Texas Children’s Hospital: Relationship-Centered Communication

Added on Feb 16, 2017

Texas Children’s Hospital: Relationship-Centered Communication
By Audrey Doyle
Industry Edge February 2017

During the more than 20 years that Dr. David Coats has been with Texas Children’s Hospital, patients frequently said nice things to him but rarely went out of their way to comment on his care in writing.

Since completing the organization’s Breakthrough Communication course, however, Dr. Coats often receives written accolades from patients and families. In one recent example, appreciative parents wrote to thank him for giving them peace of mind by ensuring that they fully understood their son’s diagnosis. In another, a grateful grandmother wrote to acknowledge him for patiently explaining to her granddaughter what her appointment would entail, easing the 4-year-old’s fears; she also thanked him for his kindness toward her and for taking the time to answer her questions about the toddler’s condition.

Dr. Coats, who is chief of ophthalmology at the Houston-based organization, attributes the laudatory notes he has received to the communication techniques he learned in the course.

“I am not providing different medical care, but I am providing different and more effective communication,” Dr. Coats said in a letter he penned to Texas Children’s associate surgeon-in-chief for clinical affairs and chief of plastic surgery, Dr. Larry Hollier, in which he cited the value of the course and thanked Dr. Hollier for being one of its executive sponsors. “I feel different in the clinic now,” he wrote. “I think patients are walking away with a better understanding of their disease, [a] greater chance of [treatment plan] compliance, and a better feeling about me, the department, and the hospital.”

Dr. Coats isn’t alone in his thinking. Since last October, many other Texas Children’s providers—including OB-GYNs, who provide maternal fetal care—have taken the course and begun implementing its communication techniques. They, too, report that they have improved the care experience for their patients and families, and feel more engaged and less burned out.

According to Hasti Taghizadeh, manager of Patient Services at Texas Children’s and one of the initial coordinators of the course, effective communication is critical to patient care. “But it’s so obvious that sometimes providers take it for granted.”

“That’s why we launched Breakthrough Communication,” added Andrea Romay, senior project manager of Patient Experience. “Through this course, we’re training our providers to use relationship-centered communication techniques so they can establish a meaningful connection with patients and families and improve the nature and quality of their relationships with them. This is resulting in patients and families who are having optimal care experiences and providers who are feeling engaged and fulfilled.”

Customizing Course Content for Kids

Providing medical expertise in 40 pediatric subspecialties, Texas Children’s Hospital is an 800-bed, not-for-profit health system consisting of three main hospitals, 52 primary pediatric care facilities, five community health centers and six urgent care locations. In late 2015, the health system launched an initiative to reinforce the practice of relationship-centered care and improve and ensure consistency of care coordination systemwide in preparation for future public reporting of CAHPS Child Hospital Survey results.

Collaborating with Texas Children’s in that initiative were Press Ganey and the American Academy on Communication in Healthcare (AACH). The AACH conducts workshops in relationship-centered communication, coaching, leadership and teamwork, among other topics. Texas Children’s worked with Press Ganey and the AACH to customize the relationship-centered communication workshop so that it focuses on communicating to the different ages and stages of the pediatric population. The hospital also participated in the AACH’s train-the-trainer program to train some of its physicians to teach Breakthrough Communication to the rest of its physician staff.

According to Romay, Breakthrough Communication was developed during the first nine months of 2016 by a multidisciplinary team of hospital leaders, along with support from executive sponsors and co-chairs. The project road map consisted of the following four phases:

1. Develop the course
2. Train the trainers
3. Conduct pilot sessions
4. Roll out the course

For the first phase, the team conducted several focus groups with patients and families to create a curriculum that would teach skills based on their expressed needs and expectations. The team modeled the skills on the AACH workshop, but included communication techniques distinctly geared toward pediatric patients, said Romay, noting that Texas Children’s is the first organization to customize the AACH workshop for the pediatric population.

This customization was essential, she said, for a few reasons. “First, in pediatrics there needs to be a ‘triangle’ of communication among the physician, patient and family member in which the physician builds a good rapport with them and earns their trust. This three-sided communication is different from conversations in adult care, where the communication is two-sided: between the physician and patient,” Romay said.

Second, besides the use of age-appropriate language (i.e., basic as opposed to clinical terminology), the type of communication providers have with patients differs based on whether the patient is an infant, toddler, school-age child or adolescent. Examples include communicating to infants in a way that soothes and relieves their distress; speaking directly to toddlers and school-age children to help them feel like they’re at the center of the conversation, which reduces anxiety; and offering to speak with adolescents in private.

While the type of communication pertains to the patient, the act of conducting a relationship-centered conversation pertains to the patient and the family. Some techniques taught to providers relate specifically to the patient’s age/stage—for instance, using closed-ended (yes or no) questions and playing simple games with toddlers. Others apply regardless of the patient’s age and include interpreting nonverbal communication such as facial expressions, eye contact, body language and tone of voice as emotional cues; listening reflectively, which means not just hearing what the patient or family is saying, but actually taking the time to understand what they’re saying; and expressing empathy.

