Lee Snorkel Transcript

Welcome to the Indiana University School of Nursing Interprofessional Education and Collaborative Practice in Education Podcast Series. This podcast series was supported by grant funding from the Health Resources and Services Administration under the U.S. Department of Health and Human Services. The goal of this podcast series is to provide ideas and information to individuals interested in implementing interprofessional education or collaborative practice initiatives in their practice or educational setting.

For this podcast, we will talking with Betsy Lee, a national expert in patient safety, quality improvement, and nursing vitality. She joined us to discuss her experience working with the primary care centers around Indiana to enhance interprofessional collaborative practice and teamwork in the ambulatory care setting. We started our conversation with Betsy telling us a little about the project, which initially intended to implement TeamSTEPPS training at the primary care sites, but took a few turns along the way.

[Lee] Well, we are working on this particular objective in the primary care settings to help them increase their interprofessional collaborative practice competencies. When we looked at the array of those interprofessional collaborative practice competencies around values and ethics, roles and responsibilities, teamwork, and communication, the idea was that we would start with training. Um, the model for TeamSTEPPS training came to mind because it is really meant to do team-based training for healthcare professionals in a variety of settings. The Agency for Healthcare Research and Quality had recently come up with a primary care TeamSTEPPS training module so that the idea was to do training in these primary care centers. 

Well, after we started doing the training, we realized that training alone was not sufficient to really help these centers achieve their population-based improvement projects. So, after that we decided to kind of re-do our implementation strategy to integrate a couple of other elements.

[CPDLL] In the past, Betsy worked with the Institute for Healthcare Improvement and IDO as part of a deep-dive project with improvement experts in Boston to discuss innovation in medical-surgical settings. The project was called "Transforming Care at the Bedside" or TCAB. During that time, the group recognized that it was impossible to take bedside nurses and other care professionals away from their unit or their work for three days, which resulted in the development of a concept called the "snorkel," which is a shortened version of the Innovation and Idea Generation exercises.

[Lee] We began with about an hour and a half period of time to get them some background with the grant and the goals of the grant from the respect of the interprofessional collaborative practice competencies and then we integrated this snorkel activity and shortened it. It's much longer when you do it in the ideal setting -- could be several hours long. In most cases we had a 90-minute total period of time so that had to include getting some baseline data, and also giving them some background around the grant, the work that we were doing. We then began with a snorkel activity to, um, just bring out their own stories and their own ideas about what might be possible to better serve the populations that they serve in these centers and then finally there's a brainstorming exercise that occurs to help them identify ideas to test for improvement. The final part of that snorkel is just to  really get them thinking about how they start doing the testing and using the model for improvement for making changes in their center.

[CPDLL] I was curious about whether some common themes arose during the snorkel process at the various sites.

[Lee]  When we began talking about the idea of working together in an interprofessional sort of way, there were ideas around teamwork and collaboration as well as communication that came to light. All of them were working with very distinct populations, and so they had ideas about the groups of professionals who were in the training session for the snorkel; they had ideas about the types of patients they wanted to serve in a different and improved way. So, that came out with sort of the main theme about whether it was improving the care they were giving their diabetic patients or their childhood asthmatics and so that formed the basis of the design challenge for each of the snorkels. The themes then emerged about handoffs and improving teamwork and ways they could better communicate and integrate their care in serving those patient populations.

[CPDLL] Each group identified the patient population they wanted to focus on but the approach was the same across sites.

[Lee] They were asked as part of the grant to select a patient population of 30 patients and that would really form the basis of the data collection of our time. These were generally the patients of one of the key providers who was going to be leading the team. So, what happened was that there was an alignment with one nurse practitioner, for example, saw a lot pediatric asthma patients in that center and had some evidence-based strategies that she wanted to test around patient follow-up, so we talked and that in that center around integrating others in the team to really smooth some of the routine work that was occurring from scheduling and follow-up to, uh, provision of some of the other patient education materials.

[CPDLL] So what came next?

