Hello students, myself Siddhaswara B. Turzaapure, Associate Professor, Department of Mechanical Engineering, Walshan Institute of Technology, Soolapur. So today, we are going to deal with the counterbalancing circuit, the learning outcome. At the end of this session, students will be able to draw counterbalancing circuit and explain its working. The contents are firstly need of counterbalancing, then we will go for counterbalancing circuit and then we will go for the downward stroke of the piston, then upward stroke of piston and lastly we will have the references. See now, firstly we will go for the need of counterbalancing. So in case of counterbalancing word, we will have the say splitting of this particular word and we will firstly consider the balancing only, say balancing. So when the word balancing it comes, so it refers to the thing that unbalancing is already existing. So now unbalance of the force may exist due to the say different conditions. So one of them is say it is vertical position of the linear actuator that is the cylinder piston it is vertical and we are having the load attached at the end of the piston rod. And that load to some extent it is heavier, say drill head assembly etc., like that we can think of where the electric motor will be there and then we are going to have the gear box and then say we are going to have the output of that one to the spindle, then the drill and the drill holder etc., these things these are going to come. The whole thing it is going to be heavier. Then this unbalanced force needs to be resisted or it is to be countered. See this counter word it is now coming. So balancing we have seen, say unbalance it is existing due to the vertical position of the cylinder and the load attached at the end of the piston rod and say next to that one that vertical downward force which is unbalanced needs to be countered. So the wordings used are counterbalancing it is. If we are not doing that one see what is going to happen, say counterbalancing is not done we are going to come across the vertical downward motion of the piston either uncontrolled or in undesired way you can say. Now that unbalanced force now you can observe, say the vertical position of the cylinder we are having the load at the end of the piston rod, say drill head assembly or similar other you can have and then we are having the say supply to this cap end and the rod end by making use of the 4 by 3 direction control valve it is. Now you have to think of whether in the present condition the piston it is going to come vertically downward automatically due to the load at the end of the piston or it is not. See the question see the diagram carefully at the end of the piston rod we are having the load which is heavier and the cylinder it is vertical and we are having the connections like this 4 by 3 direction control valve is there. So the center position of spool is there and then we are going to have whether say the question is whether the piston will come automatically downward due to the load at the end of the piston or not in the present situation. See now in the present condition you have to check the spool position also so it is in the middle say if the piston has to come vertically downward the oil from this rod end side should be going to the tank but B port it is closed so the load it is not going to come vertically downward or piston it is not going to come vertically downward but it is exerting pressure to some extent presently so that is what the answer is. Now let us go to the counterbalance circuit so now the spool it is in the center position see that we have introduced to the counterbalance valve here counterbalance valve also belongs to pressure control group and it is also normally closed valve and going to open when a certain pressure it is reached where we are having the setting of that one say now the pressures we are considering. So now when the spool is having the center position no supply of oil is there say now we are to some extent the oil will be there in the pipelines they are having some pressure but say the pump supply it is not there presently and piston you can observe that piston is exerting the pressure on that oil or force on the oil which is on the rod end ball like structure it is coming first. Now this pressure say the pressure shown here in the pressure gauge it is only due to the say load which is attached at the end of the piston rod and weight of the piston etc. So it is say 15 bar now when we have to go for the setting of that counterbalance valve we should have the values which are higher than this one that is say the 25 bar we will take the value so the spring is there the setting of that one it is done and what we will have is we will have the setting at 25 bar unless and until the pressure reaches here 25 bar or it crosses the 25 bar value so the counterbalance valve it is not going to open so it is going to remain closed. Now let us see the say further position when we are going to shift the spool in the present condition now you can observe 15 bar is the only pressure say it is only due to the load which is attached here and piston rod and piston say weight so these are the contributing factors to that pressure and the oil it has come up to the counterbalance valve and it has remained there only no further flow through the counterbalance valve is there and the say load it is retained there only but now we are shifting the spool see now when the spool is shifted towards the say this position it is going to occur and P is now we are having connection to the A P connected to the A so the pressurized oil goes to the cap end of the cylinder so in case of this one the pressure it will be exerted or force it will be exerted on the piston now the total pressure you can consider and the total pressure now it is having the contribution of the two different say components one it is pressure due to the say load and the piston rod and the piston disc etc or the piston it is so that is already existing but additionally we have come across the oil on the cap inside which has been received from the pump itself and it is also the pressurized oil so this pressure and plus the pressure due to the load so together it is going to increase now and the value