Collaborating & Co-Designing The Future of Healthcare, Julie Rish, Ph.D.

"The future of patient experience relies on meaningful strategic (maybe) relationships with each other. Where we're talking together, and where we’re coming together to solve these problems, Julie Rish, Ph.D.". 


Julie Rish, PhD is a Clinical Psychologist, Director of Design and Best Practice in the Office of Patient Experience at the Cleveland Clinic. Dr. Rish is also the Director of Communication Skills Training and an Assistant Professor of Medicine at the Cleveland Clinic.

 

Julie Rish, Ph.D., MA, Role at The Cleveland Clinic

I have spent most of my professional career helping people with health behavior change. That blends nicely to the work that I do in patient experience because it is about how do we change and adapt our behaviors to best support our mission and cause in the organization and come together. As the director of communication skills training for a medical school, I'm active in teaching our students what communication with patients and each other could look like and potentially should look like in bringing in that next generation to health care.

Most of my life is in patient experience, in really leading efforts in one; how do we partner with patients, their family and their support persons to really improve care and to reimagine what that partnership looks like, so that we can be very strategic to maximize the full potential of partnership and to manage the complexities of health care together as a community.

The other part of my life is complimentary as applying plain design thinking to our work. So, in a variety of settings having really great collaborations across the Cleveland Clinic. Questioning, how do we do that in a way that brings together all the stakeholders to design something better for patients and for our people.

Discussing Patient Experience & Humanism in Medicine

I think medicine is inherently human. The art of medicine without relationships---We're not just technicians. Similarly, providing excellent patient experience is about meeting people in a very relational human way. I think that you can't disconnect those two things. Optimal healing can’t occur without the humanity of medicine and true understanding of another person sitting in front of you, without being able to empathize with your experience.

Relationships are healing in and of themselves. When we're connecting as people it's healing to me as a clinician but it's also healing to the person that's sitting in front of me. We have to think about going above and beyond what we can do medically for someone.

Achieving excellence in Patient Experience at the Cleveland Clinic

What we've done so beautifully is really put some stake in that, that we are going to care about our patients, we’re going to care about our people and we're going to invest a lot of energy in both. Trying to understand one another, trying to appreciate each other's perspective, see things through different lenses and design it together. That's a beautiful model that will help us improve as a system but also help us improve and transform health care.

Barriers to achieving humanism in medicine

There’s a lot of barriers to being human in medicine we know about widely publicized, burnout in clinicians. The detrimental effect that has on them individually but also on patient care. It's double edged and it's complex to solve. Also, add the burden of documentation. Providers spending more time in documentation than they are in front of the patient. Trying to find meaning and purpose in their work and the complexity of trying to solve that. The knowledge and the explosion of that is another barrier in some ways. Trying to stay current when they're so much information is hard. How many hours a day can one possibly invest, then how are they finding balance in their life and spending time outside of the walls of the system that you work?

There’s a lot of barriers that equal time and task pressure. How can I be present in this moment and not thinking, three steps ahead or three steps behind but just to be present in the moment? When you do that you can find meaning and purpose in your work. The barrier is how do we overcome those obstacles to create moments of presence? Being mindful and truly connecting a human level. In doing so, that's where we can find restoration and purpose and get back to why you chose this profession, this career, this entity in the first place. That’s our greatest opportunity right now is to try to navigate those barriers in a way that is optimizing the human connection.

The importance of Humanism in medicine

The importance of clear. I talked about that relationships are healing and that it's hard to create a relationship without being present and authentically yourself. Therefore, if you're struggling with burnout and it's easy to depersonalize a situation and it creates some distance between you and the person sitting in front of you, it's also hard to create the meaningful moments. That equal satisfaction with your career, with your experience in that moment and with the quality of care.

Trending towards a barrier free healthcare delivery system

Navigating the system in a way that we are creating that is our greatest imperative. We have to think bigger than clinicians. We absolutely have to continue to invest in our people, that's clinicians but I think that's other members of her our clinical teams and our staff in a health care system that we see burnout in many different places.

Being thoughtful about what we’re and how we're investing in our people was really important. Thinking bigger than just the people, that its systemic and if we're asking people to spend half of their day in documentation and in the evenings and all hours of the night then how can we possibly expect them to overcome these barriers.

Thinking systemically, what does healthcare need to do to better support our clinicians. The burden of documentation, policy and the pressures that we're placing on top of them. While also thinking, how do we change the top down but also how do we support from the bottom up. In addition, equipping people with the skills to communicate effectively to connect to meaning and purpose in their clinical encounters. In some ways that's by just teaching someone how to listen and to empathize with someone’s experience and perspective and connect to that as a human.

Again, I would transcend more than just our clinicians. I think it is our nurses, it's the other people that are touching our patients. From the person that checks you in, to the person that you speak to on the phone when you're trying to navigate and make an appointment, to the information that you get when you leave the hospital. There's so many different touch points that we have to connect to.

Technology & healthcare

These types of solutions have to be co-designed. Oftentimes it feels like we are pushing solutions out and those solutions need to be brought together from the people most intimately affected. So our patients, our people, our clinical staff, our non-clinical staff. Those people need to come together to define what that solution looks like and what the need is.

