Orthopaedic Patient Safety: Core Competencies and Communication Skills
Aaron M. Baessler, MD
Thomas W. Throckmorton, MD, FAAOS
Dr. Throckmorton or an immediate family member has received royalties from Exactech, Inc., Responsive Arthroscopy, and Zimmer; is a member of a speakers’ bureau or has made paid presentations on behalf of Pacira; serves as a paid consultant to or is an employee of OsteoCentrics and Zimmer; has stock or stock options held in Exactech, Inc., Gilead, and Responsive Arthroscopy; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Shoulder and Elbow Surgeons, and ASES Foundation. Neither Dr. Baessler nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
ABSTRACT
Patient safety is of utmost importance in health-care. Multiple compliance organizations ensure appropriate training and oversight in patient safety, including the Accreditation Council for Graduate Medical Education and The Joint Commission. The Accreditation Council for Graduate Medical Education has developed milestones that all ortho-paedic surgeons and trainees must achieve, whereas The Joint Commission has developed institutional protocols that health care facilities must adopt. Central to patient safety is effective communication in the patient-surgeon relationship, which ensures that patients become educated in their care and become involved in the shared decision-making process. All cultures represent unique experiences and viewpoints, and surgeons must consider cul-tural values and biases in the treatment of patients to provide the best care possible.
Keywords: communication skills; cultural competence; informed surgical consent; patient-centered care; shared decision-making
Introduction
To promote patient and physician safety in orthopaedic surgery, multiple entities, including the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS), have developed core competencies for residents and attending physicians. These oversight bodies also emphasize clear, effective communication that allows for shared decision-making between patients and physicians.
Core Competencies and Patient-Centered Care
ACGME and Clinical Learning Environment Review
In 2012, the ACGME introduced the Clinical Learning Environment Review (CLER) program as part of the Next Accreditation System, with the goal of improving safety and quality of care in teaching hospitals, given the history of concerns regarding resident work hours and patient safety.1 CLER focuses on six areas: patient safety, quality improvement, transition of care, appropriate resident supervision, duty-hour oversight and fatigue management, and professionalism.1 The ACGME conducts an on-site visit every 18 to 24 months.1,2,3 The purpose of the visits is to evaluate the role of residents and fellows in each of the six CLER areas. The evaluation committee, which is separate from ACGME review committees, then provides the institution formal feedback based on each of the six areas. The CLER also provides resources to aid in faculty support and leadership development.
From 2012 to 2015, the ACGME visited participating CLER institutions and obtained surveys from designated institutional officials. Surveys revealed that participating institutions increased focus on patient safety, quality improvement, and resident supervision, and improved in assessment of procedural competency.4 Most of the responding institutions (72%) implemented
changes to individual programs to address one or more of the six CLER focus areas, with a positive, high-value CLER experience reported by leadership.5 A study independent of the ACGME revealed similar findings in that almost two-thirds of executive leaders view CLER as a positive experience, and approximately one-third of all institutions added additional resources to improve their respective programs, even in the absence of formal ACGME requirements.6 The CLER program strives to continually improve the quality and safety of teaching institutions, with the next data set from ACGME site visits to be published in the near future.7
changes to individual programs to address one or more of the six CLER focus areas, with a positive, high-value CLER experience reported by leadership.5 A study independent of the ACGME revealed similar findings in that almost two-thirds of executive leaders view CLER as a positive experience, and approximately one-third of all institutions added additional resources to improve their respective programs, even in the absence of formal ACGME requirements.6 The CLER program strives to continually improve the quality and safety of teaching institutions, with the next data set from ACGME site visits to be published in the near future.7
Core Competencies for Orthopaedic Surgery Trainees
Part of the ACGME Next Accreditation System involved milestones for residents to achieve as they progress through training.8 Specific orthopaedic milestones were later reviewed in 2015, with the goal to supplement resident evaluations with a common set of core competencies that should be achieved.9 The ACGME and the ABOS have formally defined overall and subspecialty milestones in several documents.10,11,12,13,14,15,16,17,18 The milestones include patient care and medical knowledge for common pathologies, systems-based practice, practice-based learning and improvement, communication, teamwork, and professionalism. A level from 1 to 5 is set for each milestone, with level 1 representing attributes of an incoming resident and level 5 representing a resident who has advanced beyond expectations, nearing the level of an expert (Table 1). It should be noted that graduating residents do not necessarily meet level 5 milestones, as this level is based on exceeding expectations of a graduating resident. Level 4 is the target for graduating residents. There is variability in training among residency programs, and efforts continually seek to improve milestone assessment.19
Table 1 Milestone Evaluation Levels | ||||||||||||||||||
