Monday, September 28, 2015

Weekly Tidbit #1 – Reflections on Collaborative Care

by Vicki R
Hi Everyone,

Tonight is the first Weekly Tidbit of the newly created Collaborative Care Learning Network.

This Tidbit introduces several perspectives on collaborative care. Tonight's Tidbit is an interview with the wife of a patient I am helping to care for in the intensive care unit where I practice. I wrote down her thoughts with pencil and paper this afternoon in her husband's room. He is critically ill, sedated on a ventilator. She has given permission to share these experiences and reflections with all of you.

Initially, her husband was cared for in a more traditional way by a very competent and caring cardiac surgeon who handed surgical responsibility over to me when it was my turn to be on call. My partner is very down to earth, and is thought of very highly by his patients and their families. He gave a careful sign out, reviewing every detail of the patient's medical condition and noting respectfully that the patient's family had some concerns that needed attention. At that point onward, we began using full collaborative care, similar to the collaborative care you saw in the simulations in San Antonio. Today is the fourth day of collaborative care.

As you read Vicki's comments, keep in mind that her husband has been cared for throughout his hospital stay by very good people who have worked hard to provide excellent care and to communicate with the family using patterns they are comfortable with. Her husband is still being cared for in the same intensive care unit by essentially the same people who have cared for him throughout his hospital stay...the only thing of significance that has changed is the pattern of care that is now being used. Over the next four weeks we will explore perspectives from other members of the care team, starting next week with thoughts from Noni, the chaplain.
Vicki – wife – reflections on collaborative care
            "At the beginning of this whole thing I felt very alone, very frightened, and I did not feel there was any kind of a resource for me to gain answers or to be able to even communicate. I felt that I was lucky if I managed even to find a moment with the physician or any of the medical personnel that were willing to answer my questions.
            I asked every shift of nurses to feel very free to call me day or night if I was not here. I wanted to be a part of my husband's illness and anticipated recovery. Several times I was called after the fact by a person that I did not know.  I did not feel that I could trust the very people that I needed to be able to trust.
            The turning point began when I talked with my family, and my son, Brad, who is a nurse, contacted the 'total care coordinator' for the hospital, asking for just what that person's title implied--coordinator.  So many people were working from so many directions that it was not possible for me to hear or see an overall picture. The care coordinator made the medical team aware of our discomfort and the lack of communication and sense of direction that we had.
            Now, everything is in motion. I watched that happen. It was effective immediately. What once felt random and seemed to lack direction and coordination now felt like a well-oiled machine. And that machine had heart (pardon the pun)!
            So, I could elaborate more, but it gave me new hope and new security and new respect for the medical team and the hospital.
            I love the introducing of each person, because that person immediately becomes a real person, not just a person in a white coat or nurses scrubs. Sitting down is so much more non-threatening. Its more friendly. I love the way the conversation is opened--thoughts and concerns are asked--I felt always a very kind and non-judgmental atmosphere.
            To me personally, the gathering around, laying of hands, touching the patient and each other, praying with the chaplain, made an unbelievable connection with each person there. I think it even made family members draw closer to each other and feel equally a part of the loved one. I like the board--because during all this you can feel so muddled. But the board is like a focus point that does just that--keeps you focused.
            The safety checklist--that is excellent. One of the things I appreciated, that I don't think has been done here with regularity, is not using restraints. I think they have been taught to use them. I said, 'He's been tied up. He's quiet now. Do we need to tie him up?' She said, 'OK, I just do it out of habit.' To me, I understand the need--it is very much a safety thing--but I worry it is put in place to make it easy.
            I think this is SO important. It is part of the medical science that is many times overlooked. I do know this much--from the time this was put in place there was a total change in communication. I had always tried to be sure they knew I was their friend, that I wasn't their adversary --how much I wanted to be informed of my husband's condition. My husband and I are hands on with each other in all things. With collaborative care we were given the opportunity to be present for rounds, which allowed us to not have to just hope that our paths might cross with assorted members of the medical team. Where before I was feeling disconnection and even anger at the care--in being able to watch all of the parts of the caregiving in one unit, with a mutual goal, I felt renewed confidence in the hospital setting.
            The start of collaborative care was an absolute turning point for our whole family. We were informed, we felt our loved one was valued, we were educated, we watched the team members educate one another, and many of the parts of our--many areas of our concern--were addressed including emotional and spiritual voids or gaps that we had been experiencing. A critical illness is not the time when that part should be turned off or unavailable.
            I would be honored to be a part of anything that would enable this to be offered to anyone. If I were part of a medical staff, I would love something like this.
            I've felt like this for a long time. My son had necrotizing fasciitis. He was in the ICU for several months. They would come in and say, 'We are taking him to the OR today.' There was no communication. Something like what we have put together here could have made all the difference."

