ClickCare Café

Can Leadership Benefit Healthcare Collaboration?

Posted by Lawrence Kerr on Wed, Jan 03, 2018 @ 06:01 AM

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The new year is always a time of reflection and taking stock. For us at ClickCare, we’ve taken the opportunity to step back and look at what is most needed in healthcare.

In 2018, we believe one of the things that is most crucially needed in healthcare is: leadership.  As healthcare becomes increasingly volatile, politicized, and competitive, leaders within medicine are needed more now than ever. And in 2018, we look to leadership to advance the cause of collaborative health care.

So we were intrigued to come across a series in the New England Journal of Medicine Catalyst called Lessons in Leadership. Two pieces stood out to us as especially important, and we’re going to look at them in a two-article series this week.

In Transformative Collaboration Across the Care Continuum, Dr. Slocum looks at the profound importance of teams in healthcare (as well as challenges they face). Of course, the role of teams and collaboration in healthcare is increasingly recognized as crucial to improving both care and metrics.

But there are a myriad of challenges to effective collaboration and team-based healthcare. In fact, Dr. Slocum identifies challenges like, “bridg[ing] the divides of geography and discipline” and “making cross-disciplinary collaboration between clinicians and researchers a day-to-day endeavor.” In summary, she said, “Collaborative relationships across settings are critical to optimizing care, yet they are very difficult to achieve.”

While there is a lot of truth to the challenges that exist for teams, we know for sure that it’s certainly not impossible, or even “very difficult” to achieve collaboration and strong teams across settings. Before we started ClickCare, I worked with the Craniofacial Team — an interdisciplinary group of providers, truly across the continuum of care — to collaborate on very complex cases. We got together once a month to discuss our cases and used whatever communication tools we could to collaborate outside of our meetings. The collaboration took a bit of work, sure, but it was easeful and effective.

And now, with iClickCare, we watch our colleagues create strong, agile, effective teams using the simple app to collaborate. It's work that regular providers do, every day. It's true leadership, shown by everyone from aides to super-specialists.

The truth is: we have the technology to collaborate and support our teams.  The next challenge is to develop leaders who are willing and able to:

  • Assert themselves and their ideas without fear of reprisal
  • Create an environment that empowers others to do so as well.
  • Do so in the current hostile environment of 
             Incumbents
    Regulation
    Payment distrust (insurance companies, CMS and fraud - real and imagined)

Yes, the technology and innovations (like new programs) are important. We wouldn't have created iClickCare if we didn't think the technology and tools were crucial. But more important than tools are the leaders who use them. And every healthcare provider regardless of your title or training  can be a leader this year, starting today. 

 

For more stories of everyday leaders and healthcare collaboration, download or free Quick Guide: 

ClickCare Quick Guide to Medical Collaboration

Tags: collaboration leadership, healthcare collaboration, medical collaboration

The Outcomes of Older Doctors and Female Doctors May Differ -- But Does It Matter?

Posted by Lawrence Kerr on Wed, Jun 07, 2017 @ 06:01 AM

olderphysicians.jpgOur least favorite type of research is the observational study. Think: eggs are good for you, eggs are bad for you; eat meat, don’t eat meat; statins cure everything, statins cause everything; and on and on.

However, observational studies can be a first step into deeper understanding. An example is Jenner’s observation that milkmaids who contracted cowpox did not get smallpox. In the current "publish or perish" environment, the necessary deeper inquiry (Jenner tested vaccination, albeit in a crude way as we look back) often does not happen. Public media grabs and grasps the story, disseminates the story, and the story disappears and is gone within less than 24 hours. Another publication is notched for institution and researcher. Big data is thanked. Rarely do we find someone who goes on to ask why.

Certainly, inquiry into what works and what doesn't is extremely valuable. That said, two recent studies also beg for a deeper answer. Both are by the same author. The first study by lead author Yusuke Tsugawa observes the female physicians have fewer patients die or be readmitted. They speak of adherence to clinical guidelines  and “patient centered communication." 

The second study concludes that younger physicians have fewer patients die while the readmission rate is the same. It pits older physicians against younger physicians. Medicare patients formed the sample. Policy implications concluded that medical education and its maintenance of certification is important.

There is no doubt that the younger physician is a better coder and understands the value of coding maybe even over outcome. Could this be the education that is required? 

