8 Nonverbal Communication and Empathy Eye contact most highly linked to empathyTWO Social touches (not associated with tasks such as handshake, healing touch, pat on arm, etc.)Source: Journal of Participatory Medicine.. August 14, Vol. 5
9 Physician Empathy = Positive Clinical Outcomes "Our results show that physicians with high empathy scores had better clinical outcomes than other physicians with lower empathy scores."good control*(A1c<7.0 percent)good control*(LDL<100mg/dL)Higher Empathy Good ControlLower EmpathyPoor ControlEmpathymoderate control*(A1c≥ 7.0% and A1c≤ 9.0%)moderate control*(LDL≥ 100 and ≤ 130 mg/dL)poor control*(A1c>9.0 percent)poor control*(LDL>130 mg/dL)*Source: Thomas Jefferson University, Physician's Empathy Directly Associated With Positive Clinical Outcomes In Diabetic Patients
11 Patients and Families as Partners How do they know this?We tell them“You know your health better than we do and we need your help to help you get healthy again.”“You are the only one that can tell us if we are delivering on excellent care from your perspective so we need your input on…”“We want to help you manage your pain.”
12 Benefits of Patient and Family Engagement Improves multiple aspects of hospital performanceOverall improvements in quality and safetyPatients and families as allies in safe medication use, infection control initiatives, observing care processes, reporting complicationsReduction in preventable readmissionsImproved patient outcomesEmotional health, symptom resolution, pain control, physiologic measuresImproved CAHPS® Hospital Survey scoresPatient-provider communication, pain management, medications, provision of discharge informationFor more specific information, refer to the handout “How Patient and Family Engagement Benefits Your Hospital.”AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get StartedGuide to Patient and Family Engagement
13 Benefits of Patient and Family Engagement Better response to the Joint Commission standards or other accreditationImproved financial performanceDecreased litigation and malpractice claimsLower costs per case due to complicationsImproved patient flowLess waste associated with higher call volume, repetitive patient education efforts, diagnostic testsEnhanced market share and competitivenessEstablishment of brand identify around patient and family engagementIncreased employee satisfaction and retentionFor more specific information, refer to the handout “How Patient and Family Engagement Benefits Your Hospital.”AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get StartedGuide to Patient and Family Engagement
14 Critical Care Family Navigator Establish and maintain a feeling of warmth, goodwill and trust between the staff and the familyEstablish expectations early in the ICU admissionPrevent misunderstandings and conflict, service recovery as neededConvey a receptive, professional attitude towards families as partners in careSupport the family at point of need
15 What is Patient and Family Engagement? Tool provided: AHRQ Patient Engagement ToolkitPatient and family engagement:Creates an environment where patients, families, clinicians, and hospital staff work together as partners to improve the quality and safety of hospital careInvolves working with patients and family members as:Members of the health care teamAdvisors at the organizational levelPatient and family engagement is an area of increasing importance for hospitals. The ultimate goal of patient and family engagement is to create a set of conditions where patients, family members, clinicians, and hospital staff are all working together – as partners – to improve the quality and safety of care.On one level, patient and family engagement means providing day-to-day care experiences that engage patients and family members as members of the health care team. For example, in our hospital, we provide opportunities for patients and family members to be involved in their care by: [Modify the examples below to indicate how your hospital provides opportunities for partnership and engagement during the hospital stay]Making sure that we invite patients and family members to partner with their health care team throughout their stay.Conducting nurse change of shift report at the bedside, where patients and families can participate.Involving patients and families in discharge planning and plans for safe care at home.Patient and family engagement also means that patients and family members are involved beyond their own care as organizational partners, or advisors – for example, working together with staff, clinicians, and leaders to improve policies, processes, programs, facility design, and education for hospital staff, clinicians and trainees in the health professions.Patient and family engagement is not a new initiative. It is part of what we are already doing to improve quality and safety!AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get StartedGuide to Patient and Family Engagement
16 Much of Hospital Communication is One-Way Flow of communication is “one-way” from communicator to receiver. (think discharge instructions)AdvantagesFastAppears neat and quickDisadvantagesKnowledge is imposedLearning is authoritativeNo feedbackLittle influence on human behavior
17 Barriers to Communication Physical/environmental barriersPersonal barriersPhysiological (Illness/Disease)Psychological barriers (Mental)Cultural barriersPersonal ExperiencesTIME (think discharge instructions)Language/Literacy
