Quick Safety 29: Advancing patient-provider communication and activating patients
Communication has been established as a critical focus for patient safety, especially skilled patient-provider communication, which is essential to creating a safe health care environment. Most improvement efforts to date have centered on provider-provider communication during transitions of care, and on patients with unique health care communication needs. However, inextricably intertwined with patient safety are patient-provider communication and patient activation, which is shown to enhance patient-provider communication.1 Activated patients are less likely to experience harm and unnecessary hospital readmissions. Less activated patients suffer poorer health outcomes and are less likely to follow their provider’s advice.2,3,4
It is important to recognize that there is a high incidence of disorders that impact patients’ ability to clearly communicate. For example, patients who have a physical communication limitation (e.g., from a stroke) or a psychiatric co-morbidity (e.g., severe depression). These patients are at increased risk of an adverse event during hospitalization.5 However, failures in patient-provider communication can result in harm even in the absence of a disability. Common types of errors traced to patient-provider communication include those related to misdiagnosis and medication error.6-10
Conversely, strong patient-provider communication has been tied to increased patient satisfaction,11,12 decreased emotional stress,13-15 improved treatment adherence and compliance,16-20 improved health outcomes21-23 and increased caregiver satisfaction and decreased burnout.24-26 Despite this, evidence suggests that rather than providers learning these communication skills through medical education, their skills related to talking with patients instead erode over the course of training.27
Elements of strong communication
Among the elements of strong patient-provider communication are:
- Clear expectation setting28,29
- A patient-centered approach to communication that ensures patients play an active role in the dialogue30,31
- Expression of empathy32-34
- A focus on clear information exchange and patient education that promotes the understanding and retention of key information35
These skills, sometimes thought to be inherent, instead are non-technical skills that can be systematically trained. Communication training courses have been shown to be effective, with multiple programs showing impacts in patient-perceived empathy, patient-centeredness and satisfaction, as well as increased satisfaction with care.17,32,36-42 Notably, a recent study also has shown that these training programs are considered highly valuable to staff.11
A patient-centered approach to care can also help health care organizations assess and enhance patient activation. Achieving this requires leadership engagement in the effort to establish patient-centered care as a top priority throughout the health care organization. This includes adopting the following principles:1,2
- Patient safety guides all decision making.
- Patients and families are partners at every level of care.
- Patient- and family-centered care is verifiable, rewarded and celebrated.
- In most situations, the licensed independent practitioner responsible for the patient’s care, or his or her designee, discloses to the patient and family any unanticipated outcomes of care, treatment and services. There are a few situations in which the organization may select another caregiver to disclose this information.
- Though Joint Commission standards do not require apology, evidence suggests that patients benefit—and are less likely to pursue litigation—when physicians disclose harm, express sympathy and apologize.
- Staffing levels are sufficient, and staff has the necessary tools and skills.
- The hospital has a focus on measurement, learning and improvement.
- Staff and licensed independent practitioners must be fully engaged in patient- and family-centered care as demonstrated by their skills, knowledge and competence in compassionate communication.
Safety Actions to Consider:
Organizations can create a clinician focus on patient-provider communication by obtaining a strong commitment from senior leadership, sustaining focus on staff satisfaction, committing to active measurement, supporting accountability, offering incentives and nurturing a culture that supports change and learning.22,43-45 Health care organizations can take a number of actions to help improve patient-provider communication, including:
- Conducting an internal assessment of your organization’s current communication training programs and explicit institutional focus on the value of patient-provider communication
- Demonstrating clear institutional commitment to patient-provider communication
- Providing training for frontline staff in communication skills and tactics
- Measuring clinicians’ communication-focused skills using, for example, patient satisfaction and scores related to communication competency. This information can also be used as a basis for determining goals to improve performance.
Further, to achieve the best outcomes, patients and families must be more actively engaged in decisions about their health care and must have broader access to information and support. Health care organizations can adopt a number of strategies to support and improve patient activation, including:2
- Promoting culture change
- Adopting transitional care models
- Leveraging health information technology capabilities
1. Hibbard JH, et al. Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research Journal. 2004 Aug;39(4 Pt 1):1005–1026.
