Coaching and Process Improvement
At first glance, the title of this essay appears contradictory. Coaching is, by definition, something involving individuals, while process improvement seeks to take the individual out of the equation. Yet all clinical processes involve people, so it stands to reason there might be some relationship. A recent case study by Dr. Ghazala Sharieff illustrates this.
Scripps Health has almost 80% of its in-patient population seen by one of its hospitalist groups, so they were the logical place to start efforts to improve the system’s HCAHPS scores. The author was chosen to lead the process and devoted 80% of her time to the effort.
“At Scripps, we designed the program so that I, as the physician lead, would first meet with the medical directors, and we also gave the directors the option of inviting me to their monthly hospitalist staff meetings for group training sessions. Five of our six hospitalist groups decided to invite me to their department meetings to roll out the training initiative. One of the five hospitalist groups had such low scores that they asked for 1:1 physician-to-physician coaching on rounds in addition to the group training sessions.
Monthly hospitalist department scores were sent to all of the medical directors to share with their physicians, outlining not only the roll-up score of all the Physician Communication questions, but also the scores on the following questions, which constitute the physician overall communication score:
How often did doctors explain in a way you could understand?
How often did doctors treat you with courtesy and respect?
How often did doctors listen carefully to you?
The scoring scale: never, sometimes, usually, and always. Our organization prides itself on transparency and, therefore, in addition to providing the medical directors with this information, we began to share the scores of all hospitalist groups with each other on a monthly basis. This not only helped to show differences in the scores and physician engagement, but it also created opportunities for open communication between groups about best practices.”
Teaching sessions focused on three behavioral keys to improved communication: “knock, sit, ask.” In other words, knock on the door before entering the patient’s room, sit down to talk to them, and start by asking what the patient’s greatest concern was that day? In the article she provided further examples. The most interesting was “What questions can I answer?” She recommended not asking “Do you have any questions?” They also worked to improve the handoff process so there was consistency in both treatment plan and the explanations provided to patients about what was going on.
Each of the six hospitalist groups chose different means of engagement. Groups A, B, and D, regularly reviewed their HCAHPS scores monthly in their group meeting and reinforced the training tips. Group C, which had the worst scores, asked for 1:1 training and Dr. Sharieff attended every other monthly meeting to provide tips and reminders. Group E asked for the scores, but did little else to engage in the process after the initial training and Group F did not do anything after the original training.
When the results were analyzed, groups A, B, and D had doubled their patient satisfaction scores, while group C had gone from 3rd percentile to 25th percentile. Group E and group F were essentially stable. “Of note, the hospitalist groups with the most medical director–level engagement and passion for patient experience had the best results.” Not surprisingly, groups A & B, which had good leadership involvement, had been doing the best before the intervention. In other words, those with the best internal results had the most passion for further improvement.
“This study highlights the importance of ongoing and focused attention to data as well as the role of direct physician lead support and buy-in from hospitalist medical directors. The provision of practical and easy-to-implement tips as well as a focus on monthly individual physician-specific feedback reinforced that small behavioral changes can dramatically improve percentile rank. Indeed, after the 1-year study period covered here, Group E contacted the physician lead seeking engagement and training and has since improved their overall physician-related HCAHPS communication scores by 11 percentile units.”
Dr. Sharieff does not emphasize her central role in the process, but I want to focus on this some. Another recent article points out managers in business organizations over-estimate how good they are at coaching. The authors quote Sir John Whitmore’s definition of coaching. “Coaching is unlocking a person’s potential to maximize their own performance. It is helping them to learn rather than teaching them.” They took a group of 98 working managers enrolled in an MBA course and assigned them to coach another person on time management without further explanation. The conversations lasted five minutes and were videotaped, and later analyzed. “The biggest takeaway was the fact that, when initially asked to coach, many managers instead demonstrated a form of consulting. Essentially, they provided the other person with advice or a solution.” They termed this “micro-managing as coaching,” and found that it was positively reinforced by other students prior to being trained.
Dr. Sharieff said she had been trained in coaching and the results of the process she lead show that she was able to pass this on to others in her organization. I can’t help but contrast this with the approach used by my hospital, which brought in people to provide “how-to” lessons to hospitalists on communicating with patients. Interestingly, the instructors were not physicians, the process was not associated with reliable, consistent data feedback, and there was no regular involvement of the formal physician leadership. Not surprisingly HCAPHS scores have remained static, although better than those which motivated Scripps Health to act.
In looking at the areas the Milners considered “coaching,” two showed up as skills the students struggled with before training. First was “recognizing and pointing out strengths.” The other was “letting the coachee arrive at their own solution.” The good news is that these manager-MBA students improved with training and most became at least average. The training did not take a lot of time and was not particularly expensive, although the trainers did need to be experts themselves. I wonder what this would look like in the medical setting? I suspect most of us, me included, are in the directive mode too much of the time, which is not a setting where learning takes place and teaching is, at best, scattershot. Perhaps the path to making data actionable includes a focus on making organizational managers and leaders better at individual coaching.
20 August 2018
 Sharieff, G. Q. Improving Hospitalist Patient Experience Scores: The Importance of Physician-to-Physician Coaching and Medical Director Engagement. 9 August 2018. https://catalyst.nejm.org/hospitalist-groups-patient-experience-scores/?u.
 Most people will simply say no—assuming there are questions is more open-ended and inviting. I usually ask “What other questions do you have?”
 Milner J. and Milner T. Managers Think They’re Good at Coaching. They’re Not. 14 August 2018. https://hbr.org/2018/08/managers-think-theyre-good-at-coaching-there-not.html.
If asked about the greatest advances I have seen, my outside the box answer would be the insight that the quality and safety of medical care is as much about system design as it is about human performance. Current efforts to make providers financially accountable, though, threaten the utility of this insight.
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