NURSE-PATIENT COMMUNICATION, INTERDISCIPLINARY COMMUNICATION, AND PATIENT SAFETY

Patient-Clinician Communication: Basic Principles and Expectations

Lyn Paget, Paul Han, Susan Nedza, Patricia Kurtz, Eric Racine, Sue Russell, John Santa, Mary Jean Schumann, Joy Simha, and Isabelle Von Kohorn*

June 2011

Discussion Paper

*Working Group participants drawn from the Best Practices Innovation Collaborative and the Evidence Communication Innovation Collaborative

of the IOM Roundtable on Value & Science-Driven Health Care

Advising the nation • Improving health

The views expressed in this discussion paper are those of the authors and not necessarily of the authors’ organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

Patient-Clinician Communication: Basic Principles and Expectations

Lyn Paget, Paul Han, Susan Nedza, Patricia Kurtz, Eric Racine, Sue Russell,

John Santa, Mary Jean Schuman, Joy Simha, and Isabelle Von Kohorn 1

ACTIVITY

Marketing experts, decision scientists, patient advocates, and clinicians have developed a

set of guiding principles and basic expectations underpinning patient-clinician communication.

The work was stewarded under the auspices of the Best Practices and Evidence

Communication Innovation Collaboratives of the Institute of Medicine (IOM) Roundtable

on Value & Science-Driven Health Care. Collaborative participants intend these principles and

expectations to serve as common touchstone reference points for both patients and clinicians, as

they and their related organizations seek to foster the partnership and patient engagement

necessary to improve health outcomes and value from care delivered.

BACKGROUND

Health care aims to maintain and improve patients’ conditions with respect to disease,

injury, functional status, and sense of well-being. Accomplishment of these aims is predicated

upon a strong patient-clinician partnership, in which the insights of both parties are drawn upon

to guide delivery of the best care, tailored to individual circumstances. An important component

of this partnership is effective patient-clinician communication.

In the 2001 IOM report Crossing the Quality Chasm, patient-centeredness was defined

as one of the six key characteristics of quality care and has continued to be emphasized

throughout the IOM’s Learning Health System series of publications. Dimensions of patient-

centeredness include respect for patient values, preferences, and expressed needs along with a

focus on information, communication, and education of patients in clear terms. Consistent and

effective communication between patient and clinician has been associated in studies not only

with improved patient satisfaction and safety, but also ultimately with better health outcomes,

and often with lower costs. Breakdowns of communication, or disregard for patient

understanding, context, and preferences, have been cited as contributors to health care disparities

and other counterproductive variations in health care utilization rates. Moreover, professional

ethics in health care stress the intrinsic importance of respectful and effective

communication as a core aspect of informed consent and a trusting relationship. In an era of increasingly personalized medicine and escalating clinical complexity, the

importance of effective communication between the patient and the clinician is greater than ever.

As the ultimate stakeholders, patients should expect an active role in, and often shared

responsibility for, making care decisions that are best for them. Clinicians, in turn, should respect

and support patients in this role, valuing their input and prioritizing their preferences in shaping

care choices.

1 Working Group participants drawn from the Best Practices Innovation Collaborative and the Evidence

Communication Innovation Collaborative of the IOM Roundtable on Value & Science-Driven Health Care.

Copyright 2012 by the National Academy of Sciences. All rights reserved.

2

Whether considering risks and benefits or personal values and preferences, patients and

clinicians each have unique and important information to contribute to understanding and

deciding on prevention, diagnosis, or treatment options. Obtaining the highest-value care for

each individual requires establishing common goals and expectations for care through shared

deliberation that marshals the best information. Effective communication therefore requires

clarity about patient and clinician roles, responsibilities, and expectations for health care;

principles to guide the spirit and nature of patient-clinician communication; and approaches to

tailor communication appropriately to circumstances (e.g., routine care, chronic disease

management, life-threatening disease) and individual patient needs (e.g., health literacy and

numeracy, living circumstances, language barriers, decision-making capacity).

Passage of the Patient Protection and Affordable Care Act of 2010 offers both

opportunity and mandate to reorient strategies, incentives, and practices in support of health care

that reliably delivers Americans the best care at the highest value—care that is effective, efficient,

and most appropriate for the circumstances. As an element of best practice, the effectiveness of

patient-clinician communication can be as important as that of a diagnostic or treatment tool and

should be the product of similarly systematic assessment and evaluation. The principles and

expectations identified in this document offer a framework to evaluate and improve patient-

clinician communication, and to sharpen and focus patient discussion tools, patient safety

assessment (e.g., the Agency for Healthcare Research and Quality [AHRQ], the National Quality

Forum [NQF], organizational and individual performance assessment and quality improvement

efforts (e.g., Consumer Assessment of Healthcare Providers and Systems [CAHPS], and

clinician certification processes (e.g., the American Board of Internal Medicine [ABIM]).

