Which team would you choose?

by Paul Uhlig

Our Tidbit this evening continues to explore team-level learning.

For tonight's Tidbit, imagine you or someone you love needs the care of a Code team. Three teams come running. You get to choose which team you will invite into the room.

All three teams have similarly capable individual members.

The first team is made up of people who don't work together on a regular basis. They are assigned to respond to codes based on their professional roles. When a code call comes in, a pharmacist responds, a critical care nurse arrives, and a doctor, a chaplain, a respiratory therapist, and so forth. Each person is very well trained individually. If you invite them in, they will do their very best.

The second team is also made up of good people. However, the members of the second team have been assigned to work together for an entire month at a time. When a code is called during the assigned month, this team always responds together. As the month has progressed, the members of the second team have become increasingly comfortable and better working together. It is now three weeks into their month.

The third team is also made up of good people who have also been assigned to work together for a month at a time, just like the second team. However, the third team begins every day by meeting to discuss and practice how they will respond when the next code call comes in. And, each time they do care for a patient, they sit down together afterward and reflect about the care they provided. They also ask the patients and families about their experiences. They reflect as a team about what they do, visualizing, exploring, and testing how they could do an even better job next time, as a normal part of their work.

Which team would you choose to care for you or someone you love?

This is an easy question, of course. Most people definitely choose the third team. Why? Because it seems pretty obvious that the third team will do a better job.

The third team has acquired additional abilities beyond their individual skills. Structures and routines are present that allow this team to develop and grow through team-level learning - in ways the first team can't, and much faster than the second team.

The point of the Tidbit is this question: Is your care environment organized to support the first team, the second team, or the third team?

It is startling how many care environments are organized in ways that produce care likeTeam One, and how few are organized to create care like Team Three. The potential is there, just waiting.

We can see that it would be better to have a Team Three, but, for many reasons, the changes that would bring Team Three to life are not yet common.

Is it hard to restructure a care environment so that it supports team-level learning? Well, sort of...but it can certainly be done. Is it worth it? Yes, definitely!

What can you do to set the stage for team-level learning in your own care environment?

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.

Collaborative Care - Are the Challenges the Same Everywhere?

by Lhuri Dwianti Rahmartani and Paul Uhlig

Today’s Tidbit is from a young physician leader from Indonesia.

Lhuri Dwianti Rahmartani and two of her sisters, who are also physicians, attended All Together Better Health VII in Pittsburgh two years ago. At that time, Lhuri was President of IYHPS, Indonesia’s Young Health Professionals’ Society.

Lhuri wrote recently with some questions about collaborative care. She has given permission for me to respond to her questions as a Tidbit:

Dear Paul,

How are you doing? I hope everything is going well for you. I've been a silent reader of the weekly tidbits. Although I sometimes missed an e-mail or two and didn't contribute much to the discussion, it's always a pleasure for me to read it. So thanks a lot for adding me to the list! :) …

I would like to ask a few questions. I am looking for your perspective and suggestion about the role of facilities and culture in establishing collaborative care.

Firstly, I think providing collaborative care would be a lot easier when all the facilities meet the standard. In my opinion, it may be harder for people in poor facilities with limited resources and overload patients to create such ideal social field model. Healthcare providers may have to deal with stress factors that come from overcrowded wards, substandard equipment, low incentives, etc. They might even skip meals and have no time to take care of themselves. In this case, finding a moment to sit together, relax, and discuss about GLITCHs might not be as easy as described. Do you have a recommendation or suggestion for this situation?

Next, considering culture, I think it is important to talk about health literacy. Ideally, patients and families are part of the team. However I find involving patients and families in the care can be difficult when they are not very health-literate. Please correct me if I'm wrong. I guess in the US and other developed countries, cooperating with patients are made more possible since they mostly know what's going on with their body. In developing countries like mine, often you'll meet patients and families who are very clueless about their condition and would solely rely on the doctors' order.