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Currently, orthopaedic surgery trainees are assessed by multiple individual faculty members. The Clinical Competency Committee at each training institution meets every 6 months to generate milestone evaluations for each resident. As discussed in a 2020 study, the
milestone ratings not only are used by individual institutions but are also delivered to the ACGME, creating a summative assessment of resident performance.20
milestone ratings not only are used by individual institutions but are also delivered to the ACGME, creating a summative assessment of resident performance.20
Core Competencies for the Practicing Orthopaedic Surgeon
Practicing orthopaedic surgeons also must meet competency requirements. The ABOS written examination test question writers and oral board examiners, along with the General Orthopaedic Competency Task Force, combined the medical knowledge and patient care competencies mentioned previously into two broad categories: assessment and management.21 Generally, assessment competency refers to the ability to appropriately initially evaluate, investigate, and develop a management plan for conditions. Management competency refers to the ability to provide initial or emergency care, surgical or nonsurgical care, and appropriate follow-up. Management of patients also includes the ability of physicians to assess their own ability and to either provide definitive care or transfer care to a qualified individual. There is a set of six general orthopaedic surgery evaluation competencies and several sets of individual management competencies that include adult reconstruction, acute orthopaedic care, sports medicine and sports surgery, pediatrics, spine, and foot and ankle. Similar to trainee competencies, there are competencies for office-based practice, communication, systems and culture, and professionalism.
Communication Skills and Cultural Competence
Communicating effectively with patients has been shown to improve quality of patient care.22 Historically, orthopaedic surgeons have been considered “high tech, low touch” by patients, meaning that although orthopaedic surgeons’ technical skills are excellent, compassion, listening, and overall communication skills are poor compared with other physicians.23 Empathy, in particular, has been thought to be lacking in surgeon-patient communications during office visits.24 A retrospective review of all orthopaedic patient complaints during a 16-year period at a tertiary referral hospital showed that 14% of all complaints were related to communication. However, the subcategories of humaneness/disrespect and expectation of care and treatment comprised 20% of all complaints.25 Demeanor and empathy are part of effective communication, and effective communication is paramount in meeting patients’ expectations and achieving optimal outcomes after treatment. Because 54% of all complaints were communication related, this finding suggests that orthopaedic surgeons need to improve communication skills.
Developing communication skills can improve outcomes and overall patient satisfaction. A 2021 retrospective cohort study in patients with lumbar spine surgery revealed that, after adjusting for potential confounding variables, patient satisfaction scores were directly related to physician communication.26 The authors of a 2020 study demonstrated a correlation between patient ratings of poor surgeon communication with increased postoperative pain intensity after total hip arthroplasty.27
Not only is effective communication important to patients, but it is also important among health care workers. Effective communication with patients and health care colleagues has been shown to improve outcomes and satisfaction while decreasing adverse event occurrences and length of stay.28 However, effective communication is not a diffusion of responsibility and physicians should directly communicate care to patients and not rely on support or nursing staff to relay information. One study evaluated patients in a trauma center who had a canceled orthopaedic surgery procedure for any reason, most commonly inadequate operating room time. Nurses alone delivered more than half of all explanations for surgery cancellation (54.7%) to patients. When an explanation for the surgery cancellation was provided by a nurse only, patients were much more likely to be dissatisfied than if the explanation came directly from the treating physician. If the physician notified the patient, 96% of patients were satisfied with the communication.29
CanMEDS Physician Competency Framework Project
The Royal College of Physicians and Surgeons of Canada developed The CanMEDS 2005 Physician Competency Framework Project, which promotes physician communication skills.30 Building on this framework, the American Academy of Orthopaedic Surgeons (AAOS) regularly promotes communication workshops.31 However, proper development of communication skills is still lacking in many residency programs.32 Assessing residents early in training with unannounced, standardized patient encounters allows objective assessment of their communication, patient education, counseling, and professionalism and can aid institutions in developing a plan to improve these skills in trainees.33 Furthermore, personality traits are correlated with communication skills and, when observed, can be used to identify individual residents who may need additional training. According to a 2019 study, stress-related
personality traits, such as excitable, skeptical, and imaginative negatively correlate with communication skills, whereas day-to-day personality traits, such as emotional stability, agreeability, and conscientiousness correlate with positive communication skills.34
personality traits, such as excitable, skeptical, and imaginative negatively correlate with communication skills, whereas day-to-day personality traits, such as emotional stability, agreeability, and conscientiousness correlate with positive communication skills.34
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