Cindy's Weblog

Connecting Approaches

Thu, 26 Feb 2004 00:21:13 GMT

One approach

Don Berwick’s, December, 2003 article,

“Improvement, trust, and the healthcare workforce”.

The key messages are:

· Current strategies for developing the healthcare workforce are based on outmoded theories of control and standardization of work.

· Quality is a system property; if we want better results, we have to change the system.

· We need to harness the imagination and participation of the workforce in reinventing the system.

· The workforce needs to know how to set bold aims, measure progress, find alternative designs for work, and test changes rapidly and informatively.

Change begins with a shift in attitude from “it’s your problem” to it’s my responsibility”.

Another approach:

Professor David Cooperrider, of the Weatherhead School of Management, Case Western Reserve University, has been named the recipient of the Distinguished Contribution to Workplace Learning and Performance Award by ASTD--the American Society for Training and Development. This award is presented to him in recognition of his work in Appreciative Inquiry and the impact he has had on the training and development profession. Previous recipients of the award have included Malcolm Knowles, Robert Mager, Peter Senge, Geary Rummler, Gloria Gery, Roger Schank, Allison Rossett and Meg Wheatley.

>From their letter informing David about this honor:

"As a not-for-profit organization, ASTD provides leadership to individuals, organizations, and society to achieve work-related competence, performance and fulfillment. Part of our mission is to spotlight leaders and practitioners who are role models for others. It is truly fitting that you receive this award because of your pioneering thought leadership on building better organizations and communities. You have given us a new approach, based on unconditional positive change, to organizational learning and workplace performance.”

I have believed since the beginning of this project, that Appreciative Inquiry methodology could be the catalyst for change that we need to make groundbreaking progress in transforming health care. Appreciative Inquiry gets the whole system (including all stakeholders i.e. including patients and their families) in the room to discover and illuminate its core strengths and abilities, utilizes collaborative imagination to reach beyond the known to design the future, and establish steps toward that future. The process is energizing, encouraging, uplifting, engaging and creative. Buy-in is high.

Here’s my challenge…

Getting the whole system in the room means taking time out of care delivery. Besides the issue that patient needs are ongoing, the expense to practitioners (prohibitive for many family practices) makes it quite unfeasible to pay staff for extra meeting time.

I’ve tried different approaches and continue to look for creative approaches to saving time AND still capturing the vital essence of the process. I’m looking for someone well versed in Appreciative Inquiry and health care to lend some wisdom to this dilemma. Anyone willing to be a thought-partner?

three mice in a washing machine

Tue, 25 Nov 2003 05:27:01 GMT

I had a bad river-rafting trip once. Actually, it was my last river rafting trip and it took place a few years ago on the McKenzie River, near Eugene, Oregon. I'd been on that river before with a trusted friend and skilled river guide. We worked as a team, with his expert guidance. This time the person directing the raft was someone else with less skill and less judgment, and who did all the paddling. Have I mentioned that I am a proponent of teamwork?

To make a long story short, the climax of the trip was getting caught in Brown's Hole. Picture this... three desperate mice clinging onto an inflated soap dish in a washing machine set in the spin cycle. I think you get the drift... While we did provide some captivating, and apparently humorous entertainment to some kids standing on the near-by boulders, my only thought at the time was... well, I actually had two thoughts - "I'm going to die"; and "How do I get out of this situation?". Creativity went the way of the broken paddle. We clung on to our increasingly damaged raft with all our might, throwing ourselves from side to side, trying to stabilize things. Eventually, the river tired of us, and my next awareness was that of being tossed into the air (and out of the raft). In the brief moment before hitting the water, I remember thinking one thing, OK, two things... "I’m going to die", and "Get back into that raft as soon as possible."

When I surfaced in the VERY COLD water, I gratefully realized that the raft was within reach. Obviously, I lived to tell the story... and if I hadn't been so scared, and so cold, this could have been a thrilling ride. When I related the story to my sons later, they were almost envious. All I can say is thank goodness for lifejackets.

