Namita Seth Mohta, MD, interviews Rana Awdish, MD, FCCP, Medical Director for Care Experience at Henry Ford Health System; Dale Glenn, MD, AAFP, Physician Lead of the Patient Experience Team at Hawaii Pacific Health; Ghazala Sharieff, MD, MBA, Corporate Vice President and Chief Experience Officer at Scripps Health; and Thomas Howell, MD, Vice Medical Director for Patient Medical Experience at Mayo Clinic.
Namita Seth Mohta: This is Namita Seth Mohta for NEJM Catalyst. I’m speaking today with an incredible group of leaders from across the country about effectively coaching physicians, an important topic many organizations grapple with. Joining us for the conversation are Dr. Rana Awdish, Medical Director for Care Experience at Henry Ford Health System; Dr. Ghazala Sharieff, Corporate Vice President and Chief Experience Officer at Scripps Health; Dr. Dale Glenn, Physician Lead of the Patient Experience Team at Hawaii Pacific Health; and Dr. Tom Howell, Vice Medical Director for Patient Medical Experience at Mayo Clinic.
We will be discussing the innovative physician coaching models each of these leaders have built at their respective organizations, with a focus on the practical aspects of design and implementation. Let’s start by asking each of you to briefly share an overview of why your programs were started and what the model is. Dale?
Dale Glenn: Thank you for the opportunity. I think we all have a similar goal, and in looking over the clinical results from the past couple of decades it’s become clear that physician communication is a key driver of health outcomes. In our organization we’ve been working on this for some time, but we seemed to hit a glass ceiling a couple of years ago, where we couldn’t improve the patient experience further than we thought it should be. We tried some physician coaching by bringing in some outside consultants but still weren’t moving the ball as far as we’d like, and so we felt that a deeper relationship with our physicians to engage them and help them understand why this was important and how they could improve their patient experience results was needed.
I was offered the opportunity to start a coaching program, and I learned a lot from these other physicians, their programs, and other people who have pioneered in this area. [In] the model we have right now, I’m basically the only physician coach, but my goal is to train more coaches, and to work with each of our department chairs to help them learn some coaching skills. But our first step [was] to define what behaviors made a difference, and then I will spend time with each physician who is identified — either they self-identify or they [are] identified by their leaders as needing help — and I will spend about a half a day working with them and then I do a lot of follow up as well. That’s our basic model.
Ghazala Sharieff: We had a similar experience to what Dale had. We were not moving our overall HCAHPS scores at Scripps Health. It became evident that when we went around asking different divisions how we could improve, everybody, including the staff-level nurses, said, “We have to change the doctors first.” So we decided to approach the physicians and started giving them their individual MD scores for some of our key care lines, such as surgery, ob-gyn, orthopedics, the ED, and the urgent care docs, and the hospitalists we gave an aggregate score to. We started doing that on a monthly basis, blinded and unblinded, and that started the process.
As you know, physicians are very competitive, and those who were less than 50th percentile would be highlighted in red month after month. By us giving them simple tips, sometimes even by email, [a lot of those people] came to the middle. Those who didn’t and wanted additional help could seek out my support. Similar to Dale’s program, I initially just wanted myself to be the coach because I wanted consistency across the spectrum, and we’re now in the process of training some other physicians. But that was available as one-to-one coaching if they wanted that. Our key learning from this is that [for] people I was forced upon — the division director would say, “Your scores are low; Dr. Sharieff is going to come in and help you” — those physicians did not respond well at all, as you can imagine. You really have to want to change. So a couple people actually dropped their scores. The rest only went up by 5 percentile.
The others who actively reached out and wanted to improve their scores have come up by at least 55 percentile during the coaching period. Ours is similar to what you do, Dale. I personally go in, give them some tips ahead of time, and we reinforce those in real time with a few patients and then I follow up with them over time. We’ve had pretty good success with that program.
Rana Awdish: We’ve built a structure that we refer to as the Physician Communication and Peer Support Center. It’s a virtual center that accesses a hub of resources for clinicians. Many of the elbow-level coaching happens in clinical encounters, and there we refer to it as physician shadowing rather than coaching. Dale has written about this beautifully for NEJM Catalyst. We use a similar checklist in those situations, and then we also have deeper-level communication skill courses that are separate from coaching.
When we get to what we consider to be coaching, that’s truly clinicians who have self-identified having a developmental or leadership goal that they are seeking to achieve. Our coaches, with the exception of myself — I’m a physician but the others are from our HROD [Human Resources and Organizational Development] department —have a lot of training in emotional intelligence, the Four Habits model, crucial conversations, and they do a national coaching certification as well. We use four coaches to meet with clinicians, usually, as Dale said, for about a 3-hour block the first time and then once a month for 3 to 6 months depending on the issues that they’re working toward.
