Beware of Shiny Objects in Patient Experience
How do we filter through the research, publications, and ways to measure value and quality outcomes to assess what indeed is a best practice? Join us with Laura Cooley, Ph.D., in a discussion on how we can prevent getting derailed and focus on effective best practices to create authentic connections
Beware of Shiny Objects in Patient Experience
Adrienne Boissy: Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast exploring empathy in patient experience. I'm your host, Adrienne Boissy, Chief Experience Officer here at the Cleveland Clinic in Cleveland, Ohio. We're broadcasting from the Cleveland Clinic and HIMSS Empathy & Innovation Summit at the Cleveland Convention Center. I'm very pleased to have Dr. Laura Cooley here. Welcome to Studies in Empathy.
Laura, there are a number of wonderful things that you have accomplished and titles that you have. Would you mind introducing yourself to this audience?
Laura Cooley: Sure. I have the official title of Senior Director of Education and Outreach at the Academy of Communication and Healthcare. I always like to put out the disclaimer that I am an academic by training, which means I haven't had the opportunity to spend as much time with patients as many of my colleagues. I love this work. Recently I was able to accept the role of editor-in-chief of the Journal of Patient Experience, which you know all about and maybe we'll talk a little bit more about that during our time together today. I also have an appointment at Vanderbilt, which has been a lot of fun, and I do a little bit of work with their Center for Effective Health Communication research now.
Adrienne Boissy: That's right. Totally under-accomplished. You've spent years in the field around communication in healthcare. I'm really curious, as you've listened to clinicians from across the country or gone to organizations, you've spoken on the topic nationally, internationally, what are you hearing as the pain points for patients trying to communicate with their docs and docs trying to communicate with their patients?
Laura Cooley: I wish I didn't have to call them pain points, and I think that they sometimes are. I had a conversation this weekend with somebody close to me in my life and they were in a patient encounter as the patient recently and they said to me, "All the things that we write about and think about, my doctor, they didn't listen to my perspective. He didn't care that I had done the research or that I knew myself better than he could." There was so much frustration and vulnerability and this desire to have gotten more out of the encounter with his clinician than he actually experienced.
I felt so sad and at the same time I imagined what his clinician was experiencing and he is also frustrated because the 10 patients he probably saw before this person in my life probably brought a lot of challenges and has created a a lot of skepticism and he's tired of answering questions and being challenged and he has such limited time. I think all those things are creating a really un-tasty stew of ingredients around experiences that aren't what we wish they were for both sides.
Adrienne Boissy: It's interesting, you're making me think of when the Mayo Clinic studied giving time back to clinicians. I'm sure you're familiar.
Laura Cooley: Mm-hmm (affirmative).
Adrienne Boissy: They did a randomized controlled trial of giving clinicians time with each other versus time alone in their office and only the group, of course, that had a facilitated conversation with each other had decreased rates of burnout. I think it's really interesting, this question of time, because if we gave time back to clinicians now, I wonder whether they would really spend it more with patients or if they would spend it in their office with a closed door just plowing through their work in the EHR.
Laura Cooley: Yeah.
Adrienne Boissy: It lends itself to the question and then I think really the power of some of the work that you do in training clinicians. It isn't just about the skills, it's about building that sense of community. Can you comment on that a little bit? Do you see that play out?
Laura Cooley: I'm actually really interested in that right now. That study you're referencing from Mayo had clinicians interacting, I think, over dinners and there was a bit of a facilitated environment there. But what it really boils down to, I think, is that as human beings we need that sense of authentic connection, which is kind of one of the core tenets of relationship-centered care that we write about, talk about, and teach. That connection is what I think keeps us grounded.
When we talk about burnout, lots of people throw around this word that 40 or 50% of clinicians are burnt out. What they mean when they say that is that the research shows they're indicating, they're reporting symptoms of burnout. They may not be burned out per se, but they have some symptom of burnout and that is that they are essentially boiling down to these categories of they're depersonalizing interactions with other human beings. It's because we're coming into those interactions and leaving them in an unfulfilling manner, which is ... It makes me sad, and not just in a clinical context but all around. Then those other things about feeling emotionally exhausted, of course we're reporting that when our encounters are leaving us feeling empty and we're not getting to the outcomes that we want in terms of relationship and really helping people.
Adrienne Boissy: Yeah. It's funny, I feel like we have to keep saying in the field, and I'm glad your voices is one of them that's amplifying the around we derive and can derive and will derive healing from these relationships. If we spend the time building them, both people will heal, the patient and the clinician. I know you've been an advocate of that for a long time, so thank you. I think we're all moving in the same direction.
