Carolyn D. Prouty

A web-based team-oriented medical error communication assessment tool: Development, preliminary reliability, validity, and user ratings

Background: Multiple-choice exams are not well suited for assessing communication skills. Standardized patient assessments are costly and patient and peer assessments are often biased. Web-based assessment using video content offers the possibility of reliable, valid, and cost-efficient means for measuring complex communication skills, including interprofessional communication. Description: We report development of the Web-based Team-Oriented Medical Error Communication Assessment Tool, which uses videotaped cases for assessing skills in error disclosure and team communication. Steps in development included (a) defining communication behaviors, (b) creating scenarios, (c) developing scripts, (d) filming video with professional actors, and (e) writing assessment questions targeting team communication during planning and error disclosure. Evaluation: Using valid data from 78 participants in the intervention group, coefficient alpha estimates of internal consistency were calculated based on the Likert-scale questions and ranged from α = .79 to α = .89 for each set of 7 Likert-type discussion/planning items and from α = .70 to α = .86 for each set of 8 Likert-type disclosure items. The preliminary test–retest Pearson correlation based on the scores of the intervention group was r = .59 for discussion/planning and r = .25 for error disclosure sections, respectively. Content validity was established through reliance on empirically driven published principles of effective disclosure as well as integration of expert views across all aspects of the development process. In addition, data from 122 medicine and surgical physicians and nurses showed high ratings for video quality (4.3 of 5.0), acting (4.3), and case content (4.5). Conclusions: Web assessment of communication skills appears promising. Physicians and nurses across specialties respond favorably to the tool.

CA2-03: “What Would You Say to this Patient?” Cancer Care Providers’ Attitudes and Experiences

Background/Aims Effective patient-provider communication is critical in cancer care but often does not occur. Understanding providers’ perspectives on challenges in cancer care communication could support interventions. Methods We surveyed providers in primary care, oncology, and oncology nursing at three CRN sites (Group Health Cooperative, WA; Kaiser Permanente, GA; Fallon Clinic, MA). Questionnaires assessed providers’ attitudes and experiences about communicating with cancer patients, situations providers find challenging, and how providers would communicate in two scenarios (error involving multiple providers leading to delayed diagnosis; miscommunication regarding patient symptoms). Results Questionnaires were received from 406 of the 682 eligible providers (59%). Nearly all (98% (393 of 399)) reported their organizations value good patient-provider communication, and 95% (374 of 393) agreed that they communicate effectively with cancer patients. However, only 62% (239 of 385) agreed that they knew when their cancer patients had unanswered concerns or questions, and 67% (262 of 391) agreed that they were aware of most of the serious communication breakdowns that occurred in their patients’ care. Almost all, 99% (394 of 400) 99% agreed that their organization should encourage patients to alert the system when there has been a serious care breakdown, and 88% (340 of 386) agreed these reports would provide actionable information. Providers found some communication situations especially difficult. A majority (61% (242 of 397)) found it extremely/very difficult to respond to patients’ unrealistic beliefs about prognosis, 55% (217 of 395) found it extremely/very difficult to respond to patients’ concerns about delayed diagnosis, but only 5% (21 of 397) found it extremely/very difficult to respond to patients who are unhappy about care from another clinician. In response to a hypothetical patient who experienced a delayed breast cancer diagnosis, 55% (221 of 399) would provide very limited information to the patient, not explicitly mentioning the error causing the delay. Discussion Cancer care providers value patient-provider communication but find discussions of prognosis, as well as disclosure regarding care breakdowns and delayed diagnosis, especially challenging. Providers support mechanisms to solicit cancer patients’ concerns about their care. Health systems should explore how to create care delivery environments that improve patient-provider communication.

