Drinks, Pizza, and a Little Basketball

Nostalgic for the hours I used to spend in college dining halls debriefing a long organic chemistry lab session, planning the next Chinese Students Association event or discussing the misuse of Murphy's Law when describing catastrophic global events, I take great comfort in studying in cafes or catching a casual drink at low-key bars. Food and drinks are within reach and conversations are aplenty. However, it seemed just too perfect that I would find myself at a Wolverine friendly bar and pizza joint called the Brown Dog in the middle of Telluride to catch Game 3 of the NBA finals with my new patient safety friends.

In between sips (true sips because alcohol and high altitude could turn into a physiologic disaster), we would seamlessly transition from discussing the patient harm that results from unstandardized hand-offs to watching the Miami Heat claw their way towards a lead in the series against the Thunder. The true cherry on top was the mouth-watering smells of Detroit deep dish pizza that surrounded us. Because the University of Michigan atmosphere mixed with good pizza and beer seemed to be a winning combination for stimulating patient safety conversations and Miami Heat success, we recreated the magic for the rest of Miami's journey to become the 2012 NBA Champions. As I wistfully look back on my week in Telluride, especially as I suffer in the inhumane heat wave that has metaphorically encircled Southeast Michigan in an inescapable head-lock, I can’t help but intertwine patient safety and health care quality improvement with basketball.

Since becoming a basketball fan when the Miami Heat won the NBA Championship in 2006, my home team has really tried my patience. Like any health care quality nerd, I began to see health care connections in sports. The Miami Heat represented all of the negative characteristics of a poor performing health care system, primarily an organization that had seemingly lost its way (click here to read more about the Miami Heat and its failures as an HRO).

2010 represented a turning point. In a politically unwise and arrogantly publicized event, LeBron James was recruited to join Dwyane Wade and play for the Miami Heat. Chris Bosh of the Toronto Raptors also decided to move to warmer climates. Before I knew it, amidst the global antagonism directed towards Miami, a new sense of purpose had been injected into my home team: The Big Three had promised to fill their fingers with championship rings. While the rest of the world derided the team for its bombastic promises, I bought into the dream. With three superstars on the same team, as the Boston Celtics had proven in 2007, how could the Miami Heat fail?

Did the Miami Heat succeed in the 2011 NBA Finals? No. The Big Three was simply that, three basketball superstars who all happened to play on the same team. An optimist would say that The Big Three’s first season together was a string of small experiments (PDSA cycles) on how LeBron James, Dwyane Wade, and Chris Bosh would share the court together. But, what this looked like on TV was confusion and a total lack of coordination. The Big Three had their moments when they would each individually live up to their All-Star reputations, but these occurred in unpredictable and unreliable spurts. The Miami Heat haphazardly played its way into the 2011 NBA Finals and an entire season’s worth of bewilderment became obvious to the world as it was blown out by the Dallas Mavericks. I distinctly remember watching the team disintegrate into a group of headless chickens that did not seem to know what to do even when it possessed the ball.

In retrospect, the 2010-2011 season should not have come as a surprise to me. In assembling The Big Three, the Miami Heat committed the same mistake that many health care organizations make: attempting to achieve greatness through cultivating great parts. In a thought experiment to build the world’s greatest car by assembling the world’s greatest car parts, Dr. Don Berwick, former CMS Administrator and CEO of IHI, describes:

“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence”… We’d connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”

The basketball teams that want success to become an intrinsic characteristic of the team, invest and develop not just individual talent, but also create a reliable system of teamwork.

Examining the Miami Heat’s run for the 2012 NBA Championship, the Miami Heat has done just that: built on the talents of The Big Three and transformed into a high-functioning team. For those that continue to carry Miami Heat antagonism (I realize I am in the great minority being a Miami Heat fan), I’m not claiming perfection, but improvement. Although an abbreviated season, the Miami Heat discovered a rhythm of teamwork that allowed The Big Three to play together as a more unified front. The Miami Heat faced one of its first great tests in the second round of the playoffs against the Pacers. Chris Bosh was injured and out of the picture and the Miami Heat was shut out of Game 3, falling behind in the series 1-2. The Miami Heat of 2011 probably would have been knocked out of the NBA Finals running. But, the Miami Heat of 2012 readjusted and Udonis Haslem stepped up to the plate to fill in the gap that Chris Bosh left. The Miami Heat beat the Pacers 4-2.

