Sunday, August 28, 2016

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.

Sunday, August 21, 2016

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,


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.

Sunday, August 14, 2016

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, 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!