Thursday, September 10, 2015

Preconference Tidbit #14 -- Trust

by Paul Uhlig

This final Tidbit prior to our meeting is about something precious – Trust.

Collaborative care happens in situations that are filled with vulnerabilities...for patients and families who are going through unprecedented stresses, and for professional care team members who must take down their professional guard and be authentically present as co-creators of care. Collaborative care requires everyone present to step forward into an emerging unknown together, despite their vulnerabilities. The interpersonal trust required for this can never be taken lightly.

Collaborative care can be trusted. Entered into with heart, belief, and thoughtful respect for others, the processes of collaborative care can be counted on to generate all the interpersonal trust that is needed for its success. Collaborative care can also be trusted to enable the emergence of answers to seemingly unsolvable problems, and creative options for care and healing, that, if faced alone, are difficult to achieve.

The more that a care team "believes" in collaborative care, the more it works.

Collaborative care can be trusted. Try it and you will see :)


See you tomorrow!! 

Tuesday, September 8, 2015

Preconference Tidbit #13 -- Laughter

by Paul Uhlig

Tonight's Tidbit is easy and short! It is simply this -- if you want to know if collaborative care is working, all you have to do is listen for laughter from the patient, family members, and other care team members on rounds. It is an unmistakable marker.

It may seem surprising at first that there would be laughter during something as serious as caring for a patient in the ICU. But joyful, comfortable laughter is something you hear very often with collaborative care. It is a reflection of the human connections that form, and the comfort people share together.

Preconference Tidbit #12 -- What pattern would you teach?

by Paul Uhlig

Yesterday's Tidbit contrasted two patterns for patient care, one traditional and the other collaborative. Tonight's Tidbit assumes that 1) you are a health care teacher, and 2) you are comfortable with both patterns.

The Tidbit tonight is a question...Which pattern would you teach your students?

A case can be made that teaching the traditional pattern is very important. Students need to learn the expected routines of their profession. For example, in the profession of medicine, the medical student is taught from day one that he or she will be "presenting the patient" on rounds, and there is an expected pattern that should be followed. It is what has always been done. It is part of learning to be a doctor. Learners will be judged and tested on their ability to present patients completely and concisely, using a traditional pattern.

Alternatively, a case can be made that the traditional pattern of presenting patients on rounds needs to be fundamentally redesigned for collaborative care. The traditional pattern that has been taught for years unintentionally produces distance from patients, and is highly physician-centric from the perspective of other health professionals. It doesn't serve collaborative care well. Something new and different is needed. A new kind of doctor is needed. The world is changing. We need to change with it, and help lead that transformation.

So, which pattern will you teach? As you think about this, don't forget that many forces are in place that support and expect a traditional approach to care. These include peer pressure, time pressure, standards for educational evaluation, documentation requirements for reimbursement, accountability standards for program accreditation, and expectations of learners themselves. Making changes in routines may be difficult.

As a way of seeing what others are doing, you might be interested in the video below.

Dr. Eric Warm is a Professor of Medicine and Director of the Internal Medicine Residency at the University of Cincinnati College of Medicine. The video shows Eric with a rounding team, conducting a simulation that explores an alternative approach for presenting patients at the bedside.

There is not an easy answer to this question, but collaborative care needs something different. We will explore this during our meeting.

Monday, September 7, 2015

Preconference Tidbit #11 – Lasting Connections…How they are built

by Paul Uhlig

Consider a story of two medical teams seeing patients in adjacent rooms. Both teams arrive on the floor at the same time, and leave at the same time. How they do their work is very different. Let’s watch.

