State of Washington

Medical Quality Assurance Commission

Guideline
Title: Communication with Patients, Family, and the Health MD2016-04
Care Team
References: N/A
Contact: Michael Farrell, JD, Policy Development Manager
Phone: (509) 329-2186 E-mail: [email protected]
Effective Date: May 13, 2016

Approved By: W. Michelle Terry, MD, FAAP, Chair (signature on file)

Purpose
The Medical Quality Assurance Commission provides these guidelines to help practitioners
learn to communicate effectively, prevent complaints to the Commission, and provide better
care to patients.1

Background
Effective communication is critical to the delivery of high-quality, safe and integrated health
care. Research shows that quality, collaborative communication results in increased patient
satisfaction, treatment adherence, increased practitioner job satisfaction and, most important,
better patient outcomes.2,3 Conversely, studies demonstrate that poor communication leads to
patient and provider dissatisfaction, and bad outcomes.4, 5 Communication was a root cause of
79% of sentinel events reported to the Joint Commission in 2015.6

Ineffective communication is also a primary cause of complaints filed with the Commission. In
many cases, the complainant expresses more dissatisfaction with the interaction with the
practitioner than with the medical care provided. In others, it becomes clear during the
investigation that a communication breakdown among members of the health care team
contributed to the incident being complained about. In either case, the results of
miscommunication can be devastating to the patient, family, and practitioner.

Guidelines for Communicating with Patients and Family Members

While there are many models of communication and each practitioner will have his or her own
unique communication style, there are fundamental principles of good communication that a
provider can use in every patient encounter. The Commission provides general principles to

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assist practitioners to communicate effectively in three areas that are frequently the subject of
complaints: the office visit, the difficult patient, and the seriously ill patient.

The Office Visit

The routine office visit is the source of many complaints to the Commission. The following
principles come from several sources.1,7, 8

1. The Opening: A good opening is essential to establishing a positive relationship with the
patient. The opening builds the foundation of the relationship.

a. Take a deep breath and knock on the door.

b. Use the patient’s preferred name. State your name and role.
c. Say hello to guests. Ask their names.
d. Get to know the patient personally. Consider asking “What is important that I
know about you so I can give you the best care?”
e. Start with an open-ended question, such as “Tell me what is happening,” or
“How can I help you?”

2. Interviewing the Patient:

a. Sit down, lean forward and make eye contact. Avoid crossing your arms.
b. Give the patient your complete attention. Stop talking. Allow the patient 1-2
minutes to speak.
c. Find out what the patient understands. We encourage clinicians to not use the
word understand—adults often feel like they are being tested and do not like
that. We encourage “In your own words can you tell me what you have heard
from the other doctors about your condition?”
d. Ask before you tell. Every patient will want a different level of detail of
information about their condition or treatment. Ask the patient for the amount
of information desired before providing the information.
e. Be empathetic. Acknowledge a patient’s emotions explicitly. This is essential to
the therapeutic relationship. This may actually shorten the visit by putting the
patient at ease.
f. Slow down. Provide information slowly and deliberately to allow time for the
patient to comprehend the new information and to give the patient an
opportunity to formulate questions which can help the physician provide
targeted information.
g. Keep it simple. Use short statements and explanations. Avoid long monologues.
Tailor information to the patient’s desired level of information. Avoid medical
jargon.
h. Tell the truth. Do not minimize the impact of the information.
i. Avoid “why” questions. Ask “how” questions.
j. Never answer a feeling with a fact.

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 k. Watch the patient’s body and face. Most of physician-patient communication is
a two-way exchange of non-verbal information. Be attentive to and respond to a
patient’s facial expressions. Face the patient when conversing with the patient.
l. Be prepared for a reaction. When delivering bad news, it is important for the
practitioner to be prepared, recognize the response by the patient, allow
sufficient time for a display of emotions, and listen quietly and attentively.

3. The Closing: The last moment of the interaction will reflect on the entire experience the
patient just had.

a. Keep track of personal comments. If the patient mentions a big event coming
up, mention this item in closing.
b. Use the patient’s name to create a personalized ending to the visit.
c. Make a positive statement. Show the patient you hope for the best outcome.
For example, “I hope this new medication will help you feel better.”
d. Make a partnership statement. This is a statement indicating that you and the
patient are working as a team. For example: “I know this is happening to you, but
we’ll face it together.” Or, “We’ll work on this together.”

Handling the Difficult Patient

Every practitioner has had encounters with the difficult patient. If not handled properly, the
interaction can leave both the practitioner and the patient feeling frustrated.