But, let’s not quibble over reasons and explanations. Above all, what matters most is how we can improve medicine. 

Assume the conclusions are correct, and that there are indeed differences born of gender and age. Why not encourage, support, and demand collaboration and communication? Bring the old to share with the young, the young to teach the old. The style of the female to mesh with the style of the male.

Regardless of whether these studies are strong and solid and show true causality between these physician demographics and their outcomes... Why not work together, rather than focus on controlling the parts?

 

These stories of medical collaboration show that you can take outcomes into your own hands:

ClickCare Quick Guide to Medical Collaboration

Tags: good medicine, collaboration, collaboration leadership

When Telemedicine Includes a Chicken

Posted by Lawrence Kerr on Thu, Oct 02, 2014 @ 08:39 AM

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A recent story in the NY times told the story of a doctor in Israel who offhandedly told a patient's son that, of course, a Rabbi could visit the patient in the hospital. The doctor only had second thoughts when he found the Rabbi in the hospital room, waving a live chicken around the patient's head to a unison of prayer.

The story of the rabbi, the doctor, and the chicken probably sounds a little bizarre to some. Although I'd guess that if you've been practicing for a while, it may not surprise you much. The truth is that although this particular patient's custom was a little less familiar to us, patients always have their own customs and beliefs. And as the author points out, as medical providers, we sometimes ignore, edge out, or belittle these customs or beliefs at the expense of good medical outcomes.

Maybe the little boy you just stitched up needs his twin brother to visit him in the hospital or he won't sleep well at night. Maybe the woman scheduling her surgery needs to schedule after Christmas passes or she won't actually give her wound the time to heal it needs. Maybe it's worth standing in the hallway outside the OR for a few minutes while a patient's family prays, as it will help everyone feel more comfortable, and who knows, may even help the surgery go well.

What does all of this have to do with telemedicine and medical collaboration? Well, everything, actually.

We've found that when medical providers don't collaborate, the humanity of their patients can get lost between the cracks.

If the doctor in Israel had gone off duty right before the Rabbi arrived with the chicken, maybe the new doctor would have made a different decision, without the benefit of context. The new doctor might have banished the chicken, and with it, the trust and buy-in of the patient and his family of the medical interventions at work.

With iClickCare, we find that the little things that make medicine a thoughtful, human, respectful, open practice can actually survive. The "story" of who a person is can come across in a conversation between people, or if folks are too busy or schedules don't match up, in a synchronous exchange via Hybrid Store and Forward Telemedicine. It's the little comment about "I'd say to go ahead and take the stitches out, but make sure Dad is in the room for a minimum of tears" or "Let's schedule the surgery for this week, not next, since Ramadan is coming up" that make the difference between extraordinary care and, just, medical care.

So don't banish the chicken. And use whatever collaboration tools you need, to help.


Curious whether hybrid store and forward telemedicine could help you care for your patients?

ClickCare Quick Guide to Hybrid Store-and-Forward

Tags: collaboration leadership, medical collaboration, good medicine, healthcare collaboration, store and forward medical collaboration, communication with patients, concierge medicine

5 Surprising Things That Make a Great Medical Collaboration Team

Posted by Lawrence Kerr on Sat, Sep 20, 2014 @ 07:42 AM

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Recently, a consultant from MIT visited a frustrated manager at a call center. The manager was experiencing something that many medical providers have experienced at different times. He was struggling to figure out "why some of his teams got excellent results, while other, seemingly similar, teams struggled?" It's that same frustration we wonder about as providers: we feel "flow" and pride in giving excellent care at one place where we work, while everything seems difficult at a different hospital or location.

After months of data analysis, the call center folks found that the teams that performed best were those that communicated best: "we’ve found patterns of communication to be the most important predictor of a team’s success. Not only that, but they are as significant as all the other factors—individual intelligence, personality, skill, and the substance of discussions—combined."

So how can you improve communications? Well, the hospital lounge is evidence that we've known the answer all along. The call center made one simple change to try to improve communication: they adjusted break schedules so everyone could take a break, make a coffee, and have a conversation at the same time. That change had huge consequences. Soon, they were seeing such increases in efficiency that they anticipate a savings of $15 million per year.