[Lee] After they did the snorkel activity, they decided on their focus area for improvement, uh, which again I mentioned that there was one project-related to childhood asthma. There was a couple of projects that related to care of diabetic patients. One of them was focused around group visits and improving the flow of the group visit. Another one was around increasing the connection to the diabetic education through their health educator. So, these projects then began to emerge and our team decided that education alone wasn't really going to support them in moving forward to making the changes that would lead to improvement in those projects.

[CPDLL] And at this point they had received some basic TeamSTEPPS training on the TeamSTEPPS tools, right? So they already had that sort of toolkit in their pocket.

[Lee] Right. So the way it worked was that we had one opportunity to begin with these centers to do the snorkel activity. That followed, actually, a SWOT analysis where we identified the strengths, weaknesses, opportunities, and threats within each center. That, after the snorkel activity, they then had other a very shortened TeamSTEPPS training that was focused on some of the primary care modules and tools available from the Agency for  Healthcare Research and Quality. After the TeamSTEPPS training, our team met and decided that what would be best would be an ongoing intervention with each of these teams. A facilitated coaching process that would support this improvement work that was based on what they learned from the tools training.

[CPDLL] Next came a decision to use coaching phone calls with the team to continue their work.

[Lee] We knew that there was limited amount of time that they would have, but we felt that there was a need to help them build their competencies, not just on the interprofessional collaborative practice competencies but also in their competencies for integrating evidence-based practice and for doing improvement work. So, from, with that in mind we set up about an every two-week coaching calls with these different team leaders -- usually there were probably two or three people on every single call and every call lasted from 20 to 30 minutes. We have very distinct format that we followed and that format built over time that the process that we used for working with each of these, each of these centers.

[CPDLL] I asked Betsy to help us to understand what it was like to be on one of those calls and how they were organized.

[Lee] We always started with the team leader just giving a project update.What have you been working on since our last phone call? And, I would prompt them with some things that I recall or some ideas that they were thinking about testing. Um, one of the centers was really focused on improving the huddle, which in TeamSTEPPS parlance is really a brief—it happens at the very beginning of the day, and they get together as a team to really plan what their day will look like together. So, they call these huddles and at the beginning they weren't using them at all. Um, and what we talked about after then they would give a project update: where what challenges or barriers were you really, have you faced in the last couple of weeks? Sometimes, in the examples of the huddles, they would talk about the difficulties in having that happen on a regular basis because no one really knew who was supposed to call the huddle. Um, so after that we talk about strategies to test, the next steps they might take into moving that forward, and they emerged their progress step-by-step, call-by-call and in doing testing in the intervening weeks. So, that went on for a period of several months. We had a, the limit of 12 calls per center, so over a period of six or a little over more months, these relationships and interactions were built with these centers as they were working on their improvement projects.

[CPDLL] The grant team found that the team leaders at the sites tended to emerge on their own during the initial process, and, interestingly, were often the nurse practitioners in the group with the support of someone in administrative leadership. They worked closely with the other team members who included medical assistants, health educators, community health workers, students, and others depending on the sites.

We talked a little more about what model these teams were using in making their improvements and changes.

[Lee] I generally recommend that they use the model for improvement which has been used by the Institute for Health Care Improvement. There's a book called The Improvement Guide that Jerry Langley and his colleagues actually have published that sets forth a very straight-forward way to do improvement work,that, and it simplifies the work to three questions: what is your aim, or what are you trying to accomplish? what do you, how can you know that a change is an improvement or what will you measure? And, then thirdly, what can you test to see whether a change is an improvement? And that incorporates the short cycle—the plan, do, act cycle. So, my work with them in terms of the coaching took that is a foundational piece, and we focused a lot on their tests of change. Because that is often where improvement breaks down. People think they just can implement something, but in order to really achieve that improvement, there needs to be adaptation and testing over a period of time to achieve the results that they want to achieve.

[CPDLL] Of course, one of the benefits of testing changes in an approach like the PDSA cycle or other improvement plans is that you can see if they work or don't work, and either scrap the idea and try something new or use or improve upon changes that do work. We asked Betsy to talk a little bit more about that.