Oftentimes, I feel like we're just creating solutions or “hey great lets give you some communication training”, but is that the training that you need is that what's going to solve the problem and is this actually the problem to solve or the opportunity to innovate around. I think if we are not talking to those people most intimately affected at the beginning and throughout, I'm not certain that our solutions are going to work and that we're actually going to be transformational.

Patient Experience In Its Current State & Future Outlook

In the future our patient experience relies on meaningful partnerships and collaborations. Intimately integrating our patients, their family and support persons into our work and having them help us co-design care, from the beginning and from all phases and all levels of the organization. If we're not doing that then we run the risk that we're not actually providing the care, the needs, the solutions that are patients really need.

Bringing them in and sharing that space with them in true partnership, not in a focus group setting. The true partnership where we are identifying the problems to working alongside, to creating solutions together and testing them out. The patient experience relies on our willingness and openness to do that together. The future of patient experience relies on meaningful strategic (maybe) relationships with each other. Where we're talking together, and where we’re coming together to solve these problems.

Meaningful Integration Of Technology

I would suggest that technology needs to be seamless, in that it affects both of our patients and our clinicians. It needs to solve for the tremendous burden of documentation and the non face to face time that our clinicians are struggling with. It needs to facilitate making health care more simple for patients.

If you think about we what exists right now there are thousands of apps and thousands of different platforms that someone could go to. How do you know what's the right app to download or how to even find the right one the problem that you're trying to solve. We in health care need to streamline those applications in a way that's meaningful to our patients. That's going to help them navigate the system and connect them in seamless ways.

I would say the same for our clinicians. Technology needs to create the moments of connection. The human moments and take the burden out of some of the non-human moments for clinicians. It needs to solve for both ends of that spectrum to simplify the experience of health care. Otherwise, you need an app to navigate the apps.

The most important thing is being willing to be vulnerable, humble and to learn from each other. To be thoughtful about how we partner with the people around us, how we learn from each other, etc. All of that takes deep understanding, empathy and really trying to appreciate someone else's experience and perspective.

If we’re not doing that we're not really solving at that intersect, that’s really where we need to be. What are the solutions that make the most sense for the most people, at the right time? To me that's transformational! So, we could setup really great population health efforts, but if it's not the practice, the services or the values of the community that it serves, then what have we done.

I think really being thoughtful to first understand the people that are out there. Really empathizing with that, then solve those problems together and create those opportunities together. That’s what's exciting about health care is the great potential of what you can do together and in a collaboration. I’m excited to be a part of that!


Dr. Rish At The Cleveland Clinic | Twitter | #PESummit

David Watson, MD | Amplifying Safety Cultures in Healthcare Systems

"The idea of what is called a just culture and what that means is that we adopt the ability as an organization to look at things that happen as learning opportunities rather than opportunities to punish" David Watson, MD.


David Watson, MD is a physician surveyor for The Joint Commission. Dr. Watson work for The Joint Commission serving hospitals for accreditation one week every month.

 

About The Joint Commission

The Joint Commission is the accrediting body that goes around every three years and looks at hospitals to make sure that they meet certain standards of care and that they are able to demonstrate those as we walk through the facility. As we look at the way they take care of infection, the way that they prepare food, the way that they write orders and things in the chart. We then have an engineer check out the engineering of the facility.

The standards all started many many years ago back at the turn of the last century when the American College of Surgeons decided that hospitals needed to have quality done in the same way at each hospital. That is how The Joint Commission started. It eventually became a collaboration of several organizations in about 1960 with the hope that we could give the same quality of care to all patients who received it in the United States.

Safety & Quality in Healthcare

Well safety is the foundation of good health care. Right now The Joint Commission has adopted a new motto and that is “Zero Harm”. Our goal is to work towards that and all the safety measures help us reinforce those things. For a long time we thought that we couldn't adapt things that they do in industry, but we found that those high reliable processes work very well in medicine eliminating things that are infections on a recurring basis.

We know if we take certain steps we can prevent those and just looking at safety overall. Making sure that the sterilization process in the operating room is done properly so that they go through those steps. That scopes are used for doing endoscopy those are cleaned properly. Those are all safety things that are very important and we've heard the stories where they are not carried out properly.

The Las Vegas endoscopy clinic for example with all the problems that they had there. Someone needs to be making sure that happens.We are one of the many bodies but the largest by far of the hospitals that we survey and take care of and I really enjoy being part of that process.

Thoughts On Hospital Systems That Prepare For The Joint Commission's Visit

It’s one of the things that I always say to hospitals when I survey. The words I don't want to hear is “we prepared for the joint commission”. We’re here to look at you at a point in time and hopefully that allows us to come as just be another set of eyes and have the opportunity to look at what you're doing. If you don't meet the standard we're going to explain why and give you some options to help you.

If you exceed it, and have some really great things, I'm going to look for those too because I want to take those back. I have this philosophy about medicine that are no good secrets in medicine, people need to share the good stuff. This is not like inventions. These are things that have to do with the wellbeing of all mankind, so we should share them.

