I. Rapport

— Initial introduction/Preferences

A person receives credit for this if they use one or both of the patients’ names and their own name at the beginning of the interview, in those situations where the patient is new to the interviewer. In situations where the interviewer knows the patients, credit is given for mentioning one or both of the patients’ names. Credit is given for eliciting patient’s preferences. For example, “How would you like to be called” or “Are you comfortable?”

— Social Conversation

Interactions about the weather and polite comments like, “It’s a pleasure to meet you,” or “Have a good day,” whether at the beginning or at the end are social conversations.

— Explicit “positive speak” to patient

The interviewer receives credit for all statements, which 1) demonstrate interest for the patient’s personal situation or behavior or 2) provides praise, support, or a pat on the back for the patient. Examples include the following:

· Any personal individualized statements of interest for example, “How’s work going?” or “What are you reading?”

· Statements of individualized interest in the patient that go beyond professional, social conversation.

· “Pats on the Back.” If the patient describes an accurate knowledge of diabetic complications and the interviewer says, “You’ve really learned a lot.” or “I’m impressed with what you know.” or, “You’re working very hard to get your weight under control.” or “You handle your diet changes very well.”

· Note! 1) – Questions in the middle of an interview which ask about how things are going on the job or at home, or with regards to stress are not positive talk; but are usually diagnostic questions looking for stress disorders.

2) – Statements that say, “I like to reassure you that your condition is not serious” are professional but not positive speak.

— Explicit caring, commitment or collaborative language to patients

To be identified as a collaborative statement, the statement should indicate the Interviewer’s Personal Commitment to help with one of the patient’s identified issues. This commitment needs to go beyond the usual responsibility of the clinician to provide information, order tests or write prescriptions. To apply, the expression should be in the first person or otherwise directly refer to the clinician’s interest. Provide credit for any of the following:

· “Let’s work together to get your diabetes under control.” (collaboration)

· “I’d like to help in any way I can.” (commitment)

· “I’m interested in doing everything I can to help you over this difficult time.” (caring and commitment)

· But not, “I’m going to prescribe a new medication for you.”

· Note that the use of the generic “we” or “us” alone does not constitute a collaborative statement e.g., “We’ll follow up on your blood sugars in a week.” or “Let’s get an ECG.”

— Verbal interruption

Record this if the interviewer begins to talk or ask a question while the patient is still responding to a previous question.

— Negative talk

Record any comments or expressions that would likely criticize, belittle, or disrespect the patient. Also include here any comments, which discourage the expression of the patient’s perspective, feelings, or devalue feelings. For example:

· “You worry too much.”

· “You got upset over nothing.”

· “You’ve got to try to cooperate.”

· “I’d like you to be more responsible.” (implies patient is irresponsible)

· “The problem is you’re irresponsible.”

· “You’re just too lazy.”

· Include comments that feel racist, sexist, ageist, or biased in some other way.

· Note a negative tone of voice is addressed in nonverbal expression not negative talk.

— Nonverbal interests

Regarding lean and eye contact. In this category and in voice tone, someone who is absolutely professional but without specific identifiable elements of warmth or notable personal connection would receive a neutral score in both. If the interest in terms of body language and eye contact are noticeably positive they should be recorded as (+)1. If the interviewer exhibits remarkable positive tones mark as (+)2. Similarly if there is something that is ill defined which feels somewhat uncomfortable regarding either the body language or the voice tone record as (-)1. If the non-verbal tone is clearly and remarkably negative, record as (-)2. Note, only a small number of interviewers will receive (+)2 or

(-)2.

— Rapport Building-Global Criteria

5. Demonstrates rapport-building skills such that most patients would subsequently go out of their way to tell friend or family about this interviewer with extraordinary interpersonal skills. Usually include two or more elements of “positive speak” and expressions of non-verbal interest that are exceptionally warm.

4. Notably warm and makes effective connection via identifiable elements of both verbal and non-verbal connection

3. Clearly, professional, respectful and interested but minimal or ineffective specific verbal or non-verbal efforts to make a more personal connection

2. For the most part professional and respectful. Absent of specific effective efforts at rapport building. Present are some comments, expressions or non-verbal behaviors, which might have a negative reception by a least some patients.

1. Absent are positive elements of relationship building. Present are clearly negative comments or expressions, which would leave many patients with negative feelings about the interviewer.

II. Eliciting All Agenda Items

OVERVIEW

Research shows that early complete agenda settings helps both the doctor and the patient structure the interview more effectively. Early full agenda setting decreases “by the way” statements late in the interview. Early complete agenda setting is achieved when the patient finally says, “No, that’s all.” To another request for additional agenda.

Most interviewers begin with one agenda seeking exchange, which is usually, “What brings you in today?” or “How can I be of help?” In some situations an interviewer will begin by jumping right into the chief complaint, which is taken from the chart. This is not an agenda setting activity. For example, “It says here your blood sugar is 233 how’s your diabetes coming?”

Note! At times an initial “social conversation” like, “How are you doing?” leads to the patient providing agenda items for the day. In such cases give credit for “social conversation” and for agenda setting.

— Record all additional agenda setting activities, which occur at any time in the interview.

Frequently these occur at the beginning for example, “What else?” (Reference to agenda items) or “Are there other issues we need to deal with?” but they also occur towards the end and can occur at any time. In addition the interviewer gets credit for the patient saying, “That’s all.” to an agenda setting, question.

Note! While asking diagnostic questions, the interviewer frequently asks, “What else?” The patient will interpret this as an open-ended question regarding the current line of questioning, not a request for other agenda. To receive credit for agenda setting the interviewer will need to focus on agenda, for example, “Is there anything else you would like to bring up?”

— Agenda Setting – Global Criteria

5. Explores complete agenda at the beginning (first 2 minutes after rapport building) till the point that the patient says, “Nothing else” Explicitly plans agenda and If several agenda, prioritize amongst them. Explores for additional agenda later or at the end.

4. Explores complete agenda early till “Nothing else” but does not summarize or prioritize or explore for more agenda at end.

3. Explores for agenda partially with at least two efforts at agenda setting. One can be at beginning and one at end.

2. Asks only once at the beginning e.g., “What brings you in today?” or “How can I be of help?” or at the end “Is there anything else?”

1. Doesn’t explore for agenda at beginning but begins addressing an established problem. Doesn’t return to agenda at any point.

