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By Katherine Hickner, Coleman Associates

This website has numerous accounts of the stunning achievements of Patient Visit Redesign teams, but what turned those people into teams that could produce such results? How do five individual staff members become a unified force for patient-focused change in their organization? This is the story behind the story of Patient Visit Redesign™!

Three Years Ago

I was on a community health center redesign team three years ago. This is our story.

Day One

I came in with a naïve excitement at having been recruited to be on our redesign team. I was a newcomer to our health center and was working in administration—a department distrusted by many floor staff (“What exactly do they do back there?”)—so I was looking for a way to be useful, to show people I cared for the clinic and its patients.

I came to the first redesign team meeting enthused, aglow, and eager to please. I wanted to give everybody a hug. There were no hugs. We hardly looked at each other. The five of us sat in silence as our CEO spoke.

We’re Doing What? By When?

At the end of that meeting, our CEO handed us each a binder. Finally, we had something to look at besides the floor. These were our redesign manuals. We turned the page and saw our time line for redesigning the patient visit—wholesale. Yipes! All that in five months? Anxiety was our first shared team experience! The deadline brought us a little closer together.

Our first team task was to observe several patients’ progress through the clinic. These are called patient visit trackings, and you observe each patient visit in real time from beginning to end. When the day we had chosen for our trackings came, there was a spark among us where before there had just been anxiety and panic. All of us wondered what we would discover out there.

(See Step 1: Study the Patient Experience in the How to Start section of this website for a description of the patient tracking exercise.)

Who Are You, Anyway?

I embarked on the first patient tracking with Irma, the administrative assistant in Health Education. As most redesign teams find, patients wait for ages when they come to their appointments. But this tragedy gave Irma and me the chance to talk.

This simple small talk was actually a powerful tool in the creation of our team. We had to know each other before we could work together.

The first thing I learned about Irma was that she knew everyone in the joint. Patients and staff all hailed her. She had been around in the earliest days, when there was one doctor and a handful of employees. In the months before we were thrown together, as she breezed past my desk, I heard people call out to her “Irma linda!” “Irma la reina!” Lovely Irma. Irma the queen. Now I understood why. This place was partly hers, and she possessed the graciousness of a benevolent monarch.

While keeping the patient we were tracking in view, I told Irma about the job at the homeless shelter that had brought me to town. She talked about when she was a kid and would talk to the homeless guys who lived in the tunnels around town. She mentioned that her sister worked at the shelter. Coincidentally, her sister was my beloved former boss! We had been working together how long without knowing this? In getting to know each other better, we were discovering how little we knew each other before!

Conversations like these were now occurring among all team members several times a day in meetings and hallways alike. We’d brighten when we’d run into each other, and we increasingly realized we really liked one another.

People don’t always take the time for such pleasantries, especially when it all seems unrelated to the serious work at hand. But when teams are starting out, these conversations are the work at hand! They become the foundation for great performance results down the road.

Bonded By Disappointment

As we each logged our patient visits, that hissing noise was the sound leaving our balloon of clinic pride. As we posted our diagrams of our visit trackings on our team work session walls, we realized we were sketching a picture of chaos: senseless procedures, lost patients, wasted time, and patients scurrying here to there for this and that. 

Confused, I asked questions about why things were done this way. This is one of the most poignant moments for a new redesign team as everyone looks eagerly to all others for a rationale explanation only to be met by quizzical looks and silence. We didn’t know why the visit process worked the way it did. In fact, those questions couldn’t be answered by anyone in the clinic. There were no real explanations other than “that’s the way we’ve always done it.”

(For an explanation of diagramming the patient visit trackings, see Step 2: Patient Visit Maps in the How to Start section.)

Up, Up and Away

With our preparatory work of tracking and mapping patient visits completed, leaving together for our first Learning Session in California was the next big development for our team. The very acts of getting the itinerary, packing our bags, carpooling to the airport before dawn, and walking onto the plane worked a kind of magic. Before this, we were figuratively on a new journey together. Now it was literal.

We had been plucked out of our ordinary setting. No one wore work clothes. We could talk to each other like real people, not co-workers. We swapped stories about husbands’ hygiene habits, cheating boyfriends, wonderful children, gambling in Vegas. We watched our sweetly anxious teammate bear up well as she was screened by airport security. I was mocked for bringing an enormous collection of snacks onto the plane.

