“In the current era (just as in the past), the social role and privileges of the healer seemed to be founded upon meaningful relationships in health care, not just on technically appropriate transactions within these relationships.”(1)
Communication is critical to care delivery, and its effectiveness directly bears on patient satisfaction, health outcomes, and provider well-being.(2,3) It is through communication that physicians and patients exchange information, select treatment, reach diagnoses and assess care outcomes. Effective communication can reduce medical errors, increase patient adherence to medical recommendations, and alleviate symptoms.(4–6)
One of the challenges in healthcare today is the need to build competency in communication skills. There have been a variety of approaches to improving physician communication and strengthening the patient-clinician relationship(7–10) with varying levels of success.(11) Many studies have shown that patient-centered communication training can improve communication skills and patient satisfaction scores,(12,13) however there is not yet a standard shared-communication framework in healthcare.
New Frameworks for Care Delivery and Communication
During the 1990s, medical education moved to a competency-based curriculum, explicitly defining target graduate abilities that guide curricular development and assessment.(14) During this time, six core competencies for physicians were developed, covering Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, Practice-based Learning and Improvement, and Systems-based Practice.(15)
Current medical education has a gap in the curriculum when it comes to assessing and building communication competencies.(16) The repercussions of insufficient training in communication are difficult to quantify, but it is known that specific physician communication practices are associated with rates of malpractice litigation,(17,18) and that establishing meaningful bi-directional communication is important for professional wellness.(19)
With physician burnout rates estimated in 2017 at about 44%,(20) and with an estimated 400 physician suicides per year in the United States,(21) developing communication strategies that can support physician well-being is critical. With an eye to the Quadruple Aim,(22) which considers the four outcome domains of improving population health, patient care, provider experience, and reducing per-capita costs when assessing how to optimize healthcare performance,(23) we first sought to identify what communication models exist that would increase patient experience, increase provider professional fulfillment, and mitigate burnout. The relationship-centered care (RCC) framework(1) emerged as a promising model for addressing all of these needs.
Relationship-centered Care Framework
While patient-centered care focused on shifting the emphasis in clinical interactions from the doctor’s preferences and values to those of the patient, the shift to RCC presented a new paradigm that placed the doctor–patient relationship as central to the healing encounter. This RCC values-based framework for care delivery is built on the principles of relationship being central to the interaction.
The framework involves four principles or beliefs: 1) Relationships in healthcare need to honor the personhood of participants, understanding that each person brings their personhood to the encounter and stressing authenticity in interaction. Note: While personhood may be subjectively defined, one comprehensive definition provided by Kitwood, as cited in Buron 2008,(28) is “standing or status that is bestowed upon one human being by others, in the context of social being. It implies recognition, respect, and trust.” 2) Affect and emotion are centrally important in relationship development, maintenance, and termination. 3) Healthcare relationships are reciprocal, interactional exchanges. 4) There is moral value in the formation and maintenance of genuine healthcare relationships.(1)
RCC is a bi-directional process of integrating relationships and relational components of the communication process. As a result, trust is built as the exchange unfolds. We selected this framework in part because evidence-based studies have shown that it can reduce provider burnout, increase professional fulfilment and improve the patient experience.(24,25) See Appendix A for a description of RCC and how these principles may be applied in clinical practice.
Developing Infrastructure for Organizational Change
To lay the foundation for organizational change, it is necessary to establish a collective vision and develop systems to capture and share learning. One way to secure alignment between critical stakeholders is to build a dedicated team that can serve as a bridge between leadership and frontline providers.
Committed to the investment, our Patient Experience Department hired a director with decades of experience in organizational development, coaching, and leading high-performing teams to design, develop, implement, and evaluate the RCC strategy. The department also hired a data-driven program manager, established as an influencer in the organization with expertise in stakeholder relationship building. The manager’s role was to translate data and leadership visions into actionable goals. At the executive level, a highly respected physician partner was identified to collaborate and develop a pilot program.