Tom Howell: Thanks, Rana. We have had a communication health care workshop that was essentially mandatory for everybody in the organization hopefully within 2 years of starting their employment, and came to realize that that sets a framework and gives you a base of knowledge about some communication skills. But as Dale mentioned, you hit that glass ceiling where you just aren’t getting where you wanted to get. We had about 30% of our providers in our community practice over the 80th percentile and about 30% below the 30th percentile, and it seemed like those groups never moved. So, we have multiple different opportunities, and it’s kind of a blend of everything that’s been talked about. We have some provider-to-provider, physician-to-physician coaching that happens on the floor of the hospital, or it can happen in shadowing at the clinic level. We do have a lot of patient experience staff trained to observe and give some hints.
We’re trying to move away from teaching to more of a coaching [approach], which is to say we want to connect the providers not just to skills, but to what’s important to them — if you’re the patient, what things do you want that patient to say about you when you leave the room as a provider? — and connect them to their empathy and meeting the patients’ needs where they are. We’re rolling out empathic communication across the organization, from front-desk staff all the way through providers. The challenge comes with providers, and we haven’t figured all of that out yet, but that’s the next level of peeling the onion back and moving more from a teaching skills to a coaching standpoint.
Mohta: Let’s talk about specific aspects of the model, starting with the basics. You all have referred to it, but most simply, what are the types of issues that physicians need coaching around?
Sharieff: We tailor the coaching to the scores based on which service they were getting scored on, so [for] an outpatient we would use CGCAHPS, [but for] an inpatient it’s HCAHPS. And the biggest training thing has been explaining in a way the patient understands. There’s so much medical jargon. I coached a physician the other day who said, “You want me to use the word ‘explain’? I can do this.” And [to] the very first patient she says, “We’re going to get a HIDA scan with an injection fraction to rule out acute cholecystitis.” She was perfectly happy because she used the word “explain” and thought she was doing a good job. So we are going back to the basics. When we look across the spectrum at all of the surveys, it really is going back to the beginning and sitting.
We made it simple. We asked our doctors to knock on the door before they go in, so they protect the patient’s privacy. Making sure that they sit with our patients, which sounds basic, but all the studies have shown that patients give you at least 15% extra time credit for being in there because you don’t look rushed. Then we’ve asked our physicians to ask the patients what their greatest concern is versus us trying to figure out what that is. And that’s keeping it simple. Knock, sit, ask. That’s how we roll things out.
Glenn: That sounds like a great model, Ghazala, because one of the hardest things to do is to determine what is it we need to coach people on. We have a two-step approach. First of all, in looking at the data, we try to identify first the physicians who are in the middle of the pack. As Rana said earlier, it’s hard to move those who are way down the list; if you pick the ones in the middle, it’s a little easier to move them from the middle to the top than from the bottom all the way up.
Once we identify a group of candidate physicians, we start with some simple behavioral changes. We also take a look at their working environment, because I find a lot of exam rooms are not set up in a conversation-friendly way. We have physicians forced to sit with their backs to the patient because the computer’s mounted on the wrong wall. The computer itself can be a big distraction if physicians don’t know how to integrate that into the conversation. And then teaching some real basic behaviors like sitting down, which is important. Orienting your body toward the patient. Making eye contact. Not being too distracted by note-taking and other tasks that seem to come up during the encounter.
We created a short list of best practices, best behaviors based on the evidence that was available. We start with two or three of those in each case and try to get the physicians to consistently perform them, and then we show them the impact that has on patient comments and on the results. Over time, we generally see a fairly positive impact if the coaching is consistent and if the physicians are engaged.
Howell: A couple things that have been brought up are pertinent in that you have to give physicians — or providers, because we’re working with MPs and PAs now extensively also — something that they can tangibly do that’s fairly simple. We call it “sit and listen,” [and] dyad rounding, mak[ing] sure you round with that patient’s nurse in the hospital. Simple, tangible things to do. The next piece is observing or helping them get connected with the patient on another level. Again, peeling that onion back and being empathic with them. Once they get comfortable with the simple things that help make that connection — and Dale mentioned the physical plant issues that you have to overcome sometimes — then we’re more able to make those deeper connections. You have to do it almost in a stepwise fashion.
Awdish: I would echo that. That speaks well to how we’ve structured our program at Henry Ford, because you do have to touch on all those elbow-level support issues, and then you can get to the noble purpose of medicine, and why people truly got into the work. Where I find that we’re asked to work around the most are topics of maintaining your resilience in a workplace that’s constantly asking for more from you, finding a way to feel that you’re doing good work each day even though the work is compressed, it seems, more and more. All of that comes from a deep root of connection. Establishing a therapeutic relationship, aligning with the patient’s values so that the recommendations that are made are based in what the patient’s asking us to deliver rather than our own agenda — all of that serves a greater need for physicians to feel their value within an organization.