Using Simulation and Coaching as a Catalyst for Introducing Team-Based Medical Error Disclosure

Practitioners face many barriers to disclosing errors to patients, including embarrassment, fear of litigation, and minimal training in how to discuss them. Efforts at teaching error disclosure skills often focus on a one-on-one doctor–patient interaction and neglect the inter-professional context. This chapter describes research conducted at the University of Washington to assess whether participating in a team-based disclosure simulation training improved clinicians’ knowledge, attitudes, and skills regarding team-based disclosure of harmful errors to patients and team communication about avoiding such errors in the future. We developed two surgical and two medical error case scenarios based on real incidents. The premise of the simulations was that the members of a surgical or medical team had recently been involved in a harmful error and therefore needed to meet to discuss the event and how it happened, plan whether and how to disclose the event to the patient, and then perform the disclosure to the patient according to their plan. The nurses and physicians who participated in the simulations were experienced professionals. We trained actors from a professional troupe to perform the roles of a standardized team member and a standardized patient who had experienced a harmful error. We trained professionals from the fields of risk management and officers in patient or medication safety to become disclosure coaches who helped teams to discuss harmful errors and to plan whether and how to disclose errors to patients. Participants included 38 teams of physicians and nurses and risk managers from five different healthcare organizations in the Seattle area. Findings indicate that physicians developed an appreciation for team error disclosure. Nurses gained experience in participating as partners in conversations from which they had traditionally been excluded. Risk managers learned to participate in disclosure planning as educators, focusing on helping teams to rehearse and prepare for difficult conversations rather than dictating institutional regulations. These project outcomes are potentially transformative for the individuals and institutions involved.

PS2-24: Using Patient-Centered Conversational Interviews to Collect Data from Cancer Survivors

Background The richness of patients’ experiences warrants thoughtful and careful examination. While standardized surveys or other structured approaches can be useful when the goal is to count or summarize relatively uncomplicated experiences, they may be less appropriate when the objective is to study sensitive topics, such as medical errors during cancer care. This abstract describes and evaluates a flexible, patient-centered approach to interviewing patients. Methods Using a patient-centered telephone interview guide, we interviewed cancer patients who had experienced a problem during their care. Participants were first asked to fully describe their experience; follow-up questions probed for details relevant to the study questions. Question order varied, consistent with a conversational approach. Interviews lasted 60–90 minutes and were digitally recorded. We calculated the percentage of words uttered by participants (compared to the interviewer) as a measure of participant engagement, and noted whether participants corrected the interviewer. Strengths and limitations of this approach are also identified. Results Seventy-eight patients were interviewed; 96% (75/78) were female, mean age was 57.7 [SD 10.6]. Overall, participants uttered an average of 77% (6,190/8,001) of the words in the interview. Participants corrected the interviewer at least once in 80% (62/78) of the interviews. Question order was flexible, and probes were used at the discretion of the interviewer. Thus, the interviewer could adapt her questioning to follow the participant’s lead, and sensitively encourage and support participants in sharing details of painful experiences. One benefit of this technique was that it allowed the interviewer to convey interest and respect, which enhanced rapport early in the interview. It also enabled participants to recall details that may otherwise have been forgotten. The drawbacks of this approach include longer interview times; discussion of unrelated topics (by participants) and increased time required for data analyses. Conclusions Patient-centered conversational interviewing can facilitate investigation of emotionally-charged, personal experiences. This approach appears more effective than standardized interviewing techniques when the goal is to fully understand patients’ experiences, such as those of cancer survivors who believe that an error occurred during their cancer care.

C-C1-03: A GPS for Navigating Sensitive Research Topics: The Case of Adverse Events in Oncology

Background Adverse events and medical errors are challenging aspects of clinical care delivery, and also present challenges as topics for research. Nonetheless, understanding how and why such errors occur is critical to rendering improvements. Using examples from a multi-site study of problems in cancer care, we identify potential pitfalls and strategies to consider when researching sensitive or thorny topics in our delivery systems. Methods In the context of the CRN Cancer Communication Research Center our team is studying adverse events and medical errors in cancer care (both in primary and specialty care settings), and how communication could be use to prevent problems and/or respond to patients when something goes wrong in their care. Throughout the course of developing the study, the three sites encountered challenging dilemmas pertaining to risk management, quality improvement, stakeholder “buy-in” to the study idea, and IRB review. Results Case studies within the larger context of a study on communication in cancer care will be presented to illustrate our approaches to addressing the challenges in each area. We will review how, in some instances, the anticipated challenges did not manifest themselves, and what has been required on the part of the study team to ensure ongoing buy-in, even as findings from the actual research study illuminate deficits in care. Conclusions Sensitive research topics, especially those which may reveal opportunities for improving medical care, or confronting a persistent problem in quality of care, require particular attention to partnerships with key leaders, frequent communication, and an openness to modifying the research to meet the needs of both the study team and the clinical setting.