CHAPTER 17

Train-the-Trainer Programs: Establishing Local Influence

If you are reading this chapter, we’re guessing that you are committed to improving patient experience scores for your institution. But how? Many clinicians may seem either uninterested in or threatened by this work. And although many patients are very satisfied with their clinicians’ communication and care, other patients have complaints that need to be addressed. You may have found it confusing that some of the same practitioners receive both high praise and problematic feedback from different patients.

Across the country, healthcare leaders like you are struggling to find ways to improve communication experiences for patients, clinicians, and teams. “Train-the-trainer” (TTT) programs in communication skills can offer sustainable solutions to support internal change efforts.

What are the advantages of hosting a TTT program in your own institution? First, rather than hiring outside experts to teach communication skills to all clinicians, you can reduce costs in the long run by having your internal staff learn these skill sets. Second, internal trainers often develop a sense of community and enhanced learning by engaging with each other.^{1, 2} Finally, through their communication skills expertise, internally developed trainers may realize new opportunities for career advancement and potential for leadership roles. These trainers can support your clinicians and educators to help create a culture change to promote the entire patient experience effort.³

In this chapter, we describe the format of TTT programs to prepare future communication skills trainers, explain why these programs work, and provide examples to show how these programs have affected the institutions that have adopted them.⁴

Format of TTT Programs

The TTT program for communication skills has five distinct phases, shown in Table 17.1.

TABLE 17.1 Overview of Train-the-Trainer Programs

PHASE I: PREPARING BY GAINING INSTITUTIONAL BUY-IN AND SELECTING FUTURE TRAINERS

Ms. Gray is in charge of patient experience at a health system. Leadership positions are in flux, creating an atmosphere of uncertainty and instability. Ms. Gray is committed to improving patient experience and doesn’t want to wait for leadership to stabilize before taking action. She chooses to hire highly experienced TTT program consultants from a reputable organization known for its effective communication curriculum.

Ms. Gray carefully identifies a small group of local clinicians to become communication skills trainers. These “future trainers,” mainly junior staff who believe in creating better relationships with patients, volunteer to spend extra time and energy for this effort. They find ways to cover their clinical duties and promise to work nights and weekends to make up for time spent learning to become trainers and teaching others. Ms. Gray provides training space but lacks authorization to hire an assistant to take care of logistical details. Even with these barriers, the TTT program consultants successfully train the future trainers to deliver effective communication skills workshops. Unfortunately, the senior executive leadership for the health system is unwilling to provide protected time for either her internal future trainers or for participants who would need to cancel clinical time to attend these workshops.

Ultimately, clinicians are hesitant to sign up for the training, since it would add to their already busy schedules. The new trainers, despite their commitment and willingness to help, are unable to sway their colleagues without higher-level support. So while Ms. Gray’s initial efforts hold promise, the program does not accomplish its goal of heightening patient experience.

This cautionary tale emphasizes an important fact: institutional buy-in for establishing a TTT program and supporting its efforts is essential. With institutional backing, initiatives from your patient experience officers and interested staff members thrive. In order for your TTT programs to be successful, you must provide the following support: space to conduct training, financial backing, strong administrative staff, protected time for future trainers, and other resources required to maintain the program. (Chapter 18 will elaborate on institutional factors to maximize success.)

While preparing to begin the TTT process, you will also need the proper personnel and a realistic timeline to carry out the requisite tasks.

1.   Having a skilled and organized project coordinator is important for a successful launch and program rollout.

2.   TTT program consultants tasked with preparing and coaching future trainers should have extensive prior experience in teaching communication skills, program/curriculum development, and organizational development. Many consultant faculty at ACH, for example, have worked for a decade or more in these areas. When consultants have this level of experience, your clinicians can gain confidence in the entire training process.

3.   When choosing internal future trainers, you should look for individuals with emotional intelligence, keen observational skills, and a willingness and capacity to learn and adopt learner-centered facilitation skills. Department chairs, supervisors, or other institutional leaders can sponsor future trainers to reach as many clinicians as possible. Future trainers must also have sufficient standing in the organization to be viewed as credible. For example, the program can include less experienced members of your organization, but it should not be run solely by students, visiting interns, and junior staff members. Future trainers can have varying levels of preexisting experience in communication skills; all, however, must be willing to undergo the training and be interested in the process.