2. The Joint Commission. Patient Safety Systems (PS) chapter. Comprehensive Accreditation Manual for Hospitals. 2015 Update 2. Oakbrook Terrace, Illinois (accessed Oct. 14, 2016).
3. AARP Public Policy Institute. Beyond 50.09 chronic care: A call to action for health reform. March 2009 (accessed June 6, 2014).
4. Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. British Medical Journal. 1999 Sept;18;319(7212):766–771.
5. Bartlett G, et al. Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal. 2008;178(12):1555-1562. doi:10.1503/cmaj.070690
6. Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature. Journal of Family Practice. 2002;51(11):927-932. doi:jfp_1102_ [pii]
7. Sutcliffe KM, et al. Communication failures: An insidious contributor to medical mishaps. Academic Medicine. 2004;79(2):186-194. doi:10.1097/00001888-200402000-00019
8. Beckman HB, et al. The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Archives of Internal Medicine. 994;154(12):1365-1370. doi:10.1007/s13398-014-0173-7.2
9. Rothschild JM, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Critical Care Medicine. 2005;33(8):1694-1700. doi:10.1097/01.CCM.0000171609.91035.BD
10. Levinson W, et al. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. Journal of the American Medical Association. 1997;277(7):553-559. doi:10.1001/jama.277.7.553
11. Boissy A, et al. Communication skills training for physicians improves patient satisfaction. Journal of General Internal Medicine. 2016. doi:10.1007/s11606-016-3597-2
12. Johnson MB, et al. Impact of patient and family communication in a pediatric emergency department on likelihood to recommend. Pediatric Emergency Care. 2012;28(3):243-246. doi:10.1097/PEC.0b013e3182494c83
13. Eitel DR, et al. Improving service quality by understanding emergency department flow: a white paper and position statement prepared for the American Academy of Emergency Medicine. Journal of Emergency Medicine. 2010;38(1):70-79. doi:10.1016/j.jemermed.2008.03.038
14. Step MM, et al. Modeling patient-centered communication: oncologist relational communication and patient communication involvement in breast cancer adjuvant therapy decision-making. Patient Education and Counseling. 2009;77(3):369-378. doi:10.1016/j.pec.2009.09.010
15. Stewart M, et al. The influence of older patient-physician communication on health and health-related outcomes. Clinics in Geriatric Medicine. 2000;16(1):25-36, vii-viii. doi:http://dx.doi.org/10.1016/S0749-0690(05)70005-7
16. DiMatteo MR, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychology. 1993;12(2):93-102. doi:10.1037/0278-622.214.171.124
17. Zolnierek KBH, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Medical Care. 2009;47(8):826-834. doi:10.1097/MLR.0b013e31819a5acc
18. Thompson L, McCabe R. The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review. BMC Psychiatry. 2012;12(1):87. doi:10.1186/1471-244X-12-87
19. Schoenthaler A, et al. The effect of patient-provider communication on medication adherence in hypertensive black patients: Does race concordance matter? Annals of Behavioral Medicine. 2012;43(3):372-382. doi:10.1007/s12160-011-9342-5
20. Ciechanowski PS, et al. The patient-provider relationship: attachment theory and adherence to treatment in diabetes. American Journal of Psychiatry. 2001 January;29-35. doi:10.1176/appi.ajp.158.1.29
21. Stewart MA. Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal. 1995;152(9):1423-1433. See also this commentary by Ronald M. Epstein. The Science of Patient-Centered Care. The Journal of Family Practice, 2000 September;49(9):805-807 (accessed Oct. 11, 2016).
22. Stewart M, et al. Evidence on patient-doctor communication. Cancer Prev Control CPC = Prévention contrôle en cancérologie PCC. 1999;3(1):25-30.
23. Stewart M, et al. The impact of patient-centered care on outcomes. The Journal of Family Practice. 2000;49(9):796-804. See also this commentary by Ronald M. Epstein. The Science of Patient-Centered Care. The Journal of Family Practice. 2000 September;49(9):805-807 (accessed Oct. 11, 2016).
