of the best efforts of the clinic staff, patients were uncomfortable asking the questions, so he used the "Ask Me 3" format to provide information to the patient. He told patients their main problem, what they should do about it, and why it was important. "He found this really changed his interactions," says Schlough.

Staff at WCHQ began to look at programs based on culture change, such as informed or shared decision-making and teach-back, which changes the behavior of staff within the organization, she adds. "Ask Me 3" is excellent for building awareness of the need for better communication, and some health care organizations are using it as an introductory tool before implementing something more complex, says Schlough.

Whatever methods for improving communication are selected be sure to include staff training, says Kimbrough. Practicing is a good way to improve communication skills, she adds.

Staff members at WellSpan Health were alerted to the tools being implemented via web sites, e-mails, and fliers, Hess says. "The two tools were rolled out to our medical groups during staff meetings, and training was provided," she adds.

A practice support specialist from Planned Care at WellSpan Health organized training. The specialist, along with the medical group administrators, attended an inservice conducted by Darren DeWalt, MD, MPH, an advisor for Improving Performance in Practice at the University of North Carolina Chapel Hill Center for Health Promotion and Disease Prevention. This university was commissioned by AHRQ to develop the Health Literacy Universal Precautions Toolkit. DeWalt presented the health literacy background and tools. Training was conducted at the medical group practices upon request by Robin K. Rohrbaugh, MSW, executive director of the Healthy York County Coalition.

Now there is a new endeavor at WellSpan Health to teach communication skills to patients through a train-the-trainer program. The training is based on the Patient Empowerment Training curriculum of the Washington, DC-based National Partnership for Women and Families, and program oversight is through the Healthy York County Coalition.


For more information about setting in place tools to improve patient/provider communication, contact:

• Christine Hess, MEd, Patient and Family Education Coordinator, WellSpan Health, York, PA. E-mail:

• Jen Kimbrough, PhD, Executive Director of the Gilford Coalition on Adolescent Pregnancy Prevention, Greensboro, NC, Faculty Member, University of North Carolina at Greensboro. E-mail:

• Cindy Schlough, Director of Strategic Partnerships, Wisconsin Collaborative for Healthcare Quality, Middleton. E-mail:

For more information about the resources mentioned in this article, contact:

• "Ask Me 3." Information on this communication program is available at

• WCHQ -- Improving Patient-Provider Communication. The full report on the effectiveness of the "Ask Me 3" program assessed by The Wisconsin Collaborative for Healthcare Quality and Wisconsin Department of Health Services can be accessed at

• Health Literacy Environment of Hospitals and Health Centers produced by The National Center for the Study of Adult Learning and Literacy is available at