4.   The timeline should map Phases II and III of the certification process for future trainers (see Table 17.1), as well as Phase IV, rollout of the full program. The project coordinator must choreograph the intricate dance of calendars between the visiting TTT program consultants and the entire group of identified future trainers. This level of scheduling detail is not for the faint-hearted or overcommitted.

PHASE II: PARTICIPATING IN A FUNDAMENTAL COMMUNICATION SKILLS TRAINING WORKSHOP

For future trainers to become experts in fundamental communication skills, they need a standardized approach and common syntax. They can accomplish this by participating in a standard communication skills workshop, run by TTT program consultants, before preparing to teach the program to colleagues. Instead of utilizing didactic presentations,⁵ effective workshops use facilitated skills practice, where small group leaders closely observe and conduct structured debriefs using effective feedback principles (see Chapters 10 and 16). TTT program consultants give brief presentations and demonstrations, but only to contextualize the skills that will be the basis of future trainers’ efforts.

As they undergo the standard communication skills training, future trainers learn on three different levels. First and primarily, they are learners who are practicing these fundamentals. Second, as they participate in the skills practice, they may develop insights into what future learners may experience. Third, they are training to become trainers and observe TTT program consultants as role models who demonstrate the facilitation skills that the future trainers will eventually become certified in.

PHASE III: MASTERING SMALL GROUP FACILITATION SKILLS AND WORKSHOP FLOW

Q: How do you get to Carnegie Hall?

A: Practice, practice, practice.

The point of this old joke is that mastery of anything requires practice. If you sit down to practice for hours and hours at the piano, you may not necessarily improve in mastery. In fact, all those hours of practice in some cases might cement mistakes that you are consistently making.

Literature suggests that we need more than mere practice to develop mastery. Instead, mastering a process includes not only deliberate practice (i.e., practice toward a specific goal) but also feedback.⁶ For example, a piano teacher or tennis coach can point out areas of effective performance and mistakes being made. In the case of TTT programs, consultants create practice exercises to help future trainers master fundamental communication skills and learn how to train others to acquire these skills.

Before becoming a physician, Dr. Sanchez was a giafted teacher who had received accolades from an exclusive boarding school. After six years as a hospitalist, Dr. Sanchez was selected to be a future trainer. He was an enthusiastic learner in small groups and a dynamic speaker. However, when it came to small-group communication skills work, he tended to lecture, from which it was not easy to learn skills. Through diligent work and some uncomfortable adoption of constructive feedback from TTT program consultants, he eventually became successful at facilitating learning from his participants instead of giving them information downloads, however entertaining.

As future trainers improve their fundamental communication and facilitation skills, they need more advanced practice in challenging scenarios. Future trainers can thereby practice a range of tools that they can use in various scenarios: with a silent participant, a silent group, a talkative participant, and a resistant learner, among others. Throughout this phase of training, future trainers become skilled in observation, learn how to discern between merely allowable versus exemplary communication skills, and become adept at conducting supportive and honest feedback conversations.

PHASE IV: GOING LIVE

When cast members from “Saturday Night Live” scream, “Live from New York—It’s Saturday Night!” they do so with authentic excitement. Even with significant iterative practice, there is no more energetic moment than when the whole thing “goes live.” A successful training process creates future trainers who can do their jobs independently of TTT program consultants. This is different from the traditional “see one, do one, teach one” approach. Instead, this method actively coaches future trainers toward success.

Future trainers undergo rigorous simulated practice in Phase III above, achieving familiarity with the basic skills and logistics of leading the workshop. Concurrent with these practice sessions, it is most helpful for future trainers and program leaders to create buzz for the upcoming program, recruit participants, and send invitations to targeted individuals and department leaders. Project coordinator staff can assist with registration and reminders for recruitment. After completion of these practice sessions, it’s time to go live by welcoming actual participants to the course. Future trainers cofacilitate these classes with a TTT program consultant. The consultant ensures that participants, students, and/or trainees are engaged in the learning process. The TTT program consultant also provides guidance, intervenes when necessary, and helps with logistics.