And while medical providers tend to measure success more in terms of patient outcomes than in terms of efficiency, we think there are some interesting patterns to inform our providers for medical collaboration. The coffee-break solution helped cultivate good teamwork, but what are the characteristics of what a good team actually looks like?

5 things that turn a good group of people into a great team for medical collaboration, via HBR:

  • Everyone on the team talks and listens in roughly equal measure with short communications. That's why the entire continuum of care -- nurses, aides, doctors, and everyone in between -- must be included in the care conversation.
  • With conference room encounters, members face each other and have energetic conversations and gestures. With communication technologies this means feedback, prompt responses, and a simple thanks. Video conferences take time and money. But store-and-forward telemedicine tools allow for this kind of energetic exchange of ideas.
  • Members connect with each other not just the group leader. The typical "hub and spoke" consultation doesn't allow all team members to collaborate or share information. Face to face conversations and some telemedicine can support these kinds of "horizontal" conversations.
  • Members can carry on back-channel and side conversation with the team. We feel everyone, no matter where in the hierarchy, should be talking to each other.
  • Members periodically break, explore outside the team and bring information back. While there's a place for efficiency and 100-hour weeks, we certainly think that medical providers benefit from not being excessively overworked and overtaxed. One benefit (among many) is that team members that have a little wiggle room in their schedule can bring back new ideas and information. 
And if teams are a part of your work, check out other stories of medical collaboration in this quick guide: 
ClickCare Quick Guide to Medical Collaboration

Tags: collaboration leadership, medical collaboration, store and forward medical collaboration, communication with patients, patient satisfaction, provider burnout

Progress for ClickCare, Collaboration, and New York State

Posted by Lawrence Kerr on Fri, Sep 12, 2014 @ 09:25 AM

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In the coming days, ClickCare is moving into a new office, and a new phase in our company. We are pleased to have overcome stiff competition to become part of Binghamton University's Innovation Technology Center. We will be sharing space and ideas with both growing companies and leading research programs.

Because of our mission, it's a setup that makes a lot of sense. One of our most fundamental values is collaboration -- in healthcare, in our work, and as people. So the opportunity to work alongside other innovators in the Binghamton, Upstate New York, area is a huge one for us. 

Beyond that, it makes economic sense for everyone we work with. We were also accepted as one of only a few companies who have been invited to be part of Start-Up NY, giving a local ClickCare employee a full 5 years with no NY state income tax, among other benefits. It's our way of making sure that we benefit ClickCare providers, and patients of course, but also the people who work with us. 

The country is struggling with an injured medical system. But there are certainly bright spots in the values, initative, and collaborative principles exemplified in our beautiful, expansive, new office suite and the Start-Up NY program. We look forward to building solutions together. 

 

Get more stories of collaboration from around the world:

 

ClickCare Quick Guide to Medical Collaboration

Tags: clickcare, telemedicine, collaboration leadership, medical collaboration, Start-Up NY

What Does a Tattoo Artist Have to Do With Medical Collaboration?

Posted by Lawrence Kerr on Thu, Jun 12, 2014 @ 08:24 AM

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When I saw a recent New York Times article and video about a tattoo artist that focuses on realistic nipple tattoos for women who have had cancer related breast reconstructions, I was skeptical. We certainly don't normally see a tattoo artist as part of the continuum of care or part of our community of medical providers, and I would have some hesitations about recommending this kind of post-surgery tattoo outside of the context of the surgeon's office.

I will say that while I have done nipple reconstruction, augmented by tattooing, since breast reconstruction started in the 70's, I have often wondered if the tattooing could not be done better by a tattoo artist. As a physician and surgeon, and student of anatomy, I have an appreciation of reconstruction, meaning restoration toward normal, its principles and indeed, its art (as is demonstrated in this tattoo artist's work). Nipple reconstruction is more than application of decoration. I also knew about the blood supply of the breast, where the implant may be working, and a surgeons commitment to sterility.

However, I also wondered, often, could more practiced hands and heavy duty equipment give a more long-lasting result, despite the fading all tattoos are subject to. I respect the commitment of this artist profiled in the article. Also, I have used medical tattooing as alternatives to things like eyebrow reconstructions.