I personally want my patients to understand why and how they are being treated. But explaining the rationale behind treatments may take up more time and sometimes are not very useful. If you ever encounter this kind of situation, I'd be happy to hear your strategies :)

There are several more notes that I'd like to share but I guess that's it for the moment. Please accept my apologies for taking ages to write. I've been meaning to do so but I've been busy focusing myself being a clumsy new mother in the past 9 months. Now it's midnight and my son is asleep so I finally get the chance to write this e-mail.

Thank you again for staying in touch.

With best wishes,

Lhuri

_________________________

Dear Lhuri,

 How exciting about your new son! Thanks for allowing me to share your message as a Tidbit.  Your questions are very interesting and important.

 
Your first question is familiar. To paraphrase, you ask: “How, in the impossibly busy life that healthcare requires, can people ever find time to sit together, relax, and discuss their work?”

 
I haven’t been to Indonesia to experience the challenges you describe firsthand. However, I know that here in the US, most people experience a similar sense of not having even a minute for themselves. And, during frequent conversations with a care team from the UK, those practitioners also describe similar overstressed conditions. I wonder if feelings of stressful overwork are part of health care everywhere right now. I will answer based on what I know in the US and from conversations with my friends in the UK, with the possibility that there may be similarities for you as well.


What I have experienced is that, at first, most people can’t imagine they could possibly find regular times to talk together about how care could become even better. Then, when somehow they do make time, these moments become among the most valued and protected times of their week. As people do find ways to connect and reflect, their time together becomes a treasured place of healing and solace and hope in their busy world. Their work starts having new meaning. So my advice is, just try it and see what happens! I think you will be surprised.

 
Your second question asks: Is collaborative care easier in places where people are more health-literate?

 
Interestingly – and perhaps surprisingly – I have come to believe that the most important part of health care isn’t the how or why of particular treatments. Instead, I increasingly believe that what matters most in health care is establishing human connections. After connections have been created among people, remarkable things become possible that were simply not possible before. The new things can be health literacy, and anything else you hope to accomplish. This insight, which was very surprising at first, is that what really matters for care – the thing that is truly foundational – is connections. Collaborative care has taught me that health and healing begin with this.

 
From this perspective, it is not a great worry if health literacy is missing or not at first. As connections are established, learning and literacy have a safe new home. And from that, all sorts of things become possible. I’m not sure whether people know more about their health in the US than in Indonesia, but I do know that, even in the US, most patients and families are overwhelmed as they struggle to understand and respond to a major illness. As connections are progressively established, everything becomes better – including learning and health literacy.


And, I should emphasize that learning and literacy in collaborative care are multidirectional. Rather than health professionals teaching patients in a one-way flow, everyone learns and teaches together in collaborative care, about all sorts of things. This shift – from one-way teaching to multidirectional learning and teaching – is very noticeable. It is central to the richness of collaborative care.


So my response is: I’m not sure if health literacy matters as much as it might seem at first. Rather, the foundation of care seems to be connections. Start there, and you can go anywhere.

 
I look forward to many more conversations as you carry this work forward.

 
Warmly,

 
Paul

Collaborative Care Learning Network

by Paul Uhlig

I have had the most delightful time over the past several weeks updating a list of people who may be interested in participating in the Collaborative Care Learning Network. I have been going through old emails and past meeting notes, remembering so many wonderful people - all with such a richness of ideas, varied and fascinating personalities, and shared passions for creating better care.

If you are receiving this email and haven't heard of the Collaborative Care Learning Network before, please know that your name has been tenderly harvested from these memories and past connections, and that you are warmly invited to participate in a growing, international community of people and places interested in learning together about collaborative care. If you already participate, wonderful!

Sometime in the next few weeks you will receive an email asking if you would like to participate in the email discussion forum of the Collaborative Care Learning Network.