After consultants give future trainers the green light to move to the next and final training stage, future trainers begin independently facilitating workshops. In this phase, the TTT program consultant is physically present but largely silent. By staying in an observation role, the consultant is able to see what the future trainers’ strengths and weaknesses are. The consultant intervenes minimally and mostly provides feedback during breaks.

The final observation and feedback from the TTT program consultant marks the conclusion of the program certification process. Certification typically includes a list of competencies and activities that the future trainers must demonstrate to move forward independently. The full program rollout launches in Phase V.

PHASE V: ENSURING VIABILITY AND LONG-TERM MAINTENANCE OF THE PROGRAM

After putting so much work into a program, you will want to do everything you can to make sure it will be effective—not just in the short term but well into the future. Although we list Phase V after Phase IV, efforts to ensure viability really should happen before Phase IV or at least simultaneously with Phase IV.

As seen in the earlier example with Ms. Gray, future trainers can undergo training, but if the institutional milieu is not conducive to adopting a viable program, the program will never meet its goals. Reviewing methods to create culture change is critical to the ultimate success of both the future trainers and the entire change effort itself. (We explore a detailed process for successfully creating institutional change in Chapter 18.)

An organized structure for the full program rollout is integral to program success. One way you can achieve this is by establishing a registration and reminder system for program participants. The project coordinator can implement a registration system with options ranging from e-mail RSVPs to a formal scheduling system/link, and should work with clinic scheduling personnel to make sure the workshop is appropriately scheduled so that clinical time of class participants is blocked. A reminder system to update registered participants with the details regarding their session supports attendance. Due to late cancellations and no-show attendees, the project coordinator may consider overbooking registration space (e.g., allowing eight participants to register for a session that allows only six). The project coordinator may also explore options for a convenient meeting space to extract attendees from the normal routine of clinical practice with a quiet, comfortable environment that optimizes engaged learning. Providing food and refreshments to maximize comfort and to avoid the distraction of doing work during breaks enhances the uptake of similar workshops.⁷

Ultimately, avoid regarding the TTT program as a quick, one-time fix—rather, it should metamorphose into an ongoing resource that benefits not only patients but also the health system as a whole. Sustaining the TTT program includes ongoing observation of trainers, further development of more advanced communication skills training, and possible use of some of the applications outlined in Part III of this book. Essentially, the TTT process establishes a community of interested and engaged trainers who can learn from each other to grow their skills. Attending regional and national conferences on teaching communication skills can also contribute to this growth. Finally, sharing experiences with other TTT learning communities across the country can provide additional powerful and inspirational ways to accomplish individual, group, and institutional goals.

Examples of TTT Programs

Due to the increased interest in and commitment to this work at institutions across the United States, ACH has partnered with several powerful healthcare institutions. This section will highlight some programs that have transformed the institutions that have adopted them.⁸ One common hallmark across all programs is the high satisfaction with which participants rate their experience with the communication skills course: nearly 90 percent of attendees agree or strongly agree that they learned relevant communication skills that they can readily apply to their clinical practices.

MAYO CLINIC IN PHOENIX

Mayo Clinic in Phoenix (MCP), AZ, is ranked nationally in 10 adult specialties and is a 268-bed general medical and surgical facility with more than 13,000 admissions in the most recent year reported.⁹ As an early adopter of communication skills training in 2004, MCP identified local physician leaders to collaborate with faculty members of the ACH to develop a peer-facilitated course, known locally as the Communication in Healthcare (CIH) course. Improvements in patient experience data include:

•   statistically significant improvements in patients’ perceptions of excellence in survey domains directly related to clinician communication and completely under the clinician’s control

•   an 18 percent decrease in patient complaints for clinicians who participated in the communication course, when compared to those who did not¹⁰

In an effort to continue the internal development, two MCP trainers advanced to the ACH Faculty-in-Training (FIT) program, culminating in their faculty status with ACH. These local faculty were then able to assume full responsibility for the local MCP course and for the training of additional course trainers. The program has expanded beyond the fundamental course to address broader educational needs within the system. For example, trainers offer customized training for residents and fellows, assist with the simulation center, and guide implementation of the new interpersonal skills curriculum for the new Mayo Medical School.