Don’t underestimate the power of shared memories, especially when they’re funny or painful, to create the feeling that you belong to a particular group of people. 

This is Big

We arrived in Pasadena, checked into our hotel rooms, and then headed down to the conference room together. We were greeted in front of the conference room with a smile and the impression that our competent greeter expected us. We entered the room and wove through tables to music that was simultaneously disarming and awakening. There was energy here! We looked around in anticipation. Little did we know, Coleman Associates were about to blow the sides off the little box of our clinic forever!

An official-looking person rose to convene the session. With a flurry of hilarious anecdotes, Roger Coleman destroyed all our pathetic work practices while we sat there enjoying ourselves. It was as if he’d gathered his material from us directly after we’d observed our clinics. But he hadn’t! How did he know?

The hundreds of other people around the room seemed to be having the same reaction.

At our table, we looked at each other through tears of laughter. We realized there could be a larger pattern to our particular foibles. This was encouraging, somehow. If we weren’t alone in our problems, we wouldn’t be alone finding solutions, either.

The People Must Have a Vision

During the Learning Session, we saw in the simplest terms that there was something wrong with the way we did things, that there was a better way, and that we could use that “better way” to create a better day at our clinic for our patients and staff. Through collaborative work—with other redesign teams and Coleman Associates—we realized we shared similar problems and that we could share the solutions of many, many clinics in different parts of the country. Coleman Associates had a vision, manifested skeletally in their visit redesign principles, they had built carefully over time. We took their template, and created a vision for our own corner of the world.

All our team members shared a vision, though each team member gave it a slightly different coloring. I just wanted to see a place where the working poor, people whose lives outside the clinic doors were full of stress, could find a reprieve when coming for a doctor’s appointment. The nurse and patient services representatives on our team wanted that also, but saw more details than I did of their ideal workplace. Our doctor saw a way to be more productive and effective with his patients.

Later, as we were battling to change the culture of our organization, our vision for the clinic became as real and as fleshy as an additional team member. Our most important team member. It kept us focused. It was our standard reference when we were trying to make decisions, and it reminded us that everyday drudgery was really in service of a glittering goal.

We were working in the shadow of a larger reality, now, like the New Mexican mountains outside our clinic windows.

I Do

Another defining moment came for our team later in the Learning Session. We were asked to find a quiet place in our hotel to commit ourselves to one another and our work. Despite the wave of enthusiasm we had been riding, there was nervousness in our team about doing Patient Visit Redesign, about committing ourselves to doing whatever it took to translate this into reality.

Most of our team members had been through “improvement” processes that had inevitably fizzled. They had been burned by managers who professed support but then disappeared. They knew how entrenched staff were in the old ways of working and working together. They knew more than I did what this commitment would cost. Yet they each agreed to go forward, and so I did too. Basically, there was just no way we could ever go back after seeing our promised land. But it mattered that we took turns to look each team member squarely in the eyes and promise to serve the team, its purpose, and its goals.

Back at the Clinic: Walking the Walk

When we returned to the clinic, our team really emerged as a high-performance team. We had experienced three big growth spurts together: the first as we got to know each other in the early weeks; the second as we left our normal lives behind to travel to the Learning Session; and the last as we caught the vision of redesign together and committed ourselves to succeeding together.

Back at the clinic we had a lot to do. We went through one last growth spurt when we showed each other we could and would do what we said we’d do. Right away we had dozens of opportunities to prove to each other that the commitment we made to each other actually meant something and meant something special. Simple deeds—like remembering to make a phone call, writing up a report, having a conversation, or getting a piece of information—was the final superglue that bonded us all as a team.

Happy Together, Even When We Weren’t

The respect we felt for one another through connecting as people, the energy and clarity of our vision, and the trust we established by working hard for each other made our journey together worthwhile personally, even when things didn’t go well in the clinic.  Even when we were tired or discouraged, we looked forward to our work sessions together. Our little team conference room was an oasis of sense and respect.

Postscript

Irma the queen once told me, as our work together was ending, that although she had been mightily discouraged at times, she kept at it because she saw me keeping at it. I was shocked. Because she had been precisely the same kind of inspiration for me. That’s how it works on a team. You’re each other’s heroes!

Anything worth doing cannot be done alone, especially something as big as Patient Visit Redesign.