Table 1.

a. Communication Skills Used to Create Strategies as part of the Framework for Outcomes in Clinical commUnication Services (FOCUS)
Communication skills categoriesa	Description of skills and processes	Hypothesized to influence patient experience, changes and health
Building rapport (i.e., establishing a professional relationship and mutual respect) [1, 5–7, 10]	Ask how the patient prefers to be addressed (use their own language and words if appropriate) Attend to the patient’s physical comfort and other needs Place yourself on the same level as the patient, with no barriers between you Be sincere, respectful, & culturally responsive (e.g., use person-first or identity-first language) Avoid interruptions and remain flexible in altering your approach to meet the patient’s needs Open up two-way communication (patient is given opportunities and encouraged to talk, ask questions, voice concerns, discuss options, and share information with the provider) Engage in active listening (e.g., maintain eye contact (in Western cultures), lean forward, attend to verbal and non-verbal cues, restate what the patient says to confirm understanding of the patient's perspective) Take an empathic, non-judgmental, and genuine approach Demonstrate unconditional positive regard and appreciation of patient strengths Consider how provider's own personal experiences or attitudes could impact communication Recognize that provider’s self-disclosure or intense emotional responses can shift the focus away from the patient Maintain professional boundaries and objectivity	Meet patient needs/expectations Perception of patient-provider relationship Perceptions of information provided
Mutual agenda setting (i.e., contracting) [1–4]	Elicit patient’s expectations, goals, and reason for the visit Summarize patient’s perspective Explain or clarify health provider’s goals & understanding of the reason for the visit Prioritize patient’s goals and needs and develop a mutually agreed upon agenda Manage patient expectations – (If patient’s needs/expectations cannot realistically be met, explain why & provide alternative means by which patients may meet their needs) Reassess the patient’s needs throughout the encounter	Meeting patient needs and expectations Perceptions of patient-provider relationship Perceptions of information provided
Gathering medical and psychosocial information	Gather medical records and/or ask patient questions about health history (e.g., symptoms, pregnancy history, family history, developmental history, and/or health behaviors). Use open-ended questions and reflections to elicit patient needs, concerns, perspectives, values, health beliefs, and psychological/social context	Meeting patient needs and expectations Perceptions of patient-provider relationship Accurate diagnosis
Responding to emotions [1, 3–7, 9, 11, 14–16]	Elicit, clarify and acknowledge patient’s emotions (e.g., express empathy by reflecting patient’s thoughts/feelings, develop or reduce emotional intensity) Provide emotional support (e.g., supportive comments, encouragement, or validation; normalize, limit liability, give positive feedback)	Perception of patient-provider relationship Empowered to make decisions Empowered to cope with emotions
Educating and checking for understanding [1, 2, 5–8]	Elicit patient’s beliefs about the condition/risks while listening for inaccuracy Assess patient education level, health literacy level and information preferences Modify the level of information and amount of detail provided to align with patient’s education/literacy/numeracy levels and preferences Use plain language and avoid complex terms or jargon (be clear, concise and specific) Use visual aids; organize and “chunk” information Provide accurate information in a manner that is sensitive to cultural beliefs and values Check patient understanding (e.g., use the “teach back method”; ask patients to describe what the information means for them personally and/or their family and how they plan to use the information or not) Summarize, clarify and highlight key points and take home messages	Perceptions of information provided Patient knowledge Feeling informed Perceived severity of condition Attitudes, beliefs, feelings about options and anticipated outcomes Quality health decisions
Communicating risk [3, 4, 8, 9]	Review relevant medical history, family history, and test results with the patient Provide personalized risk information based on genetic, environmental, and lifestyle risks Discuss risk implications for both the patient and their family members (if appropriate) Use natural frequencies, round numbers, and common denominators to decrease numeracy demands Assess and re-assess patient’s risk perceptions Clarify risks	Perceptions of information provided Perceived risk and susceptibility Patient knowledge Feeling informed Empowered to make decisions Accurate diagnosis Risk communication among family members
Communication framing and format [10–13]	Present risks as both the chance the patient will have the condition and chance the patient will not have it to reduce framing bias Present balanced information: include “best case”, “worst case”, and “most likely” scenarios Focus on the “most likely” outcome. Highlight the most effective or feasible options. Explain all versus a subset of anticipated signs and symptoms of the disease/condition Disclose (or not) scientific uncertainty regarding risks and anticipated outcomes Use authority (or not) in explaining the available medical evidence and what actions are anticipated to achieve optimal health outcomes Restate a situation in a more favorable light (reframing) Tailor information to the patient Use narratives (stories) to promote understanding or to elicit emotions Use appropriate decision aids and visual aids (e.g., graphs, tables, pictographs)	Perceptions of information provided Patient knowledge Feeling informed Perceived severity and risks associated with the condition Attitudes, beliefs, feelings about options and outcomes Empowered to make a decision Empowered to cope with emotions Risk communication among family members