Glenn: We need to create those same relationships with the entire clinical team, because we found that there are wonderful ways in which the team can support the provider. Let me give you a quick for instance. The patient walks up to the front desk and [they ask the patient], “Why are you here today?” And they give them a reason. Then the medical assistant takes the patient to the room and asks them, “Why are you here today?” And of course, the physician walks in the door and says, “Why are you here today?” It looks like we don’t talk to each other. It looks like we haven’t paid any attention to that patient’s chief concern, or most important concern. If we coach them as a team and as a unit, we can start to find ways they can interact in a supportive manner to create a great patient experience.
Sharieff: I’ll echo that, Dale. In the community practice groups, we’ve done coaching for both the nurses and the physicians, and our greatest success has been in team coaching. We had one physician who went from 1st percentile to 92nd percentile, and the nurse went from 12th to 90th, as well, basically by each other managing each other up. The nurse would say, “Oh, you’re seeing Dr. Wang. She’s one of our best physicians.” Then the doctor would say, “Oh, you got Lane today. She’s really, really good.” It’s amazing what the scores can do just by looking like a unified team.
Glenn: Wow. That’s a great example.
Howell: There are some things that you aren’t even aware of. We instigated a video coaching model where we videotaped the interaction with the nurse and the patient, and the physician and the patient. We did it as a way to get around the logistics of trying to get physician coaches out to everybody — that’s logistically difficult and expensive. I was the first guinea pig. My nurse walked into the room, talked to the patient, got her nurse things done, and then said, “He’ll be in in a minute.” It was never a minute. The quickest it was, was 7 minutes. She’s already set me up for failure, so we stopped saying that. But we would have never known that if we hadn’t had the videotape that [showed], oh, it’s never a minute. So there are things that are blatantly obvious if you make them available to be blatantly obvious. It’s a huge win for everybody if you can help with those small things.
Glenn: Did you use live patients?
Howell: Yeah, we did it with live patients.
Glenn: That’s incredible.
Howell: Just the video. Then we have staff go through the videotapes [and] pick out vignettes. When I watched mine, the six things that I was going to get coached on? I knew five of them before anybody opened their mouth. And we used staff, not physicians, to go through them and pick out the vignettes. They have a grid, a scoring rubric that they use. It’s been interesting. There’s nothing like watching yourself.
Mohta: In the spirit of never having enough time and always running 7 minutes behind, we are almost out of time. We’re going to do a quick round robin. I’m going to ask you for a two-word answer and we’re going to do two round robins. The first question is, what is your biggest challenge in scaling these programs? I don’t want to know why, just tell me what the biggest challenge is. The second is, what has been the one solution that you’ve put in place to overcome a barrier, or hope to put in place to overcome a barrier?
Glenn: Our biggest challenge is enough people to direct observation. That’s more than two words.
Awdish: Time and resources.
Sharieff: Time and resources, yeah. Actually, we’re finding that physicians want more data, and we need more analyst support. As you said, resources.
Howell: I would say pulling providers offline.
Mohta: What is — let me rephrase that question, because the solution to more time and resources is more money and more resources — what is one thing you are hopeful about as you think about growing your programs at your respective organizations?
Glenn: That providers will enjoy their careers more.
Howell: I totally agree.
Awdish: And team-building.
Mohta: I’m hearing physicians and team members will enjoy their careers more, and I’m hearing team-building.
Howell: Considering the future or things that you would want to get to, a lot of people are going to be interested in what are the solutions to some of the challenges and impediments in making this happen.
Awdish: I agree. They want the why.
Howell: It’s got to be little, simple things. Right?
Mohta: Do you have a short list of what those little, simple things might be?
Howell: The solutions or the impediments?
Mohta: The solutions. The impediments — hopefully the solutions will be longer than them.
Sharieff: Ours has been the simple three behaviors. And when we present the data, it’s really simple to understand, because we found [before] that when people presented the data it was so complicated nobody even understood it. So we simplified things, so that the first person who looks at their scores knows exactly what they’re getting graded against.
Awdish: For us, it was really tying values to behaviors. It’s one thing to say what we’re asking of someone, to sit and be eye level and not face the computer, but to say you want to engage with your patient because we value compassionate care.
Glenn: And then for us is tying the data, and showing how the data reflect that compassionate care. That the change in behavior actually makes you enjoy what you do, helps the patients enjoy what they do and, oh, by the way, it makes the data look better, too.
Howell: I would agree with those. If you can tie it back, what you’re trying to do, to your organization’s primary values, and then say, “And by the way, as a provider these are your values, too.”
Mohta: Thank you, everybody, for your time and your insights.