Laura Cooley: Yeah.
Adrienne Boissy: You recently accepted the role of editor-in-chief for the Journal of Patient Experience. You made me Gandalf the wizard, emeritus editor. I'm really curious as to your take. We've talked a lot about elevating the academic conversation in patient experience over the years. Even now there are two journals specifically dedicated to the patient experience, you're now editor-in-chief of one of them. Just the other day I heard from a colleague that some other journals still don't accept papers on patient experience, sort of traditional medical journals. Tell me what gets you most excited about the journal and the field in terms of elevating the academic conversation.
Laura Cooley: Yeah. Patient experience as a field, especially academically, is still really young. 10 years ago people were still, as you very much were a part of, grappling with the idea if it was even it's own real category in the healthcare world. I think increasingly it's been recognized as something we have to pay attention to and should and that there is research to show that it's important and why, but getting that to be recognized in a very traditional academic environment is not easy. Even just 20, 30 years ago the academic field of communication science in the context of healthcare was brand new and people viewed it as soft, and they still do in many medical spheres.
I think that what we've seen there in terms of communication being viewed as a science and being measured and analyzed from a scientific perspective, that same trajectory, I think, can be looked at as a lesson for where we're going with patient experience as sort of an extension of that. I really think that as patient experience professionals, if we can go beyond just implementing projects that are aimed to be quality improvement or process improvement and really look at a scientific application to the work that we do, being able to show that we had a rigorous method behind the way we designed our work and then the way that we analyzed our work so that we can say this did or did not prove effective for these and those reasons.
Then we have stuff that people want to publish that they can believe in from their other traditional hierarchies of understanding around academics and what is real science. I think that can really elevate the field beyond project or process improvement to a level of academic credibility that will will help us make it more applied.
Adrienne Boissy: It's interesting though, as I'm listening to you talk your parallel to the communication fields is a powerful one. They've been publishing literature on the impact of effective communication for decades. We were just talking about leaders in that field, icons who have been publishing for decades and yet I still feel like we're still publishing in some spaces papers saying the same things.
Laura Cooley: Mm-hmm (affirmative).
Adrienne Boissy: I'm wondering, how many times do you think we need to publish to say listening skills are important, asking for patient preference is important, partnering with patients on the care plan is more effective. It's not just important, it's more effective than not doing it in a variety of things, whether that's patient outcomes or taking your medicine or moving with the same care plan, trust, retention rate. The list goes on and on. How many more papers do you think you have to be published before we can actually agree and move on?
Laura Cooley: I'm smiling because it's kind of silly.
Adrienne Boissy: It feels crazy.
Laura Cooley: Here's what I've been thinking about lately. It's not that it hasn't been researched, and maybe it hasn't been called patient experience research. There is a good body of evidence that helps to make the case. When we talk about communication breakdowns, the problem must be that we haven't translated that in a way that the people with power and decision-making and financial control of the way our health care is delivered can receive it. Communication isn't happening if you're sending a message that is not received and transmitted back. We've got to change the way we're sharing that information and that's one of my hopes with the Journal of Patient Experience is that we can start to think about how we take things that are studied and published there that are written about and translate it and get it out to larger audiences.
That's one thing I love about the Journal of Patient Experience is that it is open access, at least people can read it, anybody can read it. I hope to see ways to not only have a section of it become increasingly academically rigorous and also to make it as accessible and translatable as possible. We need to have conversations that help people receive this information, otherwise we're going to keep publishing stuff that nobody reads and when they do read it they don't understand it.
Adrienne Boissy: No, it gets refreshed, I feel. Something new comes out and it's not always really new.
Laura Cooley: Yeah.
Adrienne Boissy: One of the things that's interesting in the context of the summit this year is one of the things we're trying to ask is as we look back over the past decade of patient experience, what do we agree on are no-brainer best practices? Have we made progress in the last decade around what do we think is important. If you're just starting as a patient experience professional or as a leader in an organization, what are the things that you will not negotiate on because they're evidence-based? Do you have thoughts as to what those are, because I know I do.
Laura Cooley: I do have thoughts. I've probably told you this before, I've been threatening for a few years to write something like beware of shiny objects in patient experience. I think it's really challenging for us to focus on what's actually important and what actually makes a difference. There are tons of vendors, tons of solutions, tons of problems that we want to fix and we want to fix them all immediately.