“Breakthrough Communication also provides tools so the physician can organize the visit in a more efficient way,” Romay said, noting that because patients’ and families’ ideas, concerns and expectations are taken into consideration through reflective listening, the flow of the visit is improved.

In addition, the course teaches providers to use teach-back techniques with families as well as with adolescents when discussing and agreeing on a treatment plan. “Adolescents are in charge or share the responsibility with their parents of following through on their treatment,” Romay said. “So you need to make sure families and adolescent patients understand the treatment plan and their role in it.”

Training the Trainers, Launching the Pilots

Once the course curriculum was finalized, 11 physicians and two advanced practice providers chosen for their communication skills underwent five full days of training over 2½ months. The physicians represented a mix of departments and specialties: In addition to six providers from the Department of Medicine, three from Surgery and one from Anesthesiology, the team of trainers also included two providers from Texas Children’s Pediatrics, the hospital’s primary pediatric care provider network, and one from the Department of OB-GYN at Texas Children’s Pavilion for Women, which provides health care to women, mothers and babies.

Once the trainers were trained, 12 pilot sessions were held. Each trainer conducted two 8-hour pilots with 132 providers from Texas Children’s Pediatrics and Texas Children’s Emergency Center. An AACH trainer co-facilitated the first pilot; in the second pilot, the AACH trainer observed and provided feedback to prepare the Texas Children’s trainers to teach the course on their own. (There are no AACH trainers on-site during the actual course.)

At the conclusion of the pilot sessions, participants were asked to rate the quality of learning per objective and the value of the course overall. The responses were overwhelmingly positive, with 93.9% of the 92 respondents giving a Very High or High rating for quality of learning per objective, and 65% rating the course overall as Excellent and 32% as Good. In fact, the only negative comments concerned the course’s length. “It was hard to get providers to clear their schedules and allocate eight hours to this,” Romay said. So they reduced the length of the course to 5½ hours.

At this point, the course details were finalized and the rollout began. As Romay explained, each class is attended by 12 physicians and taught by two trainers. The course is experiential in nature and primarily consists of role-playing exercises. Typically each class is divided into two groups, with one trainer and six participants per group; the participants take turns playing the patient, family member and provider in a variety of scenarios, and the trainer provides feedback.

For the initial rollout, which occurred from October to December 2016, the course was taught primarily to providers at Texas Children’s Pediatrics and Texas Children’s Emergency Center, as well as to several anesthesiologists and hospitalists. Rather than segregating the providers by specialty, the classes have comprised a mix of physicians from both groups. “Although the scenarios and settings are different between emergency care and preventive care, we decided to mix them because providers can benefit from learning how their colleagues in other areas communicate with their patients,” said Romay.

Based on the results of post-course surveys, providers feel the course has helped them become more comfortable using the Breakthrough Communication skills. Additional results are equally positive: Out of 93 respondents, 97.85% said they plan to use the skills they learned in their clinical activities, 86.02% said they’d recommend the course to a colleague, 82.71% said they Strongly Agree or Agree that the course was a valuable use of their time, and 91.36% said they Strongly Agree or Agree that the communication skills they learned will be relevant to their practice.

Challenges and Successes

According to Romay, allocating time for providers to train was challenging. “But we showed the executive leadership how effective this workshop has been in other institutions, and one of our executive sponsors, Dr. Joan Shook, had taken it in 2015 and was already implementing it in her practice. These tangible testimonials helped us achieve executive buy-in,” Romay said.

She added that the support from executive sponsors and co-chairs also was important and is one reason Breakthrough Communication has been effective. Another is the fact that the project was managed with an eye toward detail. “The training and the course itself require a time commitment by providers who are already very busy, so we had to be thorough, even in the pilot phase,” said Romay. “We made sure every logistic was ironed out, and we had a specific timeline and detailed action and communication plans. We also communicated everything clearly to the sponsors and co-chairs so they’d be well-informed when they sought buy-in from the executives.”

To ensure that Breakthrough Communication remains successful, a steering committee meets every two months to discuss progress and address any issues. Because each trainer teaches four times every three months, the committee also keeps the trainers motivated by holding monthly conference calls with them, sending details about upcoming courses ahead of time so that they can prepare, and offering occasional AACH retreats and workshops in order to keep their teaching and coaching skills sharp.

Thus far, about 400 Texas Children’s providers have taken the Breakthrough Communication course. The organization aims to train its remaining 1,200 providers by the end of this year.

“We want all our patients and families to have the best experience possible,” said Romay. “Our goal is to build strong relationships with all our patients and families so they view us as partners in their care. When this happens, patient experience improves, treatment compliance improves and providers feel less burned out and more rewarded. It’s a better outcome for all three sides of the relationship-centered communication triangle.”


Dr. Larry Hollier, associate surgeon-in-chief for clinical affairs and chief of plastic surgery at Texas Children’s Hospital, will deliver an in-depth presentation on Texas Children’s Breakthrough Communication course at the 2017 Press Ganey Pediatrics Executive Leadership Summit, to be held April 26 and 27 in Palm Beach, Fla. Click here for more information.