[Lee] It's really interesting that you ask because I think we all make different predictions about what will work and what won't work, and the reason that you test is to find out whether or not a change will lead to improvement. There were in the example of the group that was working on diabetic group visits; they were struggling with the flow of the provider portion of the visit, with the nurse practitioner, along with the education portion. So, there were different ways they would organize it and sometimes things would back up because they had several patients, who would then need their labs, and they would need their individualized time with the nurse practitioner. So, what our team was able to do was to provide some evidence from the literature about different options for how to structure a particular group visit, and they ended up flipping the order in order to have the nurse practitioner see the patients first and then to follow that with the educational portion.

[CPDLL] We talked a little bit about challenges and successes in the project. As is typical, possibly in many primary care settings, turnovers was a challenge across sites and across roles, which created an important need for the centers to integrate the methods and changes into the general structure of the site as well as they onboard new staff.  Additionally, their schedules were so tight that finding the time for a 20- to 30-minute call was a challenge, particularly if an unexpected or complex patient situation arose just before the call was scheduled.

And what about success? According to Betsy, defining success in these types of projects is really no different than succeeding in other areas of healthcare of education.

[Lee] So... the things that lead to success in these primary care centers are the same I see leading to success whether you are looking at in-patient units in a hospital or you look at long-term care or even other industries and other areas of education. It's that willingness to engage the front-line providers of care, um, in a way that's positive and energetic, uh, that's one characteristic. Need a strong leadership is really important. And, I think that this willingness to be adaptive, to learn from the tests of change, and then to try something different. When we worked at transforming care at the bedside through the Robert Wood Johnson Foundation Institute for Healthcare Improvement Project, there, we had a mantra that was really adapt, adopt, abandon. So when the groups and the teams on the in-patient units were testing changes that they thought would lead to improvement, they may come up with an idea that tested successfully elsewhere and make adaptations that would work in their environment. Others could adopt it wholesale, and sometimes they would try it and it wouldn't work at all, so they abandoned that tact and came up with something else to try. So, I think, think that willingness to, um, be open to these changes and to embed adaptation in their daily work is a huge predictor of success.

[CPDLL] One thing that was clear to the project team was the importance of engaged and supportive leadership and upper management at the site or within the organization.

[Lee] I think it was extremely important to have involved leaders that really understood that the team training through TeamSTEPPS or the methodology to really engage the front-line were methods that were aligned with their strategic leadership objectives. So, when we had the case that maybe wasn't as well aligned then to be able to have that conversation to make a determination about whether or not it was good fit.

[CPDLL] It was also important to allow the staff the flexibility and openness of schedule to participate in the meetings and also the time to work on the tests and changes and collect the data associated with them. One example that Betsy gave was a health educator who wanted to test the idea of sitting in a different location in the center to see if it would positively affect the flow of patients and communication between herself and the provider. Without the support of leadership, this may not have been possible.

We wondered about advice for sustainability of the work for centers who have done similar projects with an external consultant or group helping them to start after they no longer have that external support.

[Lee] It's really important. Sustainability needs to be built in to a plan for doing improvement. Not only were we attempting through this grant activity to increase these competencies that are focused on interprofessional collaborative practice that would really be focusing on how, how do they enhance their professionalism in working with one another, looking at roles and responsibilities, the elements of teamwork and communication, but also building those capacities for ongoing improvement. So, there was sort of a subtext here where through the coaching and the questions and the asking about, well, what are you learning and what are measuring, that they would then build in that competency about doing on-going improvement that they could then apply to other patients and other populations within their center.

[CPDLL] The project team is still doing exit interviews and collecting information about the experiences of the teams at the centers, but some themes are starting to emerge.