BASIC PRINCIPLES AND EXPECTATIONS FOR

PATIENT-CLINICIAN COMMUNICATION

Many factors affect the quality and clarity of communications between patients and

clinicians. However, at the core of the matter, certain basic principles pertain and serve as the

starting point for the expectations of patients and clinicians: mutual respect, harmonized goals,

a supportive environment, appropriate decision partners, the right information, full

disclosure, and continuous learning.

Patient-Clinician Communication Basic Principles

1. Mutual respect 2. Harmonized goals 3. A supportive environment 4. Appropriate decision partners 5. The right information 6. Transparency and full disclosure 7. Continuous learning

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Drawing from these principles, the basic individual and mutual expectations of both

patients and their clinicians can be identified. These expectations are discussed below and

summarized in the accompanying box.

1. Mutual respect

Each patient (or agent) and clinician engaged as full decision-making partners.

Communication should seek to enhance health care decision making through the exchange

of information and by supporting the development of a partnership relationship—

whenever possible—based on trust and focused on the whole patient. This includes

considering psychosocial needs, identifying and playing to the patient’s strengths, and

building on past experience to meet immediate needs and anticipate future concerns.

Respect for the special insights that each brings to solving the problem at hand.

Information exchange should be characterized by listening, inquiry, and facilitation that is

both active and respectful on the part of both the patient and the clinician. Information

needs include patients’ ideas, preferences, and values; living and economic contexts that

may affect patients’ health or decision making; the basis and evidence for alternative

choices and recommendations; and uncertainties related to the proposed course of action.

2. Harmonized goals

Common understanding of and agreement on the care plan. Full understanding—to the

extent practicable—of care options and the associated risks, benefits, and costs, as well as

patient preferences and expectations, should lead to an explicit determination of the shared

agenda and goals. Factors should include health, lifestyle, and economic preferences and

should accommodate language or cultural differences and low health literacy.

3. A supportive environment

A nurturing and secure services environment. The success of the care plan depends on the

attention paid in the service setting to patient culture, skills, convenience, information,

costs, and implementation of the care decision.

A nurturing and secure decision climate. The comfort and ability of the patient and

clinician to speak openly is paramount to discussion of potentially sensitive issues inherent

to many health decisions.

4. Appropriate decision partners

Clinicians, or clinician teams, with skills appropriate to patient circumstances. With

increasingly complex problems, and time often a factor for any individual clinician, it is

important to ensure that the patient has access to clinicians with skills appropriate to a

particular encounter; that, as indicated, alternative clinician opinions are embraced; and

that provisions are made for the communication needed among all relevant clinicians.

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Assurance of competence and understanding by patient or agent of the patient.

Understanding by both patient and clinician is crucial to arriving at the most appropriate

decision. Understanding of patient options is important: how specific they are to

circumstances; the associated risks, benefits, and costs; and the needed follow-up. If

indicated, an appropriate family member or similar designee should be identified to act as

the patient’s agent in the care process.

5. The right information

Best available information at hand, choices and trade-offs thoroughly discussed. The

starting point for shared decision making should be the sharing of all necessary

information. When working collaboratively to craft an appropriate care plan, clinicians

should provide evidence concerning risks, benefits, values, and costs of alternative

options. All options should be discussed to bring out patient preferences, goals, and

concerns and to explicitly consider the impact of various options on these issues.

Presentation by patient of relevant perceptions, symptoms, personal practices. The

clinician’s appreciation and understanding of patient circumstances depends on accurate

sharing by the patient of perceptions, symptoms, life events, and personal practices that

may have a bearing on the condition and its management.

6. Transparency and full disclosure

Candid and explicit acknowledgment to patient of limits in science and system. A basic

element of the care process is comprehensiveness and candor with respect to the limits of

the evidence, delivery system constraints, and costs to the patient that may affect the range

of options or the effectiveness of their delivery.

Patient openness to clinician on all relevant circumstances, preferences, medical history.

Only by understanding the patient’s situation can the most appropriate care be identified.

Patient and family or agent openness in sharing all relevant health and economic

circumstances, preferences, and medical history ensures that decisions are made with

complete understanding of the situation at hand.

7. Continuous learning

Effective approach established for regular feedback on progress. Identification and

implementation of a system of feedback between patients and clinicians on status,

progress, and challenges is integral to the development of a learning relationship that is

flexible and can adapt to changing needs and situations.

Established periodicity for course assessment and alteration as necessary. Early

specification of treatment strategy, expectations, and course correction points is important

for ongoing assessment of care efficacy and to alert both clinician and patient to possible

need for care strategy changes.