which is obtained is equal to its 60 bar 60 bar it is now suppose as it is say larger than the setting of the counterbalance valve it is 25 bar so the wall spool it has been shifted and the inlet is connected to the now outlet and we are having say the flow through the counterbalance valve and it is going to the port B and B is connected to the T so what should happen is say the pressure it should be more than that of the counterbalance valve set pressure so if it is like that then and then only the wall it is going to open and allow the flow through that one then we are going to come across the upward stroke so in case of the upward stroke again the shifting of the spool it is going to occur see now earlier we are having the first position of the spool it is so it is now in that case P it was connected to A B it was connected to T whereas in the exactly the first condition you can observe so where the question was raised so at that time so this A and B these are closed and this P it was connected to T directly now in the present condition what we are having is P is connected to B and A is connected to T so the green colored forward line you can observe and red colored return line is there so P is connected to A now see where it is going it is going to the say check wall and here this funnel like structure it is coming first and the ball it will be pushed ahead against the spring behind that one and the oil it is capable of easily flowing through this check wall it will go to the say rod end of the cylinder and the piston will be raised vertically upwards and we are going to have the oil returning from the cap end it will come to the say port it is A and A is connected to T at that time now the importance of the check wall you can observe in the earlier situation when the piston it was coming downwards at that time say the no use of the check wall was there but in case of the return stroke you can observe that we are having the use of the check wall so now it is P is connected to here it is B and from here the oil it is going to the cylinder through the check wall only it will not pass through the counterbalance wall but is it is going to pass through the check wall and it will go to the rod end and the piston will be raised vertically upwards the oil returning from the cap end it will go to the port A and A is connected to T at that time so like that what we are having is we are having the use of the counterbalance wall here and in case of the vertical downward motion we are going to have say uniform and say you can consider the situation when we are not having the counterbalance wall and we are having the spool position as one number so I have asked you the question with reference to the spool position second but if the spool position one is there so in case of that one say the combination of this total that is the pressure from the pump and the pressure due to the load will take place that is going to happen even if the pump pressure is lesser and if the load is heavier the load it is going to come automatically downward so suppose in this position we are having the say instead of three position if we are having only two position of the spool in case of that say even the oil supply is not there piston may come vertically downwards due to the load only if that is sufficiently heavy so like that we are going to have the use of the counterbalancing wall these are the references thank you


On behalf of the McLean Center for Clinical Medical Ethics, I'm delighted to welcome you to today's lecture in our series on ethical issues in healthcare reform. Our speaker today, as you know, is Dr. Matthew Winia. Matt Winia is the director of the Institute for Ethics and the executive director of the Ethical Force Program at the American Medical Association. At the Institute for Ethics, Dr. Winia oversees projects on issues such as ethical challenges in preparing for epidemics and bioterrorism, professionalism in physicians, the responses of physicians to market pressures in medicine, and ways to create measures for healthcare ethics. Dr. Winia works here at the university in the clinical area of infectious diseases. He's conducted research on doctor-patient communication, physicians' views on cost containment, and on the evaluation of ethics programs. Dr. Winia received his medical degree from the Oregon Health and Sciences University School of Medicine, completed his residency at the Beth Israel Deaconess Medical Center, and then completed fellowships in infectious disease and in health services research at Tufts. Matt received his MPH from the Harvard School of Public Health. Today, Dr. Winia will be speaking on the topic, what does physician leadership look like in a reformed healthcare system? Please join me in giving a warm welcome to Matt Winia. It's great to be here. I have to admit I'm using a new presentation program that I've only used a couple of times before, but I think it's kind of cool, and I assume you guys have seen this, so it's a nice way of kind of telling a story. I put a number of things on the desktop that we're actually not going to look at today, amongst them a bunch of quotes about leadership from a variety of people. The one that I want to focus on a little bit is this one from Jack Welch, who was not someone I found myself quoting a lot through my career, but when I saw this, it caused me to have one of those epiphanies that, in retrospect, you just think, well, that's really obvious and simple. But I've spent most of my career thinking and writing about what it means to be a medical professional. And in many ways, this has been a sort of navel-gazing exercise about getting better at being me and us getting better at being us as doctors, right? So on an individual basis and as a group activity, thinking about professionalism in medicine has largely been thinking about the relationships that we have with our patients, with our communities, and so on. And what we're being asked to do today, what I'm being asked to do at the American Medical Association, what you all are being asked to do in clinical practice, what I'm being asked to do in my own clinical practice, is to stop thinking so much about me and start thinking more about us, about teams and leading teams. And