Mobilizing patient strengths, resources, support [1, 4, 8, 9, 15]	Encourage patient self-reflection Point out specific patient strengths (praise, affirmation) Elicit how the patient dealt with other difficult situations or medical issues before and identify what strengths, skills, and support the patient drew upon Help the patient define his/her current support network Explore whether coping mechanisms have resulted in positive or negative outcomes Encourage positive appraisal of the patient's situation (reframing, re-appraisal) Describe positive coping mechanisms that other patients may have used and why they were helpful (if the patient desires this information)	Empowered to cope with emotions Empowered to access resources Empowered to make decisions
Engaging patient in decision making [1, 3, 4, 7, 10, 11, 15, 16, 18]	Assess patient decision-making style; encourage participation, while respecting patient’s preferred level of involvement Determine who else in their life may be important to their decision making process and include them if the patient desires or encourage the patient to verbalize what they believe the other(s) would want them to do and why List options and allow patient to overtly express pros and cons related to them Explore patient’s cognitive and emotional responses to options Assess patient’s outcome expectations; help align expectations with the most likely outcomes or range of possible outcomes; provide anticipatory guidance Explain the reasons why some patients tend to choose various different options Recognize and acknowledge ethical challenges and/or uncertainties related to the decision Help the patient clarify his/her values and underlying beliefs or emotions Align options with patient’s values and goals	Perception of patient-provider relationship Perceptions of information provided Empowered to make decisions Attitudes or perceptions about options action plan and anticipated outcomes Adherence / self-management Quality health decisions
Supporting patient autonomy [1, 9, 11, 16–18]	Ask patients what they want to achieve and encourage exploration and questions Evoke the patient’s own reasons for wanting to take action Elicit (or provide if patient desires) several options for achieving the patient’s goal(s) Remind them they have choices & you are there to help them figure out what is best for them Give patient time to consider choices and allow them time to provide input Explore patient’s ambivalence about taking action or committing to a decision; acknowledge the patient may not be ready; normalize ambivalence and decision making difficulty Use autonomy-supportive phrases rather than controlling language (e.g., “here are some things that may help” you instead of “do this for me, or you must…”) Get permission before providing advice Affirm patient’s competence and confidence Refrain from judgment or evaluation	Perception of patient-provider relationship Empowered to make decisions Empowered to access support Empowered to cope with emotions
Action planning [15–18]	Summarize what is most important to the patient and evoke their possible next steps Assess patient’s readiness to: implement their decision, take the next step toward their goal, or follow a medical recommendation Help patient identify barriers and facilitators that may influence their ability to take action Engage patient in solution finding to overcome barriers and elicit what would work for them Support patient in developing a detailed plan for achieving their goal, including how and when they plan to complete the next step Create contingency plans if needed (i.e., alternatives); assure patient you will help if things don’t work according to plan Help patient strengthen their commitment and identify ways to monitor their progress	Empowered to make decisions Empowered to access support Adherence / self-management
Skill-building [8, 10, 11, 15]	Engage the patient in coping skills exercises or interventions Help the patient identify and challenge negative self-talk Teach problem-solving strategies/critical thinking skills Model ways the patient can communicate and disclose information to others Practice or role play relevant scenarios Teach self-management skills	Empowered to access resources Empowered to cope with emotions Coping and psychological outcomes Adherence / self-management Risk communication among family members
Care coordination and provision of resources [19]	Coordinate testing Ensure appropriate testing is ordered Determine insurance eligibility for testing or medical care Help the patient navigate the health care system (e.g., provide referrals, schedule medical appointments, help them enroll in a clinical trial) Communicate directly with the patient’s other healthcare providers (with patient's permission) Identify and provide informational materials (e.g., decision aids, handouts, brochures, patient letters, family letters) Help patients find appropriate services and resources Provide contact information for support/advocacy groups Assist in arranging follow-up appointments Medical documentation to ensure accuracy and completeness Test results tracking, follow-up and disclosure	Accurate diagnosis Empowered to cope with emotions Empowered to access resources Risk communication among family members Accessed appropriate care

