Implementing Patient Communication Checklists

January 8, 2018

Physicians implement checklists when they are providing clinical care for patients - but what about emotional support?

Physicians have long relied upon checklists to provide proper medical care to patients for everything from diagnosis to preparation for surgery. Can this same tool be used to improve patients' emotional care and connection with physicians? Experts echo emerging research that say yes.

"For physicians, checklists should be seen as a convenience both for the provider and their patients," says Doug Levy, JD, a consultant on physician communications, who formerly taught a course called Foundations of Patient Care at the University of California at San Francisco Medical School.

Any tool that fosters improved physician-patient communication can go a long way toward helping patients regulate their emotions, better understand medical information, and allow physicians to better assess their patients' needs and expectations, according to a 2010 study in The Ochsner Journal.

"Patients reporting good communication with their doctor are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment," the authors write.

Research of this nature convinced the team at Hawaii Pacific Health in 2016 to initiate a checklist of steps for physicians to perform during every office or hospital visit, with the goal of improving patients' emotional well-being, and to encourage deeper trust between physicians and patients.

From a template, physicians identified items they already practiced, and then had to choose two more from the checklist to add to their own. These ranged from clearing their minds of distractions in order to be present, to listening to the patient for several minutes without interrupting. The result of this change in practice was a more than 20 percent improvement on a physician communication score within a year of implementation.

Checklists Can Be Formal or Informal

While the idea of a checklist may sound like an additional task to add to a physician's already full day, many doctors already have an informal process in place and it's a matter of making it more overt and consistent.

For Karen Sibert, MD, president of the California Society of Anesthesiologists and an associate clinical professor of anesthesiology at UCLA Health, the idea of this kind of patient well-being checklist is a no-brainer. She's long followed a mental list designed to do just this.

"I have a consistent approach in my mind that has these steps I repeat," she says. Sibert says she believes strongly in a quality personal interaction because "it's so critical to the patients having confidence in you, what you're going to do for them, and feeling comfortable with it."

She always begins by addressing her patients formally and establishing herself as a physician in her introduction, which creates "an atmosphere of clear communication" that includes being respectful to the patient. She emphasizes that it's important to ask questions in the interaction rather than just reading from a chart.

After decades of practice, Sibert is keenly aware that she has "roughly 10 minutes to make the patient feel as though they want to put their life in my hands."

This also includes what might seem like a small or superficial detail, but is part of a larger ritual of preparation: "My residents often comment that the last thing they see me do before I go see a patient is put on lipstick." She says it's all part of presenting herself to the patient in a certain light. "No patient wants to see a physician who looks haggard and cross," she says.

For physicians who don't already engage in such ritual behaviors with their patients, Sibert agrees that a checklist is a good idea, though "it really needs to be tailored to the situation and shouldn't come off just like reciting the phone book," she urges.

As it is, EHRs have contributed to physicians doing more work on their computers facing away from patients, so a good list should eventually become integrated into a physician's routine and allow for more engagement with the patient.

Consistency is Key

Levy points out, "There is an element of patient care that is like customer service. And consistency is one of the most important reasons that people give when they say they come back to the same store."

Similarly he's seen a lot of feedback that "patients really dislike being asked the same information over and over again, and they 'like to count on consistency between physicians as well, so that one experience is as good as the next. "

Levy feels that if physicians can look at adding a checklist in as a way of "making it so your patients have a consistent experience not only every time they're with you but every time they're with your colleagues, you'll find your practice will run better."

There are a myriad of small ways where checklists allow for standardizing practices that can help prevent missteps.

Additionally, from clerical issues, to physicians reviewing and adding to a medical history before and after a patient encounter, checklists help them do things in a logical sequence, and confirm that the task was done, Levy says. "It also is a backstop against innocent oversights as well as any urge by a harried provider to skip over a step."

Of course, he acknowledges that the term "checklist" can be an obstacle because it sounds administrative, but he urges physicians and medical systems to remember that a checklist "is about making the physician-patient experience and the care that physicians are delivering work better." Levy encourages any practice or hospital setting to be sensitive to its audience and use the right semantics when introducing the checklist concept.

Simple Ways to Create Connection

A good checklist should help create connections between physicians and patients, which should not be complicated, according to Somaia Arafa, MD, a former pathologist who now runs a physician coaching consultancy in Cleveland, Ohio.

Start by practicing empathy, she encourages. "Empathy is a tuning fork," Arafa says. Pay attention to "what [patients are] saying but also what they're not saying." This means slowing down so you can pick up on body language cues, facial expressions, tone of voice.

Sibert echoes this approach. She recalls a time when a patient was projecting a lot of negative emotion onto her. She could have simply chalked this up to anxiety over the impending surgery, but she probed more deeply. "It turned out the patient's husband had died three days earlier." Sibert says it's always worth it to ask what else is going on.

Arafa adds, "By intentionally listening deeply and actively to what patients are saying and not saying, physicians lessen the chances of any errors and/or miscommunications."

Another consideration for a practice adding a checklist is to try to "steer clear of jargon and high-level medical terminology that patients won't understand," Arafa says. This increases the likelihood that patients will understand what you're telling them, and reduce feelings of distance between physician and patient.

All of Arafa's suggestions can be summed up as: "Be fully present with patients. Listen deeply without judgments or interruptions, so they feel understood and acknowledged."

This is what she calls "mindful attention," which slows down the communication enough for the physician to observe any concern or confusion that the patient might be experiencing.

How to Implement Checklists

How do you get physicians who are already overburdened by administrative tasks and heavy panels to consider adding one more thing to their plates?

"What's key is helping show them that you're not adding something new, you're just organizing what they're already doing," Levy insists.

Most physicians already have an informal routine or set of procedures to connect with patients, but making it more formal can help to ensure consistency and improve patient outcomes.

Levy also adds, "It's really important to show [physicians] the benefits" before rolling out checklists." Levy said that while at UCSF "publishing all the data internally had a positive impact on the departments, which implemented better procedures as a result."

Peter J. Pronovost, MD, senior vice president for patient safety and quality for Johns Hopkins Medicine and director of the Armstrong Institute for Patient Safety can vouch for this. He was part of a national program 20 years ago to create a checklist to reduce infections that were killing more people than cancer using evidence-based guidelines. The checklist spread widely among physicians across the U.S., and easily preventable infections decreased 80 percent nationwide.

While that checklist was designed to help prevent a medical condition, it led to behavioral changes in both physicians and patients and cemented his belief in the power of checklists. The biggest lesson he learned in the process was that you can't standardize a checklist.

When they encouraged physicians to "make it better, make it your own, improve upon it," Pronovost explains, they found that physicians were more likely to use it. "We have to get out of the mindset of scaling and imposing interventions on [physicians and] practices, and be much more in the mindset of co-creating."

Just as the goal of better communication between physicians and patients is to build trust that leads to better health outcomes, Pronovost says he lives by the phrase, "change progresses at the speed of trust, and trust grows when we do things with rather than to others."

He says the best way to get any physician to implement a checklist of this kind is by respecting doctors' wisdom. "They have to be implemented in a way that's done with the physicians rather than to the physicians," Pronovost says.