Improving Quality Through Satisfaction: A Four-Part Series

Part 1: A New Way of Thinking About Quality Improvement
Part 2: A Happy Patient: What Drives Patient Satisfaction?
Part 3: A Happy Provider: Identifying the Importance of Employee Satisfaction
Part 4: Communication Approach: Using Best Practice

Introduction
We have now come full circle in our series. If you have read the previous articles, you may now have ideas about different ways to approach quality improvement and patient satisfaction. You may see where making a commitment to a more systematic and evidence-based communication skillset for your management team and staff could benefit your organization, its clients, and its goals. In fact, this could be the quality improvement strategy that you are missing.

Review of Effective Communication Literature
Let’s quickly review what we covered about effective communication in our previous articles. First, communication is a critical component of quality improvement outcomes. There a direct link between higher HCAHPS scores¹ (of which almost half relate directly to staff communication) and profitability, as well as staff engagement.² Multiple studies have demonstrated that clinicians with more effective communication skills have markedly better outcomes than other clinicians.² In addition, numerous studies have found that the strongest impact on patient satisfaction is the care provider’s interaction with the patient.^3,4 And the benefits of effective communication skills in the healthcare setting aren’t limited to patient satisfaction. In a Harris poll,⁵ the top three complaints of employees about their managers fell into the “effective communication” bucket.

Next, there is unanimity that what constitutes ‘‘best practice’’ for communication in medical encounters: (1) fostering the relationship,
(2) gathering information, (3) providing information, (4) making decisions, (5) responding to emotions, and (6) enabling disease- and treatment-related behavior.⁶ But the what is not nearly important as the how in these steps. In the literature on how to effectively build rapport and effect client engagement and satisfaction, the elements that come up repeatedly are those that comprise a client-centered communication approach: active listening, support for autonomy, and demonstration of compassion, empathy, collaboration, and validation.^7,3,8 Moreover, this approach is correlated with less resistance than the traditional client counseling or education approach and with better adherence to treatment guidelines.⁹

Best Communication Approach for Healthcare
In considering the best communication approach to engender in the healthcare setting, we need to consider the unique features we have, as compared to the counseling or addictions world. Communication is just part, albeit an incredibly important part, of the healthcare activities and treatment plan. In healthcare, our communication interventions must be suited for one-time encounters, brief encounters, and/or encounters at multiple touchpoints. We don’t have more time in healthcare, so any new communication approach must be efficient, as well as effective. For all of these reasons and more, we recommend the motivational interviewing approach.

Why Motivational Interviewing (MI)?
Congruent with Effective Communication Literature
Clearly, MI is congruent with the literature we reviewed above. The founder, Bill Miller, holds an innately patient-centered assumption that clients have an inherent drive toward health and wholeness. He used the Rogerian client-centered therapeutic style¹⁰, which emphasizes empathy, reflective listening, support for autonomy, respect, collaboration, and compassion; but expanded upon it. The two communication concepts unique to MI that Dr. Miller developed and formalized are: (1) giving special attention to evoking and strengthening the client’s own verbalized motivations for change (later called “change talk”); and (2) responding to counter-change arguments (later called “sustain talk”) empathically.¹¹ The main principals to achieve these objectives are: Partnership, Acceptance, Compassion, and Evocation.¹²

Evidence-based
Currently, motivational interviewing (MI) is the only health coaching technique to be fully described and consistently demonstrated as causally and independently associated with positive behavioral outcomes.^13,14,15,16 In fact, there are over 900 clinical trials completed or in progress that demonstrate the efficacy of the MI approach in improving patient engagement, self-care, and adherence to treatment plan; all resulting in improved clinical outcomes.¹⁷

Tried and True
MI has been studied and improved for over 35 years. While the bulk of the early research was in the addictions and counseling realm, there are hundreds of studies that have now been completed in the healthcare arena, demonstrating efficacy with diverse populations, topics, and settings. Multiple meta-analyses of the application of MI in the healthcare setting have all indicated support for further ingraining and studying how best to use MI in these brief encounters. One exciting finding is that the MI approach results in less time needed with patients, especially those who are in precontemplation or contemplation phase.¹⁸ Check out our own case studies and publications from using MI in healthcare for the last 15 years.

