Kay Leaming-Van Zandt, MD Mary Shapiro, MD Roger Nicome, MD

1. Breakthrough Communication:Enhancing the Provider-Patient-Family Relationship as a Therapeutic Tool Kay Leaming-Van Zandt, MD Mary Shapiro, MD Roger Nicome, MD

2. Disclosure • We do not have any relevant financial relationships with manufacturers of any commercial products and/or providers of commercial services discussed in this lecture.

3. Art of Medicine

4. Objectives • Define relationship-centered care • Describe evidence that supports a relationship-centered approach to medical communication • Apply Breakthrough Communication concepts and skills in clinical practice

5. Epstein RM, Street RL. Patient-centered communication in cancer care (NIH Pub No. 07-6225). Bethesda, MD: National Cancer Institute; 2007 Building Healthcare Relationships

6. Relationship-Centered Care: A Constructive Reframing Beach MC, Inui T, and RCC Research Network. Relationship-centered care: a constructive reframing. J Gen Intern Med 2006;21:S3-8

8. Medical Communication Epstein RM, Street RL. Patient-centered communication in cancer care (NIH Pub No. 07-6225). Bethesda, MD: National Cancer Institute; 2007 de Haes H, Bensing J. Endpoints in medical communication research, proposing a framework of functions and outcomes. Patient Educ Couns. 2009;74(3):287-294

9. Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Ed Couns.2009 Mar;74(3):295-301 How Does Communication Heal?

10. Healthcare Outcomes:Patients and Families • Trust and loyalty • Comprehension and recall • Sense of self-efficacy and support • Self management of chronic disease • Functional improvement • Treatment adherence • Satisfaction with care • Patient safety • Health status and quality of life Korsch BM, et al. Gaps in Doctor-Patient Communication. Pediatrics. 1968;42;855-871. Manary MP, et al. The patient experience and health outcomes. N Engl J Med. 2013;368:201-203. Kelley JM, et al. The influence of the patient-clinician relationship on healthcare outcomes: PLoS ONE. 2014;9:e94207 Stewart M, et al. The impact of patient-centered care on outcomes. J Fam Practice. 2000;49:796-804.

11. Healthcare Outcomes:Healthcare Team • Improves: • Efficiency • Diagnostic accuracy • Self confidence • Job satisfaction and engagement • Reduces: • Professional burnout • Malpractice claims, complaints, and grievances • Cost of providing care Mauksch L, et al. Relationship, Communication, and Efficiency in the Medical Encounter. Arch Int Med. 2008;168(13):1387-1395. Norgaard B, et al. Communication skills training increases self-efficacy of health care professionals. J Cont Ed Health Prof.2012;32(2):90-97. Weng H, et al. Associations between emotional intelligence and doctor burnout, job satisfaction, and patient satisfaction. Med Ed. 2011;45:835-842. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The Relation of Patient Satisfaction with Complaints Against Physician and Malpractice Lawsuits. Am J Med. 2005 Oct;118(10):1126-33

12. Meaning Behind the Work • Nontechnical, humanistic interactions with patients …fulfilled and reaffirmed their commitment to medicine • Fundamental change in the doctor’s perspective • Connection with patients • Difference made in someone’s life Horowitz CR, Suchman AL, Branch WT, Frankel RM. What Do Doctors Find Meaningful about Their Work? Ann Intern Med. 2003;138:772-775.

13. “Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete.” - Dr. Paul Kalanithi

14. Texas Children’s Breakthrough Communication Enhancing the Conversation Between Patients, Families, and Healthcare Providers

15. Texas Children’s Breakthrough Communication • Collaboration with Academy of Communication in Healthcare (ACH) • 5.5-hour relationship-centered communication course composed of: • Short didactic lectures • Skill set demonstrations • Small/large group role-play sessions

16. Skill Set 1: • Beginning the Encounter • Establish rapport • Negotiate the agenda PEARLS of EMPATHY string it all together PEARLS of EMPATHYstring it all together • Skill Set 2: • Relationship-Centered Interviewing • Open the conversation • Explore the patient’s/ family’s perspectives Data-Centered History Background & Physical Exam • Skill Set 3: • Ending the Encounter • Share information • Assess understanding with an interactive dialogue about the assessment and plan

17. SKILL SET 1:Beginning the Encounter Texas Children’s Breakthrough Communication

18. Beginning the Encounter • Create rapport quickly • Acknowledge barriers to communication • Voalte, computer • Elicit the LIST of all items from patient • “WHAT else?” • Reflect and respond with empathy • Negotiate the agenda