CLEVELAND CLINIC

Cleveland Clinic (CC) is a large, nonprofit, integrated health system that is ranked as one of the nation’s top hospitals. Its national and international footprint has expanded year after year, and CC is well known for its drive toward innovation and quality. In the past, CC was less known for its patient experience.

In 2006, CC began a cultural shift toward empathy and teamwork. This shift is outlined in former CC Chief Experience Officer Jim Merlino’s book, Service Fanatics.¹¹ In 2009, CC doctor communication was at the 24th percentile of all U.S. hospitals, and multiple efforts were started to tackle this metric. Since physician communication training needed to be added to these efforts, a collaboration with ACH faculty began in 2011. In total, 17 individuals were trained to facilitate the Four Habits Model¹² during this collaboration. From 2011 to early 2013, these trainers helped teach communication skills to 900 CC physicians and scores improved to the 59th national percentile.[CMS data]

CC transitioned to the R.E.D.E. Model^SM of Communication¹³ in June 2013. It shares several well-known evidence-based best practices in communication¹⁴ and further builds upon the foundational concepts of relationship-centered care as highlighted by Beach and Inui.¹⁵ The R.E.D.E. communication program, known as Foundations of Healthcare Communication (FHC), explicitly and concretely aligns relationship-centered values and mission with the communication skills themselves.¹⁶

The R.E.D.E. FHC training debuted in June 2013 and became a CEO mandate for all CC physicians, necessitating the training of more than 3,000 physicians in seven months. A 2016 study¹⁷ found that full day R.E.D.E. FHC training led to:

•   higher adjusted overall doctor communication Clinician & Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) scores compared to controls (p<.03)

•   higher improvement in Hospital Consumer Assessmentof Healthcare Providers and Systems (HCAHPS) Respect domain score compared to controls (p=.015)

•   increased levels of empathy as rated by the Jefferson Scale of Empathy (p<.001)

•   decreased levels of burnout, as assessed with the Maslach Burnout Inventory for emotional exhaustion (p<.001), depersonalization (p<.003), and personal accomplishment (p<.04)

•   overall high satisfaction with the course itself, in many domains

These results were especially interesting in that physicians’ communication ability improved regardless of baseline CGCAHPS, specialty, and years in practice. Doctor communication ratings continued to improve and are at the 67th percentile nationally in reports for 2016.¹⁸

The Center for Excellence in Healthcare Communication (CEHC) continues the communication work initiated in 2009 and has currently trained more than 7,000 individuals, both internally and externally. While the cultural focus was originally on training physicians, CEHC embraces advanced care providers (ACPs) in this work. The FHC course is a part of the onboarding process. An additional 58 Cleveland Clinic trainers, both physicians and ACPs, have been trained by CEHC faculty. As part of sustainability efforts, trainers receive quarterly faculty enrichment days and new trainers are recruited and trained every 18 months.

With the R.E.D.E. Model as a foundation, CEHC has created nine additional R.E.D.E. half-day courses. To keep the learning engaging and experiential, CEHC has deepened its expertise in unique teaching methods, such as warm-ups, sociodrama, and improv. Online communication training has been developed to further enhance sustainment efforts. Additionally, CEHC provides individualized peer communication coaching, 10- to 15-minute learning bursts, and workshops created with departments around specific communication needs. Based on the experience of launching training for experienced clinicians, CC published a book in 2016 on key strategies and practical tips for designing and implementing a successful program.¹⁹

UNIVERSITY OF MARYLAND

With 43 academic units, a faculty of more than 3,000 physicians and research scientists, and more than $400 million in extramural funding, the University of Maryland School of Medicine (UMSOM) is regarded as a prominent biomedical research institution in the United States.²⁰ In March 2016, UMSOM launched an initiative that customized the standard ACH evidence-based curriculum within their Program for Excellence in Patient-Centered Communication (PEP).²¹

Despite concerns regarding the early mandatory nature of enrollment in this full-day program, even reluctant participants usually reported positive experiences. For example, initial participant feedback evaluations (n=115) reflect a strong positive response across participants:

•   87 percent of participants rated the course as good or very good

•   85 percent of participants would recommend the course to a colleague

•   81 percent of participants agreed that they plan to make changes in their professional work as a result of this training.