Collective Mindfulness; Going Beyond Policy To Ensure Safety, & Quality As It Relates To Healthcare Workers Experience.

Policies are crafted to make sure that we have coordinated consistent way of doing things. They are the framework by which we can have all employees do the same things for the same purpose. That's one of the things we look for in The Joint Commission. When there are things that we look at that we are concerned about we want to make sure that what the organization does agrees with the policy that they read. And, it's a very intricate part of the everyday survey.

There is a concept out there as far as safety goes and the concept basically is called collective mindfulness which means that every person in the hospital is a safety officer. Therefore, if you're walking down the hall and you see something on a tile that doesn't look right, you pick up the phone and you call the people in maintenance and say “Hey the tile outside of room 247 isn’t staying, maybe something is going on”, or a stain there may be some of them. I can take a look at it if things are dirty, if something is broken or something is outdated.

It's everybody's responsibility to take measures to make sure that that's corrected. One of the other things that I like to see is, I used to do interventional blocks. I like to see the count in the operating room tagged in such a way that not only do I know that it was inspected but I know that it was inspected within the last year. I don't just look for the number but a color code that says, when I pick that gown up and put it on to protect myself from the radiation. I know that it was checked and I know that I'm doing it not because there's a policy that says I should do it but also because I know it's going to protect me.

Just Culture | Balancing Accountability In A Non Punitive Way To Reduce System Errors, Ultimately Improving Patient Safety

It's an idea of what is called a just culture and what that means is that we adopt the ability as an organization to look at things that happen as learning opportunities rather than opportunities to punish. We are open to look at those things that don't go right to figure out why they don't go right.

As I said a little bit in my talk (#PESummit), I pointed out that even when these adverse events happen 85% of the time they don't involve a medical error and even when a medical error happens over 90% of that time it has to do with the system. That the system has not organized itself in a way to prevent people from being put in that position. That pretty much sums up why we need to look at this overall structure and say “hey these are opportunities to learn not to punish”.

Real Life Example:

While on orientation (day 3) a nursing assistant was instructed by an nurse to place a hot pack on a patient’s pelvis area. The hot pack became open at some point and hot fluid from within rushed onto the patient’s skin causing burning to the scrotum. The nursing assistant was immediately told to leave the facility after the accident.  

OK, this happened but why did it happen? Did that person do it intentionally? I don't think so okay. Was she trained properly? No. Is it a systems issue? Absolutely. That goes right down to leadership, it goes back to immediate supervisor. It goes back to one of the things that we look at, always look at competency for people to see if they've been trained.

If they've checked off on that every year and if they still have that competency level. She probably hadn't even been given the ability to have the competency to begin with. Ultimately the responsibility for what happened here lies with leadership and that's the way I would look at it. That's the way it would look if I were doing a survey.

Applying Emotional Intelligence in the Medicine

Well it's that balance between what you feel and what you know. If you can apply that in the sense that it gives you that feeling of what you're doing is right, for me it would be almost like that second voice of reassurance that you're on the right track.

Thoughts On The Future Of Healthcare When Coupled With Technological Advancements  

I think there are great opportunities out there for the use of the advancements in technology. We’ve seen so many things come. I was blessed to start in anesthesia back in the 1970’s where everything was manual. I pumped up the blood pressure cuff, I listened to the heart, I felt the patient's pulse, I looked in a patient's eyes. This is all done by machines now and that microchip has come a long way.

Other things that are coming in the future I think would even be far more changing. We have the capability now of putting up a little dot like a band-aid on your wrist and it can read your pulse, your temperature. It can even by impedance tell what your blood pressure is. Now a nurse 50 miles away and she has a computer is able to Skype. She can take that information, look at you on there and to say whether she needs to come out to your house today or not. This will allow healthcare to become more efficient and hopefully less costly.

Maintaining Enthusiasm In The Medical Field

I think the excitement for me is the possibility of leaving medicine better than I found it. I started medicine in the 70’s when things were rather crude compared to what today is. Along the way I've learned lots of things and hopefully I can share those with others in their journey to make medicine better. It's always that pursuit of excellence. That wanting to reach a little bit higher, to do it a little bit better and always with the goal in mind that we're taking care of patients and we never want to harm them.

Embodying Empathetic Cultures In Healthcare Systems


I think the empathy for me and the important part of this conference (#PESummit) is what I talked about earlier, that second victim these are healthcare workers that are involved in an adverse event. The empathy that needs to be expressed to them is that connection of realizing that they've been in a difficult situation and they need to be supported.

They need to be reassured and they need to know that they went into medicine for the right reasons. They take care of patients because they love what they do and they should continue to have that fire in their eye when they go to work every day to be totally engaged. We know that total engagement leads to less errors so we want our workforce to be engaged.

Closing Remarks

This has been a fabulous opportunity to meet with other people who are concerned about the welfare of patients and about the welfare of their fellow healthcare workers. An aspect that isn't often overlooked. We take great care of patients but we don't always take the best care of ourselves.


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