This team’s purpose was to align mission and vision to the greater organization perspective and then invite insights that could allow for transformational change. These multi-faceted perspectives expanded the team’s ability to create dialogue. It should be noted that while this team focused exclusively on physicians, given the scope of our program, the principles and process described here can be adopted for other clinical team members.
This bi-directional process is critical to the strategic and operational design and development over time. To effect system-level transformation in a manner that will allow for the development of a RCC framework, the process must be as important as the outcome. In other words, it is essential to integrate the priorities of each partner and to role model, through the process of engagement, that both the task and relational elements of every conversation are critical. See Table 1 for a description of the six foundational behaviors for establishing a RCC.
Shifting from Outcome Metrics to Process Metrics
This paradigm shift to a RCC model created a communication framework focused on process metrics instead of purely outcome metrics. For example, standard practice is to use physicians’ patient experience scores as outcome measures. However, without process measures in place, it is difficult for physicians to know the pathway by which to achieve better outcome measures.
By sharing evidence-based interventions that affect the outcome measure through skill building and coaching, physicians are given the agency to effect the desired behavioral change. To drive the change, department chairs communicated expectations of physician participation in courses. Physician engagement was prioritized to support the desired change toward adopting process metrics at the organization level. Some of these process metrics appear in Table 1.
To guide other institutions in developing the infrastructure necessary to support a RCC program, we have synthesized our process into four iterative steps we call the ALPS model: Ask; Listen & learn together; Partner; Study, synthesize, and support. We detail here each component of the process by which a RCC program can be achieved and explain how this can be translated into clinical practice. See Figure 1 for a timeline of this process.
Figure 1. Physician Partnership Program Timeline
Figure 1. Physician Partnership Program Timeline (Continued)
Step 1: Ask
The first step is to conduct a needs assessment and survey of the landscape to understand current needs and organizational capacity to engage in the transformation process. At this stage, existing resources, including financial support that can be allocated, should be identified. Examples of questions that can be used to assess organizational capacity include:
Who are our key stakeholders?
Who is already doing work in this area or would be interested in partnering? Consider internal and external partners (e.g., leading organizations).
What funding sources are available (e.g., grants, departmental funds, shared service agreement, donors, etc.)?
How much money will I need to implement this program, based on the number of providers in my organization?
What metrics are the organization most interested in assessing and improving?
It is also during this stage that operational partners should be identified to establish buy-in and formulate strong partnerships on both frontline and executive levels. The exchange between various levels develops a snapshot of the current state. Data from various sources, such as patient satisfaction data or Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey results, needs assessments, and department heads can be gathered to establish the baseline metrics against which to measure forward progress. Trust and connection are built through this discovery stage.
Case Study: Academic Medical Center
At our institution, Stanford Health Care, the Ask stage identified a leadership imperative to develop new RCC practices that would increase physicians’ ability to engage effectively with patients and colleagues. A shared commitment to program development was driven by sub-optimal patient satisfaction scores and a lack of improvement over time.
As the first step in addressing this need, the director of the Physician Partnership Program met with the head of the Patient Experience Department to understand what key departments should be approached for initial input on programmatic needs.
The director’s responsibility in the first six months was to understand the current situation using an inquiry process (i.e., Ask). At first, physician coaching informed the strategy by providing a firsthand narrative of the current state of existing professional needs.
To expand beyond the coaching model, qualitative interviews were conducted with 27 physician leaders across the organization to understand their needs and what they valued as physicians (see interview guide in Appendix B). Appreciative inquiry established the current state, identified what was working, and developed themes that would inform next steps in the development process.
Eight themes emerged, which served as the foundation for the strategic design that followed. It became clear that physicians value:
Reward and recognition.
Collaboration.
Clear expectations and team goals.
Continuous learning and improvement.
Time management and wellness.
Personal development.
Support.
Alignment and integration of programs for physicians.
Physicians wanted to be involved in the development of the programs they were going to be part of, and they wanted to develop expertise and skills to further their personal and professional growth. These tenets became the foundational principles upon which all future programs would be developed.