Improved teamwork was even seen off of the court. In the wake of the Miami Heat taking the lead in Game 3 against the Thunder, the drama that erupted in the media was when Kevin Durant of the Thunder was caught telling Dwyane Wade, "You're too small." Although the statistics of the team do back-up Kevin Durant's statement, LeBron James' response that the actual size of the players doesn't matter as long as they're fundamentally sound and play with the effort that helps that makes up that difference, rang true of the 2012 Miami Heat teamwork mantra. Just looking at the media coverage of the Miami Heat's journey to the championships, the words "we" and "team" are being used more frequently and coverage of the last game sings the praises of not just the Big Three, but also Mike Miller, Shane Battier, and Mario Chalmers--critical teammates who all contributed to the win.

So, what does this all mean for health care? The theme of the week at the Telluride Roundtable was communication. While we spent the day discussing the importance of communication facilitating successful teamwork, what we had in front of us in our after hours was an example of the incredible transformation of a basketball team that truly took teamwork to heart. So, as many of us are getting ready to apply for residency and are looking for residency programs and institutions that value patient safety, don't fall into the trap of optimizing health care by just optimizing individual parts, also consider what programs and institutions do to facilitate excellent interdisciplinary teamwork.

While the IHI Open School facilitates interdisciplinary communication by bringing health professions students of all disciplines out of their isolated silos together to discuss quality improvement and patient safety, what else can be done to improve interdisciplinary communication and hence create a reliable system of teamwork? I'd love to hear what you are doing at your institutions, so comment below and share your successes and challenges--perhaps some drinks and pizza will spark some health care quality improvement magic.

Team: What’s Your Definition?

Writing a job description was not exactly what I imagined myself to be doing in the first week of a clinical immersion. (To many, this might not sound too interesting or even relevant to clinical as a nursing student.) However, it proved to be an extremely valuable experience and inspired a new thought process on defining roles among health care staff.

The task for the meeting was to draft a clear description and distinction for both the nurse and medical assistant. It turned into 2.5 hours of constructive debate about how to word the already understood roles so that they would be concise, clear, and representative of the values of the medical home – a team-based health care delivery model.

What stuck with me the most from participating in the composition of the job descriptions was the meaning of the word “team.” In the medical home model, an interdisciplinary team approach is critical. (In fact, there is even a position for a Team Coordinator.) During the meeting, we were contemplating changing the name of the job title of a Registered Nurse to Team Nurse and from Medical Assistant to Medical Team Assistant. What would be the implications of renaming the role? What does the word “team” really mean?

As I am sure many of you are familiar with, the word “team” is used endlessly in coursework. My field of study, clinical nurse leader, in fact, represents and advocates the importance of an interdisciplinary team. But does everyone think of the word in the same way? This idea was discussed and will be revisited in an upcoming meeting. In the meantime, I asked around at the center, inquired with fellow peers, family, and friends to compile a mix of perspectives on how to define the word “team.” Here are some of the responses I received:

• “A group of individuals working cohesively in order to achieve a common goal”
• “A team is people who make each other better than they can be alone”
• “A group of people working together toward a common goal, sharing resources, skills, and responsibility”
• “A group of individuals working toward a common goal with various different perspectives and approaches to reach that goal”
• “A group of people working for a common purpose”
• “A group of peers working together”

Key words in these definitions were “together,” “achieve,” and “goal.” I was pleased to see how many people chose to use those exact words or something very similar. I think the members of this task force will agree the word “team” will be well received and a positive addition to the job title and description at the center.
I’d love to hear from some of you. What does the word “team” mean to you? Does your clinical site or past sites use the word “team” in everyday practice?

- Jessica Hatch, Clinical Nurse Leader Student, University of New Hampshire

Editor's Notes: Learn more about Jessica—and her clinical nurse leader role—in her interview from the 2011 IHI Open School Student Quality Leadership Academy.

Breaking News! Medical Students Shadowing Nurses

I just received this message from one of our Deans of Medical Education. Even though I have my first anatomy practical today, perhaps this is a sign that despite all of that, today will be a wonderful day!