[Lee] What I'm hearing as we are getting to the end of these coaching calls, is really a reflection that they have made significant advances in the way they do their work together. Um, many have commented that they feel like they've created more standard work around things like patient follow-up, and they've started using scripts when they do follow-up phone calls with patients, which was something they hadn't done in the past to make sure that they were communicating the key elements to encourage that on-going self-management and connection to the center. Others talked about the reliability now of having these huddles every day, and it really stemmed from the fact that somebody was responsible for calling the huddle, they had specific things that they talked about. One of the nurse practitioners said, now I know who's going to be there and if we're short then who will be covering for some of the different tasks that need to be done. They've also pulled in their scheduler to some of these huddles to really create the connection around when different people are scheduled for diabetic education. So then, then, the situation awareness and monitoring goes on was something that they commented on around the regularity of the work that they're doing in a new way.

[CPDLL] In at least one situation a site was able to make the case to continue this work as part of a grant application for further funding.

So what about other outcomes or feedback from the project? Over the course of the project year, it became evident that the teams began to better under each others' roles—an important part of the process.

[Lee] That definitely came out in even some of the snorkel activities. One of the things that we do in the snorkel is to begin with storytelling. And, storytelling is a really powerful means to bring someone else into your world. I think that they can sometimes be very emotional, but by the same token, it is a way to create a common environment that that allows for creative thinking. So, we've been in that description of what they've been talking about sometimes issues around role clarity came to light. And, I certainly think through the testing and the work of adaptation to improve the care of these populations and patients that they tweaked a little bit about the way they did the work in order to better serve the patients.

[CPDLL] So knowing that each site and team would be different, I asked Betsy what's the timeline for a project like this in general and was there a point at which she knew things had started to click.

[Lee] There was. I think that a common characteristic when you start something like this is, there is an energy at the beginning and then the frustration kicks when where people realize how complex and how hard some of these changes can be, particularly with these issues I've mentioned earlier with staff turnover, with busy schedules, with changes in leadership in some cases. So, there definitely was a peak with the training, with the snorkel activities was generating some excitement then they struggled a little with getting clear definition with what their aims were going to be and trying to have early tests of some of these TeamSTEPPS tools or other changes. So, that frustration came through in early calls and and, and most of the places. And, then because of the regularity of the questions and the issues around what's going on, what challenges are you doing, what strategies will test next, what are your next steps. I, I felt that it did take a period of a few calls to get over that hump, um, and that's where I think it's important for anyone trying to do this on their own is to not give up too quickly, to persevere through the messiness of the early going and trying to make complex change. The goal really is, you know, looking toward improving the care to the population of patients. So, getting clear on that and then using the teams' ideas as to how it might better to then begin testing. And, once they've began to see the improved communication or that using a tool actually did have a positive outcome, then it got easier to hear from more of them on the calls, and to, I didn't hear as many barriers over time after those first those first several calls. You know, you could definitely still why are we doing this, is this just another, you know, intervention of the day. [laughs].

[CPDLL] It does seem that setting the expectation from the start that change doesn't happen overnight and can take 8 to 12 months of work to be realistic may help to set realistic expectations with the group and also decrease anxiety about making changes quickly.

[Lee] And knowing that over that period of time you're testing a lot of things in sequence. Because, I, you know the goal was really increasing these interprofessional collaborative practice competencies and increasing the capacity of the center to improve their work and to build that team's capacity underlying capacity to do improvement. It isn't hard. We all do improvement every day in what we do whether we're learning to play a sport, whether we're looking to cook, whether we take on a new hobby, whether we're raising children, we all are testing changes every day. So just applying that discipline and then when you find something that's working building it into the standard work, that learning to improve and learning to adapt is, uh, is really jsut a competency that can be mirrored in these work settings.

[CPDLL] One important point that Betsy mentioned was that these projects are not just about improving a process or a flow or a specific task, but about interprofessional relationships and interactions, and finding ways to have a team work in a cohesive, respectful and  effective way with one another.

I asked Betsy about which competency area needed the most work from the groups and she reflected on the intersection of the competencies and the fact that it is not as easy as identifying a single problem or solution area.