What I think is that we have to get to the root of what actually matters to patients and families and to clinicians, I think they're a critical part of experience. I think what matters most, through my biased lens, is communication that is authentically connecting people, whatever their role or their interaction space is. My work has really been around skills training to communicate better because I view it as a tool. It's a mechanism toward patient experience, so to me it continues to be a very high priority across all levels of healthcare. I think we need to do more with that and to do the other stuff too, it's just we have to prioritize what has the greatest contribution.
Adrienne Boissy: I've started to think about it in layers. There's interpersonal communication, there's team communication, there's organizational communication. When you think about that, there are breakdowns often in the patients' eyes for each of those layers.
Laura Cooley: Yes.
Adrienne Boissy: Interpersonal communication has been a focus and I know some team-based training as well. As healthcare becomes more of a team sport I feel like that's more important. As you often hear from patients, nobody's talking to each other, they said I'm going home but I'm still here, there's these issues. There was a study years ago, I think, that suggested only 20% of patients even knew who was in charge of their care on any given day. How do we improve communications at these different layers to make healthcare feel more empathic for people?
When I think about best practices I think about things, no-brainers like rounding at the bedside with the patient, including the patient in their care plan, bedside shift report, nurse hourly rounding.
Laura Cooley: Which we do have evidence on.
Adrienne Boissy: We have evidence on all these things.
Laura Cooley: And it's still not happening in many places.
Adrienne Boissy: That's right. I think your point around translating to actual practice is a valid one because we actually know some of the things and in an era of shiny objects, part of our job as leaders is to say actually these are the priorities. Maybe the priorities are making sure you're doing the basics well.
Laura Cooley: Mm-hmm (affirmative). I think focusing, getting back to the basics, or maybe you were never at the basics so you have to start fresh, I think that's essential. With many of the efforts around patient experience, quality, safety, I think that getting to the root of what is most important, the basics and the fundamental practices we have seen to make a difference is the simple truth, in a sense. I'm really glad that the conversation has shifted in patient experience to be part of quality safety, that things are becoming more interconnected again. I think they were working in silos for a while, and still are in many places. I'm glad that shift is happening.
I recently was dialing into this study produced by Crico, which is this benchmarking piece for the Harvard System. They look at critical incidents and whether or not a lawsuit emerges from a safety breach. 30% of those come down to communication issues and it's about 50/50 with the split between communication between patient and clinician and communication between colleagues. That's that teamwork piece, that's the bedside shift report, that's a lack of appropriate handover. I think that when I think about the basics and my commitment to communication, that's all in that interconnected piece of quality and safety and basics.
Adrienne Boissy: From your perspective, when you've seen organizations make the investment in communication skills training, what happens? What does that look like on the other side? Are those organizations who you know leadership is committed and they're going to make real change? What makes it work or not work as people might be considering, do I make this investment here or do I make it somewhere else?
Laura Cooley: The Cleveland Clinic and the work that you lead with physician communication is an excellent exemplar because a lot of what was most important there wasn't even about the actual curriculum or the training, it was about the leadership commitment before that work even began and then the commitment of leaders to model that it was important throughout. I think with any patient experience, clinician experience, change effort, if you just give it lip service or you buy a program or you slap on a curriculum, you're not going to see the culture shift that you actually need to see for real results.
If the climate of the organization and the leaders who are behind this isn't right, you can bring in the best curriculum and the coolest PowerPoints in town and it's not going to get what you're looking for. To me it really has to start with that organizational communication piece, leadership communication, and then through those layers that you described, then we can get to really meaningful intervention around the way we communicate interpersonally.
Adrienne Boissy: I often hear organizations struggling. They'll say, "I tried this program. I tried that program."
Laura Cooley: Yeah.
Adrienne Boissy: If you're the third or fourth program in, I think there's a lot of counseling that goes on around are you really ready? What didn't work previously? If you're going to make this other investment, we'll make it different. Some things that I know I've seen are when the organization owns it themselves.
Laura Cooley: Mm-hmm (affirmative). Yeah.
Adrienne Boissy: When they begin to ... Whether it's train the trainer models or adopted internally so that they're not relying on an external organization to come in all the time. Is that something you've also seen?