Subject: New Required Educational Experience - Nurse Shadowing in M1 Year

Date: Sep 25, 2009 9:52 am

Message:

Dear M1 Class:

This year we are offering you a new required educational experience to complete during your M1 Year. You will each spend one half-day shadowing a nurse in the UM Health System.

Today’s health care delivery system challenges all health care professionals to provide care that is patient-centered, efficient, effective, safe, and timely. To meet this challenge, collaboration among members of health care teams (including, but certainly not limited to, physician and nurses) is vital. In at attempt to educate medical students on the role of nurses in the health care team as well as to foster open communication and teamwork between health professionals, this shadowing program – created originally by medical students – was run as a pilot last academic year. We hope that you enjoy the program as much as students last year did, and take something away that you can use for the rest of your careers as physicians.

We developed the following learning outcomes for the experience:

* Knowledge of what nurses bring to a health care team
* Ability to communicate effectively with a nurse
* Respect for the knowledge and skills of nurses
* Openness to learning about patient care from nurses

We will be asking you to complete a pre and a post-assessment of this experience. The post-assessment will serve as your documentation of completion of the required experience.

Sincerely,
Casey White, Ph.D., Assistant Dean for Medical Education

Little things like this that remind me why I decided to come to Michigan for med school! Do y'all have programs like this in your schools?

Boston Regional Event Recap

On April 23rd, eight IHI Open School Chapters in the greater Boston area hosted the Boston Regional Event, bringing together students from a wide range of health professions to discuss health care quality.

Over delicious Bertucci's pasta and salad, the Open School students and faculty were led in a case study discussion by Dr. Dan Hunt, Assistant Professor of Medicine at HMS and Director of Inpatient Clinical Educator Service at MGH, and Dr. Meridale Vaught, Instructor of Medicine at HMS. Click here to see the case study we reviewed (Other case studies listed on IHI Open School page can be found here). While the case taught us all a little bit about the clinical symptoms and treatment of Adult-onset Still's Disease, the take home message was patient safety and the importance of the continuity of care. Dr. Hunt and Dr. Vaught discussed the case with the 50+ students as a large group and provided us with time to break into smaller groups to think about several important considerations. Questions such as:

• What were her presenting symptoms?


• What kinds of tests and questions need to be answered before a diagnosis can be confirmed?


• Because the recommended drug is relatively new, what kinds of considerations must the care team address?


• What's the patient's medical history? Does she have any other conditions that we need to be aware of?


• Will any of her previous medications interact with the new drug?


• How will the patient manage all of the different medications?


• Can the patient afford the medication?


• Will her insurance cover the medications?


• How will the primary care physician be looped in?


• What are some important details that the patient's family should know about?


• What kind of training will the patient need in order to take her medications?


• Will the primary care physician be familiar with treating and monitoring her condition?


• Does the patient understand that this is a chronic condition and that she will have to consistently take her medications?


• Because the drug she will need to take is relatively new, will her local pharmacy have the drug in stock?


• What kind of follow-up will be needed as she is discharged from the hospital?
  
  ...and much more.

Each small group was made up of a mix of disciplines. We had public health students, medical school students, engineers, and nursing students--all in varying degrees of training. It was immediately evident that this case was too big to handle alone and it was necessary to work as a team in order to provide the comprehensive care the patient deserved. A question that my group continually came back to was, "how will the patient feel?"

We also touched upon the roles of several different care team members that I hadn't originally thought of. The care team involved more than just the patient's doctors, nurses, and pharmacists. She also needed support and guidance from case managers, social workers, her family, and her insurance company. It only took walking through one case study to realize how complex our health care system really is.

After the case study, we broke for some delicious tiramisu and got the chance to mingle and meet students from Harvard, Boston University, MGH Institute, Boston College, Suffolk, Endicott, Tufts, and MIT (Click here to browse through the Chapter Directory and find out if your institution has a Chapter. If not, create one!). It was fantastic to meet people who were also interested in quality improvement and patient safety. Now that we've all found each other, I can't wait for what's to come in the future!



Thank you to Dr. Hunt and Dr. Vaught for leading such an engaging and informative case study session. I'd also like to thank the Boston IHI Open School Chapter leaders who worked together to organize the event: Dylan Carney, Yian Xiao, Jennifer Chi, Kevin Knoblock, Courtney Nielsen, Brady Evans, Andy Wurtzel, and Shabnam Hafiz. Thank you for a fun night!