Magic lever – grandchildren

My grandson, age 4: Opa (that’s me) go get your cane, let’s play in the yard.

Opa: Sure, what should we play?
Grandson: Jungle animals
Opa: What animal should I be?
Grandson: One with balance. ūüôā
Why do I feel so wonderful hanging out with my grandchildren? My heart is open, I laugh. Where else can I be, but in the moment. Truly, grandchildren are magic levers to best health.

Magic Lever – Adherence to Health Plan

Unfortunately some providers call adherence to a health plan – compliance. This unhelpful label implies singular focus on the patient, as in “they aren’t¬†compliant¬†with taking their meds”.

The ability to develop and adhere to a health plan is probably the most complex magic lever of best health. Developing and adhering to a health plan involves studying population health; evidence-based best practice; collaborative relationships, behaviors, language, and alignment of the health team; standardized work flows with on-the-spot improvisation; electronic and non-electronic tools; leadership; and management of cultural and social habits and challenges. Setting up systems to make adherence more likely is challenging and labor intensive. The effort has to be worth the outcome.


Population¬†health¬†analytics¬†– studies to predict¬†those groups of people for whom adherence planning would yield the greatest benefit to health, experience, and cost.¬†Evidence-based practice¬†– adherence planning should be based on evidence – knowing it’s likely to do what the health team expects.¬†Collaborative relationships, behaviors, language, and alignment of the health team¬†– the intricate choreography with stars and cast who can speak to,¬†understand¬†each other, and work together for a common purpose.¬†Standardized work flows with on-the-spot improvisation¬†– adherence planning is largely production work repeated across groups of people. Yet each of us is slightly different and unique. Teams respond as people and circumstances change.¬†Electronic and non-electronic tools¬†– Adherence is not a point in time, but occurs and adjusts over time. Well meaning and determined people need help.¬†Leadership¬†– Creating and maintaining adherence friendly systems needs inspired leaders. Dance without a director is just a rave.¬†Management of cultural and social habits and challenges¬†– A person who doesn’t get a lunch break can’t take a mid day medication with food. A single parent with several children depending on public transportation can find it difficult to make a physical therapy appointment three times a week. Sensitivity to such challenges and public policy advocacy can increase the likelihood of adherence.
In short, adherence is serious work for everyone. It is not compliance.

Health IT 2013 – Turning vision into reality

How will health IT make a difference a year from now? Please see the HIMSS blog carnival¬†link¬†for many visions.¬†As we look to the recent past and into the future, the¬†possibilities¬†of health IT are staggering. While visionaries and innovators plot their course, let’s think for a minute about the boots on the ground – what does it take for possibilities to be integrated into the lives of consumers and the work flow of professionals? After all technology serves people – their interactions, relationships, needs, and wants – to attain best health.¬†Early adopters, such as myself, flock to new technology, as do agencies seeking to increase volume and productivity, and businesses tapping into the next big thing. Most people and most health organizations, however, are notoriously slow to change habits that integrate the possibilities, creating a dynamic tension between what is and what could be. Adding to this tension is the generational difference between the young accustomed to and delighting in technology and the older ones hesitantly sticking their toe in.

I predict that 2013 will find an exacerbation of this tension with a demand for spiritual advisors, interpreters, change agents, and choreographers. Spiritual advisors help individuals identify and communicate their best health goals and help organizations stay focused on their mission Рthe technology vision has to accomplish something.   Interpreters translate and meld the diverse languages of stakeholders: varied educations, lifestyles, personal and world view, wonk and Luddite, best health and mHealth focused. Change agents guide health teams and organizations through rapid improvement. Choreographers design, align, and adjust the dance of cultural transformation for the stars (consumers) and supporting cast (health team). Do we value these skills as we plot the future?