I hope you will take a few minutes to browse through the website www.createbettercare.org, view some videos about collaborative care, read some posts from the Tidbits Blog, and download helpful resources such as the Field Guide to Collaborative Care, which are available without cost on the website. You may want to learn more about or make plans to attend the Second Annual Meeting of the Collaborative Care Learning Network, which will happen February 23-25, 2017, in San Antonio, Texas.

Mostly, though, I hope you will decide to continue to be part of this discussion forum, and that you will feel welcome to contribute your experiences, curiosity, wisdom, and expertise with a growing group of people committed to sharing ideas and learning together about how health care can become even better through collaborative approaches. There is no cost, and no obligation to participate. Just select "yes" when the invitation email arrives, and your name will remain on the email list. If you know someone who might also be interested, please feel free to share a link with them, too.

And, if you would like to write personally to renew or deepen our friendship, I would welcome it!

Collaborative Care Learning Network

by Paul Uhlig

Hi Everyone,

 

I have heard from so many of you about how much you miss the Tidbits, and how important these regular connections are for our work together.

 

After a little time to recharge and renew, I am writing with good news about the Collaborative Care Learning Network! It is alive and growing!

 

In the next few weeks I will write again with more information about some exciting developments and new activities -

 

1.      a new website is almost ready that will be a beautiful, welcoming home for all of us and our work together

2.      a better Tidbit Forum is being developed that will let us share ideas more easily

3.      a new series of web calls hosted by Jane Taylor will start soon so we can connect live

4.      a new webinar series on Collaborative Care will begin in September 2016. The first is called "The Basics - Getting Started" 

5.      planning is underway for the Second Annual Meeting of the Collaborative Care Learning Network  which will be in San Antonio in February 2017

       - please reply to this email if you would like to be part of the planning committee!!

 

Also, some really great meetings are happening this summer and fall that you may want to attend:

 

      - 7th Annual Meeting of the Institute for Patient and Family Centered Care (New York, July 2016)

      - All Together Better Health VIII - Values-Based Interprofessional Practice and Education (Oxford, UK, September 2016)

      - Taos Institute Meeting on Relational Practices in Health and Healthcare (Cleveland, November 2016)

 

Finally, to renew our Tidbits you might enjoy watching these YouTube videos of collaborative rounds in Salina, Kansas. Turn  up the volume a little because the iPhone audio recording is not perfect, and the video is in two parts because the phone stopped recording. But it will give you a good picture of what one care team is trying to do every day.

 

Watch especially the warmth and participation of the patient and family, who are in the middle of three weeks of being critically ill in the ICU with heart failure and kidney failure.

 

       Part 1: https://www.youtube.com/watch?v=hjpO0KKVoFo

       Part 2: https://www.youtube.com/watch?v=Zzw8jxHxnEM

 

Paul

Weekly Tidbit #12 - "One of the Best Gifts"

by Kana Kornsawad

            Hi everyone,

 

            I was attending on the collaborative care team last month and I would like to share tidbit from San Antonio. 

 

            One of the patients told the team that the thing she loves to do if she is not sick is cooking Thai and Indian food. The next day during our collaborative care rounds the intern who was taking care of her told the patient that he has 2 gifts for her. One is, she is clear for droplet precautions, and the second gift was the best Indian recipe that she can try after she gets discharged from the hospital. She looked at everyone in the room and started tearing up. She said " Thank you for all of these, they are one of the best gifts." 

 

            "The Collaborative Care model helps to create a compassionate environment where the physician and patient can learn from each other."

 

            Kana

 

Weekly Tidbit #11 -- Letting go

by Paul Uhlig

In the evolution of collaborative care programs, a common question is often heard that arises from a sense of time scarcity and overwork. The question is, "Who needs collaborative care, and who doesn't?"

When this question is asked, it usually comes with a perception that collaborative care (the bedside rounds part of collaborative care), takes a long time, and that more familiar, "non-collaborative" care, is faster and easier.