— Clarifications are closed-ended

Note a reflection or clarification of 1-2 pieces of information is a closed-ended question. For example, “So you’ve been having a sharp pain for a week?” (If there were 3 elements, it would be a summary.)

— Summary - definition

A summary needs to restate information that came from the patient and must have 3 information elements. Lots of times an interviewer will restate something that has been said and then ask another question. For example, “You said the pain was aching, how long does it last?” This is not a summary because it does not include three elements. A summary would be, “So your pain has been coming on for three weeks, it’s aching and it is located in the middle of your chest. Anything else?”

The Classic Organization of Medical Data Collection

In observing the pattern of data collection you should observe an effort to collect data in the following areas. In general, the interviewer completes one area before moving to another. Jumping around from category to category and back with repetition of questions is a sign of a disorganized interview.

Problems/Agenda identification leads to:

History of Present Illness

Symptom Description (quality, location, intensity, radiation)
Time line (Onset, setting, frequency, duration.
Modifying Factors (aggravating/relieving/treatment attempts
Associated Symptoms (other symptoms that occur in relationship with the primary or chief complaint.)
Relevant Review of systems

Medical History

Illnesses
Surgery
Allergy
Medicines and Doses

Family History Relevant to the problem
Social History (work, home life, recreational drugs and alcohol, tobacco, travel, pets etc.)
Complete Review of Systems.

Information Management – Global Criteria

5. Begin interview with effective open-ended question and non-directed facilitation. Continue in this mode (with occasional closed-ended points of clarification) till most/all of patient’s information about the condition has been expressed. Notably effective information flow with explicit summary(s), directives and/or segues. Asks appropriate focused (closed) questions towards the end.

4. Begins with a majority of effective open-ended questions/facilitations. (Required) Appropriate mixes of open and closed-ended questions. Effectively manages info flow Uses some form of summary, directives or segues.

3. Uses some open-ended and closed-ended questions from the beginning. Doesn’t use summaries, directives or segues. Organization adequate.

2. Mostly closed-ended questions. Info flow weak on organization.

1. Mostly closed-ended questions. Uses flawed, leading or repeated questions. Disorganized info flow.

IV. Active Listening for Full Understanding of the Patient’s Perspective on Illness

OVERVIEW

Active Listening demonstrates an explicit and focused curiosity or interest in what the patient believes may be going on or what their greatest concern is or what are their expectations. There are two ways that the interviewer can understand the patient’s ideas, concerns and expectations about their illness. First they can follow up the deeper or underlying meaning of a clue. A clue is defined as a statement by the patient that implies, but does not state, some underlying idea, concern or expectation regarding the illness or problem. When a clue is delivered the interviewer must restate or otherwise explore the meaning of the implied statement to get credit for active listening. The second way of identifying the patient’s perspective is to ask explicitly about the patient’s ideas or concerns or expectations.

C Responses to transcribed clues

· If the clue is not given for any reason record N/A or not applicable

· A positive response to a clue ideally begins with an acknowledgment of what has been heard and an invitation to the patient to provide more information about patient’s ideas about what is causing the problem or what concerns or expectations exist. For example the patient says, “I was wondering what could be causing this?” The interviewer responds, “I’ll be glad to give you my opinion. Obviously you’ve given the cause some thought. What things cross your mind about the cause of this problem?” This is active listening. Another example is where a patient would say, “I’m upset about this pain.” The interviewer responds, “What about the pain has you upset?” This is active listening.

· Statements by the interviewer that focus the patient on sharing more of their perspective are active listening, even if they don’t repeat the clue. For example the patient says, “I’ve got to figure out what is going on here.” The interviewer responds, “You’re worried?” This is active listening because it encourages the patient to express the implied meaning.

· Asking about the symptoms further is not active listening. For example, the patient says, “I wonder what could be causing this pain?” The interviewer responds, “How would you describe the pain?” This is not active listening.

· Sometimes after a clue, an interviewer will directly ask about a patient’s ideas. For example, the patient says, “I wonder what could be causing this pain?” The interviewer responds, “What do you think the cause may be?” When this question arises immediately after a stated clue, consider this active listening.

C Diagnosis oriented questions which are not active listening:

§ “When did this begin?”

§ “How severe is it?” (Looking for intensity not patient’s meaning)

§ “What’s it like?” (Description not meaning)

§ “Describe how this has changed over the past weeks?”

§ “What helps with the pain?” (Relief factors not meaning)

§ “What brings on the pain?” (Antecedent not etiology)

§ “What do you do to make the pain better?”

§ “What other symptoms do you find are associated with the pain?”

§ “I understand you’re concerned (acknowledges feelings.) When does it come on?”

§ “How did your cough start?”

C Questions which are active listening:

§ “You mentioned being concerned. About what?” (Exploring meaning)

§ “This is worrisome to you?” (Exploring fear)

§ “You’ve been giving this some thought?” (Explores meaning)

§ “You mentioned it being awful. What did you mean by that?”

C When is non-directed facilitation active listening and when is it an open-ended question?

At times after a clue – which includes medical information and patient’s implied meaning, the interviewer will respond with, “Go on” or “Tell me more.” If the patient responds with personal ideas or concerns, record as active listening. If the patient responds with more medical information, record as an open-ended question but not active listening.

On the other hand, when the discussion is in the active listening mode, (has just made an explicit explanation for the patient’s ideas or concerns) non-directed facilitation continues the active listening. For example:

Pt.: “I’m concerned about this headache.” (Clue)

Dr.: “What has you concerned?” (Active listening)

Pt.: “It’s better to be safe than sorry.” (Another clue)

Dr.: “Go on.” or “Tell me about that.” (Facilitation and active listening since it continues the exploration for the patient’s meaning.)

C When is addressing feelings also active listening?

The essence of exploring the patient’s perspective is a search for understanding of the patient’s ideas and concerns and expectations. Since many clues to the patient’s perspective are statements of feelings (concern, worry, being upset) acknowledging those feelings and exploring the sources of those feelings is active listening. For example,

Pt. “I’m concerned about this headache.”

Dr. “You’re concerned.” [silence, expecting the patient to continue]

Pt. “Yes, I’m afraid this could be a growth or tumor.”

C When is addressing feelings NOT active listening?