Step 2: Listen and Learn Together
After identifying operational partners, existing needs, and resources, we progressed to the Listen and Learn Together stage, which involved identifying the physicians, residents, and fellows across the healthcare system with whom to partner to co-develop successful core content. This allows for collective alignment around the direction for the next steps. It also identifies available capacity on both team and individual levels.
Establishing the right RCC framework requires an environmental awareness of what tools are available globally. The process begins by asking questions of key stakeholders and institutional partners to align around strategic priorities. Having a physician partner who serves as the “face” of the program and who can see the current state from the physicians’ perspective is valuable.
By being curious and open to exploring many perspectives, the program manager plays a critical role, synthesizing different stakeholders’ perspectives and bringing insights to the director. Adding a fourth member of the team as the program expands, an administrative coordinator, provides necessary support for program operations.
Case Study: Academic Medical Center
Because our organization has communication experts who were trained in different conceptual models, our primary question while creating the program was “Build or Buy?” This tension around developing in-house expertise versus building on external models required acknowledgment of different perspectives and collaboration at the highest levels. This allowed us to synthesize the most critical items.
This was an evolving process that required multiple iterations before alignment was reached. After extensively researching options, we proposed leveraging a nationally recognized healthcare communication framework, Academy of Communication in Healthcare (ACH), to develop relationship-centered provider facilitators who would function as RCC leaders and expand internal capacity and scale. Additionally, the upfront monetary and time costs of partnering with ACH were significantly less than creating curriculum internally.
The decision was made to partner with ACH to build onto the evidence-based framework they had created and customize the framework for our institution. This partnership allowed us to build faculty, establish a shared framework, and measure the impact of the training. We tailored the content by developing an institution-specific name for the courses, and by creating an array of courses that built on the foundational principles but were adjusted to meet the specialty-specific needs of our physicians.
For many institutions, the guiding questions will be, “What evidence informs how this strategy might add value to the organizational vision?” and “How do we support this provider in this ever-changing, high-risk environment?”
It is important to identify within the institution, how to partner with physicians across divisions. This partnership may include investigating how to buy out physician time or how to contract with them to be part of the strategy development. Considering how to ensure that all new physicians learn the framework, and providing support for the assimilation of new physicians to this evolving culture, needs to be part of the program planning process.
Establishing a shared framework allows an organization to hold individuals accountable for adhering to a cultural practice. It is important to target physicians across career stages to ensure that the program is meeting the needs of all physicians, including those with more advanced communication competencies. With today’s rapidly shifting healthcare landscape, effecting system change requires a new type of leadership: one that requires humility, listening, and collaboration.
Anticipated Barriers
In a culture that is traditionally focused on the task and outcome, transitioning to focusing on the relational components and the task is a challenging cultural shift. Listening to understand by inviting others’ perspectives is critical for developing an effective program.
Resistance is a normal response to change and a normal part of the process. Resistance can be overcome through dialogue once people recognize the relevance of the new skill sets as they apply to their clinical practice.
One key strategy we used to mitigate the resistance was sharing evidence from previous organizations about the value of RCC, with best practices provided to key stakeholders to allow for alignment and approval. See Table 2 for more details. Adopting a new framework requires a growth mindset: learning with deliberate practice and receiving feedback while practicing the new RCC skills.
Another source of resistance to implementing a RCC culture is physicians’ misconception that they are already good communicators. Studies have shown that clinicians’ self-assessment of communication competency does not accurately correlate with their patients’ and patients’ families’ assessment of their communication competency.(26,27) When resistance to change arises, this can be addressed through strengthening partnerships by inviting open discussion of perceived barriers and aligning around shared priorities.
Additional barriers include skepticism around “soft skills” like communication, and reluctance to adopt a standard framework for a process as dynamic as communication. We counter this resistance by providing rigorous evidence for the value of adopting a communication framework on patient outcomes and provider well-being.(3)
Additionally, facilitators in their certification program practice how to deal with resistance using a five-step process of acknowledging, discovering the source of the resistance, responding with empathy, setting boundaries, and extending resources available for future development.