Team A

Team A stands in the hallway while the intern presents the patient to the attending. In their pre-rounds meeting, the team decided to see this patient first, because the intern will be attending a conference in a half hour. The presentation is very thorough and there is a lot of interaction between the attending and the team. “So, what do you think is going on with the patient?”, the attending asks. “What are we going to do?” The intern presents a differential diagnosis and recommendations for a plan of care. The resident asks several clarifying questions. The attending turns to the medical student, asking, “So, why are we considering a paracentesis when we didn’t do that in the patient last week? What will we need to watch for afterward?” The attending listens carefully, teaches a little about liver disease, and then she asks another question of the intern, “What aspects of this patient’s presentation don’t quite fit together?”

After several minutes of additional discussion the team enters the patient’s room. The patient is alone. No nurse is present. No family is present. The attending and the intern stand by the patient. They are polite and respectful. The patient answers their questions. The intern tells the patient the care plan: “I have ordered a CT scan for later today. We are also going to draw off some fluid from your abdomen for tests.” The patient looks worried and is quiet. The attending asks permission to examine the patient and demonstrates a fluid wave on the abdominal exam. She asks the patient if he has any questions. He says, “No, but my wife was wondering when I will be coming home.” “We don’t know yet,” the intern says.  “We’ll have to see what the tests show. We should be able to tell you more tomorrow.” “I will call you when everything is set for the paracentesis,” the intern says to the attending. The team says goodbye and leaves the room. 

Team B

During exactly the same time, Team B is seeing a different patient with almost exactly the same medical problems. The patient’s wife and daughter are present. The patient’s nurse is present. The wife, daughter, and nurse are greeted by the rest of the team as they enter the room. Several people sit down close to the patient. The wife and daughter join the circle and to sit close to the patient. Someone takes a minute and brings an extra chair into the room. The medical student notices a picture of a young boy on the wall, and a crayon drawing that says, “Get well really fast, Grandpa!” The student smiles and says, “So you DID bring in Chase’s picture!” “Yes, he’s quite the guy,” says the patient. “My daughter and her family got in from El Paso yesterday. This is our daughter, Jeanne,” he says, smiling at her. “She is Chase’s mom.”

For the next fifteen minutes, a conversation takes place between everyone present, in ordinary language. Each person in turn around the circle adds thoughts and suggestions. Liver disease is discussed, a CT scan is decided on, a paracentesis is discussed and plans are made to do that later this afternoon. Several things are mentioned by the nurse that result in changes in the sequence of several tests. A medicine is changed because the patient’s wife remembered how weak it made him feel several months ago at another hospital. A safety checklist is reviewed and blood clot prevention medicines are added that had been overlooked. One of the medical students says, “Do you know that Chase can come up here if you want? I think he will feel better seeing you. I remember when I visited my grandpa in the hospital. I was only nine then, and people were worried whether it would be hard on me, but it made me feel so much better when I saw him. If you would like Chase to visit, I can be here if he has any questions.” The plan is written on a white board as it evolves. Everyone is clear about what is going to happen, and why. It turns out that Chase has his first baseball tournament next week. “We’ll do our very best to get you there,” the attending says. “You better! ‘Cause otherwise I’m signing out of here,” the patient says with both a smile and clear eyed look that brings a smile to the attending’s eyes. “Got it!”, she says. “We WILL get you there,” she says. “Together we will find a way.”

These two patients may have essentially the same medical plan, but they have very different care plans. And they, their families, and the health professionals caring from them are having notably different care experiences. One group of people is working together, co-assessing events and co-developing a plan of care in a way that involves all professions, invites the patient and family to participate, and illuminates nuances of care that would have been missed without the conversations around the circle. The other is doing a really good medical job, but, hundreds of things are missing that they aren't even recognizing aren't there. 

More importantly, one group is forming connections that are likely to last far beyond this hospital stay. Six months from now, if you ask Team A’s patient about the rounds this morning, it is likely that little will be remembered.  "Well, I guess they came in each day, but I don't really remember much about it." If you ask the patient and family cared for by Team B about the rounds this morning, names are likely to be remembered, the invitation to have Chase visit will probably be remembered with gratitude, and someone will probably say, “You know, his team won that tournament!” The entire experience will have a different kind of meaning, closely connected to the human spirit.

