Dr. Lorelei Lingard - Collective Competence, TEDxBayfield

Collective Competence: Thinking differently about competence to improve healthcare

Dr. Lorelei Lingard is a leading researcher in the study of communication and collaboration on healthcare teams. She is a Professor in the Department of Medicine at the University of Western Ontario (UWO) and the inaugural Director of the Centre for Education Research & Innovation at the Schulich School of Medicine & Dentistry. Dr. Lingard obtained her Ph.D. in Rhetoric from the English Department at Simon Fraser University, specializing in rhetorical theory, genre theory, medical discourse, and qualitative methodology. As a rhetorician, she investigates 'language as social action': that is, how social groups use language to get things done, and how that language acts on them, their identities, their purposes, their situations, and their relationships. Her research program has investigated the nature of communication on inter-professional healthcare teams in a variety of clinical settings, including the operating room, the intensive care unit, the internal medicine ward, the adult rehabilitation unit, and the family health centre.

>> Good evening everyone.

I am a Communications Researcher and I study healthcare teams,

that means I follow them around while they do their work,

and I talk to them afterwards about why it is that they work the way they do.

I've studied teams in all kinds of healthcare settings; operating rooms,

intensive care units, emergency departments,

pediatric hospitals, rehab hospitals, transplant units.

Whenever I study a team,

I ask three questions.

How does this team communicate?

How does their communication influence the patient care they can deliver?

How would we educate healthcare professionals and students,

so that their team communication and their patient care improve?

I've been studying healthcare teams for about 15 years,

and one of the most important things I've learned to date is this.

Healthcare is full of highly competent individuals, competent family physicians,

competent nurses and nurse practitioners, competent specialists,

competent pharmacists, dietitians, home-care workers, social workers.

But only sometimes do these competent individuals come together to form a competent team.

In fact, not infrequently,

competent individuals come together to form an incompetent team.

You might be wondering,

how is that possible?

Well, let me tell you a story.

This is Joe, he's 75 years old and he lives at home alone since his wife died a year ago.

Joe had his first heart attack at 55,

and he has had three more since.

He's been a diabetic for 25 years and

because of his diabetes he has some mild kidney trouble.

A month ago, Joe was admitted to hospital for pneumonia,

and while he was in hospital,

his kidney troubles worsened due to

a drug side effect from one of his blood pressure pills.

The hospital doctors stopped this pill and Joe did well,

recovered from his pneumonia and went home.

About a week after he went home,

he had a follow-up appointment with his family doctor,

but the discharge note hadn't made it to

the family doctor's office yet from the hospital.

So, the doctor doesn't know about his kidney trouble in hospital,

Joe doesn't have any medication list to bring with

him but he does bring all of his pill bottles

including the pill that was stopped in

hospital because Joe restarted it when he got home,

he didn't know he wasn't supposed to.

The family doctor is looking at the blood test results

from about six weeks before Joe went into hospital,

and she's concerned about his blood sugar control.

So, she refers him to a diabetes specialist who he has seen in the past.

But two weeks later when Joe goes to this appointment,

the diabetes specialist shares the family doctor's concern about the blood sugar control,

and he decides that Joe's current medication must not be working well enough.

So he prescribes a new blood sugar control medication.

On his way home from that specialist appointment,

Joe pulls into a pharmacy he doesn't usually go to and he fills this new prescription.

Now, for the last number of months Joe has been

having homecare nurses come visit him in his home,

and one of the things they'd become concerned about is his medication compliances.

You see sometimes Joe forgets to take his pills,

sometimes when Joe remembers,

he doubles the dose to make up for not taking them.

Now the nurses are working with Joe and they're teaching him

new medication management strategies to deal with this problem,

and they're recording the problem in the home care binder.

But the family doctor doesn't know about it

nor is communicated to the diabetes specialist.

Now as it happens,

the new medication that the specialists prescribed is a little hard on the kidneys,

and the specialist wouldn't have prescribed it if he'd

known of Joe's recent kidney trouble in hospital.

But he didn't know, and Joe shows

up in the emergency room couple days after starting his new prescription,

with a low blood sugar reaction.

Does any on these sound familiar?

What's going on here?

Joe got competent care in hospital,

he recovered from his pneumonia.

