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?"

 

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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.