Errors in Electronic Medical Records

I’m concerned about errors in electronic medical records. I love my technology, I’m an early adopter. I participate in several national initiatives bridging the consumer and health technology – HIMSS (Health Information Management Systems Society)¬†¬†eConnecting with Consumers¬†Committee,¬†Society for Participatory Medicine, the federal¬†Automated Blue Button Initiative,¬†TIGER¬†(Technology Informatics Guiding Education Reform),¬†Patient Adherence Workgroup. I have a PHR (Patient Health Record) through¬†Microsoft Health Vault¬†and have enrolled in patient portals for all my physicians who have one. What worries me is the quality of the data in those systems. As a nurse, quality improvement expert, informaticist, leader, and ¬†consumer, I know the opportunities for errors in data.¬†Databases and electronic information are only as good as the information in them. ¬†We all have our stories about frustration with erroneous data in our credit reports and how difficult it is to fix it. Health care data is the same only there’s more of it. Clinicians are challenged to correct mistakes in electronic data. Here is an¬†article¬†about clinicians correcting electronic data mistakes. As consumers expect and receive more and more access to their electronic health data, they will question the quality of some of that data. How will they be able to correct it? Correcting electronic data is complex and labor intensive. Here is an¬†article¬†about consumers correcting their records. Do any of you have experience with errors in your medical record, electronic or paper? Please share.

Best organizational health – recovery

 

Individual best health depends on organizational best health. I spent a valuable portion of my professional career working in behavioral health. Organizations and individuals all suffer tragedies from time to time.  Many similarities exist between organizational improvement and personal recovery. For example, an addicted person follows a longstanding behavior without question. The behavior affects the addict negatively, even tragically, but definitely results in poor performance.  Resistance to change is fierce. The addict will not be forced to change. When the addict perceives the hopeless of the addiction, usually in a heightened state of collapse and despair, he or she becomes open to exploring new behavior patterns and significant belief systems become rearranged, thus creating positive change and subsequent improvement. Paradoxically, hope evolves from despair or surrender. Healing occurs first in the spirit, then in the mind and last in the body.

When an organization suffers a tragedy, it also recovers first in spirit, then in the mind and finally in the body. An organization recovers by rebuilding its spirit (mission) by embracing and focusing on its mission in all areas of operation. Next it strengthens the mind (leadership) by rebuilding coalitions, aligning collaborations, and rounding to maximize employee and patient experience.  Finally, it heals the body (staff, processes and systems) by mindfully involving all stakeholders.
Have you experienced organizational recovery? How has it recovered?

Magic lever – resilience

Tragedy is the common unifying force of life and organizations. The more seasoned you are, the more likely you are to have experienced personal and organizational tragedy –¬†a death, diagnosis of serious illness, job loss, legal difficulties, downsizing, loss of a contract, loss of key staff, loss, loss, loss.


My daughter-in-law texted me, May the force be with you, as I was in the midst of a personal tragedy.  What is this force, this superpower? How does a person or an organization survive a loss, a tragedy and regain best health? Resiliency. According to SAMHSA resilience is the ability to:
  • Bounce back
  • Take on difficult challenges and still find meaning in life
  • Respond positively to difficult situations
  • Rise above adversity
  • Cope when things look bleak
  • Tap into hope
  • Transform unfavorable situations into wisdom, insight, and compassion
  • Endure
The American Psychological Association reports the following attributes about resilience:
  • The capacity to make and carry out realistic plans
  • Communication and problem-solving skills
  • A positive or optimistic view of life
  • Confidence in personal strengths and abilities
  • The capacity to manage strong feelings, emotions, and impulses
Can resilience be learned? How can we increase the resilience capacity for ourselves, our families, our organizations, and our communities? What tools can help increase our resilience capacity?

Magic lever – Setting a goal for best health

A best health goal is a milestone in a health journey. These goals can be set individually or collaboratively with a health team. Goals can run the continuum from lose 10 pounds in the next 3 months to make an appointment with a dermatologist to stay alive until my grandson’s wedding. The goal can be one of several, such as walk 50 feet with assistance, manage pain without IV’s or injections, and have meals brought to my home so I can be discharged. Goals need to be specific, measurable, possible, and explicitly stated. One of the characteristics of valued members of my health team is that they help me set goals and attain goals. If they can’t do this, they aren’t part of my team. The goals that I have set with my team this past year include lose 35 pounds in 9 months, walk at last 5 miles per week, do eye exercises 10 minutes every day until the double vision decreases, and stretch my quads twice a day. I have been able to meet all but the last one. Factors for success for me have been that the goals were stated and written; I kept a log of my activity and progress; and these goals were discussed at every opportunity when I met with members of my team, including my wife and my family. As a nurse it’s inexplicable to me how disconnected goal setting can be from the patient. While every profession has a treatment, care, discharge plan, often the patient and family don’t explicitly collaborate in setting the goals and mapping progress happens in the patient record or between professionals and not consistently with the patient and family. How can we get better at setting explicit measurable goals with our health team?

