Wednesday, December 16, 2015

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."

Wednesday, December 9, 2015

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."


Monday, November 30, 2015

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

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

Tuesday, November 24, 2015

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.



Monday, November 16, 2015

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!

Monday, November 9, 2015

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.

Monday, November 2, 2015

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.