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    By Jason Foltz, DO, chief medical officer, ECU Physicians/Brody School of Medicine, East Carolina University; Pamela D. Hopkins, PhD, teaching associate professor, director, Speech Communication Center, East Carolina University; Jennifer Thompson, MS, clinical quality program specialist, East Carolina University; and Robert J. LaGesse MSM, CMPE, FACHE, chief operations executive, ECU Physicians/Brody School of Medicine, East Carolina University.

    Working to achieve the Quadruple Aim,1 our group (ECU Physicians at East Carolina University) targeted the exceptional patient experience.

    Patients have always been an obvious component of medical care, but they haven’t always been active participants in their own care. Patient experience is increasingly recognized as one of the three pillars of quality in healthcare alongside clinical effectiveness and patient safety.2

    One of the essential components of patient-centered care and a positive patient experience is effective communication between clinical team members and patients. During a four-year period, ECU Physicians created a framework for improving communication skills between all clinical team members from providers to patient access service staff members and the patients and family members they serve.

    Setting the strategic framework

    The practice uses CAHPS Clinician & Group Surveys (CG-CAHPS) to gauge a patient’s perception of the care received. Are survey results and verbatim comments submitted by patients significant enough to warrant concern? Our answer is “yes.” Each person employed in healthcare is also in the customer service industry: the products being sold are excellent healthcare and wellness. To be successful, the customers — our patients — must have a positive experience with the services they receive. To that end, the physician practice created a framework for improving patient satisfaction, which also influences all components of the quadruple aim.


    In 2016, ECU Physicians’ Clinical Management Team collaborated with our Department of Quality and Analytics to improve our patient satisfaction survey scores. Recognizing that effective communication skills are essential to a positive patient experience, the initial goal was to improve communication skills between clinicians and patients.

    Data showed that 24 of 60 clinics had fallen below the desired Top Box number designated by the CG-CAHPS vendor’s database. Noting that provider communication made up a large portion of the score, we recognized that our clinical staff needed assistance developing effective communication skills to achieve our desired patient experience goals. It’s no longer enough for patients to simply be medically treated and sent on their way. Patients want to be heard, they want to feel respected, and they want to be told what to expect.


    The plan encompassed three phases:

    1. Phase 1 focused on provider-patient communication skills.
    2. Phase 2 focused on patient access service staff members and patient communication skills.
    3. Phase 3 focused on clinical engagement. A multi-faceted approach was implemented to target and improve communication skills between clinical team members and patients and between clinical team members.

    Phase one began with a pilot study shadowing four medical providers, three having been identified as scoring lower in patient-provider communication skills on CG-CAHPS, while the fourth provider served as our benchmark because of excellent survey scores. Observations included providers’ lack of eye contact with the patient and family members; turning backs to patients while updating the EHR; not listening effectively to patient responses and repeating questions or neglecting to respond; and not greeting the patient by name at the beginning of the clinic exam. Feedback about each provider’s communication skills and suggestions for best practice improvements were shared with clinical leadership, who then shared that feedback with the providers.

    Phase two recognized that patient access service (PAS) employees on the front desks at clinics are an essential piece of the patient experience. We analyzed the data and reviewed verbatim comments provided by patients in the CG-CAHPS surveys, identifying those 28 clinics where the Top Box numbers fell below expectations. We then devised and implemented a four-step process focused on improving communication skills.

    Step 1. We developed our patient philosophy, which includes the patient promise and the patient extras. The patient promise involves four steps:

    1. Greet every patient with a smile, eye contact and full attention;
    2. Listen carefully, being attentive to nonverbal communication;
    3. Be respectful. Call the patient by name, speak more loudly if patient is hard of hearing;
    4. Be clear: speak clearly, ask clearly, tell clearly.

    The patient extras involve three steps:

    1. Desire to satisfy. You want the patient to have an exceptional clinical experience;
    2. Be flexible and open-minded;
    3. Stay calm even when it’s difficult.