So, what does this have to do with medical collaboration? Everything, actually. This tattoo artist may not be a traditional member of the medical team, and I might some recommending this to a patient, but in this case, he is certainly providing care related to the healing process. How much of a smoother process would it have been if he could have used iClickCare (as one example of a telemedicine-based medical collaboration platform) to communicate with the patient's surgeon? How much less would her wait time have been? How much more confidence would she have had that this was an appropriate course of action and would fit in with the rest of her treatment? How many potential medical issues could be avoided if the traditional medical providers were able to share their information with the folks supporting the patient with less traditional medical issues?

As medicine shifts, so does the team of medical providers. Our job is to make sure that we have the tools to collaborate with every member of the medical team, traditional or nontraditional.

Of course, it's crucial to have a medical collaboration tool that allows you to respect HIPAA and communicate in a way that honors the patient. We've found that this means you need to be able to have a virtual consult that may "pick and choose" what information, pictures, or history that particular collaborator has access to. So this kind of collaboration is certainly to be handled with care, but as medicine evolves, I believe it is absolutely crucial to involve all members of the team caring for the patient. In this case, the person in question is a tattoo artist, but in so many other cases, the continuum of care for a given patient could include people like:

  • Acupuncturists
  • Therapists
  • Teachers
  • Caregivers
  • Family
  • Lactation Consultants
  • Etc.


Have you found the need to do medical collaboration with any nontraditional parts of the team? How have you facilitated communication and collaboration with them? We'd love to hear, in the comments below.

And for our "field guide" to medical collaboration, click here:

ClickCare Quick Guide to Medical Collaboration

 

Tags: collaboration, telemedicine, collaboration leadership, care coordination, medical collaboration, telemedicine solutions, store and forward medical collaboration, communication with patients, telemedicine and hippa

4 Easy Ways to Try Telemedicine Before Lunchtime

Posted by Lawrence Kerr on Fri, Feb 07, 2014 @ 09:15 AM

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We've been hearing from a lot of people that they want to give telemedicine a try. Many providers have been noticing the overall thriving of the field. Others are drawn in by data showing collaboration (especially using telemedicine) can decrease length of stay, cut readmissions, and improve rates of healthcare provider burnout. 

But despite the interest in medical collaboration with telemedicine, many people aren't sure where to start. We're the first to admit that it can feel overwhelming to pick up a new tool or adopt a new habit!

So here are 4 easy ways you can try telemedicine before the day is over:

  • Start with someone you know and trust. Think of the last colleague -- it might be a nurse, doctor, or other provider -- that you had a great conversation with or who solved a problem with you. That's the person with whom to try telemedicine and collaboration. Start with people you already know and trust, and grow your collaborative circle from there. 
  • Keep it simple. Even chatting with a colleague about their day can open the door to problem-solving, so that is a great place to start. And when you are ready to collaborate using telemedicine, start with a simple case. You can always build up to consults on your most complex case, but getting a consult or two on more basic issues lets you build up confidence. That way, when you do reach out about a tricky patient, you're not worried about the telemedicine piece of it.
  • Organize a “cool case” breakfast or lunch. We used to take medical students out to egg sandwiches before work to discuss unusual cases and share stories. While this isn't technically telemedicine, it is definitely collaboration -- and that is the important part. 
  • Try iClickCare for free. You can start inviting colleagues, sharing cases, and connecting for a couple of weeks with no cost and no complicated set-up.


Plus, we put together a couple of "quick guides" to telemedicine and medical collaboration, and we're offering them for free -- so take your pick and get started.

 

ClickCare Quick Guide to Telemedicine

ClickCare Quick Guide to Medical Collaboration

 

 

Image courtesy of svoalex on flickr.com, used under Creative Commons rights.

Tags: collaboration, hybrid store and forward medical collaboration, medical collaboration software, healthcare provider burnout, telemedicine solutions, collaboration leadership, care coordination, healthcare collaboration, decrease readmissions, decrease length of stay

Can Doctors Run Hospitals Better than CEOs?

Posted by Lawrence Kerr on Wed, Nov 13, 2013 @ 08:58 AM

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The medical collaboration that we champion with ClickCare is based on a simple concept: everyone in healthcare has different strengths, and we all do better when we work together. Every provider plays a role, whether that provider is a hospital administrator, nurse, doctor, or aide.

So we were intrigued by a recent New York Times article asking, "Should hospitals be run by doctors?" 