19. SKILL SET 2:Relationship-Centered Interviewing Texas Children’s Breakthrough Communication

20. Relationship-Centered Interviewing • Open the conversation • Explore the patient’s and family’s perspective • Reflect and respond with empathy • Transition to data-centered portion of the interview

21. SKILL SET 3:Ending the Encounter Texas Children’s Breakthrough Communication

22. Ending the Encounter • Share information and plan • Assess understanding • Reflect and respond with empathy • Summarize and clarify • Close the visit

23. Let’s Demo… • Skill Set 1 • Create rapport quickly • Acknowledge barriers to communication • Elicit the LIST of all items from patient • Reflect and respond with empathy • Negotiate the agenda • Skill Set 2 • Open the conversation • Reflect and respond with empathy • Explore the patient’s and family’s perspective • Transition to data-centered portion of the interview • Skill Set 3 • Share information and plan • Assess understanding • Reflect and respond with empathy • Summarize and clarify • Close the visit

24. Texas Children’s Hospital Experience Jan‒Apr ’16 Development May‒Sept ’16 Train the trainer and Pilots Oct ’16‒Present Training Sessions • 5.5 hr sessions (CME and ethics credit) • 2 trainers, 6-12 participants per session • >1000 providers at Texas Children’s now trained • Currently evaluating provider and patient outcomes • 5 days of training by Academy of Communication in Healthcare (ACH) • 13 Texas Children’s trainers • 12 pilot sessions • Focus groups • Benchmarking • Curriculum Development

25. Texas Children’s Hospital Breakthrough Communication Participants trained from July 2016 through June 2019

26. Measured Outcomes Participant Feedback Patient Experience and Press Ganey Scores Maslach Burnout Inventory

27. Participant Feedback

28. Participant Feedback - Nursing

29. Self-Efficacy (Learned Skills)Skill Set 1 *Using two independent samples comparing pre- versus post-course responses. Converted to RedCap in June 2018.

30. Self-Efficacy (Learned Skills) - NursingSkill Set 1

31. Self-Efficacy (Learned Skills)Skill Set 2 *Using two independent samples comparing pre- versus post-course responses. Converted to RedCap in June 2018.

32. Self-Efficacy (Learned Skills) - NursingSkill Set 2

33. Self-Efficacy (Learned Skills)Skill Set 3 *Using two independent samples comparing pre- versus post-course responses. Converted to RedCap in June 2018.

34. Self-Efficacy (Learned Skills) - NursingSkill Set 3

35. Testimonials In general, I find patient encounters are much smoother and more efficient (an experience like the cherry on top of a sundae in providing good patient care). Specifically, I was able to have a successful encounter with a difficult family who felt very betrayed by the hospital due to a CPS referral. The Breakthrough Communication techniques allowed for more productive visits and finally building trust. It wasn’t just the skills that I learned, but also renewed confidence in my ability to successfully and meaningfully communicate with families. I did the “what else” technique on a parent who brought in a 12 yo child for runny nose. After a few “what else” responses, she said, “Well, we are really here because he has had some suicidal thoughts.” I was able to elicit the real reason before going to the door.

36. Patient ExperiencePress Ganey: Pre- vs Post-Course

37. Patient ExperiencePress Ganey: No Course vs Post-Course

38. Maslach Burnout Inventory (MBI) • Emotional Exhaustion: Feeling emotionally drained by contact with other people & diminished enthusiasm for work • Depersonalization: Negative feelings and cynical attitudes toward patients • Personal Achievement: Work loses its meaning

39. Maslach Burnout Inventory (MBI) In 19 of the 22 questions, scores trend favorably after the course as compared to before the course. Only two noted above demonstrate a statistically significant change.

40. Physician satisfaction linked to patient satisfaction • Physician burnout linked to patient outcomes • At TCH, communication-related issues account for a significant number of PPE cases JAMA Internal Medicine December 2017 Volume 177, Number 12

42. Take-aways… • Relationship-centered communication in healthcare is founded on empathic connection between providers with patients/families and our reciprocal influence on each other • Literature to support using relationship-centered communication tools to improve both patient/family and provider outcomes

43. Take-aways… • Texas Children’s Breakthrough Communication focuses on relationship-centered communication: • Setting an agenda • Practicing reflective listening • Engaging in dialogue with patients/families to ensure understanding of the diagnosis and plan • Demonstrated improved patient and provider outcomes

44. Future Directions • Expansion to include: • Nurses, therapists, medical team (recruitment of facilitators) • Medical trainees • Patients and families • Development of ongoing basic education refreshers • Peer-to-peer training (i.e. how we talk to each other) • Diversity training

45. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patientis in caring for the patient.

46. Thank You