[Lee] The two competency categories of teamwork and communication really go hand-in-hand. You can't improve teamwork with improving communication. So, from that standpoint, I would probably land on a communication even though, the, the team framing activities also help create a vehicle. So, they both went hand-in-hand, um, but what I mean by that is, that we talk a lot about handoffs or handovers as a critical communication tool. That is something that can be structured, and can flow from a team activity like a brief or a huddle. But, when it comes right down to it, there's always going to be circumstances that require enhanced team communicate when it's a difficult communication or a crucial communication. And, in those cases, uh, there was actually a great example of one of the centers where we had taught the TeamSTEPPS Deskscript Tool that relates to a crucial conversation and they talked about, well, you know I actually had a chance to use that when we were having a really particularly hard day, and it went really well, and we were really able to work through a tough situation and there had been kind of a misunderstanding that until I brought it up and described what happened and what emotions I was feeling based on it and then stated what my expectation would be and the consequences that I didn't really understand that that person fit, had had something come up, and that, there there really was a sort of system level problem that was underlying what happened between what I thought was an interpersonal thing. So, I think we had some really good learning along the way about both of those areas, um, and they were able to talk about things they maybe hadn't been able to talk about as openly. When it comes down to communication and what's working and what's not, often really inform a culture, but they aren't addressed in a really deliberate way.

[CPDLL] While data or interviews with patients was not included in this process, the team was able to share anecdotal stories about the impact of their work on the clients that they serve.

[Lee] We had a couple of stories that were told on calls. One particularly that related to the work that was going on in the center working on the pediatric asthma issues and the follow-up phone calls. And, they actually had expressed on one of our calls that that these patients who were receiving the follow-up phone calls felt very cared for in that way, that they felt that they had somebody who was looking out for them and calling to make sure that their child was doing ok, and called just to make sure that they knew when their next appointment would be and that they had been taking their medications on a regular basis. We also heard positive through the work they were doing diabetic group visits, and that those patients really learned a lot and that they enjoyed having the support group element of the diabetes group visit then the support group that followed as well. So there were some anecdotal stories, I think, in all the centers about the patient impact, uh, and we will be looking at patient data but from a qualitative standpoint. There were definitely some patient stories that emerged.

[CPDLL] Obviously not every health center that might be interested in doing this type of work will have grant funding readily available. Betsy has some advice for centers who want to get started in thinking about these changes using free and low-cost resources that are available publicly before making decisions about investing in consultants or program staff to continue to move forward.

[Lee] There's some free really great resources available. I would start with the Institute for Healthcare Improvement website has the model for improvement description and there are materials, how-to guides from Transforming Care at the Bedside that describe the process of a snorkel, and engaging front-line teams. There are also free resources for TeamSTEPPS, and there actually are new primary care modules as well as some other office-based practice materials that have been posted even within the last week. So, this availability of resources to learn the evidence-based approaches to enhancing teamwork and communication are out there. And, then building in that discipline of some of the TeamSTEPPS tools, the daily huddle or brief on the unit, the focus on team communication by using some of the tools from TeamSTEPPS or other places that just encourage that honest, open communication and dialog on a daily basis. I believe that a log of these things are available and really creating that, um, that spirit of collaboration within, and dialog within a center is more possible now than probably it ever has been with respect to these free, available resources and what's out there on the web.

[CPDLL] To wrap up our discussion, I asked Betsy if there was anything further she would want listeners to know about her experience or to keep in mind if considering similar initiatives. And she clearly felt that though challenging at times, this type of project and work is so important in improving patient care and team interactions and will benefit everyone involved in the process.

[Lee] I personally have been very privileged to work on this grant and this activity. I often have an opportunity to work in different settings with front-line teams and those that are providing the direct care to patients, and every single time I learn something. Every single time I learn something about these teams, about myself, about the work that's going on. I think that because it's so complex and because there is so much change happening so rapidly, it's really to be frustrated when you're trying to get a lot done in a short period of time, and it's so rewarding to watch teams come together and to have the faith that when they work differently that it's going to have a positive impact not only for their teamwork but also for their patients. So that's just been a real joy to watch.

[CPDLL] I'd like to thank Betsy Lee for taking the time to speak with me for this podcast, and I'd like to thank you for taking the time to listen and learn more the work that is being at the School of Nursing. Make sure to check out our other podcasts and our continuing education offerings at cenurse.iu.edu. Thanks so much.