I say this because if you haven't picked up on this already, team-based care is kind of all the rage. And it's all the rage for a number of pretty good reasons, not entirely research-based at the moment, but for pretty good reasons. We have a very complex healthcare environment with something on the order of 25,000 new research trials published each year. There's something like 2,700 different clinical practice guidelines that a primary care physician is supposed to be holding somehow in their head. And the data sort of keeps growing. And beyond that, we're also overwhelmed with the task laid out before us in health policy and practice, right? So we have the Affordable Care Act. We've got a lot of new people to take care of. And this is on top of an existing system that already, in many instances, is stretched to bursting. And my favorite example of this is geriatrics, where if you look at sort of what experts have predicted as to be the need for geriatricians over the next 15 years or so with the graying of the population, if we want to keep providing seniors with the same kind of service they're getting right now today, the same number of visits per senior per year, we probably need on the order of 15,000 more geriatricians in the next 10 years or so. Anyone know how many people went into geriatrics training last year? 251 nationwide, 250. So we are not going to get 15,000 new geriatricians in the next 10 years. It's not going to happen. The only way we can manage the populations of patients that are charged to us is to get more efficient at what we're doing, which means working better in teams. So that has been the activity that I've been involved in, mainly actually with the Institute of Medicine over the last couple of years, but it's starting now to bleed into activities that we're doing at the American Medical Association. So that's the topic today. And the aims of this talk are going to be to go over some of the principles and values of effective team-based care that we articulated in a working group at the IOM about two years ago. And then to say something about how these are being applied in our work with Johns Hopkins on improving hypertension control in a set of practices here in Chicago and in Maryland. I'm going to say a couple words, maybe a few more than a couple on some of the challenges facing us as we embark on our role as leaders of teams and how the AMA is trying to tackle those challenges more or less successfully. And then I'm going to spend a few minutes on issues that frankly I never would have thought 25 years ago that I would be talking about in the context of clinical care, which is stuff about business management literature, things from the Harvard Business School reports and so on. And I'm going to end with going back to where we just started, which is at professionalism. So I have a hidden aim in all of this as well, which is epitomized by this. Does anyone know what this is? This is a slime mold. Yeah, so amoeba in, you know, free-living amoeba in situations of scarcity will come together to basically share resources and form a slime mold under conditions of scarcity. And one of the medical students involved in this project at the Institute of Medicine said, you know, it's really interesting even a single-celled organism can figure out how to work together when put under pressure. Couldn't health professionals do the same thing? And then he said, of course, one advantage slime molds have over health professionals is amoeba are not concerned about crossing professional boundaries. So this is the hidden agenda in all of this. There are a lot of folks who are thinking about team guys to care who see us as the problem and as being a challenge to be overcome. And so I think that lays in the background of almost everything that I'm going to say. I always have to put up a disclaimer slide. I am not here today speaking for the AMA. Just because I say something does not mean it's an AMA policy statement. Although I will be saying a few things about potential AMA policies that are under consideration right now. So let me say a couple of things about the principles and values of effective team-based care. And this is from this work of the Institute of Medicine's Best Practices Innovations Collaborative. And we had a really wide-ranging discussion about three years ago that ended up with a smaller subgroup of us coming together to try and collate the literature on team-based care and identify what are some of the basic underlying principles of all high-functioning teams in health care, recognizing that teams in health care are extraordinarily diverse. The disaster response team and the rapid response team in the hospital and the ED and the surgical care team and the post-op care. Each of these are teams. And a primary care team is very different in both context and constructs and infrastructure and expectations, patterns of behavior, patterns of communication. And yet, our sense was that if we ever wanted to be able to teach teamwork well, which has been a challenge, we would need to have some shared understanding of what are the basic principles. And so we brought together this multidisciplinary team. And in part, one of our aims was to be a model for what interdisciplinary teamwork looks like. This resulted in this paper for the IOM, a discussion paper, and a piece in JAMA that I'll say a couple words more about in a minute. When we started this work, we decided to transcribe our conversations and the conversations we had with a series of high-functioning teams around the country. And when we were done, we put these into these word diagrams, which show how frequently certain things came up. So when we talked amongst ourselves and with others about what are the characteristics of high-functioning health care teams, these were some of the words that came up. And I won't show you all the word clouds, but I will say that there's another word cloud for facilitators of high-functioning teams and a word cloud for barriers to high-functioning teams. And I think it's interesting to compare just without even really looking at the words, compare the nature of the cloud when you look at barriers and when you look at characteristics. There's a few core characteristics, and