More than Rounds

by Paul Uhlig

The topic this week is important. I have chosen to call it "more than rounds."

This title means that collaborative care is much more than making rounds together. The center point for understanding collaborative care isn't rounds, although rounds is important. Rather, the focus is on the care environment as a whole, and specific ways that the care environment can become smart and capable.

Collaborative care is created by careful attention to patterns of organization and shared routines in the care environment that, when present, allow the environment to become filled with highly developed team-level and program-level abilities.

To explore this further, imagine how an individual learns a complex skill, and then consider how similar mastery can be developed at the levels of a care team as a whole, and of an entire program.

To learn complex skills, people need: deliberate practice, opportunities for reflection, ways of measuring progress, and mentoring or coaching. Given these conditions, abilities will almost certainly improve. Taking abilities to a mastery level requires a pathway of development, and does not happen overnight.

In health care there is plenty of individual mastery. People don't get to work in health care without being well trained and well practiced in their individual professions. What is missing, though, so often in health care, are additional layers of mastery at the level of teams, and of programs.

It is instructive to consider what would be needed so that a care team could achieve mastery in the same way that an individual person does. First, the team would need to have consistency and continuity over time, so there is a way for the team to learn and remember. With this in place, the requirements for achieving team-level mastery would be about the same as for individuals: deliberate practice (as a team), opportunities for reflection (as a team), ways of measuring progress (as a team), and mentoring or coaching (of the team as a whole).

Sports teams, of course, do this as a normal part of preparation for high level competition. But in health care, an orientation toward deliberate pursuit of team-level mastery is rare. Instead, people are often assigned by role and then are asked to do their best--with little attention to team-level and program-level abilities that could profoundly influence their work together.

Collaborative care intentionally considers and optimizes all of these levels.

Imagine that you are hovering over an exceptional collaborative care team doing its work. You have chosen to study this program because of its reputation for excellence. This is what you will observe:

Conversations flow effortlessly. Patients and families are actively engaged. Assessments and plans are made by everyone together. Laughter and the warmth of human connections are woven throughout every interaction. Outcomes are spectacular, complications are low, readmissions are rare, patient satisfaction is off the charts, the environment is highly desirable for attracting and retaining employees, and costs are among the lowest anywhere. You want your own care environment to be exactly like this. You have finally seen a place where you can be the practitioner you always hoped to be.

What is happening that enables care here to be so remarkably good? How can care like this be created?

Achieving this level of mastery requires intentional, optimized design of the care environment as a whole. It is structural more than behavioral, and takes time to develop. It is absolutely achievable. It is much more than rounds.