He got competent care from his family doctor,

his diabetes specialist, his homecare nurses, and the pharmacist,

each of those individuals within their scope of

practice and acting on the information at hand,

did the right thing for Joe,

but the sum total of those care events is not overall competent care for Joe.

Now this is a very complex problem

and it's being tackled from a number of different angles,

systems engineers are trying to understand it better to improve the situation,

organizational scientists are trying to work on it,

sociologists are working on it.

Tonight, I'm going to shed some light on this problem from my perspective as

a communications researcher who's interested in improving medical education.

There are significant barriers that make it difficult for

individual competence to translate into collective competence,

I'm going to focus on three.

The first is scientific reductionism,

this refers to the way that we tackle

complex scientific phenomena by breaking them down into their component parts.

Now scientific reductionism has produced

some spectacular advances in our knowledge but translated into patient care,

it means that Joe's heart disease, his diabetes,

and his kidney troubles are all treated as separate entities.

The separate barrier between individual and collective competence is specialization.

Now medical specialization is necessary,

no physician can know everything there is to know about

medicine but specialization has consequences.

If I have heart disease, ovarian cancer,

and depression, all three of those issues will be treated by three different specialists.

If I live in a rural area,

those three specialists will likely work for three distinct healthcare organizations,

which will likely be located in three different cities.

The third barrier between

individual and collective competence is the very concept of individual competence itself.

The goal of producing

an individually competent healthcare provider with

their own specific tightly bounded expertise,

drives everything in health professions

education generally and medical education specifically.

Now each of these three things: reductionism,

specialization, and the goal of individual competence are in and of themselves good.

Reductionism allows us to understand complex problems,

specialization allows us to build a deep expertise in a particular area,

and individual competence well everybody

wants an individually competent healthcare provider right?

But together and kind of paradoxically,

these three factors combine to produce one of healthcare's greatest weaknesses.

That is the providers work in isolation from one another,

each person focused on the particular issue about which they are an expert.

When that happens, patients can fall into

the cracks between individually competent care providers.

The theme of tonight's event in

adaptation and one way of expressing the meaning of adaptation

is that it's a process of change by which an organism

or a species becomes better suited to its environment.

I'm suggesting tonight that we need to adapt

our thinking so that we can provide better patient care.

What do we need to adapt from?

Well, I would argue that we need to adapt from

our exclusive focus on the goal of individual competence.

Individual competence is a set of pervasive and rarely challenged assumptions.

It's not unique to medical education,

it's true of education everywhere.

Three of these assumptions are very important to my argument tonight.

One is the premise that competency is a quality the individuals possess.

So, I'm competent because of,

for instance, the knowledge I possess in my head.

Related to this is the premise that competence is

a state to be achieved so that we can take naive learners,

put them through a medical education process,

fill their empty vessels up with competence and graduate them in a state of competence.

Related to this is the third premise,

which is that, competence is context-free.

Its independent of time and space.

So, if I'm competent tonight in Bayfield,

I'll be competent next week in Toronto and next year in Paris, France.

Now, this notion of individual competence drives everything in medical education,

from the way we select candidates for entry into medical school,

to the way that we teach and assess their performance,

to the way that we license them for practice,

monitor their practice over the course of their career and if we smell a problem,

we look for the individual most responsible,

we pull them out of the system,

remediate them if necessary and put them back in.

Individual competence everywhere.

Now, this educational model made sense in the environment which created it,

and that healthcare environment was this;

a single patient visiting their physician for the care of an ailment.

The healthcare environment has changed.

This is a report published in 2011 by the Canadian Institute of Health Information.

You can find it online.

In a nutshell, what it tells us is that Joe is an average patient.

A quarter of Canadian seniors report having three or more chronic conditions.

That's about a million people.

These same people report over 13 million healthcare visits per year.

We're no longer talking about patients going to

see their single physician with a single ailment.

The environment has radically changed,

but the way we think about competence has not.

So, what do we need to adapt to?

We need to broaden our notion of competence to include collective competence.

What do I mean by that?

Collective competence is a distributed capacity of a system.

It's not reducible to a single individual.

Collective competence is also an evolving dynamic.

It's not a stable trait, it changes.

It changes in relation to context.

It is intimately tied to context.

