VA Puget Sound Health Care System

University of Washington

UW School of Medicine | UW School of Nursing 

VA Puget Sound Center of Education for Interprofessional Collaboration 

Shared Decision Making Implementation Kit
Maryann Overland, MD & Linda Pyke, ARNP

Overview

Each shared decision-making session has three parts—a large group didactic session, small group practice with standardized patients, and wrap up/reflections. For more detailed information, please click on each part below or scroll down to the Description and Implementation section.

Part One: Orientation with large group

  • Didactic overview of importance of SDM, best practices in SDM, and overlap between SDM and other communication styles (motivational interviewing, reflective listening)

  • Reflective listening exercise
    Review of OPTION tool for evaluating SDM

  • Review and discussion of shared decision-making video encounters using OPTION tool

Part Two: Small group practice

  • Trainees cycle through different stations standardized patients (SPs), observed by interprofessional peers, trainee self-reflects then receives feedback from SPs, peers and facilitators during debrief

Part Three: Wrap-up and Reflection

  • Share reflections on struggles and successes experienced in the small group practice with the large group
  • Plan for practicing and implementing SDM principles in upcoming clinic appointments
overland

The Importance of Shared Decision Making

 

Formal SDM sessions enable learners to:

  • Explore principles of shared decision-making, which are essential to successful provider communication and patient-centered care
  • Identify evidence-based tools to assess and improve shared decision making
  • Practice with standardized patients to develop technique and style in a supportive setting
  • Enhance knowledge on specific clinical topics

Clinical Problems Addressed

  • Increase collaboration between physician and patient
  • Build better rapport with patients and learn to evaluate their values and social context
  • Increase time reviewing treatment plans with patients and improve patient engagement with plans
“We were able to practice having difficult conversations around alcohol use with standardized patients and that was very helpful for initiating conversations with my own patients in clinic. As a result of participating in this session, I learned tools for using non-stigmatizing or judgmental language and gained confidence to more routinely include these conversations in my counseling with patients.”
-Internal Medicine Resident
“My biggest takeaway from the shared decision making session was the power of silence and listening. Letting the patient’s voice guide the interaction and contribute to or come up with a plan increases patient buy-in and adherence. It is so important to involve the patient so we can develop a plan together that aligns with their goals.”
– DNP Resident
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Training Goals and Objectives

Training Goals

  • Reflect on personal communication skills in practice
  • Summarize key elements of motivational interviewing and shared decision making
  • Demonstrate active, reflective listening
  • Appraise shared decision-making by other clinicians using reflective exercises and OPTION tool
  • Integrate shared decision-making techniques into common clinical scenarios with standardized patients

Rationale/Problems Addressed

  • Although shared decision-making is a vital component to patient-centered care, this skill is underutilized amongst providers.

Competencies Fulfilled

1. Person-Centered Care
2. Knowledge for Advance Nursing Practice
3. Practice-Based Learning and Improvement
4. Interpersonal and Communication Skills
5. Professionalism
6. Systems-Based Practice
7. Interprofessional Collaboration
8. Personal, Professional, and Leadership Development

IPEC VE1 : Place interests of patients and populations at center of interprofessional health care delivery and population health programs and policies, with the goal of promoting health and health equity across the life span.


IPEC VE3:  Embrace the cultural diversity and individual differences that characterize patients, populations, and the health team.


IPEC VE5: Work in cooperation with those who receive care, those who provide care, and others who contribute to or support the delivery of prevention and health services and programs.


IPEC VE6: Develop a trusting relationship with patients, families, and other team members.


IPEC CC2: Communicate information with patients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible.


IPEC CC6: Use respectful language appropriate for a given difficult situation, crucial conversation, or conflict.


IPEC TT4: Integrate the knowledge and experience of health and other professions to inform health and care decisions, while respecting patient and community values and priorities/preferences for care.

1. Practice-based learning and improvement
2. Patient care and procedural skills
3. Interpersonal and communication skills
4. Professionalism

1. Shared decision making: Care is aligned with the values, preferences and cultural perspectives of the patient. Curricula focus is on communication skills necessary to promote patient’s self-efficacy.
2. Sustained relationships: Successful shared decision making enhances patient engagement with the goal of improving patient and provider collaboration.
3. Performance improvement: Patients are more engaged in their care when included in treatment plan decision; successful shared decision making aims to improve quality outcomes.

Executive Summary

Click to Download

Implementation

Session Overview

  • The following times are estimates based on our experience at the Seattle VA.

 

Shared decision making introduction

  • Session begins with an overview of the agenda for the rest of the workshop.
  • Trainees complete the pre-session self-evaluation of SDM using OPTION tool.

Brief didactic

  • Faculty presentation with introduction of the principles of shared decision making, motivational interviewing and reflective listening
  • Discussion of avoidance of contextual errors in patient care
Click to Download PowerPoint
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Reflective Listening Exercise

 

  • Trainees pair up and make the following statement: “One thing you should know about me is…”
  • The trainee partner practices reflective listening using the following 5 techniques below
  • After 5 minutes, the trainees within each pair switch roles

 

Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35.) Chapter 3—Motivational Interviewing as a Counseling Style.