18 Factors Influencing Communication: PerceptionsValuesEmotionsCultureKnowledgeRole and relationshipsEnvironmentGenderPersonality#lovemynurse
19 Engagement is Truly Two-Way Both sender and receiver take part.The process of learning is active , open and honest.Patient’s needs, values and preferences are centerPromotes mutual understandingValues diversity, creativity and empowermentACTIVE LISTENINGRESPECTInfluences human behavior
20 Guide to Patient and Family Engagement Includes four strategies to support engagement:Working with Patients and Families as AdvisorsWorking with Patients and Families at the Bedside: Communicating to Improve QualityWorking with Patients and Families at the Bedside: Nurse Bedside Shift ReportWorking with Patients and Families at the Bedside: Care Transitions from Hospital to Home: IDEAL Discharge PlanningTested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safetyIncludes strategies that reflect critical opportunities for patient and family engagementAddresses real-world challengesContains detailed implementation guidanceIncludes tools for hospital leaders, managers, clinicians, patients, and families.The Guide contains four specific strategies that represent critical opportunities for hospitals to improve patient and family engagement. Each strategy includes a detailed implementation handbook and a set of tools (brochures, training presentations, materials) that hospitals can use to support implementation.Strategy 1: Working With Patients and Families as Advisors contains tools to help hospitals begin to work with patients and family members as organizational-level advisors, providing a mechanism for involving patients and family members in policymaking; facility design; and the planning, delivery, and evaluation of care.Strategy 2: Working With Patients and Families at the Bedside: Communicating to Improve Quality contains tools to improve communication between patients, family members, and clinicians from the point of admission, including giving patients a clearer understanding of how to ask questions, who to go to for information or help, and how to participate in their care.Strategy 3: Working With Patients and Families at the Bedside: Nurse Bedside Shift Report contains tools to support the safe handoff of care between nurses by involving the patient and family in the change of shift report for nurses.Strategy 4: Working With Patients and Families at the Bedside: IDEAL Discharge Planning contains tools engage patients and family members in the transition from hospital to home, with the goal of reducing medication errors and preventable readmissions.AHRQ Patient Engagement Toolkit - Information to Help Hospitals Get StartedGuide to Patient and Family Engagement
21 Patient Centered Care Delivery Model Hourly Rounding®Use opening Key words: RoundPerform scheduled tasksPerform 3P’sAdditional Comfort measuresEnvironmental assessment of roomClosing Key wordsTell when you will returnLog the roundBedside Shift ReportAIDET® introductionCommunication of current state and plan of careTeach back reinforcement of important patient care information such as drug side effectsNursing and Patient Care ExcellenceIndividualized Patient CareAsk what 2-3 things will ensure excellent careWrite on boardUsed by all members of the care teamAsk each shift to reinforce listeningPost visit calls1. Questions designed to assess patients progress at home2. Listening with more than your earsReference: Studer Group Patient Care Model
22 The BASIC Best Practices are Rooted in Communication Tell the Patient/Family What you want them to know by using key words, signs, sounds, or behaviorsValidate Understanding with staffCan explain why key words are importantDemonstrate competency in communicationValidate understanding with patients and familiesUse key wordsTeach-back to validate comprehensionIndividualized Care - Care/White/Communication BoardsNurse leader rounding on patientsHourly RoundingBedside handoverDischarge process including post visit calls
23 Often Missing Key Piece - Validation Nurse Leader Rounds – focused on communication and validating that our best practices are in place. Are we having the impact we expect from the patient and families perspective?Shoulder-to-shoulder direct observation and immediate feedback to staff on implemented best practices. Are we coaching behaviors?Whiteboard and Hourly Rounding® log checks – Have we fulfilled the promise?Skill labs – Do you know with certainty the skills your staff demonstrate? Are you and your staff doing these things every patient, everyday – Always?
25 Top Performers Use Key Words During this hospital stay:How often did the nurses treat you with courtesy and respect?How often did nurses listen carefully to you?How often did nurses explain things in a way you could understandStaff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.When I left the hospital, I clearly understood the purpose for taking each of my medications.
26 How Do They Know? We tell them… “Do you mind if I sit while I explain the test you are going to have today?”“ Mr. Jones, as I was listening to your wife, she has many questions about your new medication…”“I was listening to you speak about your pain and it occurred to me that we could try….”“I want to make sure I am listening to you so do you mind if I turn the TV off while we talk about your care?”“I have to document in this electronic record but just know that while I may look away from you, I am listening to you.”“Kathy does a great job explaining medicine side effects, can you tell me one of the side effects she taught you today?”