The competence of my performance is influenced by

the limitations and the affordances of the situation that I'm in at this moment.

I'm talking about an enormous adaptation, a game changer.

For hundreds of years in Madison we've thought about

individual competence and I'm talking about

changing that notion to include something very different.

You might wonder, is this even possible?

Not only is it possible but I'd like to touch on three ways in

which we are right now moving towards collective competence.

The first, I think, is a relatively simple way.

Let's go back to Joe.

The fundamental problem at the crux of Joe's situation is this.

Joe travels through the healthcare system more quickly than his health information does.

We have the technology to address this problem,

to move information more efficiently.

One example of relevance to Joe's story is the global medication electronic record.

This would have allowed the pharmacist that Joe went to,

to view the prescription in light of all of

Joe's current medications and his past medications.

Unfortunately, the pharmacist in Joe's jurisdiction

didn't have access to a global medication electronic record.

But many jurisdictions do.

A more sophisticated way in which we're moving towards collective competence right

now is an experiment that we're all involved in in this room.

That's the shift to deliver primary care through family health teams.

A family health team brings together a primary care physician,

a primary care nurses and a number of other health professionals: pharmacists,

social workers, dietitians, physical therapists, et cetera.

It puts them all under one roof so that Joe

doesn't have to go off to six different places to have six different needs met.

Family healthcare teams offer a better model for teamwork and collective competence.

They also come with new funding mechanisms that ought to promote

collective competence in a way that the traditional funding mechanisms never could.

But it takes more than putting people under one roof to get to collective competence.

Listen to these pharmacists from a new family health team.

"I'm a pharmacist, so I know how to be a pharmacist.

I don't know how to be a pharmacist in

a family health team because nobody knows about that yet.

I walked in and I did pharmacy things but I didn't know what

that meant in relation to what the nurse does or what the dietitian does."

This pharmacist is saying,

I'm individually competent but I'm not so sure about how to be collectively competent.

The structural change involved in family health teams is

an enormously positive first step but it's insufficient.

We need an educational change to go along with it.

The third way in which we're moving towards collective competence is

a more strategic way and I've picked one of many examples here.

By strategic, I mean,

take a look at the healthcare system,

find those points in the system where a failure of collective competence can have

dire consequences and build

initiatives to support collective competence in those moments.

What I'm going to talk about is an initiative to build

collective competence in the operating room to help surgical teams communicate better.

This is an initiative that my research team and others

around the world have had intimate involvement with.

Now, why pick the operating room as a moment in the healthcare system?

Well, when they analyze errors in the operating room such as wrong site surgery,

they find that the root cause is far more likely to be a breakdown in

communication on the team than it is technical skill or a lack of knowledge.

So, a number of us around the world conducted research,

myself for about a decade,

in operating rooms trying to figure out how could we help this situation.

What arose from that international research

was what's called by the World Health Organization now,

the Safe Surgery Saves Lives initiative.

What it is, is a protocol for surgeon and their citizens and nurse to come together at

points in a surgical procedure and make sure

they're sharing the critically salient information.

This initiative has in fact become so

successful that it's had enormous international uptake.

You can go to the WHO website and actually zoom in on your own jurisdiction.

I tested it. I zoomed in on us here.

You can see the hospitals that are registered in this particular checklist initiative.

In fact, it's become mandatory in this country and many others for

surgical teams to do some kind of

preoperative briefing or checklist before they start an operation.

I've described to you three advances that I think are important ones

and show the potential and the work on

the ground to move towards collective competence now.

But collective competence is about more than good software,

good Internet use, checklists, other tools.

Collective competence must be a value and

underpinning philosophy and an educational mission.

If I picture curiosity tonight and you want to think more about this problem,

I have a book coming out with my colleagues later

in the floor called The Question of Competence.

For tonight, let me summarize my argument this way.

Medical education is driven by the goal of individual competence.

Consequently, healthcare is full of highly competent individuals.

This is a very good thing.

Individual competence is absolutely necessary but it's

insufficient to meet the needs of the current healthcare environment.

Collective competence is an urgently needed adaptation.

It will require healthcare professionals to think and act differently,

and it will require patients to think and act differently too.

When we achieve it,

I believe it will look something

like this.

Thank you.