If you find your team asking this question, you might want to reflect about what this question is telling you. At least operationally, this question is saying that your team is standing with its feet in two worlds. The problem with working partially in a collaborative way and partially in a traditional way, is that your team is therefore carrying and using patterns from both approaches, patterns which are quite different and often fundamentally conflicting. Keeping and using two entirely different sets of discordant patterns, cycling between them while maintaining both, is a fatiguing burden. Having and using two patterns is probably keeping your team from reaching a smooth new collaborative efficiency -- an efficiency that will become available only when your team is able to let the old patterns go.

The responsibility of caring for patients is one of the greatest and most sacred things that a person or team could ever do. Teams approach that responsibility calmly, in part, because of the comfort of familiar patterns they know and trust. It is terrifying to let go of the patterns that we were taught and that we rely on to do our best. "Believing" in collaborative care involves a leap of faith and a commitment to new patterns, trusting that they will help us meet our responsibilities in even better ways.

The next time your team asks, "Who needs collaborative care, and who doesn't?", try this answer: "Everyone needs collaborative care."
 
Ask yourselves, "What can we do differently? What patterns can we rearrange throughout our day so we can make this happen?" 

There is a saying worth remembering: "If you want to go fast, go alone. If you want to go far, go  together."

Weekly Tidbit #10 - Care that touches everyone

by Paul Uhlig

 

The topic of rounds today is gravy. 

 

Thanksgiving is only two days away. The exploratory procedure planned for a brief hospital stay had become a much longer recovery with no end in sight. The nurse practitioner is sitting near the end of the bed cradling her tablet computer with labs and vital signs, but her attention is devoted to a heartfelt story of gravy anxiety. The husband and others are listening and nodding. The patient's daughter has mastered the intricacies of raising three young children, but gravy making remains a mysterious, unsolved art. Grandma will not be home in time to provide the magic.

 

Fast forward three days. Rounds begins. "How was the gravy?" "It turned out great!" is the happy reply. And then another gravy story, this time from the doctor. His family's gravy exploded yesterday. The Pyrex dish wasn't Pyrex. Gravy and glass flew everywhere, over the turkey and the pies, flooding the stove and spilling over the floor. Thankfully, no one was hurt. Thirty minutes later the kitchen was spotless again, the food was carefully cleaned, and a wonderful dinner was enjoyed with much laughter and new memories. Connected by gravy.

 

Fast forward three more days. Rounds again, this time with an entire extended family present. Several little ones are moving from mother to grandmother to grandfather. Members of the care team are sitting in the morning sunshine by the window. Progress is reviewed. Plans are made. Laughter is shared.

 

A few minutes later, as people prepare to leave the room, the littlest one present, a three year old granddaughter, raises her head which had been nestled in her mother's shoulder. She looks around the room at each person, smiles, and says, "Thank you for helping to care for my grandma."


    

Weekly Tidbit #9 -- Setting the Stage for Collaborative Care, and Assessing Progress

by Paul Uhlig

Tomorrow, December 1, the collaborative care team in San Antonio will be devoting an entire day together, reflecting on their past year of implementing collaborative care. Part of their reflection will be guided by two inventories that were developed to help teams with this important work.

This week's Tidbit invites you to use these inventories to reflect about your own care environment, in the same way the San Antonio team will be doing.

One of the inventories is called the Collaborative Care Activation Inventory (CCAI). The items in the activation inventory are "preconditions" that can intentionally be put in place to help support the development of collaborative care. If present, these preconditions are believed to make the emergence of collaborative care more likely.

The CCAI inventory is a guide for action, helping teams recognize and strengthen any preconditions that may be missing or underdeveloped in their care environment. The Social Field Model of Collaborative Care emphasizes the importance of these preconditions for implementing collaborative care -- put them in place, then believe/trust/know that collaborative care is highly likely to emerge. If these preconditions are not present, other well intentioned actions such as team training, safety initiatives, and similar efforts to improve team-based care are not as likely to have a lasting impact.