At times an interviewer can acknowledge a feeling and instead of pausing to have the patient continue may change the topic to medical data collection. For example:

Pt.: “I’m concerned about this headache.” (Clue)

Dr.: “I can see you are concerned. [Acknowledges feelings] How long have you had the headaches?” [Not active listening]

C When clues are repeated

If a clue is not explored when 1^st given, record as “No”.

If that clue is repeated and is explored, record as “Asks about patient’s ideas” and note the clue and response in the right hand column.

C When clues are combined

If two clues are combines and the interviewer responds to one, record active listening for the clue that received the response and not applicable to the other combined clue.

C Delayed response

Sometimes a patient will provide a clue and the interviewer does not respond immediately but comes back later to note what has been previously been said and to explore this. This is effective active listening. For example, the patient says, “I wonder what could be causing this pain?” The interviewer goes on to ask, “Describe the pain.” and proceeds with further questioning. Several minutes later the interviewer says, “Earlier you were wondering what could be causing that pain, what thoughts do you have?” This is active listening.

C Asking directly about the patient’s perspective

At times the interviewer will ask, “What do you think is causing your symptom?” When they do this unrelated to the clues and when this does not quantify as a delayed response, record under “Asks about ideas, concerns, and expectations. Note! Do not include active listening responses to transcribed clues in this category.

C Active Listening to understand the Patient’s Perspective on Illness-Global Criteria

5. Very effective at identifying the patients perspective on illness PPI (i.e. what the patient thinks may be going on; the greatest concern about the problem; and the expectations for the visit) The PPI is repeatedly explored using active listening to understand the meaning behind the patients “clues” Once the PPI is disclosed these elements are acknowledged, normalized and used as part of a plan to address the medical diagnosis and the PPI.

4. Demonstrates genuine interest in the PPI by using active listening at least part of the time. Does explore the clues initially, but not always fully. Once identified PPI will be partially addressed with some elements of acknowledgment, normalization, and building a plan based on the PPI.

3. Demonstrates some interest in the PPI through occasional exploration of clues (efforts may not be effective). May not pick up on clues but rather asks about the patient’s ideas.

2. Fails to demonstrate effective interest in what the patient thinks may be going on; his/her greatest concern about the problem; and the expectations for the visit.

1. Actively discourages or devalues the PPI.

V. Addressing Feelings with the Patient

C Nonverbal and transcribed feeling clues

For the feeling comments or clues transcribed on the rating form, provide the credit for responses, which acknowledge, restate, legitimize or normalize, or further explore the patient’s feelings in regard to these statements. For example, the patient says, “I’m concerned about these headaches.” Give credit for, “I can see you’re concerned.” “What has you concerned?” “It would be normal to be concerned in a situation like this.” “Would you like to talk about your concerns?” Clearly a person does not get credit if they respond, “How long have you been having these headaches?”

C When is Active Listening NOT addressing feelings?

A person would get credit for active listening but not for addressing feelings with a response like: “What do you think may be causing this headache?”

C When DOES active listening count for both active listening and addressing feelings?

The interviewer gets credit if they do both active listening and addressing feeling, for example: “I can see you’re concerned (addresses feelings), what do you think may be causing your headaches?”(active listening) OR they would get credit for both if they respond, “You’re concerned.” [Followed by a pause and silence with expectation that the patient will continue. The patient does continue to describe WHY he or she is concerned.]

C Exploring or addressing other feelings

Note any time that the interviewer explicitly brings up or asks about the patient’s feelings in other areas of the interview aside from the response to feeling clues. For example in the middle of the interview, an interviewer asks, “Does your high blood sugars worry you?” Or the patient describes a sick or dying grandparent and the interviewer responds with a statement, “I bet that’s upsetting.” or “How are you handling the loss?” Do not record statements that imply feelings (but do not state these especially). For example, “You think that this pain might be serious?”

C Addressing Feelings-Global Criteria

5. Responds to all opportunities to Address Feelings. When feelings surface, these are effectively addressed and then incorporated into the visit. Also effectively seeks out the “potential feelings” when situations with high likelihood of feelings surface in the interview.

4. Acknowledges feeling when expressed. Does not fully address/incorporate into visit. Does not fully address “potential” feeling situations.

3. Acknowledges expressed feelings but does not attempt to integrate into visit.

2. May not acknowledge any of the feelings of the case or does so ineffectively.

1. Comments or responds in a way which demeans, criticizes, or devalues patients’ feeling

VI. Reaching Common Ground

OVERVIEW

¨ Some interviews involve only the review of a medical history. In these situations the section on Reaching Common Ground is N/A (not applicable).

¨ Other interviews include the development of a plan but there is no evidence for disagreement. In these situations use the scale for Developing a Plan (no disagreement apparent).

¨ In some interviews tension exists between the interviewer and the patient. Observe how the interviewer responds to such disagreement and what skills or strategies are used to resolve the differences of opinion. You will only be asked to rate this category in situations that require such negotiations. Use these rating categories for what happens after the “non common ground” situation develops.

I. Develops a Common Ground Plan when no disagreement is obvious

A. Identifies Patient’s Perspective (knowledge, concerns, values) and Builds Plan Accordingly

No = Little or not at all. For example, in this situation the patient’s perspective has been implied through clues or nonverbal communication. The clinician fails to explore that perspective. There is no effort to identify and incorporate the patient’s values and beliefs into the treatment plan.

1 = Partially. In this situation, there is some effort to accommodate at least part of the patient’s ideas, concerns, expectations into a treatment plan. However it is clear that there are significant pieces of the patient’s perspective that go without acknowledgment and which are not incorporated into the plan.

2 = Adequately. In this case the interviewer demonstrates clear and explicit efforts to elicit the patient’s perspective. Once elicited this set of beliefs and values are partially included in the intervention plan. Not all of the patient’s perspective may be completely elicited and not every piece of it will be incorporated into the plan, but there is clearly interest in connecting the plan to the patient.

3 = Notably. In this case the interviewer makes an effort to fully explore the patient’s perspective regarding the problem and the intervention. There are multiple explicit efforts to address the patient’s perspective in developing a plan.

B. Explains Impressions

No = Strikingly ineffective. In this case there are striking omissions, mis-explanations, confusing explanations, contradictions, and unnecessary repetitions as part of the explanation such that the patient would likely be confused and unable to adequately apply the plan after leaving the office.