Even more important, CGCAHPS® results for the group of faculty physicians who participated in a PEP workshop (the coached group) indicate a promising trend. Prior to program launch, the coached group ranked in the 18th percentile nationally in the physician communication quality domain. By March 2017, the coached group improved to the 60th percentile and outperformed the group of faculty physicians who had not been coached by nearly 30 percentage points.

Of the six individual survey items that comprise the physician communication quality domain of CGCAHPS, the coached group made the most significant strides in the areas of listening carefully and explaining clearly. More specifically, performance on the survey item “provider gave easy-to-understand instructions” improved from the 20th percentile nationally in 2015 to the 79th percentile nationally by March 2017. Performance on the survey item “provider explained things in a way that was easy to understand” reached the 71st percentile nationally by March 2017, up from the 21st percentile in 2015. Finally, the survey item “provider listened carefully to patient” increased from the 13th percentile in 2015 to the 63rd percentile in March 2017. These early outcomes have encouraged the institution to reinvest in the program by recruiting a new cohort for the TTT process and exploring ways to expand the program to other members of their healthcare teams.²²

SAN MATEO MEDICAL CENTER

San Mateo Medical Center (SMMC) is a public general medical and surgical hospital in San Mateo, CA, with 137 beds. Survey data for the latest year available shows that the hospital had more than 3,500 admissions.²³ SMMC started their TTT program in June 2016. Trainers were strategically selected across specialties and departments, and to include various leadership roles. Program efforts have shown excellent success. By May 2017, trainers trained more than 80 percent of their primary care providers. The program is currently focused on specialists and emergency department clinicians.

SMMC reports a steady improvement in their CGCAHPS scores in the provider communication section, leading to a steady improvement in “likely to recommend” scores for the ambulatory department.

Engagement scores for providers have also steadily improved since the communication program launched. For example, the net promoter score for the question, “How likely are you to recommend SMMC as a place to work?” has increased by 11 points, and the score for the question, “How likely are you to recommend SMMC as a place to come for care?” has increased by 16 points.

WAKE FOREST BAPTIST HEALTH SYSTEM

Wake Forest Baptist is an integrated system in Winston-Salem, NC, that operates 1,000 acute care, rehabilitation and psychiatric care beds, outpatient services, and community health and information centers.²⁴ With enthusiastic support and solid financial backing from senior health system leadership, the Program to Enhance Relationship-Centered Care (PERCC) began in January 2016 and went “live” in March 2016, facilitated by a cadre of nine physician trainers representing internal medicine, hospital medicine, surgery, pediatrics, and critical care/anesthesiology. As of May 2017, more than 300 physicians, 125 advanced practice providers (APPs), and more than 70 nurses, healthcare educators, and senior residents have attended workshops. Although there was some initial concern about blending audiences, PERCC workshops engage a mix of providers (e.g., nurses, APPs, and physicians), which has promoted understanding and mutual respect.

Positive reviews by respected senior clinicians earned credibility for PERCC, and attendees consistently rate PERCC the “best faculty development program we’ve ever had at Wake Forest.” While enrollment is intentionally voluntary, several departments count PERCC attendance toward the “quality component” of their compensation plans. Testimonials that “PERCC works” were confirmed by patient experience surveys for the initial 70 ambulatory physician attendees. In the first six months after attending a workshop, physicians saw a significant improvement in their CGCAHPS scores on “Provider Communication Quality” when compared with a control group of non-attendees (p=0.026).

With the aim of establishing a common communication language across every facet of the health system, PERCC was incorporated into the communication skills curriculum for Wake Forest medical students (2016) and the Physician Assistant Program (2017). PERCC workshops have been tailored to fit the needs of two major residency programs (internal medicine and emergency medicine), with more programs starting each year. Trainees, nurses, and faculty working together in clinical settings are applying communication approaches learned in PERCC to the care of their patients.

