Monday, April 10, 2017

Team Meetings: What if Everyone Gets A Voice?




Teamwork is now the name of the game in group endeavors. Google recently conducted Project Aristotle, a three-year study on teamwork, synthesizing its experiences along with previous research.  Some teams got better results than others. Why? 

Among the key variables were:
  • The ability of every person to speak up equally. No one individual dominated discussions.
  • The freedom to share what each member was really thinking. The team is psychologically safe.
  • The availability of a good model to guide their problem-solving.

Julia Rozovsky, the Project Aristotle lead, concluded, “Don’t underestimate the power of giving people a common platform and operating language." [1]

Could this principle apply to health care teams when discussing patients’ care? Could team conferences be regarded as the “common platform” and the Siebens Domain Management Model (SDMM) framework as the “operating language”?

Yes on both counts. The conference assembles the members in one platform. The SDMM serves as a simple “operating language”. 

Recent studies examined this approach for inpatient rehabilitation team meetings, with emphasis on barriers to discharge home. When the SDMM served as the team’s framework: 

  • Many patients left functioning better,
  • More went directly home rather than to nursing homes or back to acute care hospitals,
  • Patients spent less time in the rehabilitation hospital.

These results are summarized in the table below. 

What’s the take-away?  Clinicians improved teamwork significantly using the SDMM to guide their work.  Other teams – within health organizations and/or the community - may also benefit when applying the SDMM as they serve individuals with health care needs.

TABLE - Outcomes from Use of SDMM with Focus on Barriers to Discharge in an Inpatient Rehabilitation Hospital[2]



Comparison/Variable
All Stroke
Geriatric Stroke
 All Geriatric

Patients’ Demographics
Number of Patients  
Before and After
154 and 151
66 and 58
429 and 524
Average ages in years
in Before and After Groups
70.8 and 68.9
83 and 82.8
82.8 and 83.5
Percentage of Women
In Before and After Groups
45%  and 53%
58%  and 64%
65%  and 64%
Results
Did rehabilitation happen using fewer inpatient days?
Yes, 5 fewer days
Yes, 4 fewer days
Yes, 2.6  fewer days
Did both groups have similar function on admission?
Yes
No, the after group has slightly better function
Yes,

Were more patients discharged home in the After group? By what percentage increase?
Yes
23.4% more
Yes
19.4% more
Yes
15.9% more
Were fewer patients discharged to nursing homes?
No

No

Yes
13.6% fewer
Were fewer patients discharged back to the acute care hospital?
Yes
17.9% fewer
No

No
-
Results Compared with National Benchmarks
Was the shorter length of stay even shorter than changes nationally between 2010 to 2012?
Not compared
Yes
Yes
Was the improvement in function per day of inpatient treatment higher than the national averages?
Yes
Yes
Yes
Were the increased number of discharges to home more than national averages?
Yes
Four times more
Yes
Four times more
Yes
 More than three times more
Were there fewer readmissions to the acute hospital compared to national averages?
Not compared
Yes
Six times fewer
Yes
Almost three times fewer

Patients are in three different groups – all stroke patients, stroke patients 75 years old and older (geriatric stroke) and all patients 75 years old and older (all geriatric).  The groups’ results are compared between 2010, before the SDMM was used in team conference, and  2012, after the SDMM was started in 2011. 



[1] Duhigg C. What Google learned from its quest to build the perfect team. New York Times Magazine, February 25, 2016.
[2] Adapted from Kushner DS, Peters K, Johnson-Greene D. Evaluating the Siebens Model in geriatric-stroke inpatient rehabilitation to reduce institutionalization and acute care readmissions. Journal of Stroke and Cerebrovascular Diseases 2016;25(2):317-326.

Friday, December 2, 2016

Person-focused Care



Person-focused Care

An expert geriatrician recently listened to my TED-like talk. That 15-minutes summarized 25 years of work. It covered why and how I consult with health care organizations. The work entails applications using 4 simple domains to think efficiently about patients and improve the care delivered. This geriatrician was a long-time used of these domains. (The domains’ plain names are Body, Mind, Activities, and Surroundings ©.)