The other inventory is called the Collaborative Care Resource Inventory (CCRI). This inventory was developed to help care teams assess progress toward collaborative care by looking at the development of socially constructed "resources" in their social field. You can think of these resources as team-level capabilities for collaborative care that develop over time as a care team becomes progressively able to work well together. The resources assessed by this inventory were identified by interviews with highly developed collaborative care teams, and seem to be hallmarks of exceptional collaborative care.

In other words, and, to use a garden metaphor -- the Activation Inventory (CCAI) offers guidance about how to plant your garden (prepare your environment for collaborative care), and the Resource Inventory (CCRI) helps you assess the beauty and bounty of what you are producing there.

Both inventories can be downloaded using the links below, and are also available on the Collaborative Care Alliance website at www.createbettercare.org

Collaborative Care Activation Inventory (CCAI)
Collaborative Care Resource Inventory (CCRI)

Weekly Tidbit #8 -- Richness of Communication

by Chris Moreland

 

Hi Everyone,

 

Our weekly Tidbit this week is from Chris Moreland, a hospitalist attending physician in San Antonio. Chris wrote recently about collaborative care with a patient whose primary language is Spanish. 

 

His note is interesting and prompts thoughts about all of the ways that people communicate, the importance of respect-filled interactions, and the richness of communication that is possible in collaborative care.

 

Chris wrote:

______________

 

            Hi, all:

            Health disparities are well documented among people who speak a language other than English. I wanted to share a particularly striking experience during my last week of collaborative care in September, when our team took advantage of opportunities to work with our Spanish-speaking patients on their own terms (figuratively and literally).

            On Tuesday that week, we scheduled UH's staff Spanish interpreter, Irene Jiminez, to join us while visiting one of those patients. Before we entered the room, she laid out some crystal clear ground rules (eg, speak directly to the patient). During our discussion, the patient and his family members ended up switching between both languages, so she interpreted when needed and monitored the discussion otherwise. While it was a bit chaotic with 15 team members and varying levels of Spanish usage, it was nice to see our focus switch from our favored English more toward their primary language.

            Later in the week, we spoke with our non-interactive patient's mother, who spoke only Spanish. We decided beforehand that her primary intern, Jose, and Tiffani (who all speak Spanish) would manage the collaborative care conversation with her, while the rest of us observed. Todd wrote notes on the paper in Spanish and summarized for us. (See the attached photo.)

            On Friday, we were unable to secure an in-person interpreter, so we communicated through an over-the-phone interpreter, with Jose scribing and summarizing. While the phone protocol took a while, it did force us to stay on-message and limit tangential comments.

            The literature on communicating with limited-English proficient patients often addresses three methods: in-person interpretation, over-the-phone interpretation, and language-concordant providers. I'm proud to say that the team successfully used all three methods during collaborative care rounds, inching ever closer to true patient-centered care.

            Thanks,

            Chris

Weekly Tidbit #7A - Helpful Routines

Angela Zarnoti

This weeks' Tidbit is from Angela Zarnoti, business manager for the Hospital Medicine division at UT San Antonio.

Angela has been an active participant in implementing collaborative care there this past year, helping in many ways including planning, meetings, coordinating schedules, arranging filming of educational videos, and acting in the roles of patient and family member for many of the implementation simulations.

Recently Angela visited a friend in the hospital. 

This is her note:

            Just last weekend I was visiting a “sorta” family member in the hospital and had the oddest sensation. I kept looking over my shoulder to see the “poster paper-white board” with all the info and plans and tests and updates!  Alas, there just wasn’t one there……. even after looking back several times!!

 

            What a shame, since the patient wasn’t sure of much.  She had just learned she had major cancer problems. She couldn’t remember where all the cancer sites were, or when the oncologist was coming or what the plans were.  Other family members were flying in and they would have the same experience of not knowing any details. She was at a well-respected hospital and she liked her doctor that she had just met. But it felt just so lonely and disjointed compared to what I’ve seen Team 3 give.

