A Donabedian perspective is pertinent to the review article by Chalwin and Flabouris.[1] Avedis Donabedian was an international leader in public health who provided key contributions to the fields of health services and quality of healthcare.[2] He believed that two elements were instrumental to the performance of practitioners: (i) technical skill and (ii) interpersonal skill.[3] Donabedian lamented that interpersonal skill was ‘so important (but) so often ignored … (as) the criteria and standards that permit precise measurement of the attributes of the interpersonal process are not well developed’.[3] No doubt Donabedian would have been delighted that there are now validated assessment tools for non-technical or ‘interpersonal’ skills in medical emergency teams (MET) and rapid response systems (RRS), as was outlined by Chalwin and Flabouris.[1]

But what of patient communication? Many of the non-technical skills (NTS) assessment tools appraise communication between team members in a MET/RRS.[1] However, a MET call is a frightening, bewildering and often perplexing event for a patient. Patients may feel they are being ‘spoken over’ and events are not properly explained. Patient-centred care is a component of quality, and the physician–patient interaction is a vitally important aspect to the delivery of care. It is a non-technical or ‘interpersonal’ skill. As such, how can we best assess the physician–patient interaction in an emergency setting?

Donabedian outlined the importance of structure, process and outcome to evaluate the quality of healthcare, known as the Donabedian Quality-of-Care Framework.[2, 3] Structure denotes the attributes of settings in which care occurs, process indicates what is actually done in receiving care and outcome reflects the effects of care on the health status of patients and populations.[3] To assess communication with the patient, one could observe the physician–patient interaction as a process, in the same manner that the validated NTS assessment tools evaluate emergency team interactions. However, an even more powerful tool might be the outcome measure of patient satisfaction. Patient satisfaction in emergency settings has been explored in several studies.[4-8] One review found that empathy and information dispensation were key elements of patient satisfaction in an emergency department.[4] Patient satisfaction assessments can provide insight into perceptions of NTS in emergencies.

What would Donabedian say? As a public health pillar ahead of his time,[2] I cannot profess to know. I can only speculate that Donabedian would congratulate those who are developing tools to assess interpersonal skills, a key component of quality. However, he may remind us of the importance of incorporating the ‘patient experience’ in an assessment of NTS.


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  2. References
  • 1
    Chalwin RP, Flabouris A. Utility and assessment of non-technical skills for rapid response systems and medical emergency teams. Intern Med J 2013; 43: 962969.
  • 2
    Frenk J. Obituary: Avedis Donabedian. Bull World Health Organ 2000; 78: 1475.
  • 3
    Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260: 17431748.
  • 4
    Welch SJ. Twenty years of patient satisfaction research applied to the emergency department: a qualitative review. Am J Med Qual 2010; 25: 6472.
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    Boudreaux ED, D'Autremont S, Wood K, Jones GN. Predictors of emergency department patient satisfaction: stability over 17 months. Acad Emerg Med 2004; 11: 5158.
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    Halter M, Marlow T, Tye C, Ellison GT. Patients' experiences of care provided by emergency care practitioners and traditional ambulance practitioners: a survey from the London Ambulance Service. Emerg Med J 2006; 23: 865866.
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    Crofts JF, Bartlett C, Ellis D, Winter C, Donald F, Hunt LP et al. Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Qual Saf Health Care 2008; 17: 2024.
  • 8
    Yates M, Barrett A. Oncological emergency admissions to the Norfolk and Norwich University Hospital: an audit of current arrangements and patient satisfaction. Clin Oncol (R Coll Radiol) 2009; 21: 226233.