I’ve had the opportunity to work with healthcare clients for over ten years and I want to tell you about a healthcare initiative I’ve been a part of, that is the best example of collective sensemaking I’ve seen. More importantly, I truly believe it is capable of transforming healthcare as we know it – making it both more humane and more effective. It‘s called “Collaborative Care” and it is about involving the whole medical team, including the patient and the families in care decisions. Those of you who have read Being Mortal can think of it as Atul Gawande’s ideas writ large.
Let me explain what I mean by asking you to imagine that you are lying in a hospital bed after a serious operation and in comes a whole team of medical professionals, your surgeon, pharmacist, nurse, physical therapist, hospitalist, respiratory therapist, nutritionist. Wow! These healthcare professionals take time to introduce themselves and to learn about you as a person, your hobbies, work, interests and those of your family as well. That is the beginning of building connections among your healthcare team, with you an your family included as full members of that team. A few of the team members sit down so they are at eye level as they talk with you. All these people are talking with you, not at you or about you. And perhaps most important, they are listening. Ultimately caring may be more about listening than talking – we are aware of the caring of others when we sense that we are being heard. The interaction among those around the bedside begins to seem like a conversation among friends. The language in the room is understandable by everyone; no one is using specialized medical terms that only the healthcare professionals can interpret.
As the conversation continues, you and the healthcare professionals in the room jointly develop the next steps of your care. These steps are noted on a goal board that is posted on the wall in your room and is left up to help you, your family and the hospital staff, that will be coming on later, know what is going to happen and what to watch out for. During the conversation a new idea emerges that is sparked by a remark that a member of your family makes. Others in
the room take the idea seriously, even though it is an idea that no one had thought about before this conversation. That idea goes up on the goal board as well. Seeing it up on the goal board convinces you that this team really is including you and your family in planning for your recovery.
Today is not the only time this healthcare team will be at your bedside. They will return again tomorrow to review the goal board with you, check each item that was accomplished and to set new goals with you and your family. Each time they return, a stronger relationship builds among all the members of the team. This closeness is evident in their gestures and looks and is visible to you as you see members of the healthcare staff lingering for a moment to say goodbye or to touch your hand.
I asked you to imagine that scene, but it is a scene I have watched come to life at University Hospital in San Antonio. The hospital has been working with the developers of collaborative care, Paul Uhlig, a cardiothoracic surgeon, and Ellen Raboin, a health care researcher/consultant. In their new book, Field Guide to Collaborative Care, they talk about how to conduct grand rounds in a way that engages patients and families in all aspects of care and decision-making. Equally important they talk about the way each team continuously learns, a necessity for the transformative change in healthcare that collaborative care engenders. In this post I have drawn heavily on their book to provide the examples of what makes collaborative care successful.
As you were reading my story of a team conducting their collaborative care rounds, you were probably contrasting it with a hospital visit you or a loved one has experienced. Caring has been so long absent from our medical system that my story may have seemed close to unbelievable. We expect hospitals to provide care, but we no longer expect caring. Rather, we expect nurses to be too busy to do more than appear to give us a shot or to respond after repeated distress signals from our call button. We expect that we will have only four or five minutes of a surgeon’s time when he or she comes by on morning rounds. We anticipate that during much of our stay at the hospital we will not know what is going to happen to us next; that we will receive conflicting information from different healthcare professionals; and that in the hands of those professionals we will feel powerless and alone. What is always on our mind is, “How soon can I get out of here.” That reality is a strong contrast to collaborative care.
Paul and Ellen have worked with a number of hospitals to implement collaborative care and in the process have learned a great deal about what it takes to transform a hospital from competent care to collaborative care, which they define as: “exceptional health care in which patients, family members, and other care team members are able to consistently co-create care that is meaningful, safe, reliable, resilient, efficient, and exquisitely responsive to the hopes, needs, goals, and purposes of everyone involved.”
Listen to this story from their book that exemplifies collaborative care.
“The story concerns a patient who was not doing well after heart surgery. He was a farmer who lived alone in the woods. His nearest neighbor lived several miles away. His operation had gone very well and everything measureable about his recovery was coming along fine. His laboratory values and chest x-ray were normal, his vital signs were normal. But he was not eating well, and was not walking. He was growing weaker and beginning to have difficulty coughing and clearing his lungs. Everyone on the care team could see his deterioration and worried about him. No one knew what should be done differently.
One morning during collaborative rounds someone noted on the goal board that the patient had a dog. When the dog was mentioned the patient’s eyes lighted up for a brief moment, then tears came to his eyes. The social worker comforted him and the team listened attentively as she asked him about his dog. He loved his dog. His dog was his family. When he came into the hospital he had left his dog with his neighbor, but he had not been able to talk with his neighbor since his surgery. He was literally worried sick about his dog. His most important goal was making sure his dog was OK. He didn’t know how to do that. His worry occupied his thoughts. The team was able to send the sheriff to check on his neighbor. His dog was fine. The next day the patient was much better, and several days later he was able to go home.
There are many stories like that, stories that illustrate how having a meaningful conversation between the care team and the patient reveals a way to speed healing and to express caring. “[One] patient wanted to see her son play in a special football game. This father knew his daughter needed a special blanket. This family knew their sister was having a stroke because her unusual symptoms were just like what their brother had. This son knew that his father was having a life-threatening reaction that wasn’t listed as an allergy.”
University Hospital in San Antonio has calculated a .7 day reduction in stay in those units that are engaged in collaborative care. That means $1.5M in avoidable costs and 780 more patients over a 6 month period. The power of collective sensemaking!
You may well wonder how having conversations with patients could possibly yield those results. One of the answers is that collaborative care rounds provide a scaffold that allows the healthcare team to bring together information from each team member, as well as providing the time to assemble that information with everyone present. Having the big picture enables the team to make the best decisions possible about care. It is a great example of the benefit that can come from “working outloud.”
But of course the “how” is more complex than the conversations that occur during grand rounds. Collaborative care requires ongoing team learning, system changes, and monitoring to continually improve. Two kinds of meetings are central to moving from care to caring, daily reflection meetings and system meetings.
Daily Reflection Meetings
When the team that I described in the opening paragraphs, has finished its rounds it holds a brief reflection meeting. This is the reflection part of an action-reflection cycle that provides the way for the team to continually learn. The talk in the reflection meeting is not about patients, that discussion has already taken place in its fullness at the bedside. The reflection meeting is about how to work more effectively as a care team and how to more effectively engage patients and their families. It is in these meetings that new ideas
emerge and improvement results. For example, it was out of one such meeting that the idea of using a goal board in the patient room was borne. And since that time, the goal board has become a pivotal element in collaborative care rounds. As the daughter of a patient noted, “One thing we liked was the goal board. One of the nurses would write on it, and sometimes my sister did that on rounds. It was a good checklist to be sure nothing got missed. The next day somebody would read it. We put some simple things on it: shower, hair combed, shaved. These things were very important to him.”
The reflection meeting is critical because a team that has been functioning in a traditional setting has a great deal to unlearn as well as to learn in order to function effectively as a collaborative care team. The following examples are just a few of the many changes a team struggles with when it begins the challenge of being more collaborative and more caring.
- Making use of distributed leadership.
Although a physician and head nurse participate in collaborative care rounds, they do not run the meeting at the bedside. It might be a nurse, social worker or other staff who facilitates the discussion. But as the meeting moves along, leadership continually shifts to the person who has the most knowledge about the particular issue under discussion. For example, if a medication question is asked, the pharmacist will take the lead. Over time, and through distributed leadership, team members come to appreciate the wealth of knowledge each of their colleagues has. That understanding and the respect it generates greatly increases the insights available to the team for problem solving. Uhlig and Raboin called these insights “contextual resources” and as those resources grow within a team, the team becomes more reliable and resilient. A reliable team has worked out effective ways to handle those situations that they encounter on a regular basis. A resilient team has also developed the resources to handle the unexpected - situations the team has never encountered before.
- Changing language from talking about the patient as “he or she” to talking to the patient as “you.”
This is a difficult change to make because the choice of words we use is largely tacit. Using the third person is so familiar to residents and nurses, particularly in teaching hospitals, that they don’t think about it. Even the daily exchange between a doctor and nurse at the bedside often excludes the patient by the use of “he or she” rather than “you.” It is in such small changes in language, eye contact, whether people stand or sit, that inclusion is expressed.
- Acknowledging mistakes in front of the patient and family
Without the willingness to acknowledge mistakes, authenticity, which is at the heart of caring, is absent. If a mistake related to a patient has occurred then during their rounds the collaborative care team explains to the patient and family what happened and why. They express their concern, apologize, and encourage questions. The care team even goes further on rounds to seek out problems or issues that they may be unaware of. A regular part of collaborative care rounds is to ask each patient and their family members, “What could have been different or better yesterday?” Collaborative care teams call the responses to this question “GLITCHES,” defined as “Gathering Little Insights That Can Help.” One of the fundamental things a collaborative care team has to learn is to respond to glitches and mistakes with a sense of interest and curiosity rather than to react defensively or view them as failures. Some glitches are easy fixes, for example, “The light in the shower is dim.” But sometimes glitches point to ways the system needs change. For example, one family member responded to the glitch question with, “Wish we could have been with our mother during shift change.” That fix required a lengthy conversation at the system level, but eventually resulted in a new open visiting policy.
- Learning how to invite the participation of the patient and family
Patients and families are also acculturated to deference to physicians and others in the hierarchy and thus expect to mostly listen. A technique care teams use to invite participation during the conversation at the bedside, is a “go around.” The person acting in the facilitator role asks each person in turn to speak about the issue that is under discussion. Using a “go around” ensures that every voice in the room is heard, even those who are naturally hesitant to speak up. Another way collaborative care teams encourage participation is for some members of the care team to sit at eye level with the patient, rather than all standing. Being at the same level, literally, communicates a sense of equality. Sitting also signals that the team is going to take the time they need with this patient. To enter a room and just stand is a strong signal that “I’ll just be here for a moment.” How the team introduces the idea of a collaborative care team to the patient also impacts the level of participation of patient and family members. Without an explanation patients may see so many people coming into their room as scary or threatening. During the first visit of the collaborative care team a team member might say something like “Good morning, Mr. Smith. This is our daily collaborative care rounds. We are glad to see you and delighted your family is here. Our purpose is to be sure that we are all on the same page, and that all of us, including you and your family, are working together to take the best, safest, care of you possible” followed by introductions of each member of the team.
- Moving from individual work to collective work
In traditional settings each healthcare professional individually prepares for his or her task with each patient, gathering test results, reading charts, reviewing records, planning - all too often without awareness of what other team members are preparing. With collaborative care “the emphasis shifts away from gathering information in preparation for rounds. Instead, everyone brings their small part, and an entire picture is then assembled by everyone together.” Moving from individual work to collective work is a significant change in role and identity. “One collaborative care team member said, ‘In the past, rounds was something that was preparatory for the work of the day, something you had to do before you started your real work. Now, with collaborative rounds, we are realizing that rounds has become our most important work of the day. We do our real work in rounds, and touch up things here and there afterwards.'" By the end of the collaborative care rounds with a patient everyone knows what to expect and that allows all of them to recognize when a deviation from the expected occurs and to be able call attention to the change.
The examples above are the kind of topics that are raised in the daily reflection meetings of a collaborative care team. The reflection meetings are essential, because collaborative care teams have a steep learning curve, with learning leading to change over a period of months.
Another kind of discussion occurs in the weekly system meetings. Here collaborative care teams from different units come together to think about how the hospital system as a whole might need to change to facilitate collaborative care. The system meetings are the place for longer-term planning and organizational change related to issues of structure, staffing, learning, and leadership. For example, visiting hours may need to be altered to allow family members to be in the hospital at the time of rounds; the way nurses are assigned to beds may need to change so that a consistent and co-located team is able to work and learn together.
There are questions about how to gain and sustain the support of upper management for such a different way of delivering care. And questions about how to involve Quality, Patient Safety, and HR in the change process. If collaborative care has started in one or two units, there are questions about how to invite other units of the hospital into collaborative care. There will, of course, be hospital staff that are not comfortable with distributed leadership or with any one of the other significant changes that collaborative care brings. The way in which these professionals are invited into collaborative care is significant.
Just as a collaborative care team respects the meaning each patient voices during collaborative care rounds, it is important to respect the meaning of those who are committed to traditional hospital protocols. They have the best interest of their patients at heart and are working from the meaning they have gained from their professional experience perhaps, for example, that hierarchy inspires confidence and willingness to follow medical instructions. It is neither beneficial nor just to mandate that those individuals engage in collaborative care. Uhlig and Raboin suggest starting with the willing, while always leaving the invitation open for others to join, confident that they will change when they are able to see the benefits that collaborative care brings to their patients and to their own experience with patients.
Uhlig and Raboin say, “In our experience, the most effective way to begin building an exceptional collaborative care environment is by inviting people to participate in weekly system meetings as a new routine. These meetings are your most important implementation intervention.” They are the place where the relationships between those interested collaborative care are formed.
I was initially drawn to collaborative care because I saw it as an excellent example of using collective sensemaking, a concept I have been studying and writing about for several years now. Through my case based research with the Ecopetrol, the Utrecht Government, Proquest, and Kessels and Smit, I knew collective sensemaking to be a powerful practice that creates change and innovation in organizational settings. The nine guidelines I have suggested for collective sensemaking are all central to collaborative care.
- Connection before content - getting to know patients, their hobbies, goals, and interests before turning to medical issues– there is often laughter in the room as stories are told. Laughter is a great builder of connections
- Circles connect – team members circling the bed of the patient
- The small group as the unit of learning - the care team reflection meetings are where learning happens – they are the unit of learning
- Divergence before convergence –asking each team member to talk about what they have seen in their data and measurements before jointly developing the next steps for care - asking for glitches
- Cognitive diversity increases innovation – the inter-professional composition of the care team brings the gift of different ways of thinking to the difficult issues the collaborative care team faces
- Visible ideas span boundaries - the goal board is an essential element of rounds, making the ideas of patients and healthcare professionals understandable to each other
- Shared experience builds shared understanding – patients and professionals sharing stories, grieving over setbacks, and celebrating successes at the bedside
- Physical space changes the conversation – the patient room becoming a place for conversation – team members sitting at eye level with patients
- Enable all voices to be heard – inviting participation from patient and family members - distributed leadership – go arounds.
As I have learned more about collaborative care I have come to realize how powerful collective sensemaking really can be. I have thought of collective sensemaking as a means that an organization can use to reach a desired end, for example, for Proquest collective sensemaking is the way to be more innovative software developers and to coordinate development in a team that is spread across the world, or for the Utrecht government a way to solve long standing problems and to have more genuine citizen involvement. In my work I have been primarily concerned with figuring out the basic components of the means, (e.g. the nine guidelines) and I have left it to the organizations I work with to identify the end they want to achieve. All the while knowing, that because of the nature of collective sensemaking, it is only really useful to organizations when the ends collective sensemaking serves have the characteristics of inclusion, learning, and the identification of goals, that all those who contribute their thinking, find worthy.
However, in working with Paul and Ellen, I have become equally interested in the end – the transformation of healthcare. I can think of no more worthy goal than transforming healthcare to be more caring, inclusive, and therefore more effective for both the caregivers and those who need their care. For this reason, I began a partnership with them in 2014 to help spread these ideas among a growing network of healthcare professionals who are implementing collaborative care. Working with Paul and Ellen, I am focused not only to the means, collective sensemaking, but also on the end, transforming healthcare to a place where patients feeling a genuine sense of caring from those whose work is to care for them, and where care givers being able to give the kind of caring they went into medicine to provide. You can expect to hear much more about collaborative care on this blog as our partnership continues over the next months and years. I hope you will find collaborative care as exciting as I have.
The Field Guide to Collaborative Care is available for download at www.cca-home.org under resources. Even if your work is not in healthcare there is great wisdom in the book about how to use “invitation” and “conversation” to bring about change in a complex system and it will warm your heart to read the words in this book.