Seeking Health Care’s Future:Moving Beyond Time-Honored Patterns, Creating Even Better Ones

Paul N. Uhlig, MD University of Kansas School of Medicine-Wichita

Baldwin Seminar SeriesSeptember 20, 2017

nothing to disclose…

but many to thank…

A living legacy of progress and growing understanding…

with special gratitude to two visionary pioneers…

It is my privilege to be with you here at the ACGME.

Where do we begin?

Get up.Sit with someone you don’t know. Introduce yourself. Why did you come here today?

David Harber“Matrix Garden Sphere”

The (Tightly Connected) Patterns of Health Care

Patient Care

The (Tightly Connected) Patterns of Health Care

Patient CareEducation

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation

The (Tightly Connected) Patterns of Health Care

Patient CareEducation AccreditationProfessional Roles

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational Design

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement Practices

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement PracticesPayment Policies

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement PracticesPayment PoliciesLaws and Regulations

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement PracticesPayment PoliciesLaws and RegulationsResearch Agendas

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement PracticesPayment PoliciesLaws and RegulationsResearch AgendasHealth Policy … and …

The (Tightly Connected) Patterns of Health Care

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement PracticesPayment PoliciesLaws and RegulationsResearch AgendasHealth Policy … and …

much more

What does it mean to be a doctor, a nurse, a health professional?What are our roles as patients? As friends and family members? What is Health? What is Healing? What should Health Care be like?

The (Tightly Connected) Patterns of Health Care

Societal Agreements

Who are we, in this room?

The Health Care Paradox

The very best people that society has…

and yet

Unsolved Challenges ofCost, Quality, Access,

and Experience of Care

How can this be? What can we do?

My Grandfather’s Bag

FlexnerHopkins

1893

ABMS

FlexnerHopkins

1893

ABMS

FlexnerHopkins

1893

ABMS

FlexnerHopkins

1893

ABMS

FlexnerHopkins

1893

ABMS

FlexnerHopkins

1893

ABMS

?

“Second Curve”

Flexner

(Martin Merry)

Hopkins 1893

ABMS

“Second Curve”

Flexner

(Martin Merry)

Hopkins 1893

ABMS

“Second Curve”

Flexner

(Martin Merry)

Hopkins 1893

ABMS

Our main work in health care today is helping people move across this valley.

It’s not an easy thing to do yet.

Ask yourself, “What is best for the patient?”

It isn’t complicated.

Introduce yourselves again. Find a doctor. Talk about: What is the medical pattern?

We know our old patterns.We use them all the time.

Our talk today is about –

What might be possible with different patterns?

What if…

At Rounds The patient is there. The family is there. The entire care team

is there. Ordinary language is used. Hierarchy is lowered. greater emphasis is placed on human experiences. People sit at eye level. The pace is different.

There is conversation. There is empathy. An assessment is made, together, in real time. A plan of care is made, together, in real time. Goals are agreed upon. Roles are clarified.

Mutual expectations are made clear. Communications and trust are built.

Implementation of Collaborative Care

2002 Eisenberg Patient Safety AwardJoint Commission and National Quality Forum

“Don’t you people talk to each other?”

Collaborative Care Research

“Way Cool X-Team”

Jeff Brown – safety scientistCindy Dominguez – cognitive engineerLorri Zipperer – knowledge managementEllen Raboin – human & organization systemsPaul Uhlig – surgeon, research team leader

Gerry Stahl – collaborative work & learning Wes Shumar – cultural anthropologist Alan Zemel – interactional video analysis Olga Gurevich – organizational psychologistAddie Camelio – patient/family advocate Carol Bliss – group process dynamics

Mastery =Rich Tacit Knowledge

Collective Tacit Knowledge

of an Entire Team

Social FieldsThe collective intelligence of a care team

…consisting of memories, wisdom, emotions and patterns of interaction…

…arising over time from shared experiences, reflective conversations and team learning.

Social Fields

Accumulating resources people can draw from during their work together…

From a Social Field perspective, the work of transformation involves building exceptional social fields.

Can we do that?

“Of course not.It is impossible.”

Well, what if we…

Co-Locate?

Meet/Reflect/Plan?

Simulate/Practice/Explore?

Start with 1-2 Patients/Grow?

“Exceptional health care…in whichpatients, families, and health professionals are consistently able to co-create care that is meaningful, safe, reliable, resilient, efficient,and exquisitely responsive to the hopes, needs, goals, and purposesof everyone involved."

Collaborative Care

Observing Collaborative Care

• Average number of patients seen by team daily: 17

• Total number of patient discussions observed: 152

• Proportion of observed discussions that followeda collaborative rounding pattern: 57%

Patient and Family:

Not involved Rarely involved Usually involved Always involved Always involved

Presentation:Intern/Student

present to Attending

Intern/Student present to Attending

Intern/Student present to

Patient

Intern/Student and Nursepresent to

Patient

Intern/Student and Nursepresent to

Patient

Location: OutsidePatient’s Room

Inside Patient’s Room

Inside Patient’s Room

Inside Patient’s Room

InsidePatient’s Room

Contributing Providers:

Med. Team, Pharmacy

Med. Team, Pharmacy

Med. Team, Pharmacy

Med. Team, Pharmacy,

Nursing

Med. Team, Pharmacy,

Nursing, PT,Social work

White Board: Never Never Almost Always Always Always

Safety Checklist: Never Never Occasionally Always Always

Observing Collaborative Care

Hallway Bedside Physician-Patient

Partial-Team

Full-Team

CollaborativeIndicators

Observing Collaborative Care How long do patient discussions take during rounds?

Observing Collaborative Care Who contributes to Patient Discussions During Rounds?

Observing Collaborative CareHow does the Conversation Flow?

Traditional Rounds

Patient Family

Comp.

R RN

PD

I

I

A

MS

Observing Collaborative Care

Traditional Rounds

Patient Family

Comp.

R RN

PD

I

I

A

MS

Traditional Rounds

Patient Family

Comp.

R RN

PD

I

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A

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Observing Collaborative Care

Observing Collaborative Care

Traditional Rounds

Patient Family

Comp.

R

RN

PD

I

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A

MS

Observing Collaborative Care

Traditional Rounds

Patient Family

Comp.

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RN

PD

I

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Observing Collaborative Care

Traditional Rounds

Patient Family

Comp.

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RN

PD

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Traditional Rounds

Patient Family

Comp.

R

RN

PD

I

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Observing Collaborative Care

Collaborative rounds

Patient Family

Observing Collaborative Care

Collaborative rounds

Patient Family

Observing Collaborative Care

X

Observing Collaborative Care

Collaborative rounds

Patient Family

Comp.

R

RN

PT

CCPD I

I

A

MS

Observing Collaborative Care

Collaborative rounds

Patient Family

Comp.

R

RN

PT

CCPD I

I

A

MS

Observing Collaborative Care

Collaborative rounds

Patient Family

Comp.

R

RN

PT

CCPD I

I

A

MS

Observing Collaborative Care

Collaborative rounds

Patient Family

Comp.

R

RN

PT

CCPD I

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Daily Reflective Sessions: Themes

Meetings held in workroom every day for 30 minutes. Provides a protected time for team to:

– Reflect on the day’s successes and stumbling blocks– Plan the next day’s activities, make incremental changes

to the model – Communicate plans and ideas across disciplines– Follow up with others on specific patient discussions– Develop and strengthen relationships – Decompress

Daily Reflective Sessions: Evolution of the conversations

We can’t do this!

• “I haven’t seen half of my patients today!”

• “All I can think about is everything else I need to do”

Maybe we can do this…

• “This has cut down on the calls I get from nursing…”

• “I feel so behind when I can’t round with everyone!”

How do we keep doing this?

• “We should work on including family in rounds.”

• “How do we orient new people to this model?”

Implications / Insights for Learners and Teachers

University Health SystemUT Health San Antonio San Antonio, Texas2 ½ years

Beaumont HospitalBeaumont HealthRoyal Oak, Michigan1 ½ years

Oak Hill HospitalHCA West Florida HospitalsBrooksville, Florida3 months

HealthSim United Wichita, Kansas

Faculty, too!

Interprofessional Student Learners

Collaborative Care Learning Network

3rd Annual Meeting - September 20-22, 2018UT Health San Antonio San Antonio, Texas

www.createbettercare.org

Implementing Collaborative Care

• Knowing what to expect and do• Alertness/Responsiveness/Patience• Ability to Invite and Welcome• Commitment to Learning and Change• Active Engagement with Patients and Families• A Web of Monitoring• Emergence• Aliveness

Resources of Collaborative Care (team-level capabilities)

Many others working toward the same goals

Patient CareEducation Accreditation Professional RolesOrganizational DesignManagement PracticesPayment PoliciesLaws and RegulationsResearch AgendasHealth Policy

The (Tightly Connected) Patterns of Health Care

Patient CareEducation AccreditationProfessional RolesOrganizational DesignManagement PracticesPayment PoliciesLaws and RegulationsResearch AgendasHealth Policy

The (Tightly Connected) Patterns of Health Care

?

Slowly, steadily, these are starting to really make sense

1893 1910Osler Flexner

from learning individual skills …to…developing shared capabilities in learning systems

Future?

CLERCompetencies

//

Truly Engaging Patients and Families

“Nothing about me without me.”

Truly Engaging Patients and Families

Everything Changes

Truly Engaging Patients and Families

9:08

What if every patient…wrote the music and conducted the orchestra?