“Wow, this is very polished.” Then he added, “Have you heard about person-centered care?” No, I hadn’t. “You should find out about it.”

The domains’ applications have evolved to improve individual patients’ care and be easy for clinicians to use. They support important themes – patient-centered care, health care literacy, self-management, and so on. What about “person-focused care”?

Good articles were easy to find.1 Among the core concepts are:
  • Individuals’ priorities or preferences for their care must be known.
  • The person’s care must be viewed over time, beyond the few days or weeks of an acute illness.
  • Added to the care of the patient (when an individual is sick) is an awareness of the whole person (the individual when not sick).

So too in our work:
  • Patient/person preferences are an explicit sub-domain.
  • The 4 domains remain consistent over a person’s lifetime regardless of health status. Health-related issues evolve within each domain.
  • The domains are extended to patients/persons through a health care notebook they own. To it clinicians and/or they add, over time, their key health-related information organized by the 4 domains (Health Issues, Taking Care of Your Mind & Feelings, What You Do, and Where You Live and Work ã). This Notebook helps bring important aspects of their personal lives more reliably into the clinical world.

Good… our work supports another important theme - person-centered care - in health care delivery. 



1 Barbara Starfield, MD, PhD, a well-known professor in health policy, wrote about it in 2011 in The Permanente Journal. The American Geriatrics Society published an expert panel’s definition in 2016.

Wednesday, July 13, 2016

Simple But Profound Conversations



I just finished reading Dr. Atul Gawande's book Being Mortal.  He explores how we fail to talk about death - those important and uncomfortable conversations between doctors and patients.  Dr. Gawande provides multiple examples where treatments continue while healthcare professionals miss the forest for the trees. The patient is dying but no one talks about it.
As an example, I became responsible for the care of a middle-aged patient with metastatic cancer in our rehabilitation unit.  He and his wife had been told that we would get him better.  He would be going home.  After reviewing the records, examining and talking with him, I realized the man was actively dying.  He was in the last weeks of life when death is unequivocally near. No medical professional had told him the facts.
It fell to us, admittedly late in the situation, to have the conversations as described by Dr. Gawande.  We began to review the patient’s understanding of his illness and what was most important to him at the moment.  We shared the cancer's reality and how it was affecting his body.  These conversations involved his family and the treatment team. But before the discussions could be completed, he died suddenly. Tragically for his family, we had not resolved all the issues. It was also profoundly painful to me as his doctor, trying to do the right thing.

Talking honestly with patients is crucial to the quality of our work, whether in crisis or in basic care.  But how to structure those conversations in the crazy pace of patient care?  I have come to a framework based on my own experiences with rehabilitation and geriatric patients.  It is a simple 4-domain outline, easy to remember.  Each domain addresses a different area of the patient’s health: body, mind, activities, surroundings. Identifying issues within the domains can be key to providing quality care (1).