TEXAS CHILDREN’S HOSPITAL

Texas Children’s Hospital (TCH) in Houston, TX, is consistently ranked among the top children’s hospitals in the nation.²⁵ In late 2015, TCH launched an initiative called Breakthrough Communication. Anticipating future public reporting of CAHPS Child Hospital Survey results, the program’s goal is to reinforce the practice of relationship-centered care to improve and ensure consistency of care coordination systemwide.

After conducting focus groups with patients and families, TCH created a curriculum that incorporated the stakeholders’ expressed needs and expectations. This customized relationship-centered communication training includes addressing the different ages and stages of pediatric and obstetric patients. The program also emphasizes a triadic method of communication (patient-family member-provider) as opposed to a dyadic method (patient-provider) seen more commonly in predominantly adult populations.

The hospital selected 13 providers to participate in the ACH-sponsored TTT program in order to teach Breakthrough Communication to the rest of its physician staff. Trainings began in July 2016, and in the first nine months, they trained more than a third of the medical staff. Feedback from providers has been extremely positive and enthusiastic, as the training provides tools to benefit patients as well as providers’ daily encounters.

Early results show:

•   over 90 percent of participants said the skills were relevant to their practice and have implemented them in their activities

•   a statistically significant reduction in physician burnout, as measured by the Maslach burnout inventory three months postsurvey

UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

The University of California, San Francisco (UCSF) Health System, associated with an academic center that is ranked annually among the top 10 hospitals in the nation, is an integrated healthcare network serving multiple inpatient and outpatient sites across the San Francisco Bay Area. In late 2015, UCSF launched a TTT program and has now trained hundreds of providers across mixed specialty areas. Participants attend on a voluntary basis and are encouraged to do so based on professional development goals, rather than on patient experience data incentives.

Similar to the feedback reports we collect from participants attending ACH courses at various institutions across the United States, feedback samples were provided by participants after attending the one-day UCSF course.²⁶

Multiple participants note the impact on the quality and effectiveness of their care of using the communication tools. For example, by asking a patient for a list of topics to cover, an otolaryngology physician assistant elicited the patient’s concern for a skin lesion that wasn’t the original reason for the visit—and made a new diagnosis of an intranasal melanoma. Another noted a conversation with parents about placing tubes in the ears of their child, a procedure that was recommended but had not been acceptable to the parents after several visits with other colleagues. Using empathy and eliciting the parents’ perspective, the provider found that the parents’ position on the procedure changed easily, allowing them to move forward with the indicated procedure.

The TTT program also enables local trainers to continue advancing communication skill improvement, beyond simply offering the one-day course. At UCSF’s Center for Enhancement of Communication in Healthcare, 90-minute sessions allow participants to build on their learning from the foundational one-day course. These courses help learners to delve deeper into specific challenges in communication and follow the same structure of brief didactic material introduced in small group settings with emphasis on skills practice. Four “microskills” courses are now available: Anger, Conflict, Breaking Bad News, and Feedback.

UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES

The University of Arkansas for Medical Sciences (UAMS) is the state’s only health sciences university; it is composed of five colleges (Medicine, Nursing, Pharmacy, Health Professions, and Public Health), a graduate school, and the UAMS Medical Center (hospital and associated ambulatory practices). Following an ACH-led TTT program and certification in late 2016, 12 carefully recruited UAMS “Communication Champions” began delivery of the program, known as MASTER Classes (Mastering Advanced Skills To Enhance Relationships). In February 2017, faculty physicians and advanced practice staff began attending the class. House staff started participating in the program in June 2017.