there are about a million barriers. So without going into a lot of detail on this, you can pull down this report and read it. I want to talk about two of the characteristics or principles of high-functioning teams that have particular salience with regard to leadership, since that's the topic of the talk today. One of these is the idea of shared goals. Every team had a process, a formal process for eliciting patient goals, writing them down and tracking how you were doing with regard to achieving those goals. This is something that many of us do in our practices with our patients. We elicit goals, it's informal though. What these teams did, and we were talking to hospice teams, we were talking to a variety of different teams from around the country, they all had a formal process for documenting patient goals. And the reason for this was several fold. One was that we heard variations on this theme that if you assume that everyone has the same goal, you're probably gonna be wrong sometimes. And you end up with a team working at odds with each other. And number two was if you don't document your goals, you won't ever know whether you're hitting them or not, whether you're moving in the right direction. The other one that I wanna mention, because this gets, when you start talking about documenting goals and eliciting goals, it gets to a very thorny issue actually, which I'm not gonna spend a lot of time on today, but what is the role of the patient on a healthcare team? Is the patient a member of the team? Or are they the recipient of services from the team? And when you start really trying to break down what it would mean to say a patient is a member of the team, it gets very thorny because if you say the patient is the quarterback, all these analogies start to fall apart. If the patient is the quarterback, well, that's like a football team with a different quarterback every play of the game. It doesn't work, right? If you say the patient is the conductor, same thing, it's like saying you have a different conductor every song you play. It's very difficult to figure out how to analogize or describe the appropriate role. And one of the things that we spent quite a lot of time talking about was the reality that this is not a dichotomous thing. Patients have a variety of different roles in healthcare teams. Sometimes they are the driver and sometimes they are the recipient of services and many times they fall somewhere in between those two roles. So that gets though to this issue of clear roles and this is where leadership really does come to the fore in terms of our conversations at least in this small group. And we had a couple of minor epiphanies in the context of this work about what does leadership mean in the context of team-based care. One was these issues, we all walked into this work knowing that issues of leading teams were very controversial. Scope of practice issues come into play. When you sit down at a table with a leader from the AMA and a leader from the American Nurses Association, this will generate a fight, right? Who gets to lead healthcare teams is a major policy controversy. It was not controversial in any of our conversations with these teams that were actual high functioning teams. And yet it was clear who led tasks. And so we started thinking, well, why is it that these teams can work at a high level without getting into fights about who's leading what? And it turned out that the nuanced understanding they had of leadership as a term was an important piece of this. So there were recognitions that in the end, the doctor has responsibility, legal responsibility for outcomes for certain tasks and so on. But in the context of our teamwork, we look at this as who can do this job the best? That's the person who leads this task. So I'll give you an example. There's a clinical care team at Mount Sinai that we spoke to. And one of their decisions was they realized that they had this weekly team meeting where they were talking about clinical topics, care of patients and clinical decision making. And this meeting, the group felt was not working very well for them. And so they rethought who should be leading this meeting? And you would think a clinician should lead the clinical meeting. The chaplain ended up being the person best suited to lead this meeting. And it's working well now because the chaplain had the leadership skills necessary to do that work.  Leadership skills are not clinical skills. They're a different skill set. So let me just say that the other issue that came up really quickly as we talked to these teams was we presented them with a set of principles of teamwork that we had culled from the literature. And they quickly said, yeah, you could have all those principles. If you don't have the right people, it won't work. So there's something about the value set of the individuals on the teams. And every team had examples of people they had to let go because they didn't fit in. They didn't understand what a team-based care environment was like. And so I won't say really anything more about these. There is a more descriptive language in the papers. But there were a set of core sort of values that were held by the individuals who ended up being productive members of high functioning teams. So the deeper exploration areas that we suggested in this JAMA piece were as follows, that we need more understanding and a better sort of framework for what it means to have patients and families as members of teams rather than as recipients of team care. That we needed more work on leadership in the context of team-based care. That we needed to better understand how to train people for team-based care because this is not book learning. This is stuff that you can really only pick up by being involved in a high functioning team environment. And we don't have a whole lot of those to use yet. And where we do have them, many times people would say, you know, we have a really high functioning team here, but it's because of the people here. It's because of the idiosyncratic mix of the right people in the right place, all of whom's hearts are in the right place, and so on. So they didn't necessarily believe that what they were doing was teachable or transferable. So we've got to