1 = Somewhat ineffective. In this case, the interviewer explains the plan in a way that includes a smaller number of the problematic examples listed above. In this situation some but not all patients would be confused by the explanation and some would be unable to initiate the desired plan.

2 = Effective. Explanations are generally clear with a minimum of jargon. The explanation may be reasonably but not fully complete. It should be free of errors while there are ways to improve the explanation for clarity, consistency, and thoroughness, most patients will be able to follow the plan after the visit.

3 = Notably effective. In this case, the explanation is clear and thorough, identifies most all of the potential areas needed and explains them simply yet thoroughly so that the patient has an excellent understanding of the problem, the treatment and what to expect. The great majority of patients will be able to return home with all the information needed to initiate the plan and will understand the condition adequately to successfully to explain that to friends and family.

C. Agreement Feasibility

No = None. Fails anywhere in the end of the interview to check whether the proposed plan is feasible and agreeable to the patient.

1 = Minimal. In this situation there is a simple closed ended or leading question regarding feasibility. For example, “That’s OK with you, isn’t it?”

2 = Effective. In this situation there is some form of initiated dialogue regarding feasibility. For example the interviewer asks, “How does this sound to you?” The patient then goes on to say that the plan sounds fine and they don’t see any problems doing it.

D. Checks for Understanding

No = None. No attempt made to check whether the patient understands what has been explained.

1 = Minimal. Asks a simple closed ended question, for example, “Do you understand?”

2 = Effective. In this situation the interviewer asks the patient to describe or explain what they understand about the plan that has been described.

E. Mutual Responsibility

No = None. In this case there is no clear effort to describe what it is that the patient needs to do and what it is that the physician commits to do as follow up.

1 = Partial. In this case the interviewer makes at least a minimal attempt to identify the clinician’s responsibility with a statement like, “If you have any problems you can reach me anytime by calling our office.” Or explaining at least one contingency situation like, “If the fever doesn’t go away by Sunday you will need to start this medication.”

2 = Thorough. In this case the interviewer finishes the plan development by describing what appears to be a pretty complete palate of options and contingencies. Explains several or many situations that may occur and what the patient would be expected to do in these situations and what the clinician would be expected to do in these situations.

C. Less Effective Strategies

1. Restating suggestions – The first time that an interviewer makes a particular recommendation, this is recorded as an informational approach. Frequently if there is a disagreement or if the patient is not following suggestions then the interviewer restates the suggestion. These restatements of earlier suggestions are often stronger, louder, slower, and/or with more authority. Record each time the interviewer restates any previously stated position without using additional strategies. In some interviews the initial directive was made on a previous visit and clearly the patient is back in for a follow up and has not followed the directions. In this situation, record the directives to the patient to take all of the medicines as a restatement. This is simply restating the recommendations from the previous visit.

2. Personal appeal – Record in this category when the interviewer is asking the patient to follow his/her direction or guidance and implies or states personal appeal rather than threats or the use of authority. For example, “I’d really like you to promise me that you will take the insulin.”

3. Use of authority or defensiveness – This is used when the interviewer orders or directs the patient to follow suggestion. For example, “You need to start insulin now.” or “It’s essential that you go to the hospital now.” Sometimes information or other initial responses are expressed with a nonverbal (paralinguistic) tone or edge of defensiveness that carries an air of authority or criticism. When observed record as less effective.

4. Attempting to persuade using morbidity and mortality data – Among the most frequently used strategies is explicitly telling a patient about some significant complication or death related to the behavior in question. When the interviewer tries to get the patient to follow directions by using these techniques, record in this category. Note If the interviewer says, “I don’t mean to scare you, but people with diabetes can develop blindness.” Even though the interviewer states that there is not an attempt to scare the patient, the reference to complication is frightening.

5. Making a doctor-centered recommendation – This type of recommendation comes from the interviewer’s “bag of tricks” that they learned as a routine response to a particular situation like a high blood sugar. If the suggestion for improved management refers in no way to something specifically identified by the patient then record as a doctor-centered recommendation. (See Patient-Engaging Strategies for Additional Clarification.)

C Reaching Common Ground - Developing a Plan (No disagreement apparent)-Global Rating Criteria.

5. Plan development linked explicitly to a thorough understanding of the patient’s knowledge and perspective. Discusses feasibility. Explains the diagnosis and treatment clearly and concisely, checks effectively for understanding (tell-back) and feasibility.

4. Plan begins with some understanding of patient’s knowledge and perspective. Explains clearly with only occasional use of jargon. Checks for understanding and feasibility.

3. Partial or minimal understanding of patient’s knowledge. Provides information with general clarity. May include some jargon. Some effort to determine understanding and/or feasibility. (Often with a closed ended question)

2. Minimal or absent understanding of patient’s knowledge. Information provided is somewhat confusing. Minimal effort to check understanding and feasibility.

1. No patient baseline assessment. Explanations confusing/disorganized/misleading. Minimal or absent attempt to check understanding or feasibility.

C Reaching Common Ground (Differences in expectations apparent)—Global Criteria

Note – Rating is based on what the interviewer does; not how the patient responds.

5. Works very effectively at bridging differences between the interviewer and the patient. Performs a full exploration of the PPI and uses the PPI to reach common ground. Uses a number of the more effective skills in reaching common ground, e.g. full exploration of the PPI, decision analysis, ask/tell/ask approach reframing, patient centered suggestions, criteria setting, brainstorming, compromise etc. Avoids less effective methods, e.g. use of authority, personal appeal, repetition of serious complications or chance of death. Would likely facilitate a desirable change in behavior towards health.

4. Demonstrates clear skills in reaching common ground. Does obtain most of the PPI and attempts to use at least some (but not all) of its elements in a plan. Uses a mix of strategies to reach the plan. Heavier use of the more effective skills.

3. While does not connect the plan with PPI, uses a balanced mix of skills to reach common ground that includes at least one of the more effective strategies.

2. Does not use the patient’s issues to help to solve the difference. Uses more of the less effective strategies in trying to create a plan, e.g. use of authority, personal appeal, and repetition of serious complications. For most patients this plan would not significantly affect the long-term behavior in question.

1. Uses less effective strategies almost exclusively. In missing the patient’s issues and in using authority or threat, the patient would be unlikely to change long-term behavior and would probably leave upset with the interviewer’s approach to problem solving.