24. Bourgault P, et al. Relationship between empathy and well-being among emergency nurses. Journal of Emergency Nursing. 2015;41(4):323-328. doi:1H0.1016/j.jen.2014.10.001
25. Wright KB. A communication competence approach to healthcare worker conflict, job stress, job burnout, and job satisfaction. Journal for Healthcare Quality. 2011;33(2):7-14. doi:10.1111/j.1945-1474.2010.00094.x
26. Krasner M, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association. 2009;302(12):1284-1293.
27. DiMatteo MR. The role of the physician in the emerging health care environment. Western Journal of Medicine. 1998;168(5):328-333.
28. Garrity TF. Medical compliance and the clinician-patient relationship: a review. Social Science and Medicine, Part E Medical Psychology. 1981;15(3):215-222. doi:10.1016/0271-5384(81)90016-8
29. Golin CE, et al. The role of patient participation in the doctor visit. Diabetes Care. 1996;19(10):1153-1164. doi:10.2337/diacare.19.10.1153
30. Longtin Y, et al. Patient participation: current knowledge and applicability to patient safety. Mayo Clinic Proceedings. 2010;85(1):53-62. doi:10.4065/mcp.2009.0248
31. World Health Organization. Exploring patient participation in reducing health-care-related safety risks. 2013. doi:978-92-890-0294-3
32. Mercer SW, Reynolds WJ. Empathy and quality of care. British Journal of General Practice. 2002;52(SUPPL.). doi:10.1016/j.jpsychores.2014.03.005
33. Chu C-I, Alex Tseng C-C. A survey of how patient-perceived empathy affects the relationship between health literacy and the understanding of information by orthopedic patients? BMC Public Health. 2013;13(1):1. doi:10.1186/1471-2458-13-155
34. Hoffman, J. Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Cambridge, Massachusetts: CRICO Strategies; 2016 (accessed Oct. 28, 2016).
35. Ong LM, et al. Doctor-patient communication: a review of the literature. Social Science and Medicine. 1995;40(7):903-918. doi:10.1016/0277-9536(94)00155-M
36. Bonvicini KA, et al. Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling. 2009;75(1):3-10. doi:10.1016/j.pec.2008.09.007
37. Simmons SA, et al. Implementation of a novel communication tool and its effect on patient comprehension of care and satisfaction. Emergency Medicine Journal. 2012:1-9. doi:10.1136/emermed-2011-200907
38. Stepien KA, Baernstein A. Educating for empathy: a review. Journal of General Internal Medicine. 2006;21(5):524-530. doi:10.1111/j.1525-1497.2006.00443.x
39. Griffin SJ, et al. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Annals of Family Medicine. 2004;2(6):595-608. doi:10.1370/afm.142
40. Stewart M, et al. Improving communication between doctors and breast cancer patients. Annals of Family Medicine. 2007;5(5):387-394. doi:10.1370/afm.721
41. Lee SJ, et al. Enhancing physician-patient communication. Hematology 2015. American Society of Hematology Education Program. 2002:464-483. doi:10.1182/asheducation-2002.1.464
42. Harms C, et al. Improving anaesthetists’ communication skills. Anaesthesia. 2004;59(2):166-172. doi:10.1111/j.1365-2044.2004.03528.x
43. Epstein RM, et al. Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Social Science and Medicine. 2005(61)1516-1528. doi:10.1016/j.socscimed.2005.02.001
44. Simpson M, et al. Doctor-patient communication: the Toronto consensus statement. British Medical Journal. 1991;303(6814):1385-1387. doi:10.1136/bmj.303.6814.1385
45. Carroll A, Dowling M. Discharge planning: communication, education and patient participation. British Journal of Nursing. 2007;16(14):882-886. doi:10.12968/bjon.2007.16.14.24328
Note: This is not an all-inclusive list.
Contributors include: Emily Aaronson, MD, Emergency Medicine Attending, Patient Safety & Quality Clinical Fellow at Massachusetts General Hospital, Boston. Dr. Aaronson is also a 2016 Joint Commission Fellow.
Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert.
The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations.
The information in this publication is derived from actual events that occur in health care.
©The Joint Commission, Division of Health Care Improvement