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Melissa Stratman

07 Apr, 2016
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Melissa Stratman

07 Apr, 2016
Follow Coleman!

When You Are the Coach: Coaching Rapid Redesign Tests

Redesign teams running test clinics, or Rapid Redesign Tests (RRTs), always need coaching to be able to derive the greatest benefit from testing their model. Coaching is a great role for a manager who has passion for the redesign team’s goal of transforming the patient experience and who is also well-steeped in clinic operations. What many teams really want the coach to do is praise them for their work and leave. Unfortunately, it’s not an effective approach for pushing team boldness and confidence.

There are three distinct phases of the redesign process where redesign teams benefit greatly from being coached:

  • Preparing for the RRT
  • During the RRT
  • Debriefing After the RRT

Preparing for Rapid Redesign Tests

A few weeks before the RRT is scheduled, the coach should thoroughly query the team about the schedule template for the RRT. The main weakness of most early RRTs is that there are too few patients scheduled for the new model. The more patients the early model handles well, the more confidently the redesign team emerges from an RRT. Reviewing patient scheduling with a team a few weeks before you coach the RRT gives the team enough time to correct problems.

If the team has not already revamped the scheduling template, the coach should move the team to quickly adopt Simplified Patient Scheduling (SPS). In Simplified Patient Scheduling (discussed elsewhere on this website), all patient visits are booked in 15 minute appointment slots—only one visit type and one time. Remember: There’s no correlation anyway between the amount of time a patient is scheduled to be seen by a clinician and the length of the slot. So, you’ll probably need to strongly encourage the team to try this radically simplified approach. One visit slot every hour is left open for same-day call-ins or walk-ins. Only one “long” visit is booked per hour, but still for only 15 minutes. Be sure to review the longer explanation of SPS before trying it, though.

If patient reminder calls are part of the model, and some scheduled patients have disconnected numbers, advise the team to treat these patients as likely “no shows”, and book another patient in the slot. This is the only instance where double booking is allowable under Simplified Patient Scheduling. Warn the team that sometimes a “disconnect” shows up for the appointment, but remember, as the RRT coach, you are generally more worried about not having enough patients to fully tax the team and model. The goal of an RRT is not merely to test the model, but to develop the courage and confidence of the redesign team. The best way to build confidence is for the team to gain mastery over challenging situations. The worst way to build confidence is to engineer a perfectly safe RRT.

All good RRTs are preceded by a team huddle. Make sure the team has developed a huddle agenda and checklist and has appointed the best person possible as “huddle captain”.  Coach the team members to arrive on time to work and to conduct a great huddle that prepares the team mentally to “take control of the day”.

Make sure that prior to the RRT, all RRT participants have learned how to use any new equipment, including walkie talkies. Also make sure that all team members are thoroughly oriented to the redesign model and their individual roles on the Patient Care Team.  Finally, the coach should give the team a heads-up about allowing ample time to debrief after the RRT. Plan on an hour for the debriefing.

Coaching During a Rapid Redesign Test: Three Models

Model #1: Coach as Observer.

The RRT coach observes throughout the day, beginning with the huddle. It is in the huddle that the coach explains her role and how she will approach her work. After the huddle, the coach carefully observes all RRT players in action and keeps a close eye on cycle time and productivity data as the RRT unfolds. Post the data publicly or follow the example of your Coleman coach and use their  sample data collection sheets. The coach-observer is mobile, starting at the front and watching for 15-20 minutes, then moving to the back and doing the same, then moving to medical records or another department to witness the impact of the RRT and the response of staff.

The coach-observer then presents a cogent report of her/his observations during the team’s debriefing after the conclusion of the RRT. This is probably the most ineffective way to coach an RRT, since the intervention occurs after the RRT concludes, rather than during it. However, it is the most comfortable RRT coaching model for teams.

Model #2: Coach as Gentle Interventionist.

The second model, and the most popular among RRT coaches, is the coach as the gentle interventionist. This intervention consists of asking the team members Socratic questions and as the RRT unfolds, and giving helpful hints to nudge team members to conduct the RRT more effectively. The coach intervenes with coaching suggestions when team members are not working according to their model, or flaws are evident in the model, or when teamwork is faulty. It can be a difficult balancing act. Teams are usually very nervous having an someone observe them at work, much akin to the nervousness of a student taking a test. In general, it is more effective to coach teams “in the moment” as opposed to making recommendations in the debriefing, but it is more unsettling to teams.