GLOBAL RATING OF CORE, COMMON GROUND INTERVIEW SKILLS

Rapport Building-Global Criteria

4. Notably warm and makes effective connection via identifiable elements of both verbal and non-verbal connection

3. Clearly, professional, respectful and interested but minimal or ineffective specific verbal or non-verbal efforts to make a more personal connection.

2. For the most part professional and respectful. Absent of specific effective efforts at rapport building. Present are some comments, expressions or non-verbal behaviors, which might have a negative reception by a least some patients.

1. Absent are positive elements of relationship building. Present are clearly negative comments or expressions, which would leave many patients with negative feelings about the interviewer.

Agenda Setting - Global Criteria

5. Explores complete agenda at the beginning (first 2 minutes after rapport building) till the point that the patient says, “Nothing else” Explicitly plans agenda and if several agenda, prioritize amongst them. Explores for additional agenda later or at the end.

4. Explores complete agenda early till “Nothing else” but does not summarize or prioritize or explore for more agenda at end.

3. Explores for agenda partially with at least two efforts at agenda setting. One can be at beginning and one at end.

2. Asks only once at the beginning e.g., “What brings you in today?” or “How can I be of help?” or at the end “Is there anything else?”

1. Doesn’t explore for agenda at beginning but begins addressing an established problem. Doesn’t return to agenda at any point.

Information Management - Global Criteria

4. Begins with a majority of effective open-ended questions/facilitations Appropriate mixes of open and closed-ended questions. (Required) Effectively manages info flow Uses some form of summary, directives or segues.

3. Uses some open-ended and closed-ended questions from the beginning. Doesn’t use summaries, directives or segues. Organization adequate.

2. Mostly closed-ended questions. Info flow weak, repetitive or disorganized.

1. Mostly closed-ended questions. Uses numbers of flawed, leading or repeated questions. Disorganized, confusing, misleading info flow.

Active Listening to understand the Patient’s Perspective on Illness-Global Criteria

3. Demonstrates some interest in the PPI through occasional exploration of clues (efforts may not be effective). May not pick up on clues but rather asks about the patient’s ideas.

2. Fails to demonstrate effective interest in what the patient thinks may be going on; his/her greatest concern about the problem; and the expectations for the visit.

1. Actively discourages or devalues the PPI.

Addressing Feelings-Global Criteria

4. Acknowledges feeling when expressed. Does not fully address/incorporate into visit. Does not fully address “potential” feeling situations.

3. Acknowledges expressed feelings but does not attempt to integrate into visit.

2. May not acknowledge any of the feelings of the case or does so ineffectively.

1. Comments or responds in a way which demeans, criticizes, or devalues patients’ feeling

Reaching Common Ground - Developing a Plan (No disagreement apparent)-Global rating criteria.

4. Plan begins with some understanding of patient’s knowledge and perspective. Explains clearly with only occasional use of jargon. Checks for understanding and feasibility.

2. Minimal or absent understanding of patient’s knowledge. Information provided is somewhat confusing. Minimal effort to check understanding and feasibility.

1. No patient baseline assessment. Explanations confusing/disorganized/misleading. Minimal or absent attempt to check understanding or feasibility.

Reaching Common Ground (Differences in expectations apparent)—Global Criteria

Note—Rating is based on what the interviewer does; not how the patient responds.

3. While does not connect the plan with PPI, uses a balanced mix of skills to reach common ground that includes at least one of the more effective strategies.

Overall Interview Global Criteria

5. At the level of an experienced clinician who is expert in using all communications skills effectively. Skills demonstrated such that a patient would likely note such skills to friends and family

4. Uses all communication skills effectively; minor suggestions for change are noted which are unlikely to have measurable importance on encounter.

3. Uses most communication skills effectively; some interview behaviors present which, if modified, could lead to an even more effective impact on a real encounter.

2. Uses some communication skills effectively and others ineffectively; certain areas of communication might cause clinical problems. (Patient dissatisfaction or confusion)

1. Inadequate communication skills; likely to create significant clinical problems (Patient dissatisfaction or confusion)

In general, the numbers above translate into the following:

5 = Exemplary 4 = Very Effective 3 = Competent/Adequate 2 = Marginal 1 = Needs Improvement

GLOBAL CRITERIA-SPECIAL SITUATIONS – FAMILY INTERVIEWING

Global Assessment of Family Interviewing Skills

5. Notably involves all those present, establishing rapport and agenda and exploring the perspective of each appropriately so that each would feel involved with the visit and would likely remark to family and friends on the family communication skills of the clinician.

4. Involves all those present successfully.

3. Partially involves all those present. Includes welcome and some input from others on some issues.

2. Minimally involves all those present. May include welcome but encourages little other input into the visit from the others. Communications such that some others might feel that the visit excluded them.

1. Minimally involves all those present or absent. May include welcome, but no other efforts in involve others. May include active blockade of input from others. Communicates with others such that patient or others would likely feel excluded/ignored or disrespected.

In general, the numbers above translate into the following:

5 = Exemplary 4 = Very Effective 3 = Competent/Adequate 2 = Marginal 1 = Needs Improvement

1. Rapport

(Number of Occurrences)

No	1	2	3	4	5
O	O	O	O			Initial introduction/preference
O	O	O	O	O	O	Social conversation
O	O	O	O	O	O	Explicit “Positive Speak”
O	O	O	O	O	O	Explicit caring/commitment
O	O	O	O	O	O	Verbal interruption
O	O	O	O	O	O	Negative talk (implied or explicit)

Nonverbal	-2	-1	0	+1		+2
Rating Scale	Strong Negative	Negative	Neutral	Positive	Strong Positive
Body position and Eye contact	O	O	O	O		O
Voice Qualities	O	O	O	O		O

(Rating Scale)

1	2	3	4	5	NA Overall Rapport
O	O	O	O	O	O

2. Eliciting all Agenda Items

(Number of Occurrences)

No	1	2	3
O	O	O	O		Agenda setting effort “What brings you in?
O	O				Early (1-2 min.) full exploration i.e., “That’s it.”
O	O	O			Checks for additional agenda later.
(Rating Scale)
1	2	3	4	5		NA Overall Agenda
O	O	O	O	O		O

3. Information Management O

(Number of Occurrences)

0-1	2-3	4-5		6-7	8-10
O	O	O		O	O	For the first ten questions record the open ended questions.
0	1	2		3	4
O	O	O		O	O	Performs summary (3 or more items), segues, organizing directives.