The faculty meet twice a year for development sessions around difficult encounters they have experienced throughout their facilitation. Continuously coaching faculty is key to keeping the program evidence-based. We continue to invest in our faculty members’ growth through these development sessions. Examples of anticipated barriers and targeted solutions appear in Table 2.
Step 3: Partner
Engaging key stakeholders in establishing a common vision and shared expectations is essential in the initial phase of developing the strategic vision. One effective strategy for developing and honing this shared vision can be to organize a board of advisors consisting of key patient experience leaders and physician faculty.
The true emphasis on partnership with physicians creates a core shift in approach that is critical for success. These partnerships are critical to continuous learning. See Table 1 for strategic behaviors that facilitate establishing a RCC.
Step 4: Study, Synthesize & Support
To demonstrate the impact and value of RCC interventions and know how to refine the program, it is critical to have an evaluation plan in place from the beginning. This includes developing data management strategies (e.g., data storage, privacy considerations) and identifying access to the research personnel resources needed to create a study design and provide support during the data collection and analysis phases.
Below, we provide examples of what an iterative loop of study, synthesis, and support may look like. In our program development, pilot tests formed the basis of this stage and were used to gather data that informed movement toward the goal.
In our pilot tests, case studies were presented and physicians practiced how to respond to emotion and handle difficult clinical situations. These 90-minute sessions involved a short didactic, followed by role play and a question-and-answer period. Feedback from these pilot test sessions confirmed that physicians were interested in learning these communication skills. Input from the initial sessions was also used to inform curricular content around topics desired and allowed us to tailor content to common challenges.
The evaluation process can be approached from either an operational or research perspective. Regardless of approach, the evaluation pathway for dissemination of data needs to be a conscious decision. The function of the evaluation team is, at minimum, to track the impact of the program to be able to iterate and improve, and maximally, to be able to create generalizable data that can be broadly disseminated.
Lessons Learned
Many of the lessons we learned during the development process we expect may be shared by those at other institutions. Below, we detail some of the barriers we encountered, effective strategies developed, and summaries of the lessons learned. We report additional details on the preliminary impact of the implementation of a RCC program elsewhere.(3)
Ask Stage
Establish the financial and administrative infrastructure necessary to support a RCC program. We encountered structural constraints that made it difficult for physicians’ time —the time required to train as faculty facilitators and the protected time away from clinical or other duties — to be compensated due to complications of funds flow between the hospital funders and the School of Medicine. Many institutions face similar challenges, where physicians are employed by the School of Medicine, so establishing a pathway that can allow physicians to be adequately compensated for their involvement is essential.
The contracting process can be cumbersome and, if not initiated early enough, may detract from physicians’ ability to participate. Thus, it is essential to examine physicians’ contracts at early stages to ensure they can be adequately compensated for their involvement.
Another way to support physicians’ involvement in the program is to deliver presentations to department chairs, then have the chairs sign a contract, along with each participating physician, stating that the physician is released to participate in the RCC work and that this work would be funded.
To socialize the program, we engaged physician leadership chairs and academic program directors. Together, we designed and developed pilots in each specialty to study various delivery methods. For example, we offered content as two four-hour classes, blended online and classroom learning, one-hour courses over four months, and coaching. It was critical to establish a communication feedback process and proactively seek regular input from physician patient experience directors in order to tailor the intervention effectively.
Listen and Learn Together Stage
Be open to the value of the exchange, as it supports curiosity to apply the RCC in practice. The Listen and Learn Together stage revealed surprising insights. One theme that consistently emerged was how little time physicians have to learn together, and how isolated they feel on a daily basis. Physicians shared a desire for more social interaction and asked for the protected time and space to do so.
Those who took part in the program reported how much they enjoyed learning from their colleagues. They spoke to the need for dedicated time to have lunch with someone, as this experience is missing from traditional clinical professional life. Physicians reported that one of the course strengths was the opportunity to give and receive feedback from peers while practicing the RCC skills.
Partner Stage
Integrate the physician perspective. The primary lesson learned from enacting a cultural shift toward engaging physicians as partners in developing a RCC culture was that physicians were eager to be included in the cultural transformation process. Integrating physician wellness as a core goal in the RCC development process allows for greater alignment between institutional and physician goals.
