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improv

Authority and confidence does NOT equal right

By Caregiver, Consumer, Leader, Musician

I play saxophone in a combo – I’m the only horn. I come in with the melody – after we’ve improvised – with authority and confidence. My teacher tells me, “come in strong whether or not you’re right. The band will adjust. Better than hesitating and coming in weak.”

I thought about this when I was in a meeting the other day with a labor lawyer and benefits consultant. They both sounded authoritative and confident – and had opposite opinions. I spent as much time watching the strength of their presentation as thinking about whether their advice was right for the agency.

I recall that my 17-year-old cousin recently expounded about the biology of memory with authority and confidence: “You sure speak with authority and confidence,” I noted. “Sure,” he said with a proud smile, “I’m on the debate team!”

Authority and confidence and being right – not necessarily connected.

As a nurse I watch the expression of authority and confidence often from professionals and see how it affects people at the center of care and their caregivers. It’s hard to separate strength from right. One of the reasons I’ve chosen my doctors is that they can sound authoritative and confident, but they engage me in the question of what’s right for me.

A wise person once advised me, “when someone speaks to you with force, either positive or negative, imagine blue smoke coming from their mouth. Let the blue smoke pass you by before you consider the words generating that smoke.” 🙂

Walking and Chewing Gum at the Same Time

By Consumer, ePatient, Family man, Leader, Musician
As LBJ said about Gerald Ford, I can’t walk and chew gum at the same time. Yesterday, while rehearsing and improvising on the baritone saxophone, I reflected on my continued difficulty keeping my place in the tune while improvising. Either I listen and keep my place or I improvise, get lost, and lose my place – so frustrating. It feels like multitasking and I’m notoriously bad at multitasking.   I notice that some others in the combo, don’t lose their place, but they lose the groove. I seldom lose the groove – it’s in my bones – I lose my place. H’m, feeling the groove doesn’t feel like multitasking to me, but does to someone else. Maybe if I play much less while improvising and focus on the chord changes and the structure of the tune I would be less likely to lose my place.

As a catalyst for change at work, my challenge is to listen, feel the rhythm of the work flow and be a catalyst.  The more active and frenetic I become as a catalyst, the less I listen. Not so different from improvising. Listen more, feel the groove, do less.
How about as a patient? Listening to my body, understanding the machinations of the world around me, and picking one or two routines or habits at a time to work on. Listen more, feel the groove, do less. Might work.

First, I Listen – Improv

By Consumer, Musician
As I wrote a few weeks ago, First, we listen, is the tag line of Advocates, Inc., my current employer. The power of listening continues to move me in my work and my music. I’m finding it relatively easy to listen 50% of the time, 75% is a serious challenge.  My energy comes out of my mouth – somehow, mouth open closes my ears – must be a check valve. It’s not just opening my ears, it’s pausing my mind. What’s helped is my music. Working on improvisation, I often lose my place in the tune. I’ve been trying to listen to the rhythm and chord changes and play fewer notes. Play a few notes, pause, hear and feel the rhythm and chord structure, play a few more notes. Focus on the space between beats and notes. Play simply. It’s technically easier and makes more sense and I get lost less often. Hmmmm. At work and playing with the combo I get more nods. Nods are good. Some people are master listeners – my wife, my 2-year old grandson, my primary care doc, and Miles Davis. Is listening a magic lever of best health?

Improvisation, rhythm, repetition, and caregiving

By Caregiver, ePatient
I’m learning more about improvisation in my musical life – jazz improvisation. In my early days I had thought that the improviser just let loose playing whatever came through his fingers with the rhythm section in the background. Creating music on the fly. I’m learning – not so much. The structure of the tune – melody, chords, rhythm – provide the framework. Then the improviser draws on a library of note patterns aligned with the chord structure that she has repeatedly played into muscle memory. This library provides the material of improvisation. Much structure, much practice leading to better improvisation. Some minutes I think I’m a better improviser, most hours I think not.

In my health journey improvisation helps me understand the importance of melody, rhythm and repetition – structure, muscle memory, habits in care. The melody is the state of the person receiving care, with the rhythm being the daily pattern of care (activities of daily living). The more challenging the care, the more severe the disability, the more importance the melody, rhythm, and repetition. It seems that even with the most severe disability, caregivers can more easily manage and improvise if the pattern, repetition, and muscle memory is there. It’s when the melody and the rhythm frequently change, when the unexpected constantly occurs, that playing and improvisation becomes too draining and almost impossible in the best of circumstances.
Can we help the helpers better cope and improvise if we explicitly clarify and simulate the underlying melody and rhythm?