Called the Siebens Domain Management Model (SDMM), this framework is gradually being applied by others because it works. Here are three examples from clinicians who have used it during their patient conversations:
1. A physician in a rehabilitation unit reported, "I would have normally not considered asking Mr. A. about his future employment just a week after his bilateral below-the-knee amputations.  However the SDMM cue card (2) prompted me to ask about his work.  It required driving.  We set him up with our vocational rehabilitation services to start right after he left the hospital.  From there, he was set up with a training program for drivers with amputations.  Had I not started the ball rolling, there may have been some real delays in getting these services started.  The patient may not have returned to work as soon as he did, leading to possible significant loss of income."
2. Another physician had an  inpatient, wheelchair-user,  heading for discharge.  He was returning to his "previous living arrangements, which was with his wife in a first floor apartment with wheelchair ramp access and no stairs." The plan seemed appropriate.  However, using the SDMM framework, the physician knew to ask about his surroundings.  He revealed that he was not on good terms with this wife.  She had moved out two days earlier.  She would no longer care for him. She would no longer drive him thus leaving the patient without transportation.
The physician added, "This information greatly changed his discharge plan."  Had she not inquired systematically about his living situation, the patient's new circumstances might not have been discovered as quickly.  Bringing his major non-medical concern to light better informed the treatment plan for his life post-hospital.
3. A seasoned primary care physician had a patient with multiple sclerosis. He was losing his ability to walk.  During an out-patient visit, and using the SDMM cue card, she inquired about his spirituality.  She learned that he had a strong faith that helped him live day-to-day.  She told me, "I had had no idea and it was remarkable. I really learned something important about how he managed.  This helped me connect with him much better."
Conversations with patients provide us a deeper appreciation for them.  They need not always lead to immediate medical decisions, as in the discussion with the patient suffering with MS.  Other times, the resulting connections often improve our diagnoses and care plans.  Either way, the connections are at the core of what we doctors love most: providing quality care that includes conversations about strengths and solutions in the midst of adversity. Conversations that save us from missing the forest for the trees. Conversations that are simple but profound.



1 The Siebens Domain Management Model has 3 sets of terminology for the four domains. The four listed above – Body, Mind, Activities, and Surroundings – are the simplest. See Siebens H., "Proposing a practical clinical model," Topics in Stroke Rehabilitation 2011;18:60-65.
 2 The SDMM Cue Card (also called SDMM Communication Card), downloadable at no charge from the Resources on this website's home page. Please note Guidelines for SDMM Use as well. 



Friday, April 29, 2016

Laboratory Bench Research, the SDMM, and the Most Important Hurdle



Here’s my first blog post. This not-so-new technology is magic to those of us familiar with the pre-internet era. Here's something from my background to address a first question I hear often: "Why are you doing what you're doing?!” 

In college I found myself really enjoying laboratory “bench” research. We studied a “living fossil," a single cell organism that contained a cyanelle. This cyanelle was thought to be a step in plant cell evolution. It had characteristics similar to a blue green algae that may have been "eaten" by the organism. It then perhaps gradually evolved into modern day chloroplasts, those energy producing units in all green plants. Looking at the cyanelle's RNA could give us some clues about this possibility.

The experiments followed a careful protocol. There was an exact amount of solution, at a specific pH (better not mess that up), and a series of steps to be executed as precisely as possible. Then the extracted RNA was put on a gel electrophoresis to generate a pattern. This could then be compared to the RNA pattern of modern-day chloroplasts.

The RNA patterns turned out to be similar, between the more primitive cyanelle and today's chloroplast. It is hard to explain my excitement when discovering this finding, tracing prehistoric plant life to our modern gardens. (OK, exciting only if you are into that stuff.)

While I loved the bench research, I opted for medical school and patient care. But there was one aspect of the lab that I constantly wanted as a doctor. My hectic clinical care couldn’t be further from the clean (usually), organized (mostly) science laboratory. It bugged me no end that systems weren't more structured, more “scientific” in clinical care – especially when applied to  information management. I found myself making non-optimal decisions simply because easily attainable pieces of information were missing.

The drive to bring better organization to clinical care has pushed me for over 30 years to research and develop the Siebens Domain Management Model (SDMM). The SDMM's four domains (and sub-domains) can help to introduce a more systematic approach especially with more complex patients. The SDMM is designed to address our collective challenge to better manage health care by introducing one important kind of standardization.

I know I am not alone in searching for better organization in clinical systems. Just a few weeks ago, the theme was echoed in a public health lecture which touched on research by The Advisory Group. In its survey of 160 health care industry leaders there was general  acknowledgement that clinical standardization is the most important hurdle to integrating health care services. Maybe some of those leaders, like me, really enjoyed lab bench research with clear protocols.