The best approach is prevention. To avoid difficult interactions, first acknowledge and address
underlying mental health issues in your patient early in the relationship. Second, be aware that
the greatest source of discontent for patients is feeling that they don’t matter or that they are
not heard. Third, consider your body language while you are interacting with the patient; sit
and look at them when they are providing their history. Fourth, be aware of your own
emotional state; it is often the first clue of a potential conflict.

If a patient encounter becomes tense, there are two things you can do to de-escalate the
situation:

1. Remain professional. If you feel your own emotions getting the better of you, step
outside the room and take a few deep breaths. While you are cooling down, ask
yourself what the patient is really asking. Put yourself in their shoes. Anger is most
often an outward expression of fear, and recognizing this can restore your sense of
compassion.

2. Engage in active listening. Set aside your agenda and give the patient your full
attention. Summarize what the patient has said and acknowledge the emotion they
are expressing.

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By taking these steps, you will help maintain a therapeutic relationship with the patient, as well
as greatly reduce the likelihood the patient will file a complaint with the Commission.9

Communicating with Seriously Ill Patients

Interacting with seriously ill patients takes special care and attention. The Commission
recommends following these principles:

1. Spend at least a moment giving the patient your complete, undivided attention.
2. Start with the patient’s agenda.
3. Track both the emotion and the cognitive data you get from the patient.
4. Stay with the patient and move the conversation forward one step at a time.
5. Articulate empathy explicitly.
6. Talk about what you can do before you talk about what you can’t do.
7. Start with big-picture goals before talking about specific medical interventions.7

If you follow these steps, you will build strong relationships with your patients, reduce the
chances of a complaint to the Commission, and provide better care to your patients.

The Need for Formal Communication Training

Effective communication is becoming a standard part of practitioner training. Many medical
schools teach communication skills. Both the American College of Graduate Medical Education
and the National Commission on Certification of Physician Assistants lists communication skills
as a core competency.

Once in practice, however, the busy practitioner may not give quality communication the
attention it deserves. Communication skills are like any other set of skills used in practicing
medicine. The Commission strongly encourages all practitioners to develop and maintain this
skill set through formal training and practice.

Health care organizations play an essential role in improving communication in healthcare.

Healthcare organizations should advocate for and fully support communication training for all
employees who have contact with patients, including non-clinical staff. Every employee can
help improve the patient experience and healthcare outcomes with good communication, even
if they are not involved in patient care.

The amount and type of training will depend on the employee’s job responsibilities. Employees
with clinical responsibilities should receive the most in-depth training. Ideally, training will
address implicit bias and its effects on perception and communication with people from
different backgrounds.10

Whenever possible, training should focus on team members who work together rather than
training that isolates people based on professional discipline. This approach helps establish a

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culture of effective communication in which multi-disciplinary team members can reinforce the
same skills working with one another during day-to-day activity.

Communication training will be most effective if the organization requires active practice and
reinforcement at regular intervals. A simple seminar on effective communication without the
opportunity to practice, get feedback, and refine skills is not likely to result in meaningful
change.11

Resources for Communication Training

The Commission does not approve or endorse specific trainings and encourages practitioners to
take training most relevant to their practice. The Commission offers this list of courses and
books that may be helpful.

Trainings:
 American Academy on Communication in Healthcare has an on-line communication
curriculum, “DocCom,” with training modules that address a range of
communication and relationship-centered topics. Interactive videos demonstrate
interactional skills with standardized patients and provide text and video
commentary.
http://www.aachonline.org/DocCom
 The Center for Healthcare Communication offers programs, webinars and written
materials designed to increase patient satisfaction and safety and decrease
communication-related medical errors.
http://www.communicatingwithpatients.com/index.html
 Vital Talk is a non-profit with the mission of nurturing healthier connections
between patients and clinicians. It offers in-person communication courses and will
soon offer on-line training. www.vitaltalk.org
 The Center to Advance Palliative Care has a web-based communications curriculum
with interactive video modules and webinars.
https://www.capc.org/providers/courses/
 The Institute for Healthcare Communication offers a wide variety of in-person
communication workshops. http://healthcarecomm.org/
 The Physician Assessment and Clinical Education Program (PACE) at the University of
San Diego offers a one day course in “Clinician-Patient Communication to Enhance
Health Outcomes.” PACE offers an interactive program in which participants analyze
video-taped reenactments of actual cases.
http://www.paceprogram.ucsd.edu/CPD/PatientCom.aspx
 The Center for Personalized Education for Physicians (CPEP) offers a two-day
advanced course in clinician-patient communication. CPEP’s course helps clinicians
refine and enhance their communication skills using personalized learning, practice
with simulated patients, and individualized coaching.
http://www.cpepdoc.org/programs-courses/clinician-patient-communication

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 Books:
 Back A., Arnold R., Tulsky J., Mastering Communication with Seriously Ill Patients.
New York, NY: Cambridge University Press; 2009.
 Boissy A., Gilligan T., Communication the Cleveland Clinic Way: How to Drive a
Relationship-Centered Strategy for Exceptional Patient Experience. Columbus, OH:
McGraw-Hill Education; 2016.
 Van Servellen, G., Communication Skills for the Health Care Professional: Concepts,
Practice, and Evidence. Sudbury, MA: Jones and Bartlett Publishers; 2009.