Noise

By Leader, Musician
Composer, John Cage said, “Wherever we are, what we hear is mostly noise. When we ignore it, it disturbs us. When we listen to it, we find it fascinating.” As a change agent in healthcare I find myself filtering the noise. Noise can be a cacophony of voices or motion without much meat. I’m annoyed with the din and peeved at the duplication of efforts. In my jazz combo I listen to the noise. We’re student amateurs after all. I hear us struggling with technique on our instruments, anxious to keep our place in the roadmap of the tune, vulnerable and overwhelmed with lack of confidence. Buried in the noise are some inspiring licks. Fascinating – what might listening to the noise in healthcare do for us?

A new threshold – laid off

By Caregiver, Consumer, ePatient, Leader

As you were recently informed, due to the need to reduce operating costs, the Hospital is required to eliminate positions. Unfortunately, your position is one of those affected by this difficult decision.

A definite threshold in a health journey. Going through the stages of grief exiting one space and excited by new prospects as I enter the next. This is where some earlier posts on my blog come in: Resiliency, Superpowers, Rest, Improvisation.
What have I learned these past few weeks about the industry? Frantic rush to merge, expand, and cut expenses – dynamic tension between these simultaneous imperatives. A few organizations are well poised to consider, now what – many are not. The challenges of creating systemness and alignment from diverse cultures and entities, always endemic in health care, are now more pressing. Rapid, intense change causes teams within organizations to constrict, contract, protect. Leaders can leverage this stressful opportunity to create alignment by focusing on the patient, providers, and staff experience. Who can disagree with this beacon? Focusing on patient experience across the continuum of care is intrinsically rewarding – spiritually healing – and makes business sense because positive experience prevents leakage and increases loyalty. Clinicians are critical – they understand healing. Leaders need their help applying their craft to organizational health. Their jobs are harder, they need superpowers more than ever. They know where the system is weak and wasteful, just look at their workarounds – pearls  for change. Patients want their journey to be simpler and kinder – it’s far cheaper and more effective to anticipate their needs rather react to their dissatisfaction. Everywhere we find relationships requiring information and communication – patients, caregivers, providers, staff, leaders. Automate that sharing of information – bidirectional where possible.
I need to rest and heal to prepare for the intensely exciting new vistas ahead. I have worked my whole career to be ready for this moment. Be still my heart.
Photo by Paweł Czerwiński on Unsplash

Magic Lever – Adherence to Health Plan

By Caregiver, Clinician, Consumer, ePatient, Leader
Unfortunately some providers call adherence to a health plan – compliance. This unhelpful label implies singular focus on the patient, as in “they aren’t compliant with taking their meds”.

The ability to develop and adhere to a health plan is probably the most complex magic lever of best health. Developing and adhering to a health plan involves studying population health; evidence-based best practice; collaborative relationships, behaviors, language, and alignment of the health team; standardized work flows with on-the-spot improvisation; electronic and non-electronic tools; leadership; and management of cultural and social habits and challenges. Setting up systems to make adherence more likely is challenging and labor intensive. The effort has to be worth the outcome.


Population health analytics – studies to predict those groups of people for whom adherence planning would yield the greatest benefit to health, experience, and cost. Evidence-based practice – adherence planning should be based on evidence – knowing it’s likely to do what the health team expects. Collaborative relationships, behaviors, language, and alignment of the health team – the intricate choreography with stars and cast who can speak to, understand each other, and work together for a common purpose. Standardized work flows with on-the-spot improvisation – adherence planning is largely production work repeated across groups of people. Yet each of us is slightly different and unique. Teams respond as people and circumstances change. Electronic and non-electronic tools – Adherence is not a point in time, but occurs and adjusts over time. Well meaning and determined people need help. Leadership – Creating and maintaining adherence friendly systems needs inspired leaders. Dance without a director is just a rave. Management of cultural and social habits and challenges – A person who doesn’t get a lunch break can’t take a mid day medication with food. A single parent with several children depending on public transportation can find it difficult to make a physical therapy appointment three times a week. Sensitivity to such challenges and public policy advocacy can increase the likelihood of adherence.
In short, adherence is serious work for everyone. It is not compliance.

