Research by Paul Barr


PDF version

of Gatefold

H&HN has created this exclusive yearlong series called Fiscal Fitness with the support of the VHA. Finding ways to rein in expenses without sacrificing quality and safety is imperative for hospitals as they struggle to maintain financial viability in a shifting payment system even as their operational costs continue to climb. Over the next several months, we'll look at everything from the supply chain to pharmacy, IT and more. Follow the Fiscal Fitness series in our magazine and in our e-newletter H&HN Daily.

Improving patient engagement is on the short list of strategies for hospitals and health systems to improve quality and patient satisfaction. But for patients to become actively engaged, their physicians, nurses and other clinicians need to be supportive and competent in providing care that encourages involvement.

Getting to that point is likely to require a change in organizational culture, given the types of operational and philosophical adjustments needed to get patients and their families engaged in their care, as well as the ingrained procedures found in a hospital.

Changing a hospital's culture is difficult, but possible, experts say. "Culture is really just the norms and behaviors of the way we work," says Pat Rutherford, R.N., vice president at the Institute for Healthcare Improvement. But norms and behaviors aren't altered at the drop of a memo or a daylong training session. A hospital's patient engagement efforts usually are put in place using long-term timeframes of several months or even years.

"Culture change requires a change in the hearts and minds of clinicians and staff," Rutherford says.

That gets easier once staff have the opportunity to truly listen to what patients have to say. Seeing things through the patients and families affects staff perceptions, she says.

Another key ingredient to changing culture, one that is sometimes overlooked, comes from management, Rutherford says. "The real crux [of patient engagement] is the interaction between the clinician and the patient and family," she says. "The care environment has to be supportive of that interaction. They have to be in a work environment that supports their spending more time with patients."

Changing care culture also entails improving the way doctors, nurses and other caregivers communicate with each other and with the patient, says Malik Joshi, president of the Health Research & Educational Trust and senior vice president of research at the American Hospital Association. "One of the biggest challenges we have in health care is in information exchange," Joshi says.

Many of the clinician-driven strategies to engage patients and improve outcomes and satisfaction involve increasing communication, according to a patient engagement framework produced by the AHA's Committee on Research called "Engaging Health Care Users."

Such strategies include clinicians using bedside change-of-shift reporting, patients participating in multidisciplinary rounds and both patients and clinicians using shared decision-making tools and techniques, according to the report.

Research indicates that communication skills can be learned, and the health care industry is working to improve physicians' ability to listen and talk to patients. "People are starting to recognize it's an important skill," says Eric Holmboe, M.D., chief medical officer for the American Board of Internal Medicine. "It's getting more attention in training and programs at medical schools."

The types of communication acts that have been shown to be open to improvement include agenda-setting at the beginning of a care visit, responding to emotions and concerns, and ensuring discharge instructions are accurately understood, says Stephen Henry, M.D., assistant professor of medicine at the University of California, Davis.

And even veteran physicians and nurses can learn to improve their ability to interact with patients when given the appropriate training and skills to work on. Henry says that good communication skills are not something you have to be born with. "I think one of the keys to teaching communication is to think of it as a task or procedure, one that is analogous to other tasks and procedures, like taking a blood pressure or doing a physical exam," Henry says. "It's not a nebulous art of medicine, it's a practical skill that can be improved with practice."

Case Study

Emory Healthcare Atlanta

After about five years of work transforming its operation to become more patient-centered, executives for Emory Healthcare in Atlanta have noticed some patterns when introducing the new concepts to clinicians.

"Individually and collectively, we go through three stages," says Hal Jones, director of Emory's care transformation program. "The first stage is, 'You want me to do what?'" There can be "a lot of resistance there," Jones says. In the second stage, clinicians recognize Emory leaders are serious and cooperate but don't necessarily buy into the program. Tying it to pay helps. "People will do it, but only because they have to," he says. The third stage comes when they work with patients, who have been integrated into Emory's care teams as "legitimate members. We orient them, they're members in the same way the physician and nurse are members." Clinicians begin to realize having the patient involved leads to better decisions, says Jones, who adds the process is far from finished. One goal is to give patients access to their medical records, another step in making them partners on the care team.

Case Study

Virginia Mason Medical Center Seattle

Virginia Mason Medical Center has undertaken a number of projects to bring caregivers closer to patients and their families. For example, nurses now give change-of-shift reports at the bedside. Previously, they conducted the reports in a group away from patients. The new approach began in 2007 and took getting used to, says Charleen Tachibana, R.N., senior vice president and chief nursing officer. The hospital still monitors it "to make sure it stays in place," she says.

Another effort is a 24-hour open-door policy for the intensive care unit. "You would never separate a mother from a critically ill child, so why would you do that to a spouse?" says Ian Smith, M.D., medical director, critical care. Some worried about lawsuits if family members saw what they thought was a mistake. Those fears proved unfounded, and the policy is now accepted by clinicians, Smith says.

Placing the patient above all others on the care team — and continually reminding staff of that — has made it easier to convince clinicians to adopt new policies. "Keeping the patient at the top of the pyramid, that's the theme to all of this," says Dan Hansen, M.D., a hospitalist.

HOW TO: A framework for engaging health care users


Increase the skills, knowledge and understanding of patients and families about what to expect when receiving care.

Health care team

Promote shared understanding of expectations among patients and providers when seeking


Encourage partnerships and integrate the patient and family perspective into all aspects of
hospital operations.


Expand the focus beyond the hospital setting and find opportunities to improve overall
community health.

Teaching Communication

Examples of measurable clinician communication skills


  • Ability to take accurate and complete histories
  • Ability to communicate with other doctors
  • Ability to communicate with members of health care team
  • Ability to set agendas with patients


  • Ability to assess and improve patient adherence
  • Ability to deliver diagnostic and prognostic news
  • Ability to elicit patients' beliefs, perspectives and concerns
  • Ability to communicate treatment plans


  • Ability to establish patient rapport and demonstrate empathy
  • Ability to manage conflict and negotiate
  • Basic patient counseling skills
  • Counseling families and caregiver.

Content by Health Forum, Sponsored by: VHA.