Laura Cooley: I think that's a critical success factor. Sometimes in my work with the Academy of Communication in Healthcare people invite us to come and teach. What I try my best to do now is to say we could do that and it would be much better if we could just help you do that, help you own this. Let's put your name on it, let's have your people become the experts. That's the model that you guys followed here at the Cleveland Clinic. I think that people have been a little distracted by the idea that you need a certain curriculum and certain acronyms and certain whatever. What you need are really thoughtful, skilled people from within who lead this effort. That's why I focus on the leaders being behind it, then you need the champions or the teachers, the facilitators, the coaches. Those people really help to shift the tide towards behavior change across a system.
Adrienne Boissy: Yeah. My other observation is just the backend too has to exist in the sense that there's either transparency of what patients are saying about you or that's part of your annual professional review, whether you're a clinician or a caregiver. This is part of how you'll be evaluated at how you do your work, not in terms of a boring did you check the box of you were kind and empathic, but whether it's others observing how you interact or feedback coming from patients themselves to have some sense of are you living the values and expectations of the organization. Are you seeing places do that effectively, build that accountability, or is that a piece we still have work to do?
Laura Cooley: I think we've got a lot of work to do. By we, I mean all of us. Change is hard. It takes time, it takes commitment, it takes practice. I think if we can look to our colleagues and things like organizational culture studies or business, they can teach us some lessons around this idea of fixed mindset versus growth mindset. If we can really foster this idea that we're always growing, we always want to do our best to be our best and there are ways that we can learn and improve, I think that can be helpful, whether it's in patient experience or whatever.
I think if we look more to some of the best practices we see in some other organizational cultures beyond healthcare, we see that that's a factor there and that once we can get that implanted that we're a place where we grow and we develop and that's just who we are. Then you can build in that layer of accountability that this is an expectation. Of course we all need development, of course we want our continuing education to be real education, not just a badge that you got or a piece of paper.
Adrienne Boissy: Let's expand on that for a second because something I've been thinking about recently is this idea that ... I don't know if you realized US News & World Report is making a shift from weighting patient safety measures into their rankings into patient experience and they're using HCAHPS as the measure of that. What's fascinating about our conversation, we're going to spend some time talking about it here as well, is although HCAHPS contains categories around communication of listening, explaining, and respect, there's not a single category on the HCAHPS survey about better knowing who a person is or caring or empathy or compassion.
And yet you and I both know that's what bubbles up time and time again. I worry that, again as HCAHPS is viewed as the gold standard that people will be teaching to the test. We'll be saying, organizations might say go fix the scores and then you or I are called in to come fix and train. The truth of the matter is that I'm not even sure that's the right target, and yet it's out there and it's being weighted in all these important spaces that organizations are really concerned about. How are you counseling organizations or healthcare leaders about that? When you hear that verbiage, how do you respond?
Laura Cooley: I guess from an optimistic standpoint I'm grateful that there even is a measure, so I do look to that.
Adrienne Boissy: Yeah, I'm with you there.
Laura Cooley: I'm glad there's a measure. I wish it were ... It's important and it's still insufficient. It's not really getting to the heart of what matters. I had this interesting growth opportunity myself earlier this year taking a value-based health care course with Michael Porter at Harvard and it kind of blew my mind because they are helping us see this simple equation that we should measure the outcomes that actually matter to patients divided by cost, and then we know what value is.
I don't know that our CAHPS measurements are getting to what value looks like for patients. Sure, we didn't harm them or they didn't have a serious safety event, but is their life as functional as they wish it were? How much are they actually suffering when they leave the hospital? I'm starting to think more holistically about the big picture of the things that matter most to patients and families and what can we do about it if we really want to drive value.
Adrienne Boissy: It's interesting, there are some sessions on value here and I always find myself asking the question, according to whom?
Laura Cooley: Mm-hmm (affirmative).
Adrienne Boissy: If you don't know quality according to whom, you don't know value according to whom, then your improvement plan is going to look totally different. Your point is well taken, if we're looking at value through the eyes of our patients ... There are some nice international studies that look at value articulated by the patient in terms of health outcomes were quite different than what traditional healthcare thought of as quality outcomes. I do sense it's a shift in the field to begin thinking about these deeper, thoughtful questions. A decade in, at least from from me being at it at the Cleveland Clinic, there's evolution in the conversation that's coming and I think you hit it head on.
