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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