 

            I guess it was like a Reverse Tidbit!

 

            Angela

Weekly Tidbit #7 - Reliability, continued

by Paul Uhlig

 

Collaborative care creates a stable, rich tacit knowledge environment that otherwise doesn't usually exist in health care. This shared environment of trust and learning grows over time if conditions are in place and right for that, and helps make reliable, safe care possible.

 

This week's Tidbit is the last in a short series on reliability. The main lesson of this Tidbit is the importance of team-level tacit knowledge for achieving reliability. Explicit knowledge is knowing "what." Tacit knowledge is knowing "how." Team-level tacit knowledge means, "knowing how, at the level of the team itself."

 

In traditional health care, a care "team" may not really be a team at all. Various health professionals on any given day may never have worked together before, and may not work together again. The patient's nurse may never see the doctor; the pharmacist may never see the nurse, the respiratory therapist may never see the social worker, and so forth. Health professionals may know the patient mostly from the perspective of their area of expertise and task. It is not uncommon that people in traditional health care interact only through notes and explicit instructions left in the patient's record (orders).

 

Viewed from the perspective of each individual, there is a lot of individual tacit knowledge in health care. People have learned how to do their individual jobs well, in highly developed routines. Yet, if viewed from a perspective of the team itself, there is much less tacit knowledge. Team-level knowledge requires consistency and learning to develop, and practice to maintain. Achieving reliability requires connections and integration that bring together disparate experiences, understandings, and goals, so that a composite picture of events emerges that the team as a whole is aware of and can account for together. Traditional health care assumes that team-level awareness and coordination depends on explicit knowledge, and tries to accomplish this by carefully specifying everything in written notes and orders. Collaborative care makes a different assumption: that the team-level coordination needed for reliability depends mostly on tacit knowledge, and that this team-level tacit knowledge arises over time if conditions are in place and right for that.

 

This distinction, between relying on explicit knowledge for coordination, or building environments where people are able to coordinate their actions almost effortlessly by relying primarily on rich tacit knowledge that has developed within the care team itself, is one of the most important differences between traditional care and collaborative care. Of course, explicit knowledge is important. But, when there is a foundation of rich, team-level tacit knowledge, the explicit knowledge that matters is easy to identify and use by the care team. Without a rich tacit foundation, people may lose sight of what truly matters.

 

Think of it like this: Here, on this hand, are the things we want always do for every patient. Here, on this other hand, are the things we want to do, uniquely, just for this particular patient. Reliability requires doing both of these things well. Having a rich context of team-level tacit knowledge makes routine things truly routine and effortless, so that the unique things - things that actually do require explicit knowledge - can be more easily seen and accomplished.

 

Envision your care environment. In your mind's eye, consider how your team works together. How does your team-level coordination feel? Think about how well information and coordination flow through your team (or not!), and whether this feels like "riding a bicycle" (effortless and intuitive--tacit knowledge at work!), or like the struggle of learning how to ride a bicycle (explicit knowledge doesn't work very well for activities that depend on tacit knowledge).

 

As yourself, "What if reliability requires rich team-level tacit knowledge - rather than explicit knowledge (notes and orders)? What would it take for team-level tacit knowledge to grow and develop for our team? Is our care environment intentionally designed to make that happen really well?"

 

__________________

 

 

Teaching a child how to ride a bike:

1. Find a grassy field with a gentle downhill of 30 yards or so, that then flattens out or goes uphill slightly.  Ideally the grass is short enough that it doesn't create too much drag on the wheels, but still can provide a soft landing in case of a fall.. A hard surface learning area can also be used, but it should have only a very slight slope - almost flat.
2. Go about 15 yards up the hill.  If necessary, hold the bike while the student gets on.  Have him or her put both feet on the ground, then you should be able to let go of the bike and nothing should happen. Praise the learner.
3. Have the child lift his or her feet about an inch off the ground and coast down the hill or scoot along.  The objective here is to get a feel for balancing on the bike.  Try to resist holding the bike to steady the learner.  Because the bike will coast slowly, the cyclists can put his or her feet down if they get scared.
4. Repeat until your student feels comfortable coasting and doesn't put his or her feet down to stop.  Throughout the progression there is no need to rush moving on to the next step.