Do these differences matter? In terms of hard, measurable clinical outcomes, yes, evidence shows that they definitely do. But what may matter even more is that these differences produce a different kind of care. Does this matter? Yes it does. Very much.

The nice thing is, it’s not “either/or.” With collaborative care you get both. You get better clinical outcomes, and you get a fascinatingly different human experience. Most of us who have tried it don’t ever want to go back. We are somehow changed for having done it, definitely for the better.

For practitioners, joy is back, hope for the future is back, and why we went into healthcare in the first place is remembered again. For patients and families, fear and worry are smaller, awareness and knowledge are greater, and there is a validating sense of participation and control. They ARE listening! We CAN do this! We will do this together.

Sunday, September 6, 2015

Preconference Tidbit #10 - Lasting Connections – Jim V

by Jim V

Tonight's Tidbit is another story about the lasting connections formed during collaborative care.

Jim V is a quality expert with a deep interest in organizations. He was a collaborative care patient at Concord Hospital, where he worked as a hospital administrator.

His story is about the impact of collaborative care on his recovery and his wife's comfort; and about a time, later, when he was able to provide the same kind of care for someone else. It is now fourteen years since his surgery. His experiences are as alive for him today as they were then. What are the connections he is describing? How are these connections created? Tomorrow we will talk more about that.

Jim V: 

            "The collaborative care team was more interested in making me self-reliant than getting me discharged. They wanted me involved in my care in a way that I understood what was going on, so that when I went home I knew about things, knew what to look for. That is the greatest gift that the team gave me. They provided me with a comfort level that let me say, “I can do this. I can still live a very productive life. Yep, I need to pay attention to things, but this is not the end of the world.”

            The important thing is, it was a gift. What the team gave to me was a gift. I’ve never in the 14 years since been able to find another way to describe it. Pat was so nervous about losing me. The team gave her a level of comfort. She was included and her questions were answered. Did it take away her emotion completely? No. that is still there, even today. But it was extremely comforting that the team was able to take her seriously, take her questions seriously, and understand what she was going through.

            How does that make a long term connection?  People listened to us. They gave Pat comfort and information, and they wanted me to get well on my own terms.

            I won’t have my valve replaced again. I went through this once, the company has promised me a 45 year warranty, and the next time God wants me it is time to go. If it ever comes to that, I think they will try to talk me out of it, but is how I feel now. So, I decided to take the best care of myself possible. I decided to run. The way I started running was, I did a program called “Couch to 5K.” You do something every day for 35 minutes, three times a week, for 9 weeks. You start by walking three minutes, and running one. The other rule is, if you can’t finish a day, you keep repeating that day until you can. Then you can move on.

            When I started, my heart rate would go up and stay up. It took forever to recover. Now, I can be running in the middle of the race and sometimes my heart rate comes up to 170, even though I try to keep it about 150. When I finish running, and my heart rate comes down to my recovery rate of 120, it takes about 100 feet! I didn’t really understand how valuable this is, exercise. It is just amazing how quickly this heart comes back now. I’m back to resting within 3-4 minutes. It is amazing. That is a healthy heart!

            I’m running 5 Ks now. I think of you every time I do my 5 Ks. The object is not to win. It is to finish.

            There is a story that I love to tell. Addie had a patient who was very optimistic about surgery, very upbeat. His surgery went very well, and the whole care team was ecstatic, but when he came out of surgery he was depressed. He wouldn’t talk to anyone. Addie looked at the team and said, “Can I go up and get Jim? He will listen to Jim.” She came up to my office and told me the story. I went down to the ICU and introduced myself. I looked around and said, “Whoa, this was my room!” Steve, who was my nurse, walked in, and I said, ‘You have my nurse! You are in great hands here!” But it didn’t do any good. He kept pointing his head over to the right. I thought, “What is he doing?” After the third time he did it I followed his gaze and saw one unit of blood going into him. I asked, “The unit of blood?” He said, “They are lying to me. I’m having a blood transfusion and that means I am dying.” I said, “I don’t mean to be disrespectful, but I had twelve. Look at me. I passed out when they tried to stand me up. You have one unit. You are doing fantastic.” He got this smile on his face that I will never, ever forget. When somebody has been through it, you can listen to that person differently. He listened to me. It turned everything around. That is my favorite story. I gave back. I made a difference for all that was given to me.”

