Development of a Standardized Kalamazoo Communication Skills Assessment Tool for Radiologists: Validation, Multisource Reliability, and Lessons Learned.

OBJECTIVE: The purpose of this study was to develop and test a standardized communication skills assessment instrument for radiology. MATERIALS AND METHODS: The Delphi method was used to validate the Kalamazoo Communication Skills Assessment instrument for radiology by revising and achieving consensus on the 43 items of the preexisting instrument among an interdisciplinary team of experts consisting of five radiologists and four nonradiologists (two men, seven women). Reviewers assessed the applicability of the instrument to evaluation of conversations between radiology trainees and trained actors portraying concerned parents in enactments about bad news, radiation risks, and diagnostic errors that were video recorded during a communication workshop. Interrater reliability was assessed by use of the revised instrument to rate a series of enactments between trainees and actors video recorded in a hospital-based simulator center. Eight raters evaluated each of seven different video-recorded interactions between physicians and parent-actors. RESULTS: The final instrument contained 43 items. After three review rounds, 42 of 43 (98%) items had an average rating of relevant or very relevant for bad news conversations. All items were rated as relevant or very relevant for conversations about error disclosure and radiation risk. Reliability and rater agreement measures were moderate. The intraclass correlation coefficient range was 0.07-0.58; mean, 0.30; SD, 0.13; and median, 0.30. The range of weighted kappa values was 0.03-0.47; mean, 0.23; SD, 0.12; and median, 0.22. Ratings varied significantly among conversations (χ26 = 1186; p < 0.0001) and varied significantly by viewing order, rater type, and rater sex. CONCLUSION: The adapted communication skills assessment instrument is highly relevant for radiology, having moderate interrater reliability. These findings have important implications for assessing the relational competencies of radiology trainees.

Development of a Brazilian Portuguese adapted version of the Gap-Kalamazoo communication skills assessment form.

OBJECTIVE: The goal of this study was to translate, adapt and validate the items of the Gap-Kalamazoo Communication Skills Assessment Form for use in the Brazilian cultural setting. METHODS: The Gap-Kalamazoo Communication Skills Assessment Form was translated into Portuguese by two independent bilingual Brazilian translators and was reconciled by a third bilingual healthcare professional. The translated text was then assessed for content using a modified Delphi technique and adjusted as needed to assure content validity. A total of nine phrases in the completed tool were adjusted. The final tool was then used to assess videotaped simulations as a means of validation.  Response process was assessed using exploratory factor analysis and internal structure was assessed via Cronbach's Alpha (internal consistency) and Intraclass Correlation (test-retest reliability and inter-rater reliability). RESULTS: One hundred and four (104) videotaped communication skills simulations were assessed by 38 subjects (6 staff physicians, 4 faculty physicians, 8 resident physicians, 4 professional actors with experience in simulation, and 16 other allied healthcare professionals). Measures of Internal consistency (Cronbach's alpha = 0.818) and test-retest reliability (intra-class correlation coefficient = 0.942) were high.  Exploratory factor analysis confirmed the uni-dimensionality of the instrument. CONCLUSIONS: Our results support the validity and reliability of the Brazilian Gap-Kalamazoo Communication Skills Assessment Form when used among Brazilian medical residents.  The Brazilian version of Gap-Kalamazoo Communication Skills Assessment Form was found to be adequate both in the linguistic and technical aspects.  The use of this instrument in Brazilian medical education can enhance the assessment of physician-patient-team relationships on an ongoing basis.

The International Charter for Human Values in Healthcare: an interprofessional global collaboration to enhance values and communication in healthcare.

OBJECTIVES: The human dimensions of healthcare--core values and skilled communication necessary for every healthcare interaction--are fundamental to compassionate, ethical, and safe relationship-centered care. The objectives of this paper are to: describe the development of the International Charter for Human Values in Healthcare which delineates core values, articulate the role of skilled communication in enacting these values, and provide examples showing translation of the Charter's values into action. METHODS: We describe development of the Charter using combined qualitative research methods and the international, interprofessional collaboration of institutions and individuals worldwide. RESULTS: We identified five fundamental categories of human values for every healthcare interaction--Compassion, Respect for Persons, Commitment to Integrity and Ethical Practice, Commitment to Excellence, and Justice in Healthcare--and delineated subvalues within each category. We have disseminated the Charter internationally and incorporated it into education/training. Diverse healthcare partners have joined in this work. CONCLUSION: We chronicle the development and dissemination of the International Charter for Human Values in Healthcare, the role of skilled communication in demonstrating values, and provide examples of educational and clinical programs integrating these values. PRACTICE IMPLICATIONS: The Charter identifies and promotes core values clinicians and educators can demonstrate through skilled communication and use to advance humanistic educational programs and practice.

Assessment of communication skills and self-appraisal in the simulated environment: feasibility of multirater feedback with gap analysis.

INTRODUCTION: Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach. METHODS: The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach's Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman's Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics. RESULTS: Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received. CONCLUSIONS: Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and "safe" environment, may assist in the delivery of feedback to trainees.

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals.

