Program aims to improve communications

Patients given photos of members of their care team

With The Joint Commission and other organizations noting that poor communications are often at the heart of bad outcomes and that care must become more patient-centered, it's not surprising that facilities are seeking to improve the ways that providers deliver information to and share care plans with their patients. One such initiative — at the University of Colorado Denver/Anschutz Medical Campus's Acute Care for the Elderly (ACE) Service — involved the education of hospitalists about the importance of introducing themselves and ensuring that patients understood who the members of their team were.

"Physicians take for granted that their patients know who they are and what their role is in the patient's hospital care, but in fact when you look at the literature you find this is not the case at all," says ACE director Ethan Cumbler, MD, FACP. "One of the eye-opening articles for me appeared in the Archives of Internal Medicine (2009) — 'The ability of hospital patients to identify their in-hospital physicians' — which found that 75% of the patients were not able to identify any of their physicians, and that of the 25% who were, 60% of them were wrong." Such studies, says Cumbler, "really highlight the kind of communication deficits that exist between patients and hospitals."

Such lack of understanding, he continues, extends to patients' lack of understanding what the plan for the day is. "We did not look to get at specific detail, but at the global concept of how well we communicate with patients, starting with who we are and explaining our role in the care of the patient, and then extending it to what our care plan is for the patient," he says. "All of these are prerequisites for involving the patient in being an active participant of their care plan."

Using communication tools

The hospitalists' education involved different tools and three basic communication strategies, says Cumbler. "All of them were reviewed in writing and in orientation to the service for new members," he says.

The first strategy is to provide a handout, which includes the names and pictures of the members of the care team, and also establishes expectations of care, such as when the patients should expect to see their doctor. It also asks that patients bring up questions, and that invited family members be part of the discussion on rounds.

"We now customize the handouts each month to show those providers who will be participating in the patient's care — hospitalist, resident, intern, medical student," says Cumbler.

The second strategy involves the use of white boards in the patients' rooms. "When we go in and do team rounds, we work on team communications," Cumbler says. "While one person is talking with the patient, another will be writing the plan on the board." This is important, he explains, because: A) Communication in writing is more durable than something you say in person; and B) Oftentimes other family members come in and ask what the plan is, so it's good to have that written reminder.

"I think we've all had that experience of going into an emotionally charged high-stakes discussion with a doctor and as you come out of the room you do not remember all the things that were said," Cumbler observes. "I tell my own family members to take notes, and I do the same with my patients and their family members."

The third element is the action plan, based on a technique developed by one of the hospital staff. "He had a patient that went down for a procedure and declined it," Cumbler shares. "When he was asked why, he said 'I did not know I was going to get it so I said no.' The doctor realized that while we had discussed the procedure among ourselves we had not discussed it with the patient."

A part of the routine

So now, when hospitalists enter a patient's room they introduce themselves, and then go through their normal routine, asking the patient how he or she feels, conducting the physical exam, discussing the care plan, as well as potential future events that may be happening during their stay. "The last thing we do after asking the patient if they have any questions about the care plan is a scripted communication," says Cumbler, adding that it involves bullet points on the concrete things the patient should have happen that day. "We should remember the last thing the best," he says.

The program appears to be effective. "Anecdotally, we did a survey of patients' experience as part of a 360-degree evaluation of our ACE program in January-March 2008," Cumbler says, noting that there were positive responses when asked if the doctors did a good job of managing patients' problems, and whether their opinions were respected by the team.

"These strategies as part of an interdisciplinary model that emphasizes team communications are noticed by patients and did appear to improve patient satisfaction with the quality of communications," says Cumbler, noting that the satisfaction levels were significantly higher than those of another group of patients that was not part of the ACE program.

"We had several goals in creating the handout," Cumbler says. "We felt we could and should do a better job communicating with patients — not only who we are and our role, but also what they could expect of us, and when they should be able to expect to see us. We also wanted to include expectations of the patients, and involve the family in the care plan and be active participants — not only physically, but in asking questions."

Ultimately, he continues, he wants to get the patients more actively involved in participating in their care plans. "What we really want is for our elderly patients to be participants, and not simply recipients, in their medical care," says Cumbler. Apparently, he says, that goal is being achieved. "I have patients who, when I go into their room, show me the sheet and say, 'Don't worry, I already walked twice today,' or make some other reference to the handout."

[For more information contact Ethan Cumbler, MD, FACP, University of Colorado Denver/Aaschutz Medical Campus, University of Colorado Hospital, 1250 14th Street, Denver, CO 80201. Phone: (303) 556-5600.]