Saturday, September 5, 2015

Preconference Tidbit #9 - Lasting Connections

by Kana Kornsawad

Tonight's Tidbit is a short one. It introduces a series of several Tidbits about the connections that form during collaborative care.

Tonight's Tidbit is a note from Kana Korsawad about a patient she reconnected with recently. It is both happy and sad.

            Hi Everyone,

            I have some news to tell everyone. if you remember, during our pilot study in January there was a patient who was very sweet, and we talked about inviting her to the ACGME presentation and joining the patient committee group. She was working at the ENT clinic. 

            After she was discharged from the hospital I tried to reach her, but her cellphone was disconnected. Around May I tried again, but was still unable to contact her. I found out from Mike that she returned to the hospital in June and was admitted to another service for surgery. Mike was consulted for medical management. However, her hospital stay was complicated and she left the hospital with home hospice.

            Last week, Mike told me she was back in the hospital again for intractable pain. We went to see her in her room. It was such a big surprised when I stepped in to the room. I almost couldn't recognize her. She was very thin, lying in bed, and looked tired. She opened her eyes, and, the minute that she saw us her eyes lighted up and she smiled. I asked her if she still remembered me. She said, "Of course! How could I forget?"

            She started telling me the story of what happened after she left the hospital. She had to stop on and off due to shortness of breath. But I could tell that she was happy. 

            I went back the next day to visit her. One of the things she said was, "You all are a blessing in my life. I am so thankful to have you all taking care of me." 


Thursday, September 3, 2015

Preconference Tidbit #8 - Social Field Model

by Paul Uhlig

This is the last of the three Tidbits about conceptual models. This one is about the Social Field Model.

The Social Field Model was developed by Paul Uhlig and Ellen Raboin in collaboration with research colleagues Jeff Brown, Cindy Dominguez, and Lorri Zipperer. It is based on their work implementing and studying collaborative care over many years.

The Social Field Model is a way of explaining how collaborative care arises and develops, with special emphasis on how collaborative care can be intentionally implemented through structural and social interventions in care environments. The model has been used to implement collaborative care with notable improvements in measured team performance, patient satisfaction, and care outcomes, but needs to be more rigorously evaluated by additional objective research.

The model is based on the concept of “social fields.” A social field is a way of visualizing the shared knowledge, mutual expectations, emotions, and collective capabilities that develop among a group of people who are able to work and learn together over time. Social Fields are the reason that the fifth floor feels different than the third floor, in a way you can sense when you first get off the elevator. They are why a certain care environment is a delight to work in, while another is a very different kind of place where certain things just aren’t possible.

Social fields carry the connections, abilities to coordinate, and sense of “oughtness” that develop as people do things together. A social field is similar to culture, but is highly local and specific to a particular care environment and the people who work there. The abilities of a collaborative care team to connect, coordinate, make decisions, manage differences, actively engage patients and families, and achieve reliability and resilience are carried in the team’s social field.

A theory at the core of the Social Field Model is called Social Construction. Social Construction theory proposes that people are active social participants in creating their own realities, through ongoing patterns of interactions and conversations. Social fields are continuously being made and remade as people the in care environments do things together and talk together. A group can either participate in patterns of interaction and conversations that reinforce certain ways of relating; or, in some way, break those patterns and begin to establish new ones.

If a social field seems stable, that is because people are doing the same things they have always done. If, in some way, people change how they interact and what they talk about, their social field will evolve to reflect the new ways. Collaborative care is implemented by making intentional changes in the care environment that produce new relationships, and new patterns of interaction. “We become the things we do together. If you want to see the future, look at what we are doing now."

The Social Field Model was created by asking: “If you wanted to build a place that is really good at collaborative care, what would you do, and what would it be like?” An analogy is growing a garden.