27 Hardwire AIDET® and Key Words at Key Times Narrate the care – be more verbal in our approach with patients and familiesWatch body language and avoid silent assessmentsDo you really accomplish the objectives of AIDET®Acknowledge/thank – courtesy and respectIntroduction – instill confidenceDuration/Explanation – reduce anxiety
28 Acknowledge A Acknowledge Key message: You are importantEye ContactShake handsAcknowledge everyone in the roomSit91% of patients want to be addressed by name and 78% of patients wanted their physician to shake hands YET physicians use the patients’ name less than 50% of the time. * Annals of Internal Medicine * Mayo Clinic ProceedingsBecause greetings are one way to ensure proper identification of patients, they may well be considered a fundamental component of patient safety.”It is also very rare for physicians to knock and ask permission to enter the room. This is a definite sign of respect which is one of the core questions on the HCAHPS survey.Less than 50% of physicians used the patients name – yet 91% of patients want to be addressed by name. Now if they wash their hands before and after entering the room, 78% of patients want their physician to shake their hand. This is another sign of respect.
29 IntroduceIIntroduceNameSpecialty and what a Hospitalist is“ I am Dr. Beeson, I am a hospitalist, and hospitalists see patients in the hospital only, I am working with your doctor who sees you in the clinic”With the increase in hospitalists, patients don’t know who is taking care of them – this is a critical opportunity for improvement. This is the opportunity to manage up yourself, your role, your team and others that are part of the care team.75% of patients admitted to the hospital were unable to name a single doctor assigned to their care. *Archives of Internal Medicine
30 DurationDDurationKey Message: I anticipate your concernsHow long will the hospital stay be?How long will the test, procedure, appointment or admission actually take?How long will you be on service?How long before you come back and see the patient?These are more examples for a hospitalist who does not see the patient every day.You can also use duration when discussing how long before the results are back, what the plan for discharge is etc. Try to avoid broad generic terms like “you will be discharged first thing in the AM.Patients’ rating of quality is more predicted by their rating of the quality of communication than technical care. * Annals of Internal Medicine
31 Explanation E Explanation Listen to the patient’s story – 2 minutes!Clarifying questionsEmpathy through words and body languageExplain the treatment planUsing language that patient and their family can understand with “teach-back” if appropriate74% of patients are interrupted by physician within 17 seconds of giving their history. *J Gen Int Medicine, 2005
32 Thank You T Thank You Key Message: I appreciate the opportunity to care for youClosing Key wordsWhat other questions can I answer for you?Thank you for your patience in our slight delay today.
33 Types of Communication: Verbal Language:Chief vehicle of communication.CLEAR & BRIEFThe words we use:Abdomen vs Tummy vs StomachPacingTiming and relevanceHumorToneExamples of SVHNurse AdvisorIntercom/SwitchboardRoom ServiceWalkie TalkiesAppointments: SVPNVoceraHCAHPSTriage ERReport to FloorHuddles
34 Types of Communication: Written SIGNSWHITEBOARDSMENUSs/TextsEducation handoutsMedication BottlesManuals, OrdersPolicies and ProceduresEMRPatient complaintsAn interaction that makes use of the written word and at times pictures.