    Step 2. We created a secret shopper program, making random visits to clinics falling below expectations. After developing a simple scorecard (see Figure 1) with a five-item rating system and space for comments, we used these as criteria as we observed interactions between PAS staff members and patients. In response to clinic management requests, we also initiated secret shopper phone calls to clinics during peak times. Copies of scorecards with verbatim comments from the secret shoppers were compiled and shared with clinic management who then invited us to present feedback and suggestions for improvement to clinic staff.

    Step 3. We went “behind the glass” at clinics to observe daily interactions with patients. We were able to view the PAS employees’ daily work through their vantage point, and it also allowed us to demonstrate that we were at the clinic to be helpful and not to work against staff members. We asked questions, took notes, compiled our feedback and suggestions and distributed everything to clinic management who then shared those results with PAS employees.

    Step 4. We conducted clinic “walk-throughs” in the company of clinic management, making observations including residents and providers discussing patients outside exam rooms within earshot of other patients; loud conversations taking place in the break room or copy room; noxious smells coming from break rooms where food was being re-heated; front desk staff members chewing gum or eating while checking in patients; and PAS employees interacting casually with each other while patients waited to be checked in.

    Phase three focused on clinical engagement. We planned to shadow patients from check-in to checkout, observing clinical team engagement throughout the visit. First, we created a scoring rubric, covering clinical team communication at patient check-in, during the patient exam, in the lab, at patient checkout and during any phone calls. In addition, we conducted a pilot study at one clinic where PAS employees were aware of our project. When patients checked in, the PAS employee identified us as communication experts at the clinic to observe clinical team members, not the patients. We requested and received permission to shadow the patient throughout their visit. We stayed with those patients who gave us permission. We observed each patient interact with all clinical team members and observed the interactions of all clinical team members with each other.

    Throughout this journey of learning and using the tools outlined above to seek areas of opportunity upon which to focus, we continued to invest in our teams’ communication skills training. We initiated targeted training based on the Agency for HealthCare Research and Quality (AHRQ) Program called TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety).3 We initiated biannual training with our new employees during our Ambulatory Care Academies. In addition, we partnered with clinics on targeted TeamSTEPPS® Training for areas noted to struggle with communications between staff and patients and internally between staff based on the above observations.

    As we progressed with our efforts, we experienced a marked improvement in patient perceptions of staff communication with them and the sense that staff felt more at ease in communicating with each other.

    To maintain our improvements, we also needed to address our culture of excellence while ensuring our staff enjoyed their work environment. We recently invested in ongoing training aimed to boost morale and improve results. This program, based on the FISH! philosophy,4 emphasizes how we expect our staff to work together through the four FISH! principles of:

    1. Play
    2. Make their day
    3. Be there
    4. Choose your attitude.

    We implemented this training practice-wide and made it mandatory for clinical, provider and staff support.


    We have seen steady improvement in all our clinics in the area of patient satisfaction. The key to success has been a combination of developing and implementing a variety of practical tools and many hours spent working in our clinics along with a central management team focused on our common goal: “to provide the highest quality and most compassionate health care to the people of eastern North Carolina while educating the next generation of health professionals to do the same.”


    A strong, multi-faceted plan focused on improving the communication between clinical team members and patients and among clinical team members has changed the results of their patient experience survey scores used in the physician practice at East Carolina University. In addition, the changes are creating a more profound positive impact on the culture of the organization. These same steps can begin to change the culture of your organization to one with the goal of providing exceptional patient care at all levels.


    1. Bodenheimer T, Sinsky C. “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” The Annals of Family Medicine. November 2014, 12 (6) 573-576;
    2. Doyle C, Lennox L, Bell D. “A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.” BMJ Open. 2013 Jan 3;3(1):e001570. doi: 10.1136/bmjopen-2012-001570. PMID: 23293244; PMCID: PMC3549241.
    3. AHRQ. “TeamSTEPPS®” Available from:
    4. Lundin SC, Paul H, Christensen J. Fish: A Proven Way to Boost Morale and Improve Results. Hachette Book Group, 2000.

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