Quick Safety 29: Advancing patient-provider communication and activating patients

Update: April 2022

Issue:

Communication both among healthcare team members and between patients and providers is essential to high quality and safe care. Most improvement efforts to date have centered on provider-provider communication during transitions of care or during high-risk periods such as preprocedural time-outs. However, equally important for patient safety is adequacy of patient-provider communication allowing for patient activation and, as a result, their ability to become further engaged in their care.¹ Activated – engaged – patients are more likely to follow medical advice and subsequently are less likely to require hospital readmission, experience harm, or suffer poor health outcomes.^2,3,4

While much prior attention has focused on communication challenges related to patients with physical communication limitations (e.g., prior stroke) or psychiatric co-morbidities (e.g., psychosis), it must be recognized that failures in patient-provider communication can result in harm even in the absence of a disability.⁵ 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 experience,^11,12,13 decreased emotional stress,^14-16 improved treatment adherence and compliance,^17-21 improved health outcomes^22-24 and increased caregiver satisfaction and decreased burnout.^25-27 Despite this, evidence suggests that rather than providers learning these communication skills through medical education, skills related to talking with patients erode over the course of training.^28,29,30

Elements of strong communication

Among the elements of strong patient-provider communication are:

• Clear expectation setting.^31,32
• A patient-centered approach to communication that ensures patients play an active role in the dialogue.^33,34
• Expression of empathy.^34-37
• A focus on clear information exchange and patient education that promotes the understanding and retention of key information.³⁸

These skills, sometimes thought to be inherent, 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 with care.^18,35,39-45 Literature also has demonstrated the value of such training programs to staff.^11,46

A patient-centered approach to care also can help healthcare 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 healthcare 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.
• 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.^23,47-49 Healthcare 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 experience and scores related to communication competency. This information also can 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 care and have broad access to information and support. Healthcare 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 including online patient portals and real-time mobile device-based communication platforms.

Resources:

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.
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. Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. Journal of Patient Experience. 2018 Jun;5(2):101-106. doi: 10.1177/2374373517731359. Epub 2017 Sep 29. PMID: 29978025; PMCID: PMC6022944.
14. 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
15. 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
16. 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
17. 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:10.1037/0278-6133.12.2.93
18. 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
19. 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
20. 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
21. 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
22. 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).
23. Stewart M, et al. Evidence on patient-doctor communication. Cancer Prev Control CPC = Prévention contrôle en cancérologie PCC. 1999;3(1):25-30.
24. 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).
25. 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
26. 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
27. 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.
28. DiMatteo MR. The role of the physician in the emerging health care environment. Western Journal of Medicine. 1998;168(5):328-333.
29. Chen D, Lew R, Heshman W, Orlander J. A cross-sectional measurement of medical student empathy. Journal of General Internal Medicine. 2007 Oct;22(10)1434-1438.
30. Mandel ED and Schweinle WE. A study of empathy decline in physician assistant students at completion of first didactic year. The Journal of Physician Assistant Education. 2012;23(4):16-24.
31. 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
32. 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
33. 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
34. World Health Organization. Exploring patient participation in reducing health-care-related safety risks. 2013. doi:978-92-890-0294-3
35. 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
36. 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
37. Hoffman, J. Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Cambridge, Massachusetts: CRICO Strategies; 2016 (accessed Oct. 28, 2016).
38. 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
39. 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
40. 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
41. 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
42. 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
43. 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
44. 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
45. Harms C, et al. Improving anaesthetists’ communication skills. Anaesthesia. 2004;59(2):166-172. doi:10.1111/j.1365-2044.2004.03528.x
46. Aaronson EL, White BA, Black L, Sonis JD, Mort EA. Using Design Thinking to Improve Patient-Provider Communication in the Emergency Department. Quality Management in Health Care. 2020 Jan/Mar;29(1):30-34. doi: 10.1097/QMH.0000000000000239. PMID: 31855933.
47. 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
48. 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
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Note: This is not an all-inclusive list.

Contributors:

• Emily Aaronson, MD, MPH, Emergency Medicine Attending, Associate Chief Quality Officer, Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston. Dr. Aaronson also was a 2016 Joint Commission Fellow.
• Jonathan Sonis, MD, MHCM, Emergency Medicine Attending, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital, Boston.

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