Review and discussion of shared decision-making videos

  • Trainees use OPTION tool to score videos and become more familiar with the components of shared decision making
  • Faculty facilitator leads discussion with the large group of how each video was scored
Click here to Download Option Tool

—-Break for trainees—-

Small group standardized patient encounters

  • Small groups of 2-3 trainees rotate through 3 standardized patient stations with 2 roles for each standardized patient (for a total of 6 different scenarios).
  • Trainees are placed in interprofessional groups (at least one NP trainee, at least one MD resident).
  • Trainees are provided with evidence-based fact sheets, clinical guidelines, or sample decision aids for each case scenario to provide background and fill any knowledge deficits (see examples below).
  • Below are examples of handouts for each of the following shared decision-making topics we use at the Seattle VA. Of note, guidelines and best practices on management of many of these conditions have changed in the time we have been running this seminar. Fact sheets must be updated annually.
IMG_20200106_160616
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Wrap up

  • Faculty facilitator leads trainees in discussion of what worked, what didn’t work, what was easy, and what was hard.
  • Trainees set personal goals for shared decision making, motivational interviewing, and reflective listening during the coming week.

Evaluation

Evaluation by trainees

  • Trainees evaluate shared decision-making session immediately upon completion of the wrap-up portion. These evaluations are used to tailor the curriculum of future shared decision-making sessions.
Download Evaluation Form

Average rating of session components by past trainees

 

Translation of panel management to clinical care

  • Current QI work is being done tracking patient perceptions of the shared decision making of COE trainees, non-COE trainees, COE faculty, and non-COE faculty using the Decision Conflict Scale to assess for differences between groups that received shared decision-making training and those that did not.

Sustainability & Dissemination

What makes this curriculum sustainable?

  • This training has become a core CoE IPC session because of its feasibility, benefit to patient care, and interactive as well as interprofessional nature. Additionally, faculty preceptors continue to encourage use of shared decision making long after the training has been completed.

SDM significance to training and patient care
 

  • Shared decision-making training is an essential component in patient-centered care, allowing for enhanced communication and collaboration with patients based on literature evidence of benefit in clinical care.
  • Trainees in primary care are expected to learn and become proficient in the skills of motivational interviewing and shared decision making.
  • The curriculum we have described is highly rated by trainees, with reported increased confidence and likelihood to use shared decision making in their patient encounters.
  • Trainees learn and work together in an interprofessional setting, learning from the experiences and strengths of different professions and peers.
    Validated tools allow for ongoing assessment of the applied use of shared decision making in real clinical encounters. 

Dissemination

  • Our trainees have encouraged continued curriculum development through interprofessional consultation and engagement specifically targeted at behavior change and shared decision making, care conferences for challenging patients that require multiple levels of support.
  • Presentation of this curriculum at both regional and national conferences

Curriculum Authors & Acknowledgements

Curriculum lead authors

  • Maryann Overland, MD; University of Washington Internal Medicine Residency Associate Program Director in Primary Care, Assistant Professor in Medicine University of Washington
  • Linda Pyke, ARNP; Director of Primary Care Nurse Practitioner Training Programs SVA PSHCS, APD for CoEIPC SVA PSHCS, Clinical Instructor University of Washington School of Nursing

Curriculum teaching session evaluations

  • Anne Poppe, PhD, RN; Director of Nursing for Rehabilitation and Nursing Education and VA Puget Sound, UW Instructor of Nursing

Implementation kit

  • Meghan Rochester, MD; Website Chief Editor, Clinician Teacher Fellow, Seattle VA, University of Washington Internal Medicine Residency
  • John Geyer, MD; Website designer and developer, Director of  Primary Care Telemedicine, VA Puget Sound,  Acting Instructor, University of Washington 
  • Joyce Wipf, MD, MACP;  Website Assistant Editor, Director of CoEIPC Puget Sound, Full Professor in Medicine, University of Washington

References

  • Braddock CH III, E. K. ( 1999). Informed decision making in outpatient practice: time to get back to basics. JAMA, 2313-2320.  
  • Braddock CH, e. a. (1997). How doctors and patients discuss routine clinical decisions: informed decision making in the outpatient setting. J Gen Intern Med, 339-345.  
  • Elwyn G, E. A. (1999). Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract, 477-82.  
  • Elwyn G, E. A. (2003). Shared decision making: developing the OPTION scale. Qual Saf Health Care, 93–99.  
  • Lloyd AJ, e. a. (1999). Patients’ ability to recall risk associated with treatment options. Lancet , 645.  
  • Waitzkin, H. (1984). Doctor-patient communication: clinical implications of social scientific research. JAMA, 2441-6.  

Comments and Questions

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