Outcomes from the first quarter of MASTER Class training have been very encouraging, as seen in the feedback responses from a sample of 175 participants²⁷:

•   93 percent assessed the education material as “helpful”

•   90 percent of those participants rated the course as “excellent” or “good”

•   88 percent strongly agreed or agreed that what they learned in the MASTER class will allow them to make helpful changes in the way they interact with patients, staff, and trainees

Anecdotally, the Champions have observed that a significant number of participants start the day skeptical about the value of the class and are reluctant to give up a full day of clinical practice. Almost invariably, attendees leave intrigued by the utility of the new communication framework and skills they have practiced to do their most fundamental work: connect with patients in a way that enhances clinical outcomes, patient satisfaction, and provider satisfaction. Comments on the course evaluations frequently credit the skills of the Communication Champions, who make the learning immediately credible and relevant to clinical practice. Educational leaders in the College of Medicine are incorporating the ACH model into the medical students’ communication skills curriculum. There are conversations about adapting the model for use with teams from clinical units across the hospital and ambulatory practices.

ZUCKERBERG SAN FRANCISCO GENERAL

Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) is a Level I trauma center and safety net hospital staffed by University of California, San Francisco faculty and trainees in collaboration with the San Francisco Department of Public Health. The hospital’s ACH train-the-trainer program launched in 2014, and the relationship-centered communication (RCC) program has seen steady growth since.

A distinguishing focus of the ZSFG RCC program is its application to interprofessional teams (see Chapter 12). All members of the healthcare team are welcome to ZSFG’s RCC workshops, and customized workshops are offered for intact teams, including coordination of RCC retreats for as many as 75 participants from primary care clinics. Preparatory needs assessments coordinated by team leadership enable trainers to focus workshop content and skills practice effectively. Prework identifies a team’s strengths (e.g., appropriate collaboration to address lengthy patient agendas), as well as opportunities for intentional improvement and practice (e.g., direct team communication when perspectives differ).

Zuckerberg San Francisco General Hospital and Trauma Center has made three revisions to the core RCC workshop: (1) didactic presentations using language inclusive of all participating team members; (2) trainer demonstrations of fundamental skills using team-based scenarios; and (3) small-group skills practice structured to balance participation across roles. Examples of team-based scenarios used for demonstrations include following a patient from registration with a clerk, to screening by a medical assistant, to the exam room with a physician, and, finally, to discharge teaching with a nurse. Alternatively, application of RCC to challenging team encounters may be demonstrated: a typical instance could be a charge nurse using open-ended questions and empathy (see Chapter 4) to explore a resident physician’s concerns about clinic workflow. Small-group assignments are designed to optimize a collaborative, interprofessional learning environment and, in the case of intact teams, allow for facilitated skills practice of cases faced jointly by team members on a day-to-day basis. This learning environment provides teams with opportunities to strengthen not only communication skills but also relationships.

Qualitative feedback from participants supports the utility of these sessions. One nurse manager related, “Now all members of our team, from clerks to nurses to physicians, have a shared vocabulary to help us create a more welcoming environment for patients and staff alike.” More specifically, participants recognize that effectively eliciting perspective with open-ended questions and listening in response are skills relevant to both patient and team interactions: “I will be more intentional in my interactions with colleagues and also more proactive in reaching out to staff to elicit feedback.” From another participant, “The RCC skills help me to step back and slow down in order to really listen to my patients and coworkers. What I learn makes me a better educator and nurse.” Empathy for fellow team members may also be enhanced: “[I will] be more conscientious of the complexities of coworkers’ jobs.”

Creating a learning environment in which these insights are possible requires skillful facilitation, including attention to the impact of hierarchy and interventions designed to support engagement of all team members. Zuckerberg San Francisco General Hospital and Trauma Center continues to refine its efforts, which include professional diversification of the facilitation team itself. By fostering compassion and respect in all relationships, ZSFG seeks to enhance and accelerate the impact of its RCC program beyond provider change to culture change, which ultimately includes all team members.

Conclusion

A wealth of evidence across institutions and geographic locations supports the train-the-trainer program model. We now know that clinicians’ communication skills are teachable to clinicians across institutions and geography, that their increased skill levels lead to enhanced patient outcomes, and that customized solutions for institutions can succeed. When we train future trainers, allowing them to practice and receive feedback with increasing levels of autonomy, we arm ourselves with internal experts who can teach our clinicians and ultimately support the overall patient experience. The process of developing effective trainers is only one step in a complex journey toward improving overall experiences and outcomes. The successes of these program exemplars reflect the necessary strong commitment by organizational leaders and the trainers who deliver these programs.