Each specialty and department has a culture in healthcare. The physician partner helps us understand what are those critical needs in practice and how best to support the adoption of these new skills.
Study, Synthesize & Support Stage
Research needed infrastructure. To demonstrate the impact of the intervention and systematically identify opportunities for improvement, it is essential to gather baseline and ongoing data. This metric development process requires research support and can be pursued using either a quality improvement or research approach.
Benefits to gathering metrics as part of a quality improvement project include the ability to rapidly iterate based on programmatic input. If a research approach is pursued, benefits include being able to collaborate across organizations to create generalizable knowledge, but the process takes longer due to the time necessary to seek approval from the institutional review board.
Regardless of the evaluation method pursued, a RCC framework must be agreed upon before measuring it. Once measured, the efficacy of the program can be confirmed and its value for providers and patients can be demonstrated.
Conclusion
Successful adoption of a RCC framework requires change at every level of the organization. Establishing an organization-wide RCC approach begins with asking. Engaging in a relationship-centered approach requires a shift from “I” to “we,” acknowledging a shared investment. This process transforms the exchange into a relational rather than a transactional dynamic.
The leader’s role in effecting this transformation is paramount and consists of translating the vision for, and value of, a RCC culture. Comprehensive alignment of process and outcome metrics is necessary as a precursor for creating a RCC culture. These steps provide an evaluation method with which to measure the impact of the tailored intervention. Striving to identify the behaviors or habits that will achieve optimal performance requires continual evaluation.
Now, more than ever, it is essential to provide physicians with tools that can enhance professional fulfillment, promote team cohesion, and foster physician well-being. Developing a RCC framework promotes these goals by creating a culture of inquiry in which physicians are able to safely fail and evolve. Delivering the tools for a bi-directional exchange allows physicians to focus on honing the relational aspects of the clinical encounter.(25)
Future Directions
Establishing the RCC framework is only the beginning of the cultural transformation. Ongoing attention is needed for leadership development and continuous research. Future considerations include measuring the effect of these behavior changes in the entire care team, from patient interactions to colleague-colleague, to colleague-team.
Although patient experience metrics are the current standard for assessing clinician performance, greater emphasis should be placed on equally using clinician well-being metrics to assess organization-level success. In light of our recent global pandemic, delivering care interventions virtually is an essential consideration that can be supported by a RCC approach. Recognizing nonverbal cues can be more challenging online. As we continue to study virtual communication approaches, new research opportunities abound.
By using the ALPS model to guide the process of developing a RCC culture, organizations can effectively identify needs and resources, partner with appropriate stakeholders in order to develop a tailored RCC model and pilot interventions, and study and synthesize findings to optimize the framework. Developing the evaluation support necessary to measure the effect of a RCC program is critical to being able to iteratively refine the content and demonstrate its impact.
Acknowledgments: The authors would like to thank Alpa Vyas, Mysti Smith-Bentley, Jonathan Berek, Amir Rubin, David Entwistle, Bryan Bohman, Lidia Schapira, David Spiegel, Laura Cooley, Calvin Chou, Stephanie Harman, Joe Hopkins, Steve Coutre, Justin Ko, Paul Maggio, Norman Rizk, Ann Weinacker, Stanford Healthcare Partner Fund, Stephanie Wong, Maddy Fithian, Manuela Kogon, Felicia Hui, Quinn McKenna and the ACES Faculty: Alyssa Burgart, Sheela Pai Cole, Joshua Fronk, Carl Gold, Lori Guelman, Natalya Hasan Hill, Seth Hollander, Meghan Imrie, Tyler Johnson, Nitin Joshi, Lawrence Kwan, Sheila Lahijani, Teri Longacre, Kate Luenprakansit, Alex Lyapin, Lisa Miller, Lars Osterberg, Judy Passaglia, Rachel Roberts, Saket Shah, Torrey Simons, Amit Singh, and Deepa Thakor, for their contributions in support of this work.
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