Cleveland Clinic's Experience Chief Shares Lessons in Communication

Adrienne Boissy, MD, says "any experience program that is going to have teeth must be designed in such a way that we're listening to and harnessing the power of the very people who serve patients."

Most patient complaints, many malpractice suits, and aspects of clinician burnout have one common denominator: Ineffective communication.

In a new book, Communication the Cleveland the Cleveland Clinic Way, Chief Experience Officer Adrienne Boissy, MD, MA, and colleagues share their patient-experience turnaround story and how to use their foundational communication model known as REDE (pronounced "ready"), which stands for Relationship: Establishment, Development, and Engagement.

The Clinic was readying to host its 7th annual Patient Experience: Empathy and Innovation Summit when I interviewed Boissy about this project.

"We're all going to be talking about the great patient experience programs we're rolling out, which is great," she says. "Yet this journey has made me realize that any experience program that is going to have teeth must be designed in such a way that we're listening to and harnessing the power of the very people who serve patients."

The transcript below has been lightly edited.

HLM: What is the significance of promoting "relationship-centered" versus "patient-centered" communication?

Boissy: We knew we could have just a list of communication skills, but we wanted to really nudge thinking by using a model based in relationships. What we were really asking them is, "do you understand that part of your role may be to build relationships with your patients?" And if so, "what would your language look like?"

Also, I think everybody in healthcare understands that patients come first; but at the same time, there's a feeling that if patients come first, there are a lot of people left out of that equation.

Relationships allow you to pull everybody in, and more overtly honor clinicians' perspective and contribution to the patients we serve.

Lastly, we wanted to emphasize that these relationships can be therapeutic for both people. To us that was very powerful.

HLM: Clinicians sometimes say that time pressures make communication difficult, but your book says the opposite is true. How is expressing empathy more efficient?

Boissy: The evidence suggests that you can actually save time by making a single empathic statement. The rationale behind that is that if someone is coming to me emotionally charged and I ignore those cues and continue on my own agenda, those dues will either continue to surface and escalate.

Or the patient will stop talking because you've demonstrated that you're not willing to "see" the emotional human in front of you.

It takes longer to do all that. If we address the cue the first time, then it's done.

HLM: The book includes a lot of sample dialogue, especially surrounding difficult conversations. How important was it to include suggested wording?

Boissy: I think you have to, because you can't just say to a clinician, "You need to communicate better."

However, we have heard from a lot of clinicians who don't want to be told what to say or to be scripted. They're exactly right. We know that adults don't learn by scripting their conversations, especially not highly intelligent adults.

You have to allow them to leverage their own experience and come up with their own words. Some of them have the words intrinsically and yet some of them don't, so they need help.

We do one exercise where we go around the room and take turns giving an empathic statement, perhaps for a given scenario. And that way the learner has an opportunity to hear a collection of empathic statements that would work in a situation.

It generates some dialogue about what people intend to say compared to how they come across. When we ask, "What are you hoping to communicate to this patient?" invariably the clinician will say, "that I care." And then we say, "Well, why don't you just try that?"

Isn't it funny that so often we don't just say that out loud?

HLM: The book's opening scene describes a patient asking for pain medication. How can communication skills be applied to addressing the national opioid epidemic?

Boissy: As we've thought about some of those conversations that are really difficult for clinicians, I feel as though we've bumped up against this misconception that if you're an effective communicator, that you're ineffective about creating boundaries.

You can care about people but still set guidelines or boundaries about their behavior, or about what you will or will not do. It's an area that still needs a lot of work.

Because what I hear clinicians say is, "Well, I'm just not going to give it to them," drawing a hard line without communicating other things such as, "I care about you," or "this has got to be difficult." They can follow those statements up with, "And I'm not going to prescribe narcotics today."

Sometimes I also hear clinicians on the other side, say, "I'm just going to give it to them because I'm under pressure with these scores to make patients happy." But compromising professional integrity is not part of being a clinician.

So we have to find the middle, where empathy is still at the forefront yet we're capable of saying, "I'm not going to do blank." It's possible; it's just difficult.

HLM: What's next for this work?

Boissy: The sky's the limit. Communication work is so interesting because it's pervasive. It touches safety, quality, malpractice, errors, and leadership.

So one thing we're thinking about is how to create roots within the organization so that relationships become foundational to how we lead and how we keep our patients and our own people safe.

My hope is that these communication skills remain central to how we train leadership and it's not just a little effort over in patient experience. I just see the potential growing and growing.