(Rating Scale)
1	2	3	4		5	NA	Overall Information
O	O	O	O		O	O	Management

4. Active Listening for Full Understanding of Ideas, Concerns, and Expectations

No	Yes	N/A	PT’s clues or statements needing follow up.
O	O	O	#1
O	O	O	#2
O	O	O	#3
O	O	O	#4

(Number of Occurrences)

0	1	2	3	4
O	O	O	O	O	Asks (or affirms) about patients’ ideas, concerns, expectations.
(Rating Scale)
1	2	3	4	5	NA Overall Active Listening
O	O	O	O	O	O

5. Addressing Feelings with Patient

No	Yes	N/A	PT’s stated or implied feelings needing follow up.
O	O	O	#1 -
O	O	O	#2 -
O	O	O	#3-
O	O	O	#4

(Number of Occurrences)

0	1	2	3	4	Explore or address other feelings..
O	O	O	O	O
(Rating Scale)
1	2	3	4	5	NA Overall Deals with Feelings
O	O	O	O	O	O

6. Reaching Common Ground

A. Develops a Common Ground Plan when no disagreement is obvious.

(Rating Scale)

No	1	2	3	N/A
O	O	O	O	O	Identifies patient’s perspective (knowledge, concerns, expectations) and builds plan accordingly: No = Little or not at all; 1= Partially, 2 = Adequately; 3 = Notably
O	O	O	O	O	Explains Impressions (Dx, Tx, options): No = Strikingly ineffective, 1= Somewhat ineffective, 2 = Effective, 3 = Notably effective
O	O	O		O	Checks for agreement/feasibility No = None, 1 = Minimal, 2 = Effective
O	O	O		O	Checks for understanding No = None, 1 = Minimal, 2 = Effective
O	O	O		O	Establishes mutual responsibility No = None, 1 = Partial, 2 = Thorough

B. In Non-Common-Ground situations, uses:

(Number of Occurrences)

Informational Strategies

Provides information, explanations, and recommendations.

____________________________________

Patient Engaging Strategies è

___________________________________

____________________________________

Less Effective Strategies

Direction, repetition of position, using morbidity/mortality data (fear); clinician centered recommendations, personal appeal or authority

(Rating Scale)

NA Overall Reaching

O Common Ground

7. Global Interview Performance

(Rating Scale)

1	2	3	4	5	NA Overall Global
O	O	O	O	O	O Interview

Observations and Comments

Patient Engaging Strategies

___Pt centered (ideas, concerns, expectations)

___Agenda for change

___Information – Ask, Tell, Ask

___Decision analysis (1-4 elements)

___Ambivalence

___Brainstorming

___Criteria

___Doctor’s recommendation

___Empathic response

___Family involvement

___Framing differently (reframing)

___Follow up

1. Rapport

(Number of Occurrences)

No	1	2	3	4	5
O	O	O	O			Initial introduction/preference
O	O	O	O	O	O	Social conversation
O	O	O	O	O	O	Explicit “Positive Speak”
O	O	O	O	O	O	Explicit caring/commitment
O	O	O	O	O	O	Verbal interruption
O	O	O	O	O	O	Negative talk (implied or explicit)

Nonverbal	-2	-1	0	+1	+2
Rating Scale	Strong Negative	Negative	Neutral	Positive	Strong Positive
Body position and Eye contact	O	O	O	O	O
Voice Qualities	O	O	O	O	O

(Rating Scale)

1	2	3	4	5	NA Overall Rapport
O	O	O	O	O	O

2. Eliciting all Agenda Items

(Number of Occurrences)

No	1	2	3
O	O	O	O		Agenda setting effort “What brings you in?
O	O				Early (1-2 min.)full exploration i.e., “That’s it.”
O	O	O			Checks for additional agenda later.
(Rating Scale)
1	2	3	4	5		NA Overall Agenda
O	O	O	O	O		O

3. Information Management O

(Number of Occurrences)

0-1	2-3	4-5		6-7	8-10
O	O	O		O	O	For the first ten questions record the open ended questions.
0	1	2		3	4
O	O	O		O	O	Performs summary (3 or more items), segues, organizing directives
(Rating Scale)
1	2	3	4		5	NA	Overall Information
O	O	O	O		O	O	Management

4. Active Listening for Full Understanding of Ideas, Concerns, and Expectations

No	Yes	N/A	PT’s clues or statements needing follow up.
O	O	O	#1
O	O	O	#2
O	O	O	#3
O	O	O	#4

(Number of Occurrences)

0	1	2	3	4
O	O	O	O	O	Asks (or affirms) about patients’ ideas, concerns, expectations.
(Rating Scale)
1	2	3	4	5	NA Overall Active Listening
O	O	O	O	O	O

5. Addressing Feelings with Patient

No	Yes	N/A	PT’s stated or implied feelings needing follow up.
O	O	O	#1 -
O	O	O	#2 -
O	O	O	#3-
O	O	O	#4

(Number of Occurrences)

0	1	2	3	4	Explore or address other feelings..
O	O	O	O	O
(Rating Scale)
1	2	3	4	5	NA Overall Deals with Feelings
O	O	O	O	O	O

6. Reaching Common Ground

A. Develops a Common Ground Plan when no disagreement is obvious.

(Rating Scale)

No	1	2	3	N/A
O	O	O	O	O	Identifies patient’s perspective (knowledge, concerns, expectations) and builds plan accordingly: No = Little or not at all; 1= Partially, 2 = Adequately; 3 = Notably
O	O	O	O	O	Explains Impressions (Dx, Tx, options): No = Strikingly ineffective, 1= Somewhat ineffective, 2 = Effective, 3 = Notably effective
O	O	O		O	Checks for agreement/feasibility No = None, 1 = Minimal, 2 = Effective
O	O	O		O	Checks for understanding No = None, 1 = Minimal, 2 = Effective
O	O	O		O	Establishes mutual responsibility No = None, 1 = Partial, 2 = Thorough

Observations and Comments

B. In Non-Common-Ground situations, uses:

(Number of Occurrences)

Informational Strategies

Provides information, explanations, and recommendations.

