Patient Safety, Core Competencies, and Communication Skills

Jorge Manrique, MD

Scot A. Brown, MD

Dr. Manrique or an immediate family member serves as a paid consultant to or is an employee of Stryker. Neither Dr. Brown 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

Many institutions are involved in supervising training to ensure surgeons are able to deliver safe, quality care. Others ensure patient safety and well-being throughout a surgeon’s career via surgical and institutional protocols. Among the different institutions, the Accreditation Council for Graduate Medical Education (ACGME) ensures training quality and competency acquisition and the World Health Organization (WHO), as well as the Joint Commission, ensure patient safety. Different milestones for each training program are delineated by the ACGME, and institutional protocols have been defined by the WHO and Joint Commission. Additionally, to achieve patient-centered care, communication plays an essential role. Interactions of healthcare professionals with both patients and other team members are critical to avoid confusion and undesired errors. As orthopaedic surgeons, we must strive to provide excellent care while adhering to the available guidelines that have determined to be successful with a focus on effective communication and cultural competency to ensure patients are engaged in their care.

Keywords: patient satisfaction; person-centered care; shared decision making; surgical patient safety

Introduction

As part of patient-centered care, patient safety is a primary goal of orthopedic surgeons. High-quality patient-focused care not only ensures better outcomes but plays an important role in current healthcare policies. Core competencies at both the resident and attending level have been developed by various oversight bodies. A key component is clear effective communication and involvement of the patient in decision making along the course of their treatment. Ultimately, our responsibility can even extend beyond the office as we have a moral and often legal imperative to identify and report abusive behavior including child abuse, domestic abuse, and elder abuse. This chapter will cover different aspects of these topics.

Core Competencies and Patient-Centered Care

The Accreditation Council for Graduate Medical Education (ACGME) was created in 1981 to supervise and ensure the quality of postgraduate medical education and training in the United States. Many changes have taken place throughout the years in an attempt to ensure patient-centered care along with ensuring the well-being of training physicians. To standardize this effort, they developed the Clinical Learning Environment Review (CLER) Program.¹

This program focuses on six competencies:

Patient safety
Quality improvement
Transitions in care
Supervision
Duty hours oversight, fatigue management, and mitigation
Professionalism

The CLER program has three areas or activities to accomplish its purpose: the site visit, the evaluation committee, and support for faculty and leadership development. The visit evaluates the sponsoring institution, focusing on the role of the residents and fellows in the six competencies described above. These are evaluated or assessed by five questions:

Who and what form is the infrastructure of a Sponsoring Institution’s (SI’s) clinical learning environment?
How integrated is the Graduate Medical Education (GME) leadership and faculty within the SI’s current clinical learning environment infrastructure?
How engaged are the residents and fellows in using the SI’s current clinical learning environment infrastructure?
How does the SI determine the success of its efforts to integrate GME into the quality infrastructure?
What areas has the SI identified as opportunities for improvement?

The evaluation committee differs from the ACGME review committees, as it sets expectations for the six focus areas and provides institutions with feedback from the visit. Faculty and leadership development focuses on establishing resources to educate and support faculty and executive leadership across the six focus areas.

Core Competencies for Trainees

Different core competencies have been described in orthopaedic surgery throughout the years. Recently, the orthopaedic community has had special interest in determining the specific competencies of an orthopaedic surgeon to ensure the patient receives safe, timely, and adequate orthopaedic care. The ACGME, in conjunction with the American Board of Orthopaedic Surgery (ABOS), provides oversight and evaluation of trainees to ensure they have successfully completed their training. These institutions, as part of the above-mentioned efforts, promote strategies to ensure patient safety and quality of care.

A combined document has been developed by the ACGME and the ABOS.² This document has been created to define milestones for programs to be used in resident evaluation and training. The defined milestones are knowledge, skills, attitudes, and other attributes for each competency in a structured manner. This structure involves five different levels (Table 1).

Core Competencies for the Practicing Orthopaedic Surgeon

Core competencies for attending surgeons have also been defined to promote safe and appropriate care for patients. A recent consensus effort among orthopaedic surgeons aimed to identify these competencies was conducted.³ The General Orthopaedic Competency Task Force (GOCTF) and the ABOS sent an e-mail-based questionnaire to written examination question writers. Core competencies of medical knowledge and patient care were combined into two major groups: assessment and management. It was considered that a practicing orthopaedic surgeon should have the following knowledge competencies (extracted form “The Core Competencies for General Orthopaedic Surgeons”³) (Table 2).

Table 1 Levels for Milestones Evaluation

Level 1	The resident demonstrates milestones expected of an incoming resident.
Level 2	The resident is advancing and demonstrates additional milestones but is not yet performing at a midresidency level.
Level 3	The resident continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for residency.
Level 4	The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target.
Level 5	The resident has advanced beyond performance target set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

Table 2 Knowledge Competencies

Understand bone and soft-tissue biology and pathophysiology including growth; development and aging; injury, disease, and repair of musculoskeletal tissues including rehabilitation; and assessment of return to vocational and recreational activities
Understand the relative effectiveness of various surgical and nonsurgical options
Understand the comorbidities of a patient that will impact the orthopaedic surgeon’s care plan
Understand conditions that are expected to be cared for by other specialists or subspecialty orthopaedic surgeons, eg, metabolic bone disease in the adult including osteopenia and osteoporosis, crystalline arthropathy: gout and pseudogout, tumors of musculoskeletal system, diabetic foot ulcers, exercise-induced leg compartment syndrome, and stress fractures
Perform an assessment and management of postoperative complications for patients, even if referred
Perform an assessment of musculoskeletal conditions using a history, a physical examination, and an investigative plan to develop a differential diagnosis based on an understanding of the pathophysiology of musculoskeletal conditions