Magic lever – changing habits

One of the magic levers impacting best health is automatically using widely accepted, well tested practices (evidence-based practice). For example hand washing. Seems like a no brainer – washing hands between patients for professionals, before caring for your loved one, after going to the bathroom for everyone. Another is limiting¬†antibiotic use to treat viruses. Also preventing or reversing obesity. I’m fascinated how hard it is for professionals to change practice informed by widely accepted research or even common sense. Is it similar to maintaining good life habits? I suspect that inertia plays a major role. It’s hard to change gears in a busy productive life. Heck, its hard to change gears in an unproductive life. How do we get the stars in alignment to do the right thing when we definitely know what the right thing is? How do you effect change in your professional and personal life? What are key factors that others can replicate? We spend so much money and human capital on trying to change behavior – consultants, training, how-to-manuals. What works? Being able to change habits is a superpower.

Me? or Populations?

One of the challenges for the health care team – patient, caregivers, and professionals – is arriving at the patient’s personal goal of the moment and collaborating toward reaching that goal. I have found myself struggling to differentiate¬†the likelihood of treatment success for a population versus the likely effect for me, my patient, or family member. ¬†As my neurologist says to me, you are not the population. What works or happens for populations doesn’t necessarily happen or work for you. As a multiple sclerosis patient effects of treatment choices on populations is only one consideration got me. For example, I know that I will take no medication that makes me depressed or even less optimistic, no matter its proven clinical effects. My health team knows this.
Have you confronted such dilemmas in seeking best health?

Releasing the Inner Improviser

Best health includes improvisation in the relationship between health professionals and those in their care. One picture of improvisation is discretion to customize response and interaction and go off script and track with each individual’s or families journey. Yet the capacity of health professionals to remain up-to-date in their knowledge, compliant with practice and regulation, and productive while still able to be kind and improvise approaches possessing a superpower. As Kate commented yesterday, other knowledge workers Рteachers Рhave the same challenges.

What conditions release the inner improviser?  Let’s consider a few: clarity of purpose; trust and team dynamics; predictability and responsiveness of  systems; and ability to learn from the improv: fix what seems broken.

Clarity of purpose can be mission, focus on the task at hand, or even clear boundaries. Every organization I’ve worked for had a mission statement. St. Peter’s Health Care Services (SPHCS) in Albany, NY, was committed to being a transforming healing presence in the communities we serve. Like the golden rule, easy to say, tough to do. Difficult decisions at SPHCS often included explicit consideration of the mission.  Focusing on the task at hand is mindfulness. As in right now the task at hand is pain relief, teaching, mobility, whatever. Not my co-worker, not the next person who needs me, not Dancing with the Stars. Concentration. Zen. Finally, improvisation occurs within boundaries – knowing the tune. For health workers the tune is policies and procedures, regulations, standards of practice.

Trust and team dynamics. Sustaining kindness and improvisation without feeling trust in yourself and your team truly IS superpower. Good team dynamics are healthy relationships – role clarity, communication that greases the constant shifting and movement of the day’s flow, re-prioritization, and mutual helpfulness.

Predictability and responsiveness of  systems used by your team –  workflow, supply chain, information systems. Knowledge workers create work arounds when systems don’t work quite right. They ingeniously seek a state where they can accomplish their daily tasks productively. Disruption of these systems draws valuable energy away from kindness and improvisation.

If all the stars are in alignment and staff feels able and empowered to improvise, we are idiots if we don’t learn and fix. Some proportion of improv is kindness and some is in response to something that is broken. Often both. Lord, I feel another post coming on.

I contend that the most important job of leaders – the people who supervise those who touch the public – is to nurture the environment of kindness and improvisation. Nurture the environment and model the behavior.