OBJECTIVE: To examine how patient-centredness is understood and enacted in an American (US) and an Italian group of health care professionals. METHODS: An action research methodology was used. Two interprofessional groups of US (n = 4) and Italian (n = 5) health care professionals independently wrote a patient-centred dialogue between a doctor and a patient based on the same scenario. The dialogues were then translated and exchanged. Both groups independently commented on the patient-centred aspects of the other's dialogue by completing a written questionnaire. Their respective comments were then shared by international videoconference. The transcript of the videoconference was analysed via content analysis. The participants' opinions about the study were then evaluated. RESULTS: Exploring the patient's illness experience and handling the patient's emotions were identified as core components of patient-centred care by both the US and Italian groups, but were expressed differently in their respective dialogues. Respecting the patient's autonomy was recognised as a component of patient-centred care only by the US group. The Italian group demonstrated a more implicitly paternalistic approach. Participants highlighted the usefulness of one another's feedback to uncover cultural assumptions of patient-centred care and increase self-awareness. CONCLUSIONS: Results suggest that the concept and practice of patient-centred care is variable and may be influenced by culture. The study methodology improved participants' self-awareness of cultural values, and has potential as a cost-effective, experiential educational approach.

A model for communication skills assessment across the undergraduate curriculum.

Physicians' interpersonal and communication skills have a significant impact on patient care and correlate with improved healthcare outcomes. Some studies suggest, however, that communication skills decline during the four years of medical school. Regulatory and other medical organizations, recognizing the importance of interpersonal and communication skills in the practice of medicine, now require competence in communication skills. Two challenges exist: to select a framework of interpersonal and communication skills to teach across undergraduate medical education, and to develop and implement a uniform model for the assessment of these skills. The authors describe a process and model for developing and institutionalizing the assessment of communication skills across the undergraduate curriculum. Consensus was built regarding communication skill competencies by working with course leaders and examination directors, a uniform framework of competencies was selected to both teach and assess communication skills, and the framework was implemented across the Harvard Medical School undergraduate curriculum. The authors adapted an assessment framework based on the Bayer-Fetzer Kalamazoo Consensus Statement adapted a patient and added and satisfaction tool to bring patients' perspectives into the assessment of the learners. The core communication competencies and evaluation instruments were implemented in school-wide courses and assessment exercises including the first-year Patient-Doctor I Clinical Assessment, second-year Objective Structured Clinical Exam (OSCE), third-year Patient-Doctor III Clinical Assessment, fourth-year Comprehensive Clinical Practice Examination and the Core Medicine Clerkships. Faculty were offered workshops and interactive web-based teaching to become familiar with the framework, and students used the framework with repeated opportunities for faculty feedback on these skills. A model is offered for educational leaders and others who are involved in designing assessment in communication skills. By presenting an approach for implementation, the authors hope to provide guidance for the successful integration of communication skills assessment in undergraduate medical education.

A model for merging residency programmes during health care consolidations: a course for success.

INTRODUCTION: As health care delivery systems experience economic and competitive challenges, institutional mergers have become a means for economic survival. Academic hospital mergers are well chronicled, yet little has been written about postgraduate, or residency, training programme mergers and their human and programmatic consequences. Mergers present opportunities to strengthen and redesign residency programmes, but risks include programme disruption, resident and faculty morale, and housestaff and faculty recruitment and retention. Mergers can cause a sense of disequilibrium, influencing resident and staff perceptions of job security, commitment to teaching, and even the viability of the residency programme. OBJECTIVE: We describe a process for the survival and successful merging of existing residency training programmes in the context of larger health care mergers. People, management, and communication skills are critical for leaders of the change process. We offer approaches and guidelines for leaders and others who are involved health care and residency training programme mergers. Awareness and understanding of systems issues and human factors improve the likelihood of success. Although our guidelines are intended primarily for residency programme mergers, they are equally applicable to mergers of health care institutions. CONCLUSION: Successful residency training programme mergers require a carefully planned and executed series of actions that minimise disruptions. Effective communication on all levels is key. Success is associated with effective leadership, good communication skills, an open process with physician input, attention to institutional cultures, and a relatively short timetable. Most important is the continuous involvement, input, and creation of the programme by those most affected.

Performance profiles: the influence of patient satisfaction data on physicians' practice.

OBJECTIVE: Health maintenance organizations and other payers increasingly use patient satisfaction data to profile physician performance. Little is known about physicians' use of patient satisfaction information or how profiles affect individual physician behaviors. The objective of this study was to examine primary care physicians' perceptions of performance profiles based on patient satisfaction data, whether physicians use profiles to change practice behaviors, and which profile components physicians think are important for assessing quality of care. METHODS: A written survey was conducted in 1998 in Massachusetts with 810 primary care physicians (304 pediatricians, 201 family practitioners, 305 internists) who had at least 100 patients in a large managed care plan and had received 1 or more profiles based on patient satisfaction data. Physicians in training were excluded. Physicians' perceptions of profiles and their reported use to change practice behaviors were measured. RESULTS: The response rate was 68%. Twenty-three percent reported that profiles were very or extremely useful for improving care. Only 7% reported using profiles often or always to change care. Although specific profile components related to interpersonal aspects of care were rated more useful, <11% reported using profiles often or always to make changes on any individual component. A majority, 67% to 89%, reported making no or minor changes on profile components. Responses did not vary by specialty, demographics, or practice characteristics. Physicians rated interpersonal factors (eg, ability to communicate with patients, ability to show caring and empathy) as the most important indicators of quality of care; they report having the most control over these factors. Office factors (eg, staying on schedule, ease of scheduling appointments) were ranked as least important for assessing quality of care. CONCLUSION: Although health maintenance organizations and other payers increasingly use patient satisfaction reports to profile individual physicians and guide physician compensation and health plan participation, <25% of primary care physicians find profiles useful for improving patient care and even fewer report using profiles to change practice. Profiles likely have limited influence on behavior changes. Payers who invest in profiles may find it advantageous to focus on health plans and practice facilities rather than on individual physicians.