The memory popped into my head tonight for some reason, and I reflected that sometimes working in health care feels a little like being in that raft in Brown's Hole... spinning around and around, and being tossed from side to side, desperately trying to hold on. In these types of situations, creativity is abruptly replaced with an intense focus on survival.

In his book, "The Consultant's Journey" Roger Harrison, makes the point that organizations are so inundated with non-stop change, and people are so change weary, that what is needed instead of change agents are "facilitators of healing". I think he makes a good point. What I'm realizing once again is the incredible importance of relationship building in any change effort. Relationship building and breathing. We need to find ways to acknowledge and appreciate each other and breathe and reflect upon the work that is being done. We also need to find ways to reduce anxiety whenever possible. These things seem like luxuries sometimes, but they are just as essential as efficient processes.

Tue, 25 Nov 2003 04:27:23 GMT

Mon, 17 Nov 2003 18:33:36 GMT

Browsing through Marc's weblog this morning, I was intrigued by his latest entry regarding narrative approach. Dr. Charon's description of the use of narrative in her medical practice is registering with some thinking I've been doing lately. I've been wondering what truly transformed medical practice looks like for the patient, the family, and the health care clinicians. It has seemed to me that time for the patient's story is an integral part of this practice.

I'm recalling working with Dr. Andrew Elliott, ND, a physician in Eugene, Oregon. This man has been one of my greatest teachers in the field of healthcare. One thing that was integral part of Dr. Elliott's practice was listening compassionately, non judgmentally and intently to patient's stories. Being a classical homeopath, gleaning the small details about symptoms, reactions, even states of mind was an essential part of his effective practice. Andrew's compassionate and quiet listening approach almost always drew out very complete pictures of the patient's current state and also built a trusting relationship. Part of the reason he was able to do this (and still does, in a thriving practice), is that he also respected and cared for his own physical, mental, and spiritual needs.

So how does a practice with established production demands take the time to listen to patients' stories? Isn't part of efficiency, trying to get just what you need out of a patient to make an accurate diagnosis, and move on to the next patient as quickly as possible? How does one balance this with taking a comprehensive approach to patient care?

I certainly don't have the answers and I've never practiced medicine. I keep coming back to the wisdom of another teacher: David Cooperrider at Case Western University. http://connection.cwru.edu/ai/ David's quote, "We are made and imagined in each other's eyes." comes to me at least once a day.

When I reflect upon my experience as a patient, I realize what matters more to me than the amount of time spent with me in the exam room, is how present the care provider is. Is she/he really there - really listening? And, what are they doing with their judgments? How is this person's belief about me impact how they imagine me, their presence with me, and, my response or reaction. How does the image I hold about my care providers impact my presence and response to them? How can we really see each other?

Once my medical record got confused with someone else's at an office. The other patient has a very complicated and challenging social history. The assistant , thinking I was actually someone else, approached with an aura of suspicion, caution and judgment. It wasn't until she began asking me questions that didn't make sense, that we identified the source of the confusion and her demeanor changed entirely. As she shifted in her approach, my defenses began to drop and my responsiveness to her shifted back to what is normal for me.

So, it seems to me, if we believe that patient stories are a vital part of healing care, then we must help ourselves be in a state of mind in which patients feel comfortable sharing them. Self awareness can help here.. recognizing one's own internal reactions, keeping our intent and desire towards healing at the foremost of our approach, and therefore enhance our responsiveness. And, remember healers need to take care of themselves, too!