Standardized
MI is now being taught around the world in over 43 different languages. There is an international organization – Motivational Interviewing Network of Trainers (MINT) – that has standardized and shared the most effective strategies to train clinicians. In addition, there are multiple standardized and validated assessment tools that measure the fidelity of a health coaching session to the MI approach. Therefore, we know how to teach it, assess it, and provide concrete feedback to help clinicians grow their MI skillset to the proficiency level that is associated with the clinical outcomes demonstrated in the research.

Downside of MI Approach
A limiting factor of the MI approach is that it is a complex skillset and does not lend itself to the typical “one-and-done” trainings. Similar to learning a foreign language, it takes practice, feedback and continuous support after the initial training over a period of time to develop proficiency. The good news is that there are multiple follow-up activities that are effective and can be seamlessly integrated into current QA efforts.

MI Training for Staff
There are many credible resources for assisting you in planning and implementing a comprehensive MI training for your staff. See www.motivationalinterviewing.org for initial workshops in your area. We would love to discuss Q-consult training options with you. And look for our upcoming blog articles for more on MI and the best training modalities to ensure your staff develop full proficiency.

References:

¹ Hospital Consumer Assessment for Healthcare Providers and Systems. Centers for Medicare & Medicaid Services, Baltimore, MD. Accessed November 16, 2016. Available at: http://www.hcahpsonline.org

² API Healthcare. The Rising Importance of Patient Satisfaction in a Value-Based Environment. 2015. Accessed on November 16, 2016. Available at: https://apihealthcare.com/sites/default/files/MC_CL_PAS_PPA_0000000001.pdf

³ Weinacker A. Press Ganey Again? Strategies for Improving the Patient Experience. Stanford Health Care. Accessed on October 11, 2016. Available at: https://stanfordhealthcare.org/health-care-professionals/medical-staff/m...

⁴ Johnson DM, Russell RS. SEM of Service Quality to Predict Overall Patient Satisfaction in Medical Clinics: A Case Study. Qual Manage J 2015;22(4):18–36.

⁵ Solomon L. The Top Complaints from Employees About Their Leaders. Harvard Bus Rev. June 24, 2015. Accessed on December 20, 2016. Available at: https://hbr.org/2015/06/the-top-complaints-from-employees-about-their-le...

⁶ King A, Hoppe RB. ‘‘Best Practice’’ for Patient-Centered Communication: A Narrative Review. J Grad Med Ed September 2013:385-393.

⁷ Dagger TS, Sweeney JC, Johnson LW. A Hierarchical Model of Health Service Quality: Scale Development and Investigation of an Integrated Model. J Serv Res 2007;10(2):123-142.

^8. Moyers TB. The relationship in motivational interviewing. Psychotherapy 2014;51(3):358–63.

⁹ Moyers TB, Miller WR. Is low therapist empathy toxic? Psych Addic Behav 2013;27(3):878–84.

¹⁰ Rogers, Carl R. Significant Aspects of Client-Centered Therapy. Am Psychol 1946;1(10): 415-422.

¹¹ Miller WR, Rose GS. Toward a Theory of Motivational Interviewing. Am Psychol 2009;64(6):527-537.

¹² Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. New York: Guilford Publ.: 2012.

¹³ Butterworth SW, Linden A, Mcclay W. Health Coaching as an Intervention in Health Management Programs. Dis Manage Health Outcomes 2007;15(5):299-307.

¹⁴ Noordman J, van der Weijden T, van Dulmen S. Communication–related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Educ Couns 2012;89(2):227-44.

¹⁵ Olsen JM, Nesbitt BJ. Health Coaching to Improve Healthy Lifestyle Behaviors: An Integrative Review. Am J Health Prom 2010;25(1):e1-e12.                                        

¹⁶ Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare. Globl Adv Health Med 2013;2(4):38-57.

¹⁷ National Center for Biotechnology Information, U.S. National Library of Medicine. Key word: motivational interviewing; Article type: Clinical Trial. Accessed on October 23, 2016 at https://www.ncbi.nlm.nih.gov/pubmed

¹⁸ Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL. A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Res Soc Work Pract 2010;20:137–160.