Releasing the Inner Improviser

By Caregiver, Clinician, Leader

Best health includes improvisation in the relationship between health professionals and those in their care. One picture of improvisation is discretion to customize response and interaction and go off script and track with each individual’s or families journey. Yet the capacity of health professionals to remain up-to-date in their knowledge, compliant with practice and regulation, and productive while still able to be kind and improvise approaches possessing a superpower. As Kate commented yesterday, other knowledge workers – teachers – have the same challenges.

What conditions release the inner improviser?  Let’s consider a few: clarity of purpose; trust and team dynamics; predictability and responsiveness of  systems; and ability to learn from the improv: fix what seems broken.

Clarity of purpose can be mission, focus on the task at hand, or even clear boundaries. Every organization I’ve worked for had a mission statement. St. Peter’s Health Care Services (SPHCS) in Albany, NY, was committed to being a transforming healing presence in the communities we serve. Like the golden rule, easy to say, tough to do. Difficult decisions at SPHCS often included explicit consideration of the mission.  Focusing on the task at hand is mindfulness. As in right now the task at hand is pain relief, teaching, mobility, whatever. Not my co-worker, not the next person who needs me, not Dancing with the Stars. Concentration. Zen. Finally, improvisation occurs within boundaries – knowing the tune. For health workers the tune is policies and procedures, regulations, standards of practice.

Trust and team dynamics. Sustaining kindness and improvisation without feeling trust in yourself and your team truly IS superpower. Good team dynamics are healthy relationships – role clarity, communication that greases the constant shifting and movement of the day’s flow, re-prioritization, and mutual helpfulness.

Predictability and responsiveness of  systems used by your team –  workflow, supply chain, information systems. Knowledge workers create work arounds when systems don’t work quite right. They ingeniously seek a state where they can accomplish their daily tasks productively. Disruption of these systems draws valuable energy away from kindness and improvisation.

If all the stars are in alignment and staff feels able and empowered to improvise, we are idiots if we don’t learn and fix. Some proportion of improv is kindness and some is in response to something that is broken. Often both. Lord, I feel another post coming on.

I contend that the most important job of leaders – the people who supervise those who touch the public – is to nurture the environment of kindness and improvisation. Nurture the environment and model the behavior.

Improv and Health Leadership

By Caregiver, Clinician, Consumer, ePatient, Leader

Why improv and health leadership? Health experience is unique, of the moment, a journey. A different possible riff every moment.

The patient, client, consumer (let me use the term consumer for now) expects safe, quality, kind, empathetic care and service from professionals and their organizations-it’s a given. Even when safe, quality, and kind are present the health journey can be a very rough road. The challenge for the professional and support staff is to maximize the ability to know and relate to consumers as individuals and respond to the roadblocks, detours, potholes of that journey. 

The compliments my peers hear about health care are not usually about saving a life, successful surgery, hand washing. Rather it’s about the housekeeper who brought coloring books to the child; it’s about the nurse who knew the child’s passion for Ninja Turtles and brought a Ninja Turtle balloon to the bedside or exam room; it’s about the doctor who called the family on her day off; it’s about the registrar who found a private space for a mother to breast feed a non-patient child. These leverage the whole experience positively.

The relationship between professional caregivers and consumers includes constant improv-discretion to customize response and interaction and go off script. Yet the capacity of caregivers to stay up-to-date in their knowledge, compliant with practice and regulation, and productive while still able to improvise approaches superpower.

How can professionals and support staff tap their inner superpower without the intentional complicity of their leaders? Health leaders model and create the conditions that cultivate and learn from this improv. More about those conditions in the next blog.

Improv and Best Health

By Clinician, ePatient, Musician

Why improv and health? Health is unique, of the moment, a journey. A different possible riff every moment. Successful maneuvering the roller coaster of dis-ease depends on religious taking care of what is well with your instrument; on you and your team dynamics; on the predictability and responsiveness of the tune: systems and infrastructure through which you journey; listening for the germ of truth in yourself, your caregivers, and professionals. Best health seeks simplicity: values, mission, common sense and of course chutzpah when you can afford it. The rest is commentary.

How is your health improv?