Laura Cooley: Yeah. I think another evolution, especially where we're situated today. We're at the Empathy and Innovation Summit, which has been an awesome place for these ideas to percolate over the years. Even the word empathy I think has shifted its meaning in a sense. I actually heard somebody criticizing the word empathy and the way that we've made this commitment to it. I think the piece that's often missing, and it's missing on the CAHPS survey questions, is that perhaps empathy is simplistically defined as feeling what somebody else feels. That's actually not what we're talking about in patient experience. Yes, maybe we want you to imagine what someone else is experiencing or how they might be suffering or perceiving things. What we really want is for you to act in a way as if you recognize that and that's when we can get to the heart of expressing ourselves so that someone else knows we do value them as a human being, that's respect.
We are listening and responding in a way that says, "I heard you. That sounds challenging. Here's what I can try to do to help." It's not about feeling somebody else's stuff, it's about reacting and responding in a way so that they are respected and heard and cared for as a human being. That applies to patients and our colleagues. I think we've got to stay focused on what we really mean. When you're talking about responding with empathy, not just being empathic.
Adrienne Boissy: That's right. My bias is ... My favorite definition is the four different components. There's cognitive empathy, I can imagine but I don't feel with you. Affective empathy, I feel it with you. Behavioral, what are you going to do as a result of all your imagining? And then a moral, we're connected to want to be able to do that. I have an intrinsic desire to be connected and to demonstrate that somehow. Many people associate that act with compassion, but I agree with you, if empathy is all sitting in your head, you're doing all this hard work of imagining, you're not maximizing its potential if you don't demonstrate that in some way back, whether that's a nod, a gesture, a hug, a word, we're not capitalizing on all that it can do.
Laura Cooley: Yeah. The meeting we're at today, there's a lot of conversation around technology and I think we need to stay dialed into the fact that the experience is beyond the exam room and beyond the hospital bed and that technology and the way we communicate messages through electronic health records or through secure text messaging or a phone call, we have empathic opportunities there as well and we don't-
Adrienne Boissy: I love that you said that. Have you ever tried one of these symptom checkers?
Laura Cooley: I think I have, yeah.
Adrienne Boissy: It says, hey are you feeling okay? And then you text back well, I have a cold. Oh, is your nose runny? Yes, my nose is runny. Is your throat sore? Yes, my throat is sore. Do you have a fever? It's just a series of back and forth questions. After two minutes you get to the point where you have a fever, you've been vomiting, you're throwing up, you have a runny nose, sore throat, and you haven't eaten anything in five days, and it just keeps asking questions.
Laura Cooley: Yeah. What if we programmed the robot to say wow, those are a lot of symptoms. That must be really hard for you.
Adrienne Boissy: That's right. Then people would begin to really engage as opposed to just a series. It's just a shining example to me, even the most basic of symptom checkers is still not optimizing its potential to connect with the person. I understand you don't know what it's like, Mr. Symptom Checker, to have a sore throat and a runny nose, but you could at least make some offering back of what a horrific experience you're capturing in all these closed-ended questions.
Laura Cooley: Yeah. We can reprogram our human selves and our technological tools to be more empathic with our responses.
Adrienne Boissy: Yeah.
Laura Cooley: They won't feel anything perhaps but they can respond in a way that helps the human receiver feel more human. To me that's where I'm trying to go with the actions.
Adrienne Boissy: You have been studying communication for many, many years and promoting it and speaking on it. What one lesson have you had for yourself about the way that you communicate? What one thing do you do differently in terms of your conversations that you think others might benefit from?
Laura Cooley: Sometimes we see people in our lives and we're like, well they're an expert at that or they're really good at this. Apparently I'm supposed to know how to communicate ...
Adrienne Boissy: You are.
Laura Cooley: ... And to teach other people-
Adrienne Boissy: To see all these papers.
Laura Cooley: Yeah. I constantly ground myself into the idea that I need to listen. I have to listen and then respond. I fall short of what I wish I were all the time and I'm always looking for those exemplars and practicing and learning. I feel like if at the end of the day, if I can just continue to check myself again and again, I can stay grounded in what I care about. I think it's not until we continue to listen and to check back to what's important that we can get to what matters.
That's where we can stay connected to the soul of medicine that we hope to contribute to. I think if that were just the one thing that we did we would see a difference.
Adrienne Boissy: Great. I want to thank you for joining us so much today, Laura. I really appreciate it.
This concludes Studies in Empathy Podcast. You'll find additional podcast episodes on our website at myclevelandclinic.org/podcast. Subscribe to Studies in Empathy Podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcasts. Thank you for listening. Join us again soon.
This concludes Studies in Empathy Podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts. Subscribe to Studies in Empathy Podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcasts. Thank you for listening. Please join us again soon.