The article addresses whether hospital CEOs with a medical background have better results than hospital CEOs without a medical background. The answer is a bit ambiguous. Only 3.6% of hospitals are run by physician administrators. And new research by the Social Science & Medicine journal showed that hospital quality scores were about 25% higher when doctors ran the hospital. That said, that's not a proven causal relationship... and "quality scores" may not be the most precise measurement of success.

The tone of the article, and the implied competition between physicians and administrators, got us thinking. As pressure increases to drop costs and perform -- whether in terms of length of stay, readmissions, outcomes, or something else -- there is a temptation to play the blame game. We've all been guilty of it -- at some point, everyone has blamed everyone else. And there is something in the tone of this article that tries to single out hospital administrators as the scapegoat of the week. 

If there is anything that our work in telemedicine and medical collaboration has taught us, it's that blame and competition are never helpful. With every case we see, we notice that when medical providers just collaborate in service of the patient, everyone has a better outcome than they would have otherwise. We believe the question is not so much whether doctors can run hospitals better than CEOs, but rather how we can all run our hospitals and practices better -- together. 

 

Click below for our "field guide" to medical collaboration -- healthcare and beyond:

Download Quick Guide Medical Collaboration

 

 

Tags: collaboration, collaboration leadership, medical collaboration, telemedicine solutions

The Shocking (and obvious) Truth About Medical Collaboration

Posted by Lawrence Kerr on Mon, Aug 12, 2013 @ 09:41 AM

This post was originally published on July 24th. Since this piece of our website was not working for all viewers, we're republishing some selected posts this week.  

Working with the doctors and nurses I see every day is one of my favorite things about this work. I also observe a lot of folks working together, and the frustrations and successes I have been seeing made me want to look in the literature for other perspectives on medical collaboration. I found many articles, but two of them really struck me. 

The first was about teamwork on inpatient medical units and the second discussed barriers to nurse-physician collaboration. They made some pretty stark observations about the ways healthcare providers are failing to work together effectively -- and why. 

Sure, we're working in teams and we're trying hard. But working in a team is not the same as working together in a team.

These studies found 4 key barriers to medical collaboration:

  1. People aren't in the same place at the same time. This may sound obvious, but the fact that medical teams are working in different buildings, across organizations, and over different shifts creates a unique communications challenge. Communications systems that ignore this challenge (like video conferencing systems or pages in hospital hallways) ultimately fail. 
  2. Common systems don't work. Healthcare providers report that the communications systems they're expected to use don't facilitate collaboration or coordination of care. Whether it's an EMR, a paging system, or telephone calls, providers are frustrated with the current options. They're old technologies that don't match the pace, aspirations, or reality of healthcare today. 
  3. Coordination of care is basic, and not happening. You would think that the question, "who is taking care of this patient?" would be pretty basic. But providers report that coordination of care is taking up increasing amounts of their time and happening poorly. So poorly, in fact, that knowing who is taking care of a given patient is becoming a daily challenge.
  4. The "cockpit approach" doesn't work. Well, to be more specific, it does work -- 10% of the time. In a few specific situations, like in ERs and NICUs, applying learnings from airplane cockpits works (e.g., using checklists). But as Zwarenstien and Reeves point out, 90% of medicine takes place outside of this type of setting. The rest of medicine involves fluid teams, long-term and complex problems, and takes place in different locations and different times. That means that the cockpit construct doesn't help much, and these teams are left without a solution.

These barriers are familiar to me, both in our own hospital setting, and in the experience of many ClickCare users. The good news is that time and time again, I've seen creative, courageous nurses, aides, and physicians overcome these barriers, creating better patient care and a better provider experience.

What ClickCare's users taught me about breaking through to medical collaboration: 

  1. Accept that this is your problem, even if it's not your fault. We may not have caused these difficulties in collaboration and communication, but we're suffering from them. The good news is that we've noticed ClickCare users getting a lot of satisfaction and stress-relief from collaboration. It wasn't their fault that it wasn't happening in the first place, but it did benefit them to make it happen.  
  2. Experiment. There isn't a one-size-fits-all solution for collaboration, and so we have to experiment with figuring out what can work for us. The thing about experimentation, though, is that new efforts may not work right away. In the words of Seth Godin, "Anyone who says failure is not an option has also ruled out innovation." 
  3. Choose a communications technology that works for you, even if not everyone is using it. As human beings, we have a tendency to wait for permission, to wait for standardization, to wait until we find out what everyone else is doing. But given the slow rate of change in the medical world, we have to take change into our own hands. Even if not everyone has adopted a new technology, it could easily be the right thing for us, for our organization, and for our patients. 
Try the iClickCare 14-day evaluation