38 Hardwire the Use of Communication Boards These are for the patient, not for the staffCustomize them for your facility or care areaFocus on the use of the information by the whole care teamGaps in data on the board don’t fulfill the promise to patients and families
39 Hardwire Use of Patient/Family Tools General AdmissionsOrthopedic & Bariatric
41 Hardwire Bedside Shift Handover Transitions in care have potential for medical errorsResearch shows bedside shift report can improve:Patient safety and qualityImproved communicationDecrease in hospital-acquired complicationsPatient experiences of careTime management among and accountability between nursesDecrease in time needed for shift reportDecrease in overshift timeWe are interested in focusing on Strategy 3: Working with Patients and Families at the Bedside: Nurse Bedside Shift Report.Patient safety and quality. Bedside shift report is an opportunity to make sure there is effective communication between patients and families and nursing staff. One study found that more than 70 percent of adverse events are caused by breakdowns in communication among caregivers and between caregivers and patients.1 Studies have shown that bedside shift report improves patient safety and service delivery.2,3 For example, one study showed a decrease in patient falls during change of shift, dropping from one to two patient falls per month to one patient fall in six months.4Improved communication during shift report can help catch potential medical errors in blood incompatibility, catheter-associated urinary tract infections, and air embolism, all of which are on the Centers for Medicare and Medicaid Services’ (CMS) list of hospital-acquired complications “never events.”Patient experience of care. After implementing bedside shift report, hospitals reported an increase in patient satisfaction scores and improvements in the nurse-patient relationship.5,6 Also, one study noted a sharp decline in the average number of call lights on by the end of shift change.4Time management and accountability between nurses. After implementing bedside shift report, nurses have reported better ability to prioritize their work or cases during their shift and an overall decrease in staff time.4,6 One study noted a decrease in overshift time by 100 hours in the first two pay periods on a 32-bed general surgical unit.6 In another study on a 34-bed progressive care unit, a 2-month review of overtime data demonstrated an $8,000 reduction directly associated with the decrease in time for shift report.4[Include hospital specific goals or data]ReferencesSentinel event root cause and trend data. Improving America’s hospitals: the Joint Commission’s annual report on quality and safety; Available at Accessed July 23, 2010.Athwal P, Fields W, Wagnell E. Standardization of change-of-shift report. J Nurse Care Qual 2009;24(2):143–7.Chaboyer W, McMurray A, Johnson J, et al. Bedside handover: quality improvement strategy to ‘transform care at the bedside.’ J Nurse Care Qual 2009;24(2):136–42.Chaboyer W, McMurray A, Wallis M. Bedside nursing handover: a case study. Int J Nurse Pract 2010;16(1):27–34.Anderson CD, Mangino RR. Nurse shift report: who says you can’t talk in front of the patient? Nurs Adm Q 2006;30(2):112–22. Kelly M. Change from an office-based to a walk-around handover system. Nurs Times 2005;101(10):34–5.
42 Addressing HIPAA concerns Health information can be disclosed for:TreatmentHealth care operationsPaymentHIPAA acknowledges incidental disclosures may occurNot a HIPAA violation as long asTake reasonable safeguards to protect privacyDisclose only or use the minimum necessary informationAs nurses, you may be concerned about violating HIPAA, especially when family members are present at shift report or if you have patients in semiprivate rooms. It is important to know that because bedside shift report is part of treatment and normal operations, it does not violate HIPAA.Strategy 3: Nurse Bedside Shift Report (Tool 3)Strategy 3: Nurse Bedside Shift Report Training (Tool 3)
43 Accelerator – Patient/Family as Advisors Patient and family advisors help us provide care and services based on patient- and family-identified needs rather than our assumptionsPatient and family advisors offerInsight on our strengths and areas where changes may be neededFeedback on practices and policies that can help patients and families be active partners in their careFeedback that is timely and gives a fuller picture of the care experience than standard patient and family satisfaction surveysWe are interested in focusing on Strategy 1: Working with Patients and Families as Advisors.Working with patient and family advisors can help us improve the quality and safety of care we provide by building a shared agreement around quality and safety priorities.In addition to the improvements in hospital performance already discussed, working with patients and families at an organizational level has benefits [read slide].Information to Help Hospitals Get Started
44 Accelerator – Patient/Family As Advisors Formal – Advisory CouncilFocuses on strategies, priorities, input on decisionsInformal – Spontaneity, convenienceWaiting rooms, bored familiesInvite 2 families per unit to have lunch that day with the CNO (planned every other week)Past employees who received care“What rules did you have to break to get care?”“What made you most/least proud of the care?”
46 Accelerators: Every Department, Every Experience
47 Accelerators - Infrastructure Senior leaders integrate family/patient engagement strategies into cultureServe as role models for engaging in partnerships with patients and family membersProvide resources to support initiativesIntegrate into personnel policies and practicesAlign incentives to resultsPatient and family engagement can be a way to improve quality and safety at our hospital. But, sustained change does not happen without a clear mandate and ongoing support from leadership – you. There are different ways you can show support for patient and family engagement.Note to presenter: For more information, see the handout “Supporting Patient and Family Engagement: Best Practices for Hospital Leaders.”Guide to Patient and Family Engagement
48 Final thoughtsOur hospital is committed to patient and family engagement — everyone plays a critical partPatients and families won’t engage if they believe that you don’t want them to—it is simply too risky for themYour job is to make it safe for them to be involved, not just as patients but as partners in their careHow do they know ___ - you tell themHow do we know ____ - we askWe would like to end by reiterating how important patient and family engagement is to our hospital. Clinicians and hospital staff play an important role in inviting and support patients and families as full partners in the health care team. By doing this, we can work together as partners to improve care experiences for everyone.Strategy 3: Nurse Bedside Shift Report Training (Tool 3)
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