Conclusion
Effective, collaborative communication is critical to the delivery of high-quality health care. The
Commission encourages all practitioners to take training in effective communication, practice
the skills learned, and reinforce those skills in day-to-day practice, both with patients and with
other providers on the health care team. Health care organizations can support training that
includes active practice and reinforcement. A practitioner who communicates effectively
creates stronger relationships with patients, reduces the risk of complaints to the Commission,
and provides safer care.

The Commission would like to thank Larry Mauksch, M.Ed., Clinical Professor Emeritus, Dept. of
Family Medicine, University of Washington, for providing suggestions and advice for this
guideline.

1 The Commission has adopted several guidelines in the past few years that address specific aspects of
communication in health care. These guidelines may be of interest to practitioners seeking specific advice in these
areas:
Transmission of Time Critical Medical Information (TCMI) “Passing the Baton” Guidelines, MD2015-02, adopted
in 2011 and revised in 2015.
The Commission adopted these guidelines to emphasize the responsibility of consultants and practitioners to
identify and responsibly communicate time-critical medical information in a timely and effective manner for
quality patient care. The Commission revised the guidelines in 2015.
Professionalism and Electronic Media Guidelines, MD2014-02, adopted in 2014.
The Commission adopted these guidelines to assist practitioners to adhere to standards of professionalism in
using electronic media, or social media, for personal, non-clinical purposes.
Physician and Physician Assistants’ Use of the Electronic Medical Record Guideline, MD2015-09, adopted in
2015.
The Commission issued these guidelines to assist practitioners in the appropriate use of electronic medical
records.
A Collaborative Approach to Reducing Medical Error and Enhancing Patient Safety, MD1015-08, adopted in
2015.

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 The Commission issued this guideline to combine three existing policies designed to help reduce medical error.
This guideline (1) expressed support for just culture principles, (2) encouraged institutions to adopt
Communication and Resolution Programs and summarized a protocol the Commission adopted in 2013 for
handling complaints of medical error; and (3) set up a collaboration with the Foundation for Health Care
Quality to disseminate lessons learned.

2
Travaline J, Ruchinskas R, D’Alonzo G, Physician-Patient Communication: Why and How. JAOA. 2005;105(1): 13-
18.
3
“Impact of Communication in Healthcare,” Institute for Healthcare Communication,
http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ accessed March 2, 2016.
4
Woolf S, Kuzel A, Dovey S et al. A String of Mistakes: The Important of Cascade Analysis in Describing, Counting
and Preventing Medical Errors. Annals of Family Medicine 2004 Jul; 2(4): 317-326.
5
Improving Diagnosis in Health Care, Institute of Medicine, National Academy of Sciences 2015.
6
Sentinel Event Data, Root Causes by Event Type 2004-2015, The Joint Commission,
http://www.jointcommission.org/issues/article.aspx?Article=1AF4aJcIzvBc%2bAMu%2fi5RwBBiJDoM0RWvmjtlIqw
p6HM%3d&j=2829096&[email protected]&l=94_HTML&u=73636271&mid=1064717&jb=51.
7
For more information on these steps, see Back A., Arnold R., Tulsky, J. Mastering Communication with Seriously Ill
Patients. New York, NY: Cambridge Univ Press; 2009.
8
Leigh E, “Engaging Your Patients,” The Center for Healthcare Communication. 2016 webinar.
http://www.communicatingwithpatients.com/prog_engaging.html accessed February 29, 2016.
9
C. Peine, Dealing with Difficult Patients. The Report, Idaho State Board of Medicine. Volume 1, Issue I, 2015.
10
Chapman E., Kaatz A., Carnes M., Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health
Care Disparities. J Gen Intern Med 2013; 28(11):1504-10.
11
The Denver Health Medical Center, an urban public safety-net hospital, studied the implementation a
comprehensive provider/team communication strategy and published the results in 2008. They also developed a
toolkit that can be used in other settings. Dingley C, Daugherty K, Derieg MK, et al. Improving Patient Safety
Through Provider Communication Strategy Enhancements. In: Henriksen K, Battles JB, Keyes MA, et al., editors.
Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville
(MD): Agency for Healthcare Research and Quality (US); 2008 Aug. Available from
http://www.ncbi.nlm.nih.gov/books/NBK43663/ accessed May 26, 2016.

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