Center for Senior Health teaches us a lesson

Thu, 24 Jul 2003 18:43:53 GMT

The Center For Senior Health has done it again. Their team development score has surpassed all others. This, while integrating a new director, welcoming new staff and saying goodbye to others, adding new clinicans, working through major reorganizational efforts and being involved in P2! A great deal of the credit goes to Erin Baumgart, Nurse Practitioner, who makes it her business to pay attention to the dynamics in this fine clinic. At the recent Guidance Team meeting, I asked the members what contributed to the success of this team. This is what they told me:

Communication is open and people can say what they think and be heard. Also, they can talk about their feelings. Everybody is allowed to share their feelings and is validated for having them. Communication is open and honest. People feel secure, knowing their jobs aren’t threatened if they make a mistake, "we just try and fix it". It’s the job that’s the issue, not the person. Erin has a basic belief (modeled by her mother) in trusting in the good of a person. Also, modeling the way, rather than telling people the way to behave.
Denise Fischer contributes by supporting Matt Groenig (Director of the Clinic). She is responsible for recruitment and selecting finalists for positions. She take the culture of CSH into consideration when choosing candidates.
Kathy Higgerson, front office team-lead, helps by keeping people aware that they are begin heard and something is being done about their requests. Even if the process is slow – she keeps people abreast of progress.
Matt Groenig helps by doing the same thing. He responds quickly to staff’s need to hear information from him, or for him to listen to them.
There are no white elephants among the group.

Our former process facilitator, Terry Wagner has contributed by just being herself and building relationships while working on P2 projects in the clinics. Bringing chocolate was a big plus. Terry also tried to just "be present" with the with staff and connecting on a person-to-person level.

Once again,, it just isn't rocket science. Paying attention to relationship is the key to good teamwork.

Chaos and transition

Fri, 18 Jul 2003 22:09:05 GMT

Met today with FHA's leadership team, which is composed of the clinicians and manager. Stacey and I have recognized the value of staying in close touch with leadership as the clinic traverses all the changes ahead. Late yesterday afternoon, we got wind that staff were reporting high stress levels at FHA. Stacey and I charted out the projects currently, or soon to be in process for the clinic. This list includes:

Open Access, Planned Care, Idealized Office Design Efficiency, Shared Care Plan, Alternative visits, HF and DM registries, Patient Centeredness, EMR, Millbrook upgrade, transcription changes, recovery from docu-scan and Millbrook implementations, a remodel on the horizon, and HIPAA regulatory remodeling. Phew! No wonder people were getting a little frantic!

This morning, we asked the clinicians what they've noticed as far as staff behavior. Their observations were that staff were expressing increased fragility, frustration, anger, sarcasm, fear, shock and anxiety.

Here's what the clinicians identified that seems to be helping:

Relationship building that is happening in the redesign teams

Quick fixes being addressed and attended to

Cross-function mixing of staff on teams

Adhering to team agreements up front

Role modeling

Everyone together in a room hearing the same thing at the same time (the most recent all-staff meeting)

Acknowledging the situation and the magnitude of the changes, regularly

Expressing gratitude to the staff

We agreed to schedule another all-staff information/sharing meeting in the next few weeks.

What I know from William Bridges excellent work, Managing Transitions, Making the Most of Change is that people benefit from the following in times of change and transition:

knowing why this is happening -- and the benefits
understanding the problem with the old way
focus on the future rather than on the past
keeping communication lines open
sharing feelings and plans
ceremonies to "let go" of the old
defining what is over and what isn't
support/caring
gleaning ideas/ sharing ideas and support
acknowledgment of the fear and chaos
understanding that chaos is normal
focusing on short-term goals
rewarding small successes
promoting personal responsibility
converting complaints to action
modeling new behaviors
slowing down and enjoying the newness as much as possible
mark the arrival of new beginnings with a celebration
choosing new patterns before routines set in
noticing the difference.

In addition, I believe this journey is a survivable one if we can just keep our eyes focused on the vision of excellent, patient-centered care and appreciate each other along the way.

FHA's Journey of Excellence

Fri, 06 Jun 2003 17:01:10 GMT

The Access, Planned Care, Patient Flow, and Culture teams at FHA have now created their mission statements and group agreements. The mission statement creation process

Appreciative Inquiry Category

Thu, 15 May 2003 21:48:46 GMT

I have created a special category to post information about Appreciative Inquiry or similar approaches.