Tags: medical collaboration, coordinated care, collaboration, communication with patients, provider burnout, nurse practitioners, good medicine, collaboration leadership, nurse collaboration, clickcare

Richard Branson's Unorthodox Tips to Avoid Provider Burnout

Posted by Lawrence Kerr on Wed, Jul 03, 2013 @ 08:35 AM

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I'll say it up-front: Richard Branson has very little in common with most doctors.

He's the founder and Chairman of the Virgin Group, which means he runs over 400 companies. He's one of the richest people in the world, owns an island, and has a penchant for risque PR stunts. Not exactly a conservative professional. When he was in elementary school, the headmaster -- fed up with his poor behavior and worse grades -- told him he'd either end up in jail or a millionaire.

That said, Branson juggles priorities and people in the same way healthcare professionals do. As the operator of an airline he is in a high-risk field with plenty of regulation, as are we. And with half of healthcare providers reporting burnout, we need to start drawing creativity and strategies from outside of medicine. So in our ongoing effort to swap healthcare provider burnout for collaboration and ease, we're featuring Branson's wisdom, practices, and ideas.

Richard Branson's top tips for avoiding healthcare provider burnout:

  1. Swim around the island. Branson explained in Fortune Magazine that he gets up at 5:30 every morning to swim around Necker Island to care for his body, recharge his mind, and cut stress. True, you may not own an island and your mornings may already be maxed out. But with new research showing that even 7 minutes of exercise can be hugely beneficial, it might be time to consider whether a little pre-work workout could be just the burnout prevention you need.
  2. Use technology in a low-tech way. Richard Branson is famously low-tech, using pencil and paper more than a computer, and often dictating email responses instead of typing. But in running an airline, a space travel company, and a mobile phone empire, he certainly needs to tap into tech in savvy ways. So we often take a page from his book and choose the most modern, best-designed apps and programs for our work because they are actually the most intuitive to use and easiest to integrate into our lives. For instance, ClickCare is designed to feel like a conversation, not a technological marvel. Whether it's ClickCare or something else, don't be afraid to use the best, most high-tech solutions out there, choose low-tech options when they make sense, and let it all follow whatever workflow works best for you
  3. Ignore (some of the) rules. In medicine, we're trained to be rule-followers. We follow standard of care guidelines, HIPAA regulations, and administrator admonitions. Most of the time, this is exactly how it should be. There's no need to get creative and put someone at risk. But as Richard Branson says"You don’t learn to walk by following rules. You learn by doing.”  So while your actual practice of medicine should probably continue as-is, healthcare providers may experience less burnout if they create some rule-free zones in their work. Whether it's how you paint the office, what you put in the waiting room, or how you collaborate with your colleagues, it's likely that there are rules you're following that are unnecessary -- and that you'd benefit from ignoring.
  4. Communicate. Collaborate. As Branson said in Business Insider, "The quality of business communications has become poorer in recent years as people avoid phone calls and face-to-face meetings, I can only assume, in some misguided quest for efficiency."  As in business, communication (among providers and to patients) in medicine has gotten exponentially harder in recent years. But one of the best ways to avoid healthcare provider burnout is to cultivate the collaboration, support, and encouragement that comes from good communication. So use ClickCare or another tool, and invest in communication, even if it's just a few minutes per day.
  5. Avoid an "us vs. them" environment. Few people talk about it, but it's incredibly common for an adversarial environment to exist in medicine. Providers vs. administrators; patients vs. providers; and everyone against HIPAA. There are some valid reasons for the tensions that exist in medicine, and the challenges are real. But within a team, it can drop stress levels and up performance if you look for ways to collaborate rather than compete, and encourage rather than reprimand. Branson says that this is one of the things that makes Virgin Group what it is, and he works with tens of thousands of employees worldwide. It's not always easy, but it's always worth it. As our good friend, Dr. Rudolpho Suguitan, always said, "You can always afford to be gracious."
Learn more about how ClickCare can help you avoid burnout here...
Tell Me More About iClickCare

Tags: collaboration leadership, medical collaboration, healthcare provider burnout

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