b. Communication Process Measures from the Framework for Outcomes in Clinical commUnication Services (FOCUS)
Categories of Communication Process Measuresa	Description	Example Measuresb
Use of communication skills	Fidelity to a specific counseling or educational technique, approach, or strategy (i.e., extent to which skills were implemented as intended). List of skills and processes that are checked if completed. Samples of processes that could be on a checklist include: 1) Open-ended questions used to elicit patient needs, perspectives, concerns, questions, values, or social context 3) Three- or four-generation family history was completed 4) Patient risk perceptions were elicited 5) Personalized risk information was given (visuals used) 6) Beliefs/emotions about health condition were discussed 7) All reasonable options were considered 8) Patient’s attitudes/feelings about options were elicited 9) Anticipatory guidance was provided 11) Discussed implications and risks for family members 12) Provider used active listening skills; few interruptions 13) Provider’s statements conveyed empathy versus unsolicited advice and judgmental comments 14) Patient’s goals or outcome expectations were elicited 15) “Teach back” used correctly to check understanding 17) Patient’s readiness to take action was determined 18) Barriers to the decision or action were identified and ways to overcome them identified 19) Pain was assessed (if applicable)	Rochester Participatory Decision-Making Scale (RPAD) (Shields 2005) measures patient-physician collaborative decision-making (observer coded) [1] Informed decision making coding (Braddock, 1999) measures degree to which physician recommendations satisfy informed decision making (observer coded) [2] Empathic Communication Coding System (ECCS) (Bylund and Makoul 2002) (observer coding) [3] Roter Interaction Analysis System (RIAS) (Roter and Larson 2002) identifies information seeking and information-giving utterances (observer coding) [4] Physician-Patient Verbal Coding Scheme (Gordon, Street, Sharf, and Souchek, 2006) measures physician information giving across several categories (observer coding) [5] The 5-As model (Glasgow, Emont, and Miller 2005) measures 4 steps to physician facilitation of patient health behavior change: ask, advise, assess, assist, and arrange follow-up. [6] Empowering Health Counseling scale (Kettunen 2006) completed by patient & provider [7]
Appropriateness of testing and accuracy of results interpretation [8]	Reliable and clinically valid testing was offered (if appropriate). Test results were interpreted accurately by the provider, taking into consideration the medical and family history.	Proportion of cancer patients who have a variant of uncertain significance who are told their family history should determine cancer risk screening and management options (and the test result does not change their risks or management options). Proportion of patients with a variant of uncertain significance result who are inappropriately informed that this result means they are at increased risk for disease Proportion of prenatal patients who are told that results of noninvasive prenatal screening should be confirmed with amnio or CVS.
Appropriateness of informational content	Information provided was up to date, accurate, and culturally appropriate. Information was tailored to the patient’s health literacy and education levels as well as the patient’s needs and desired amount of detail.	Experts can evaluate information accuracy. Compare patient reported preferences for information to actual information that was provided: Information Styles Questionnaire (Cassileth Zupkis 1980) [9]; Information Preference Scale (Blanchard, et al 1988) [10]; Willingness to discuss psychosocial and physical aspects of health (Street et al 1995) [11]; Preferences for discussing prognostic information (Hagerty 2004) [12].
Patient involvement (e.g., reciprocity of communication and content of patient responses) [13]	Extent to which the patient actively communicated as evidenced by how often the patient talked, asked questions, offered opinions or beliefs, stated preferences, introduced topics for discussion, expressed emotions, and disclosed concerns. Certain content of patient utterances may be predictive of key changes or outcomes.	Analyzing Patient Participation in Medical Encounters (Street and Millay 2001) observer coding [14] Proportion of patients who offer their opinions or state their preferences and values. Motivational interviewing commitment language by the patient (especially at the end of the session) is strongly correlated with behavior change.[15]
Care was coordinated & resources or follow-up provided	Whether and how the provider helped the patient navigate the healthcare system or share information with family members and what support resources, referrals, or written information were provided to patients. Provider followed up as planned in a timely fashion.	AHRQ Care of Coordination Measure Atlas. [16] Proportion of individuals with a new diagnosis who are given information about support or advocacy groups. Proportion of individuals sent a written summary of visit. Timeliness of follow-up task completion by the provider
Followed professional guidelines and ethical practices [16–18]	Appropriate options and medical management recommendations were discussed in line with professional practice guidelines. Provider behaved ethically (e.g., was honest with the patient; did not push their own values on the patient).	Comprehensive family medical history completed according to standardized nomenclature. [20] Checklist documenting that important points identified in an evidence-based practice guideline were completed. Proportion of patients who meet certain criteria and receive appropriate evidence-based care.
Accurate diagnosis	An accurate diagnosis is necessary for the patient to access appropriate care and make quality health decisions. An inaccurate diagnosis can lead to more costly and inappropriate medical care, which can negatively impact patient health outcomes.	Proportion of patients seen by a genetic counselor who received an accurate diagnosis.

^aCommunication skills can be combined to create a strategy for achieving patient and provider goals and positively influencing patient experiences, patient changes, patient health, and/or family changes.

References

^[1]P. M. Veach, D. M. Bartels, and B. S. Leroy, “Coming full circle: a reciprocal-engagement model of genetic counseling practice.,” J. Genet. Couns., vol. 16, no. 6, pp. 713–28, Dec. 2007. http://www.ncbi.nlm.nih.gov/pubmed/17934802

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^aCommunication process measures, in general, reflect the healthcare services provided to a patient (including what occurred during the communication process and whether strategies were implemented as originally prescribed or intended). Several process measures are expected to influence patient care experiences and may contribute to other changes.

^bTypes of process measures include: checklists, chart reviews, observer coding documenting use of communication strategies, and adherence to professional guidelines. Measures can be based on coding by a third party observer during or after the visit (if it is audio recorded) or through medical record checklists completed by providers.

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