One question that I routinely encounter from rehab professionals as I teach therapeutic neuroscience education across the country is this: “PNE is such great stuff! But HOW do we get EVERYONE in our facility on board?” That is the million-dollar question, isn’t it? All too often we face frustration born out of our own facility or system’s silo-approach to patient care: we provide stellar education to our patients with complex chronic pain, have them on board and progressing towards meaningful life change, and then they go to that “consult” that was arranged six months ago. They return to us, new plan in hand, because, lo and behold, it IS the disc/SI joint/labral tear/you-name-it that is the problem after all! Inwardly, we scream, “Nooooooooo!!!” Outwardly, we bite our tongue as we politely smile, re-group, and salvage the situation to the best of our ability. It makes us wonder, is it even possible to create a culture within our systems that truly serves patients with chronic pain in an evidence-based, responsible, compassionate and effective manner?
Last fall, I had the privilege of getting to know several members of the Tomah, Wisconsin Veteran’s Administration’s rehabilitation team. Hearing their story of implementing an innovative and highly successful multi-disciplinary pain program was one of the most exciting and encouraging experiences I have had in a long time. After initially meeting at a CE course, the team was kind enough to invite an ISPI colleague and I to their facility to see first hand what they have been doing. Watching the team in action gave us a glimpse of what is possible when a small group of committed individuals buckle down, cooperate, and keep patients at the center of their mission.
The PT-led team in Tomah brought about huge, in-house, multi-disciplinary change, and now their expanded, interdisciplinary team is taking steps to multiply that change in sister facilities. Starting with their knowledge of pain science and the conviction that everyone involved in patient care needs to grasp how pain works, they did the hard work of initiating a culture change, from bottom to top and top to bottom. As I observed their interactions with one another, from the PT stationed right in Primary Care to offer early intervention alongside the physician, to the psychologist working alongside PT and OT for patients in the addiction program, to the chiropractor working on studying outcomes, to the pharmacists who shared their stratification of opioid risk procedure, I was struck by one resounding observation: humility. The members of this team recognized their unique strengths and contributions to patient care, but also recognized the absolute need for their colleagues in different disciplines to treat the whole Veteran. Under exemplary servant leadership, this team proved to me that it IS possible to change a culture within an organization, and it bolstered hope that a handful of committed individuals can, indeed, “change the world.”
As I reflected on what I saw in Tomah, as well as concepts of professionalism and moving above and beyond merely “playing nice in the sandbox,” I came up with a couple of Top 10 lists for in-house culture change. While each system/facility has their own unique barriers to overcome, each discipline within an organization being guided by principles like the following can foster the kind of change we are hoping for.
Top 10 Things All Disciplines Can Do to Foster Culture Change
1) Remember: It’s. About. The Patient. (It’s always about the patient…check all egos at the door)
2) Get out of our silos and learn from one another (know our roles and the roles of others)
3) Language: speak the same language with emphasis on reassurance and hope:
- Tissues heal!
- The nervous system is plastic and change is possible!
- Mantras: Sore but safe!
4) Leverage expectation (set each other up for success)
5) Perform skilled assessments (no business initiating “sensitive nervous system” conversations until we are confident that’s what is truly going on)
6) Build Trust/Therapeutic Alliance: Assure you have enough time to establish relationships to address the complexity of the pain experience (or refer to those who do)
7) Keep your own compassion /empathy fresh (personal life balance)
8) Provide positive environments (what’s on the TV in the waiting room? What’s on the covers of your waiting room magazines? Models/posters; Receptionists)
9) Have a pain champion: someone(s) in your discipline with the desire and ability to dive deep into pain science—learn from them! Consider in-house pain summits
10) Focus on function and celebrate success!
Top 10 Things we all need to STOP doing:
1) Using scary language
2) Sanctioning disability
3) Relying upon passive treatments, unless they are time-limited, supplemental and goal-oriented
4) Pushing patients before they are ready
5) Disregarding patients’ priorities/desires
6) Minimizing contributions of others
7) Hyper-medicalizing patients (too many visits)
8) Labeling patients by their diagnosis
9) Assuming patients can’t learn or that they want to be fixed passively
10) Assuming patients are faking
I’d be interested to hear your thoughts. What has made your team soar? What can we do to go beyond “playing nice” to actual bridge building? How can we foster culture change?