____________________________________

Patient Engaging Strategies è

___________________________________

____________________________________

Less Effective Strategies

Direction, repetition of position, using morbidity/mortality data (fear); clinician centered recommendations, personal appeal or authority

(Rating Scale)

NA Overall Reaching

O Common Ground

7. Special Situations:

Family Interviewing Skills

(Number of occurrences)

0	1	2	3	4	5
O	O	O	O	O	O	Communications to build rapport/provide support to “other” person(s) in the room.

(Rating Scale)

0	1	2	N/A	0 = Absent; 1 = Partial; 2 = Thorough; N/A = Not Available
O	O	O	O	Determines agenda of “other” person(s) in the room.
O	O	O	O	On potentially relevant issues, explores the perspective of the “other” person(s) in the room.
O	O	O	O	In situations where two individual have differences, fairly reframes/restates both sides/maintains neutrality (avoids triangulation.)
O	O	O	O	If separation is appropriate, negotiates with input from the patient.
O	O	O	O	Respects privacy/confidentiality

Agency/Focus/Siding

Focuses:

Pt/Only

Balanced Interest

Focus:

Other Only

(Rating Scale)

1	2	3	4	5	Overall Family Interviewing
O	O	O	O	O

8. Global Total Interview Performance

(Rating Scale)

1	2	3	4	5	Overall Global Interview
O	O	O	O	O

Observations and Comments

Patient Engaging Strategies

___Pt centered (ideas, concerns, expectations)

___Agenda for change

___Information – Ask, Tell, Ask

___Decision analysis (1-4 elements)

___Ambivalence

___Brainstorming

___Criteria

___Doctor’s recommendation

___Empathic response

___Family involvement

___Framing differently

___Follow up

East Tennessee State University

Patient’s Comments for Interviewer

Interviewer: Level of training:

Patient: Date: Time:

Situation/Role: Location:

Positive Feelings/Impressions *

Areas of your needs/interests which could have been addressed more effectively *

*Please phrase statements beginning with “As the patient…” or “I …”

The interviewer . . . . . . .. . . . . . . (Please check appropriate box.)	**Exemplary	Very Effective	Competent/ Adequate	Marginal	Needs Improvement	N/A
Ø appeared professionally competent ………………………….……
& personal rapport/support – showed interest in me as a person, not just my condition ………………………………………………
& agenda setting – encouraged me to identify everything that I needed to say ………………………………………………………
& information management– moves from an open-ended to closed line of questioning, summary ………………………………
& active listening – explored my clues for my full meaning, my *real* concerns, my expectations ……………………………………
& addressed feelings – expressed interest in my personal feelings and experience …………………………………………………….
& reaching common ground – worked toward a plan which addressed both the diagnosis and my concerns about my illness ….

Overall Impression of Interviewer’s Ability…………………….

**Exemplary should be used only for a few interviewers who do something out of the usual

FEEDBACK AND RECOMMENDATIONS – COMMON GROUND INTERVIEWING SKILLS

Interviewer:_______________________ Date ______________ Feedback Provider :

I. Interview Skills Profile - See Global Rating Guide and report score – 5 (max) to 1 (min)

Rapport Agenda Information Management Active Listening

Feelings Reaching Common Ground Overall Interview

II. Strengths and Comments – Those skills done notably well that should be reinforced and used regularly:

III. Suggestions for reinforcing/improving skills – (N=Noteworthy P=Present to some degree I=Improvement suggested)

Rapport

N P I

__ __ __ Begins non-emergent visits with a brief personal interaction.

__ __ __ Provides pats on the back/words of encouragement.

__ __ __ States a personal interest and commitment to the care of the patient.

__ __ __ Uses body lean/eye contact to demonstrate interest.

__ __ __ Effectively modifies voice tone, speed, loudness to the situation.

OBSERVATIONS

Positive speak

Non verbal

Agenda Setting

__ __ __ Specifically and repeatedly explores the reasons for the visit.

__ __ __ Regarding complete agenda patient states, “That’s about it.”

Information Management

__ __ __ Early on, uses more open-ended questions and non-directed facilitation.

__ __ __ Avoids jargon/leading/and closing open ended questions.

__ __ __ Summarizes as needed.

__ __ __ Uses transitions (segues);effectively organizes interview.

Open:

Closed:

Summary:

Active Listening—Exploring the patient’s perspective

__ __ __ Thoroughly explores patient’s clues.

__ __ __ Acknowledges/legitimizes/ normalizes patient’s ideas about their illness.

__ __ __ Only at the end, uses directed, sequenced question to determine PPI.

Clues: Response:

Feelings

__ __ __ Acknowledges/legitimizes/normalizes expressions of feelings.

__ __ __ Explores for likely but unspoken feelings.

Feelings: Response:

Reaching Common Ground

__ __ __ Builds plan explicitly on a base of what patient knows or believes.

__ __ __ Explains patient’s opinion clearly without jargon

__ __ __ Checks for understanding.

__ __ __ Checks for agreement/feasibility

When in a “non-Common Ground situation”

__ __ __ Before providing information identifies patient’s baseline knowledge.

__ __ __ Explores for a more thorough understanding of the patient’s position/expectations.

__ __ __ Uses brainstorming/suggestions linked explicitly with patient’s statements/

decision analysis/criteria setting/reframing/compromise.

__ __ __ Avoids: repetition, authority, personal appeal, excess emphasis on M & M.

Other Suggestion/Comments:

FEEDBACK AND RECOMMENDATIONS – COMMON GROUND FAMILY INTERVIEWING SKILLS

Interviewer:_______________________ Date ______________ Feedback Provider :

I. Interview Skills Profile - See Global Rating Guide and report score – 5 (max) to 1 (min)

Rapport Agenda Information Management Active Listening

Feelings Reaching Common Ground Overall Interview

II. Strengths and Comments – Those skills done notably well that should be reinforced and used regularly:

III. Suggestions for reinforcing/improving skills – (N=Noteworthy P=Present to some degree I=Improvement suggested)

Rapport

N P I

__ __ __ Begins non-emergent visits with a brief personal interaction.

__ __ __ Provides pats on the back/words of encouragement.

__ __ __ States a personal interest and commitment to the care of the patient.

__ __ __ Uses body lean/eye contact to demonstrate interest.

__ __ __ Effectively modifies voice tone, speed, loudness to the situation.

OBSERVATIONS

Positive speak

Non verbal

Agenda Setting

__ __ __ Specifically and repeatedly explores the reasons for the visit.

__ __ __ Regarding complete agenda patient states, “That’s about it.”

Information Management

__ __ __ Early on, uses more open-ended questions and non-directed facilitation.

__ __ __ Avoids jargon/leading/and closing open ended questions.

__ __ __ Summarizes as needed.

__ __ __ Uses transitions (segues);effectively organizes interview.

Open:

Closed:

Summary:

Active Listening—Exploring the patient’s perspective

__ __ __ Thoroughly explores patient’s clues.

__ __ __ Acknowledges/legitimizes/ normalizes patient’s ideas about their illness.

__ __ __ Only at the end, uses directed, sequenced question to determine PPI.

Clues: Response:

Feelings

__ __ __ Acknowledges/legitimizes/normalizes expressions of feelings.

__ __ __ Explores for likely but unspoken feelings.

Feelings: Response:

Reaching Common Ground

__ __ __ Builds plan explicitly on a base of what patient knows or believes.

__ __ __ Explains patient’s opinion clearly without jargon

__ __ __ Checks for understanding.

__ __ __ Checks for agreement/feasibility

When in a “non-Common Ground situation”

__ __ __ Before providing information identifies patient’s baseline knowledge.

__ __ __ Explores for a more thorough understanding of the patient’s position/expectations.

__ __ __ Uses brainstorming/suggestions linked explicitly with patient’s statements/

decision analysis/criteria setting/reframing/compromise.

__ __ __ Avoids: repetition, authority, personal appeal, excess emphasis on M & M.

Other Suggestion/Comments: (See over)

Family Interviewing – Special Situations

IV. Suggestions for reinforcing/improving skills – (N=Noteworthy P=Present to some degree I=Improvement suggested)

N P I

__ __ __ Communications to build rapport/provide support to “other”

person(s) in the room. Includes introductions.

__ __ __ Determines agenda of “other” person(s) in the room.

__ __ __ On potentially relevant issues explores the perspective of the

“other” person(s) in the room.

__ __ __ Addresses/respects issues of agency, primacy, and confidentiality

OBSERVATIONS

N P I N/A

__ __ __ ___ If separation is appropriate, negotiates with input from patient.

__ __ __ ___ In situations where two individuals have differences, fairly

reframes/restates both sides/maintains neutrality (avoids triangulation.)

Other Suggestion/Comments: (See over)

REACHING COMMON GROUND

[IF 5]

Your overall assessment: In developing an unconflicted plan, starts with thorough understanding of the patient’s knowledge and perspective. Discusses feasibility. Explains the diagnosis and treatment clearly and concisely, checks for understanding.

In reaching common ground with disagreement present, works very effectively at bridging differences between the interviewer and the patient. Performs a full exploration of the patient’s perspective on illness (PPI) and uses the PPI to reach common ground. Uses a number of the more effective skills in reaching common ground, e.g. full exploration of the PPI, decision analysis, reframing, patient centered suggestions, criteria setting, brainstorming, compromise, etc. Avoids less effective methods, e.g. use of authority, personal appeal, repetition of serious complications, or chance of death. Would likely facilitate a desirable change in behavior towards health.

Suggestions and Recommendations: In developing an unconflicted plan, the interview demonstrates very effective skills in clear explanations of the conditions at hand. Feasibility is fully discussed. In situations where understanding is required a thorough check of patient’s understanding is achieved. The plan directly involves everything that has been learned from the patient’s perspective on illness and clearly defines the roles of the patient and the physician.

In reaching common ground with disagreement present, the interviewer uses a variety of effective skills to reach common ground. Continue to use these effective skills in all interviews.

[IF 4]

Your overall assessment: In developing an unconflicted plan, begins with some understanding of patient’s knowledge and perspective Explains clearly with only occasional use of jargon. Checks for understanding and feasibility.

In reaching common ground with disagreement, demonstrates clear skills in reaching common ground. Does obtain most of the patient’s perspective on illness and attempts to use at least some (but not all) of its elements in a plan. Uses a mix of strategies to reach the plan. Heavier use of the more effective skills.

Suggestions and Recommendations: In developing an unconflicted plan, the interview demonstrates a clear and effective plan. The plan is built on a number of elements built on the patient’s perspective that surfaced throughout the interview. Explanations are clear and some effort is made at checking feasibility and understanding and in defining mutual responsibilities. Look for opportunities to make the understanding and feasibility explicit.

In reaching common ground with disagreement, uses a number of effective skills to negotiate common ground. Also uses some of the less effective skills like repetition, use of the threat of serious complications, personal appeal, etc. Try to use more of the effective skills like decision analysis, criteria setting, brainstorming, and patient centered suggestions.

[IF 3]

Your overall assessment: In developing an unconflicted plan, demonstrates partial or minimal understanding of patient’s knowledge. Provides information with general clarity. May include some jargon. Some effort to determine understanding and feasibility. (Often with a closed ended question.)

In reaching common ground with disagreement, while does not connect the plan with patient’s perspective on illness, uses a balanced mix of skills to reach common ground that includes at least one of the more effective strategies.

Suggestions and Recommendations: In developing an unconflicted plan, the interview demonstrates a reasonably clear explanation to the patient but one that fails to identify and use elements of the patient’s ideas, concerns, and expectations in the development of the plan. If understanding and feasibility is checked for they are often in a closed-ended question. It is suggested that every plan begin with an understanding of the patient’s point of view around the condition at hand and explicit efforts to incorporate those ideas into the achievement plan. Many times a more thorough explanation of feasibility and understanding should occur to be maximally effective.

In reaching common ground with disagreement, the interviewer uses a higher percentage of less effective skills like repetition, use of morbid complications, personal appeal, etc. It is recommended that you practice using more decision analysis, brainstorming, criteria setting, patient centered suggestions in your efforts to reach common ground with patients.

I. Rapport

II. Eliciting All Agenda Items

III. Information Management

IV. Active Listening for Full Understanding of the Patient’s Perspective on Illness

V. Addressing Feelings with the Patient

A. Identifies Patient’s Perspective (knowledge, concerns, values) and Builds Plan Accordingly

B. Explains Impressions

C. Agreement Feasibility

D. Checks for Understanding

E. Mutual Responsibility

A. Informational Strategies

B. Patient Engaging Strategies

C. Less Effective Strategies