Communication Skills and cultural Competence

Communication with patients is one of the most important aspects of medicine. Successful communication with patients directly impacts care and quality.⁴ When measured against our colleagues, orthopaedic surgeons have room for significant improvement in this area.⁵ Levinson et al,⁶ in their systematic review of surgeon-patient communication, saw that the main area of deficiency in communication skills among surgeons was empathy. They often did not adequately explore emotions or concerns of patients. Improving these skills can potentially lead to improved outcomes and greater patient satisfaction.

In the era of value-based care, excellent attention must be provided and this includes successful communication with both patients and team members. Epstein⁷ states in her literature review that communication among healthcare workers and between healthcare workers and patients reduces the occurrence of adverse events, improves outcomes, decreased length of stay, and produced greater satisfaction among all. Furthermore, a study by Hwang et al,⁸ which evaluated patients in the intensive care unit (ICU), saw that communication was directly correlated to satisfaction. In general, communication has been a common complain of patients throughout history. In a study by King et al,⁹ 1,118 orthopedic patients’ complaints were evaluated. They saw that the most common reason for complain was access and availability followed by communication. In a different study, Mehta et al¹⁰ evaluated patients whose procedure had been canceled. Interestingly 29.3% had no communication regarding the reason for their cancelation. Eighty-three percent of patients stated their dissatisfaction and noted that they would have liked to talk to their doctor and discussed the cancellation. Patient satisfaction was significantly lower among those patients with inadequate communication by a physician.

Communication, as mentioned above, has been proposed to be a key component of physician training. The Royal College of Physicians and Surgeons of Canada (RCPSC) developed The CanMEDS 2005 Physician Competency Framework Project that emphasizes in communication skills.¹¹ In orthopaedic surgery, the American Academy of Orthopaedic Surgery (AAOS) has actively promoted communication skills through workshops and other activities.¹² They consider communication to improve satisfaction, adhere to treatments, improve outcomes, and reduce liability. Although multiple efforts have been made, it has been seen that residents lack communication skills training.¹³

Educational models have been created to develop successful communication skills. One of the most popular models describes the four E’s model. The publication that mentions the four E’s model also describes the useful techniques to implement the model.¹¹ This hypothesizes that the physician-patient relationship is a consequence of the understanding of the disease by the physician. The main problem has been described to derive from not separating the body from the mind. Therefore, to successfully address the mind, communication must be efficient and thorough to be able to address the body/pathology. The strategy for successful communication is based in four aspects that begin with the letter E and therefore called the four E’s strategy. These four are engagement, empathize, educate, and enlist (Table 3).

Table 3 Four E’s Strategy

Engagement: In a physician-patient relationship, engagement between the two actors must occur. Ideas, information, and feeling will only come across if a human connection exists. Initially the physician must support the patient to be able to express the situation in a logical way. Similarly, the physician must have the ability to understand and translate subsequent medical knowledge to simple words that the patient is capable of understanding. This way both will be talking in known terminology. Furthermore, the physician must have welcoming body language and attitudes such as listening without interruption.
Empathize: Understanding patients’ feelings and concerns is crucial. It allows physicians to show their understanding and caring to the patient. It has been seen that empathy is a strong tool as it creates trust in the patient and allows them to express their concerns and allows for better understanding of the medical scenario.
Educate: When a patient understands the situation, their ability to make decisions is enhanced. Their anxiety secondary to uncertainty decreases, and their knowledge of risks and benefits reinforces communication between the physician and the patient. Educational conversations should not be one-sided. Physicians must allow for patients to formulate questions or concerns during this phase. Patients that do not exhibit concern or lack communication of the situation are often seen to complain of lack of provided information by the physician.⁵
Enlist: Allowing and motivating the patient to actively participate in decision making is crucial as it incorporates understanding and communication. Setting goals and making the patient part of the process generates patients’ desire to work toward a goal that they desire. Patients that are not involved in the treatment plan have demonstrated lack of adherence.

Cultural Competency

Communication and culture are intimately related. To have successful communication, cultural competencies must be met and different cultural aspects must be discussed. Donahue¹⁴ states that culture includes language, thoughts, ways of communication, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. He defines a culturally competent professional as one who is capable to understand that others have different needs based on the above-mentioned factors. This leads to the fact that all patients are not to be treated the same way.

According to Pedersen’s Conceptual Framework for Developing Cultural and Cross-Cultural Competence published by the University of Colorado, there are four major components to cultural competence: awareness, attitude, knowledge, and skills.¹⁵ Awareness is directly related to the notion of different values that different cultures have. Attitude is the feeling a subject has toward its own beliefs, and their strength, that could collide with others’ if different. Knowledge is important because it allows us to understand and avoid judging and or “stepping on cross-cultural toes.” Lastly, skills are crucial for interaction and put in practice the other competencies.

Only gold members can continue reading. Log In or Register to continue