Paula Barron, a Coleman Associates coach par excellence, gives the following examples of coaching in the moment: “I find most staff is uncomfortable using walkie talkies and/or they are just not used to communicating with each other. During the RRT, if a staff member needs to communicate information and forgets to use the walkie talkie, I call it to her/his attention. I tell them that this is a very good time to say such and such to a specific member of the RRT patient care team. Often a series of these little reminders will help shape behavior meaningfully.

Model #3: Coach as Assertive Interventionist.

The third model of RRT coaching was developed by Coleman Associates in RealTime Redesign, where a training team goes on site and working with staff, redesigns the clinic processes in one week.

In this model, the coach’s role is a much more aggressive one. When the doors open in most clinics, the team is usually confronted with a chaotic scene, like a movie set. The coach in this setting functions very much like a “movie director”, arriving as early as possible to greet staff and make sure they are mentally prepared for the day. The “director” participates in the huddle making sure the team discusses the needs of each patient robustly and that all is in place. Then the “director” basically says “Places everyone!” And once everyone is in place: “Now let’s open the doors. OK, action!”

The focus in the first hour of the RRT is to make sure that the session gets off to a clean and quick start. All staff is at the front, ready to take the first patients back to the exam rooms to be seen on time. The RRT may seem very chaotic for the first hour as glitches appear, but the coach is careful not to be too controlling at this point, making sure staff members begin to solve their own problems, but intervening when necessary.

“I remember a medical assistant who was so efficient she had all exam rooms loaded with patients ahead of their scheduled appointments,” recalls Coach Paula Barron. “I asked her if the provider knew patients were waiting and she said yes, so I went to ask the provider—who was in her office—why she was not seeing these patients. Her response was that she wanted to catch-up on paper work. I then explained to her that patients were ready and waiting and she’d have more command over the day if she saw the patients now and finished her paper work later. Many staff do not feel comfortable “pushing” the model if they have to hold a provider or manager accountable. I was able to do this as an outsider, even though it didn’t make me the most popular person in the eyes of the team or the staff. It did help jolt this provider out of her habit of putting the paperwork before the patient.”

For the second hour, the coach intervenes much more, facilitating the solution of sticky process problems that impede patient flow. Into the third hour, the coach focuses on watching individuals to see how well they are functioning as team players and workers, and taking corrective coaching action, sometimes with the staff member’s supervisor in tow, if needed. Emphasis during this last hour is to make sure that all patients are seen and staff gets to lunch or home on time—together.

At noon, at the end of the Rapid Redesign Test, the coach deliberately and genuinely provides ample compliments where appropriate, noting when the team was particularly effective in handling the patients and managing the flow.

This model is very effective, but it’s essential that the redesign team members be crystal clear about your coaching role—how you will play it, and why. You need their buy-in to be able to coach them assertively to achieve as successful results as possible.

Debriefing after a Rapid Redesign Test

Here’s the sad truth: most teams do not fully understand how to conduct the debriefing. Except for a “hot” team, the coach should probably take control of this debriefing, structure it carefully, facilitate optimal learning, and target the problems to be solved before the next RRT (and identify who will solve them)—in other words, model a good debriefing. The RRT Prep Checklist found in the RRT ToolKit (PDF) contains a section on debriefing after the RRT; use it as a guide in addressing the fundamental problems with the RRT.

Begin by asking team members “what worked” and “what didn’t work” in the RRT. After team members finish, give your perspective. Paula Barron offers an example of insightful facilitation: “This is the time I point out any of the inter-personal behavior I observed, positive or negative. Once I observed a nurse who was not busy with patients doing paperwork. The provider’s exam rooms were all filled with patients. One patient had a problem with medication that required a lengthy phone call. I asked the provider if the nurse could do the call so she, the provider, could continue with her work. The provider declined. I brought up this incident during the debriefing, and the nurse confessed she does not like to make those types of calls. The provider said to the nurse ‘I don’t like to ask you to do these types of tasks because you get upset.’ At that point another team member said: ‘We all have to help each other and work as a team. We can’t have the attitude that we don’t want to help each other.’ The nurse agreed and apologized. This incident helped that team to improve its performance.”

The debriefing is also the time to make sure teams have a work session planned to discuss their redesign model to work on any other outstanding issues. The RRT Prep Checklist found in the RRT ToolKit (PDF) is useful for planning RRTs, debriefing from them, and as an aid for the coach in following up with the team’s plans.

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