The wise gardener tends carefully to the soil, the sunlight, the moisture, and other growing conditions more than to the plants themselves. If the growing conditions are right, the garden will very likely grow beautifully.

Based on studying the “growing conditions” of really great collaborative care environments, the social field model proposes a set of “social and structural preconditions” that can be intentionally implemented and will lead naturally to the growth and development of collaborative care.

The preconditions of the Social Field Model include structuring the environment so people across professions can work together consistently, collaborative leadership, active engagement of patients and families, regular team meetings, daily bedside rounds, use of data to monitor and improve systems of care, and thoughtful connections with the larger organization. When these are carefully put in place, collaborative care is very likely to arise, develop, and be sustained.

The model also proposes ways that a care team can assess the evolution of its care environment by taking stock of certain “resources” that can be expected to develop. As these resources, such as "knowing what to do and expect" and "a web of monitoring," develop within the care environment, they enable the emergence of collaborative care, high reliability, and resilience.

A diagram showing the preconditions and resources is attached.


Three team-based inventories have been developed to guide team self-assessments for implementing collaborative care. 

The Collaborative Care Toolkit, consisting of the inventories, and a book based on the Social Field Model, called Field Guide to Collaborative Care: implementing the Future of Health Care, can be downloaded without cost at the Collaborative Care Alliance website

Preconference Tidbit #7 - Relational Coordination model

by Paul Uhlig

This is the second of three Tidbits about models for studying collaborative care. Today’s Tidbit is about Relational Coordination.

Relational Coordination is a rapidly growing field of scholarship based on the work of Jody Gittell, a professor of management at Brandeis University. Jody will not be at the meeting, but is very interested in collaborative care.

Her model of Relational Coordination was initially developed when studying the remarkable success of Southwest Airlines. Jody studied teams that worked together at Southwest, for example, teams that worked to get the airplanes ready, boarded, and out of the gate. There were many roles on these teams including gate attendants, baggage handlers, pilots, and many others. Jody’s research showed that relationships between these roles at Southwest were notable for shared goals, shared knowledge, and mutual respect. These attributes, she concluded, led to frequent, timely, and accurate problem-solving communication—which in turn was the basis for coordinated collective action that drove high performance outcomes.

In other words, good outcomes were the result of well-coordinated collective actions, which were the result of good problem-solving communication, which was tied to good relationships. Because the coordinated actions originated in good relationships, the model is named Relational Coordination.

At the center of Jody’s work is a seven question survey that asks people in various roles to characterize their relationships and communication with other related roles.

Frequent Communication
How frequently do people in each of these groups communicate with you about [focal work process]?

Timely Communication
How timely is their communication with you about [focal work process]?

Accurate Communication
How accurate is their communication with you about [focal work process]?

Problem Solving Communication                 
When there is a problem with [focal work process], do they blame others or work with you to solve the problem?

Shared Goals
Do people in these groups share your goals for [focal work process]?

Shared Knowledge
Do people in these groups know about the work you do with [focal work process]?

Mutual Respect
Do people in these groups respect the work you do with [focal work process]?

The results of these simple measures allow mapping of relational networks and have been carefully correlated in validated ways with a variety of positive outcomes across many areas of professional work, including health care. The RC model underpins a broader approach to organizational management and operations that Jody is developing with collaborators across the US and internationally in accumulating research, evidence, and scholarship through the Relational Coordination Research Collaborative.

Although directly useful as a way of measuring relational ties, the Relational Coordination survey and the model it is based on are often used to inform, design, and monitor organizational interventions intended to improve relationships, communication, coordination and outcomes.

There are many parallels with the purposes and nature of collaborative care. The RC model proposes that

Relational coordination is strengthened by organizational structures that cut across functional silos – selecting and training for teamwork, shared accountability and rewards, shared conflict resolution, shared protocols, boundary spanners, shared meetings and huddles, and shared information systems. These cross-cutting structures require the redesign of traditional bureaucratic structures that keep people in their silos. 

For a good overview of this work, scroll through this PowerPoint:

To read more about Relational Coordination go to the RC Research Collaborative website: