Step into a hospital room with Dr. Paul Uhlig and Ellen Raboin and see something new occur — a social invention in health care that is healing for all the participants.
We are in a patient care room. Look around: This room has been built for a purpose. Here is a bed. Here is a seating area. Here is a window. Here is a monitor. Here is a place for supplies. Here is a computer. Here is oxygen, and suction. Everything is clean, in place, and ready.
What has happened here before? Who has been cared for in this room? What joys and sorrows have been shared here? What will happen here tomorrow?
Sometime later today or tomorrow this room will come to life. Lights will be turned on, the monitor will be connected, a patient will rest in the bed, and family members will sit in the chairs or make cellphone calls by the window.
A nurse will be present and a doctor will come. Throughout the day and night many health care professionals will care for the patient, talk with the patient and family, enter notes in the record, communicate with one another, and carry out their work.
As these things are happening, hover over the care environment and see what you notice:
- Do people here seem to know just what to expect of each other and what to do together?
- Are people here alert, responsive, respectful, and patient with each other?
- Does everyone seem to feel Invited and welcomed here, sharing ideas and suggestions?
- Do you see intentional and receptive engagement with patients and families?
- Do you see a seamless web of monitoring so that anything unexpected is quickly noticed?
- Is there a noticeable commitment to learning and change among everyone here?
- Are ideas and suggestions emerging that don’t seem to come from any one person?
- Is there a sense of aliveness of the human spirit that makes work here unusually meaningful?
If you can answer a clear “yes” to all of these questions, you are experiencing a rich, vibrant social field with the special resources of high reliability collaborative care. If you cannot answer “yes” to these questions, you are experiencing a less capable social field in which these resources are not yet well developed.
In the same way that physical environments can be intentionally designed and built, social environments that support and foster exceptional care can be intentionally and purposefully created. Our social fields are built during our daily patterns of interactions and can be rebuilt in our daily patterns of interactions.
Finding better ways
Health care is evolving.
Time honored ways of working in health care are no longer meeting the needs of patients, families, and society. Nor are they meeting the personal and professional hopes and needs of the health care workforce.
The paradox of present day health care is that — on the one hand — health care professionals are among the most highly motivated, highly trained in any area of human endeavor. Health care professionals prepare for years, work as hard and as well as possible, and are deeply dedicated to the care of their patients.
Yet — on the other hand — health care costs are increasing at unsustainable rates, quality and safety are surprisingly uneven and not what we wish they would be, limitations to access affect almost every sector of society from individuals to families to businesses to nations, and the experiences of giving or receiving care — which should be one of the most rewarding of human exchanges —often feel depressing and discouraging instead of renewing and fulfilling.
What is even more puzzling and interesting is that the growing and unsolved challenges of cost, quality, access, and experience of care are not unique to this country. They are global — manifesting in every country across the world where health care is approached, organized and practiced in modern traditional ways.
How can this be?
The explanation for this paradox is that health care presently exists between paradigms. A profound and fundamental paradigm shift is happening in health care. The old ways in which health care has been organized and practiced for over a century are no longer working, yet the new ways that health care needs haven’t been fully developed or even imagined. This is a time in health care that is uncomfortable, stressful, and uncertain — and yet…filled with potential.
The future of health care requires much more than doing what we have always done, only in better or more efficient ways. Our fundamental approaches, our professional identities, and even our purposes must evolve and change.
The future of health care requires much more than doing what we have always done, only in better or more efficient ways.
Traditional and collaborative care
We define collaborative care as active engagement of patients and families, with exceptional teamwork among all professional team members, and the presence of structures that support action-reflection learning at a team level that enables high reliability and resilience.
The differences between traditional practice and collaborative care are significant. Consider some of the most notable distinctions:
- Traditional health care practice 1) is based in the work of individual practitioners, 2) has notable gradients of authority and is hierarchically directive; 3) is centered in treating or preventing disease as defined from a scientific perspective, 4) relies on notes, orders and other methods of explicit communication to achieve coordination and goal alignment among professional roles and disciplines (patients and families are not usually able to participate in this process); and 5) locates power and decision making primarily in the medical expertise of health care practitioners.
- Collaborative care 1) is based in the work of teams; 2) is participatory and inquiry-based—inviting, welcoming and utilizing the expertise of patients, families, and practitioners; 3) includes disease treatment and prevention but is centered in what has meaning for each patient, and in the strengths, values and contributions of each participant, 4) utilizes a mixture of tacit and explicit knowledge in a highly evolved context of shared experience and participatory conversations to achieve coordination and goal orientation among all participants including patients and families; and 5) distributes power and decision making among all involved.
There are observable distinctions between health care practice in a traditional model and the richly connected routines, workflows and priorities of highly evolved collaborative care with active engagement of patients and families. Envision being with a care team as the team make rounds together. Imagine what people are doing, and observe the following things:
Where does rounds happen? Who is present? How do people enter the patient’s room? Do people sit at eye level, or stand? If present, are family members included in the bedside group? How do the conversations begin? Who leads? Who does most of the talking? What are people paying attention to? Can you tell right away about the patient as a person? Is the language used medical or ordinary? Do people report about the patient saying “he” or “she,” or do people talk with the patient and family saying “you”? What does the hierarchy feel like? Does anyone ask as a routine part of rounds whether anything could have been better in any way? Are mistakes or errors openly discussed? Is a safety checklist used? Is the care plan written down, summarized, and clearly understood by everyone present? Are people including team members, patients and family members clearly engaged in something important together that has meaning for them?
As we observe care teams we are watching for whether all care team members including physicians, nurse practitioners, nurses, pharmacists, respiratory therapists, physical therapists, care coordinators, social workers, nutritionists, residents, medical students, nursing students, other care providers such as patient care assistants, and patients and families, are included in rounds together and integrated or not in collaborative daily work routines.
We are watching for whether all care team members are included in rounds together and integrated or not in collaborative daily work routines.
However, we are looking for more than that. It is one thing for different health professionals, patients, and family members to be present together in a care environment, and another for these people to be actively participating together in collaborative care.
A view of collaborative care
When we observe care teams making rounds in highly evolved collaborative care environments this is what we see:
Patients and family members are invited and encouraged to participate in rounds and all other care activities. Family members can usually be with patients at any time of the day or night.
Care conversations before going into the patient’s room are intentionally avoided. Care team members wait until they are present with the patient and family members before having conversations about how the patient is doing and before making any plans for care.
Members of the care team visibly wash or foam their hands as they enter the patient’s room. They gather around the patient, inviting and welcoming family members to join with them in their circle.
Often one or more people intentionally sit at eye level with the patient.
Rounds begins with intentional introductions of everyone present including health care professionals, the patient, and family members, with invitations to join and participate. Time is taken to ask and learn about the interests of patient and family as people, and to establish connections among everyone participating. The tone is respectful, relaxed, and inviting.
There is a clear pattern and sequence for rounds that everyone is familiar with. The rounds process is led by various people at different times depending on what is being discussed. Often a nurse practitioner or other care team member facilitates and guides the overall process.
Physicians are active participants in the rounds conversations and decision making but often do not lead or direct. There is intentional deference given to the expertise of people present, including the expertise of the patient and family members, rather than to professional hierarchy.
The interactions among people feel like a conversation rather than a report. A shared picture of what is happening emerges in real time as people talk together. Plans are jointly developed as care team members, patients, and family members contribute various perspectives and discuss these with each other.
Everyone present is engaged in a cohesive group conversation. There are few side conversations.
Everyone is given an opportunity to contribute around the circle in turn, including patients and family members. Often new ideas emerge that were sparked by these interactions.
People talk comfortably with each other and with the patient and family using “you” instead of “he” or “she.” Much of the language used is ordinary rather than technical, and when high level technical and professional terms and concepts are used they are explained. Laughter happens frequently, often with joking or teasing. The tone is professional, but warm and human.
A safety checklist is consistently used to be sure that essential items have been reviewed and discussed. Intentional time is taken to ask everyone present if anything could have happened differently or better over the past 24 hours. Any mistakes or errors are openly discussed. Any problems or concerns are noted and documented for later review in the weekly system meeting.
The plan of care is reviewed and summarized point by point by everyone present including the patient and family members, and any ambiguities and contingency plans are clarified. A goal board with the care plan is filled in as rounds progresses, and is left in the room as a reminder of what is expected. Rounds the next day includes a review of the care plan on the goal board.
When rounds ends there is a clear sense that everyone in the room has an understanding of the care plan of care. In fact everyone helped create the plan. There is also a sense of closeness among people that is evident in looks, gestures, and the way people linger for a moment or say goodbye as they leave.
More than rounds, more than behaviors
Collaborative care is much more than making rounds together. It may be tempting to view the differences between traditional care and collaborative care as behaviors that can be learned. Certainly some of the changes are behavioral and can be taught and learned. However, in our studies we have come to believe that collaborative care is something deeper than behaviors.
These differences include a central focus on the patient as a person, a commitment to inviting people into shared work together, and a belief that new ideas will be found when a team works together collaboratively, as well as many others.
Collaborative care is something deeper than behaviors — it embodies a central focus on the patient and a belief in the value of collaborative work.
Moreover, the interactions of collaborative care happen truly at a team level, and are more than the sum of individual actions. It is not easy at first to envision capabilities at a team level when we are so used to thinking about the actions and abilities of individuals.
Inviting and welcoming
One of the most important capabilities of a collaborative care team is the ability to invite and welcome others into working together. This is true for professional members of the team welcoming other professional members, and is especially true as the professional team opens itself with warmth and invitation to patients and families.
The invitation and welcoming into the actual bedside rounds process begins outside the room as the team is assembling. Every effort should be made to avoid the somewhat natural tendency to begin talking about the patient’s condition among team members outside of a context where the patient and family can participate.
There is often a strong sense of wanting to “get our house in order,” just among ourselves, before inviting anyone else in. Without realizing it, the actions of having “the conversation before the conversation,” unintentionally build distance. With good intentions, assumptions are being made about what patients and families would want. Yet the absence of the patient and family voices in these conversations means that what is being made does not truly include them.
Active engagement of patients and families
In order to accomplish true collaborative care, the patient and family must function as part of, not separate from, the care team. Relational bridges must be established that transcend expectations and past experiences of professional distance and asymmetries of knowledge.
The activities that promote active engagement of patients and families can be surprising. For example, consider the importance of intentionally waiting before having any conversations on rounds until the care team, patients, and family members can all be together. At first we didn’t recognize how important this is. You might be thinking, as we did at first, “Isn’t it helpful to have a team meeting before starting our day? Isn’t that supposed to be a best practice? Isn’t it good for the team to meet and talk?”
Gradually we began to recognize that whenever a team meets and talks together, understandings are being formed. The understandings created by these conversations depend on who is present and talking together. If patients and families are not present and involved in these conversations, the understandings being developed will not reflect their insights, needs and beliefs. These differences are not minor. We now see that by meeting and talking among ourselves separately from our patients we were unintentionally creating and perpetuating divisions of knowledge and power between ourselves and our patients. We had no idea we were doing this at first.
Collaborative care is based upon comfortable authenticity. At its best, collaborative care encourages us to build care environments that we’re comfortable sharing with others on a moment’s notice without advance preparation. It invites us to be simply who we are, welcoming others into all of the realities and uncertainties of health care decision making. Collaborative care is like having best friends stop by unexpectedly and welcoming them with arms wide open, without a thought about anything except the joy of the friendship. It is imperfect, and that is just fine.
Collaborative care is like having best friends stop by unexpectedly and welcoming them with arms wide open, without a thought about anything except the joy of the friendship.
What is made possible by this welcoming? In such a context people are free to respond in ways unburdened by unnecessary and unrealistic expectations. New ideas and insights are more able to emerge from such interactions. As people experience this comfortable generativity of collaborative care, the easier it becomes to trust that it will always be present. Over time, the capability for trusting that emergence will happen grows among people. As it does, the care environment takes on a more personal character, and is increasingly filled with new meaning and aliveness. Collaborative care weaves the disorder of health care into a “wonderfully imperfect” fabric of human authenticity and potential.
Releasing the embarrassment
Over time, welcoming without the burden of embarrassment makes possible a very different kind of conversation in which everything has changed. In place of worries about what the patient would think if they knew how disconnected things are, comes a new comfort. In place of unspoken mistrust comes a new spoken acceptance and forgiveness. The power of this kind of collaborative engagement at a true joint level, and its freshness, is startling.
A circle of mutual care
When patients and family members are truly included as active members of the care team a shift happens about what truly matters at the end of the day. As intentional actions are taken to move toward collaborative practice, and as formative conversations become possible across professions and that involve patients and families without embarrassment, and as hierarchies fall away, the experience of giving and receiving care becomes mutual rather than unidirectional.
When patients and family members are truly included as active members of the care team a shift happens about what truly matters at the end of the day.
In the context of a collaborative care environment these shifts of meaning and purpose are palpable. There is a merging of interests and abilities between the care team and the patient/family. At first these shifts seemed exceptional to us, but we now realize that they are simply what happens when hierarchies become level, and patients and families actively engage in co-creating care.
One patient said, “You let us be ourselves, and you were that way, too — just people being people with one another — and that made all the difference.”
Excerpts from Implementation Field Guide to Collaborative Practice: Hospital Care, by Paul Uhlig and W. Ellen Raboin © 2014 Collaborative Care Alliance. For more on the authors’ work in collaborative care visit http://www.cca-home.org/
Home page image: Neal