Add pedaling:

1. Reattach the pedals.  Now have your student put his or her feet on the pedals and coast down.  First just one pedal, then both pedals.  After several runs, have him or her begin pedaling as he or she is rolling.
2. Repeat coasting/pedaling until the bicyclist feels comfortable, then move up the hill. 

Riding in a straight line:

1. Go to a flat part of the field and practice starting from a standstill, riding in a straight line, stopping, and turning.
1. Starting from a standstill - Start with one pedal pointed at the handlebars (2 o'clock -- the power position).  This gives the rider a solid pedal stroke to power the bike and keep it steady until the other foot finds the pedal. Childs tend to want to rush and take short cuts on this and get off to very wobbly starts. Work to have them develop habits so that they consistently get smooth steady starts.
2. Riding straight - Look straight ahead.  Keep the elbows and knees loose and pedal smooth circles.  When a novice rider turns his or her head, their arms and shoulders follow, causing the bike to swerve.
3. Stopping - Apply both brakes at the same time (if the bike has both front and rear brakes).  Using just the front brake can launch the rider over the handlebars.  Using just the rear brake limits the rider to just 20 or 30 percent of braking power and the bike is more likely schild.

Add turning:

1. Turning - Initially, slow down before entering a corner.  Turning is a combination of a little leaning and a very little steering.  Keep the inside pedal up and look through the turn.  As confidence grows let the speed gradually increase.

Weekly Tidbit #6 -- Reliability, continued

by Paul Uhlig

This week's Tidbit continues a short series exploring the topic of reliability.

Last week we looked at data about improved reliability as collaborative care was implemented. Medications that should have been given to each patient, actually weren't given all the time until new collaborative routines were adopted.

The thought-provoking question from these data is whether care actions happen from precisely specified orders, or from something else in addition to that.

The power of "habit" and "what we always do" is quite important for how people work, in health care as in life in general. Collaborative care brings this power of habit to bear in ways that can be continually shaped and focused through ongoing conversations, shared reflection, and team learning. The care environment itself becomes capable of knowing, changing, and learning, elevating everything that happens there.

This week's Tidbit highlights the importance of conversations and social interactions for the ability to change routines, which is very important for improvement and learning.

The slide attached with this email shows data about time-to-extubation after heart surgery in the cardiac program in Concord Hospital (New Hampshire) as collaborative care was first being adopted there. The Concord cardiac program was part of a regional quality collaborative which allowed comparisons of quality data across other hospitals. During the time this data was collected, all of the hospitals including Concord were trying to shorten the time to extubation.

The data shows that progress toward this goal in the Concord program is quite notable compared to the other programs in the region. This wasn't because Concord was "better" -- there were great people at every program. What was different at Concord was that everyone who needed to work together to accomplish these changes -- nurses, anesthesiologists, surgeons, respiratory therapists, and others -- were able to meet and talk together on a weekly basis as part of the new collaborative care routines. These meetings created a safe and respectful forum where people could reflect together across professions and discuss ways to change their existing routines. People were able to monitor their outcomes, and talked together about this and other goals on a weekly basis. Through the shared learning that the conversations made possible, early extubation became a reliable and comfortable new routine in the care environment. It became "normal" to care for patients like this -- early extubation became a reliable new routine that happened every time. It didn't depend on orders. It was just what people were now comfortable doing, as a shared habit and expectation.

Collaborative care creates a stable, rich tacit knowledge environment that otherwise doesn't usually exist in health care. This shared environment of trust and learning grows over time if conditions are in place and right for that, and helps make reliable, safe care possible.

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