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TAILORING IMPLEMENTATION TO NEED AND CIRCUMSTANCE

These principles and expectations offer general guidance for successful patient-clinician

communication. Moderating factors or constraints present in individual circumstances require

certain tailored approaches and expectations for a particular visit—still with the aim of

maximizing faithfulness to these principles to the fullest practical extent. Examples of such

considerations include:

Expectations 1. Mutual respect

Each patient (or agent) and clinician engaged as full decision-making partners. Respect for the special insights that each brings to solving the problem at hand.

2. Harmonized goals

Common understanding of and agreement on the care plan. 3. A supportive environment

A nurturing and secure services environment. A nurturing and secure decision climate.

4. Appropriate decision partners

Clinicians, or clinician teams, with skills appropriate to patient circumstances. Assurances of competence and understanding by patient or agent of the patient

5. The right information

Best available evidence at hand, choices and trade-offs thoroughly discussed. Presentation by patient of relevant perceptions, symptoms, personal practices.

6. Transparency and full disclosure

Candid and explicit acknowledgement to patient of limits in science and system. Patient openness to clinician on all relevant circumstances, preferences, medical history.

7. Continuous learning

Effective approach established for regular feedback on progress. Established periodicity for course assessment and alteration as necessary.

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Visit reason

Prevention

Chronic condition management

Acute or urgent episode

Decision characteristics

Number of decisions to be made during the visit

Certainty, uncertainty, and relevance to the available evidence

Decisions related to a preference-sensitive arena or choice

Access to and use of the Internet

Patient characteristics

Functional capacity (level of physical or mental impairment)

Communication capacity (language, literacy/numeracy, speech disorder)

Receptivity (motivation, incentives, activation, learning style, trust level)

Support (skilled family or other caregiver, financial capacity)

Living situation (housing, community, grocery, pharmacy, recreation, safety)

Clinician and practice characteristics

Patient volume and complexity

Patient support systems (language aids, interpreters, physical space, digital capacity)

Decision support systems (digital platform, information access, decision guidance)

Professional team profile and culture

Condition-specific skill network and referral follow-up systems

Reimbursement and other economic barriers

DEVELOPING THE TOOLS AND PROCESSES

FOR ADAPTIVE TARGETING

As touchstone reference points for patients and clinicians, the principles and expectations

presented here are vital to achieving the full measure of potential health outcomes and value

from care delivered. But achieving that potential requires intent, commitment, and creativity in

developing the tools and processes for adaptive targeting in the myriad conditions and

circumstances found in different health care settings. Noted below are questions that may

stimulate thought, conversation, and innovative approaches to their successful implementation in

various settings and circumstances.

For clinicians and health care organizations

How are we doing now with respect to the principles and expectations?

For which of them is our current culture and practice pattern most challenging?

What initial steps might be good starting points for systems changes necessary?

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How can we enlist patients and staff working together to help develop and lead?

How can we take advantage of initiative and help from professional societies?

What community tools or resources might be adaptable for us?

How can we measure the impact for feedback to patients and staff on the results?

For patients, consumers, and advocates

What makes a clinician a good listener?

What should we expect in conversations about health care with clinicians?

How can available care and condition-specific materials be more easily understandable?

Are there helpful ways to judge a care setting’s support of effective communication?

What should we expect from clinicians to help interpret medical evidence?

How can we best help clinicians in their efforts to improve information sharing?

How will “continuous learning” from my care lead to better health care?

For professional societies, policy makers, health plans, insurers, and employers

How do current practices compare with the principles and expectations?

What ought to be our expectations for clinicians we support?

What metrics will be most useful for quality improvement and feedback?

What tools are most needed to assist in application and site-specific tailoring?

Can we develop case material to illustrate approaches and feasibility?

What information can help demonstrate material returns in outcomes and value?

Which reimbursement incentive structures are most important to consider?

SELECTED REFERENCES

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IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the

21st Century. Washington, DC: The National Academies Press.

______ . 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

Washington, DC: The National Academies Press.

Stewart, M., J. B. Brown, H. Boon, J. Galajda, L. Meredith, and M. Sangster. 1999. Evidence on

patient-doctor communication. Cancer Prevention and Control. 3(1):25-30.

Stewart, M. A. 1995. Effective physician-patient communication and health outcomes: A review.

CMAJ 152(9)1423-1433.

Wennberg, J. E., A. M. O’Connor, E. D. Collins, and J. N. Weinstein. 2007. Extending the P4P

agenda, part 1: How Medicare can improve patient decision making and reduce

unnecessary care. Health Affairs 26(6):1564-1574.