figure out how to teach this stuff and how to train for it. And then we wanted to know more about the organizational factors that support or hinder high functioning teams. Now, I put the leadership one in blue for two reasons. One, because that's what I'm gonna talk about for the rest of the talk today. But two, these other three areas are things where the IOM said, yeah, let's go, we're gonna do that work. Leadership is the one they punted. And it's because of what I was saying before, this is such a politically charged issue about leadership in teams. So let me say that I think probably the only way we can really address this, based on our experience in interviewing these high functioning teams, is by actually getting in on the ground level and figuring out how to make it work. So this is where we start to intersect now with the AMA's current strategic priorities and the tasks that I've been given in the last year by the AMA. So the strategic plan at the AMA is really different today than it was a few years ago. We now have three high priority areas. Every single, we have 1,000 employees in Chicago, 200 in Washington DC. We use a system called APEX to measure how we're doing each year. We set goals and so on for our units and for ourselves. Every person's APEX form has these three issues on it now. So this organization has become extremely focused, sometimes to our detriment, frankly, but that's a different talk. We are very focused on these three issues, understanding how to improve health outcomes, enhancing physician work life satisfaction by understanding what are drivers of payment and delivery drivers of physician satisfaction and accelerating change in medical education. And to be honest, it's actually more specific than that. It's undergraduate medical education in medical school. So my work recently has been on the improving health outcomes area. And here we spent about nine months going through the literature trying to decide, okay, we can improve health outcomes across everything. Let's pick a couple topics and get started there. We ended up, and this will be no shock to any of you, with cardiovascular disease and diabetes. For the same reasons that we have the Million Hearts campaign, the same reason, right? We did the same thing the CDC did. In fact, the CDC worked with us on this process. So it's no shock that everyone is ending up focusing on these issues as a starting point. And I'll give you just a few sort of details on why we're focusing, not just on cardiovascular disease, but even more specifically, hypertension. Hypertension is incredibly boring, I know. But every 10 years, the global burden of disease study comes out. And in the last 10 years, this came out in 2012, in the last 10 years, smoking overtook three other conditions. Household air pollution, childhood underweight, and sorry, and smoking. High blood pressure is now the number one leading risk factor for both disability-adjusted life years lost and mortality worldwide. Hypertension, the number one risk factor for disability and death worldwide. And we know how to treat this. And even marginal improvements in treatment make this situation quite a lot better. So this is a trial many of you are more familiar with, I'm sure, than I am. I'm an infectious disease person, so this is a little outside my typical bailiwick. But this is the fever trial. So thousands of people, given hydrochlorothiazide as first line therapy, half of them also get an ACE inhibitor, randomized. And over five years, they see a difference, an average difference in blood pressure of systolic 138 for those with the ACE inhibitor added and 142 for those without the ACE inhibitor added. So a four point difference in blood pressure. This generates, as the graph shows, a 27% decrease in strokes, a four point difference on average. So if we could do better on this, we could actually make a big difference in terms of health outcomes, which is what we're tasked now with doing. This is from AMGA, who's one of our partners on this work, the American Medical Group Association. They have a big program called Measure Up Pressure Down, where they're working with large group practices to do improvement work in hypertension. And the point of this slide is just to look at the reddish areas. That's the number of RVUs seen in ambulatory care related to hypertension. So more than half of the generated RVUs in ambulatory care have something to do with hypertension. So big problem, and this isn't something where we're doing uniformly poorly or uniformly well. There are individuals, this is 600 and some doctors that the AMGA is tracking across the country, huge spectrum, and it's not all related to the resources available to people in these different communities. So there are people in resource poor environments who are getting 80 and 90% control rates among hypertensives. The national average, we do about half. And good practices will do 70% control rates. So, but there are practices who are getting 80, 90%. There was a piece in JAMA just last year from Kaiser Permanente, Northern California. They're averaging now well into the 80s and many practices in the 90s. So it is possible to do much better than we are doing right now. So that's my detail on hypertension. The work that we're doing is with Johns Hopkins that I'm gonna focus on. We also have work that is directed at patient and family engagement. We have work on community engagement. I'm really just gonna talk about clinical improvement right now, the work we're doing with a number of practices here in Chicago. So we have five practices around Chicago that we're working with to prototype our improvement package, if you will. The ideas and the resources that we're putting together to help smaller practices, and most of these are small practices. So Neva Lubin Johnson, one practice, one practitioner, one MA. This is why we're working closely with the American Medical Group Association. They've kind of got Mayo Clinic covered and Geisinger, you know. But there aren't people doing work yet with smaller practices. So that's what we're focusing on. And around the Baltimore, Maryland area, we've got folks on the Eastern Shore and we've got a number of sites around Baltimore. So our improvement package, and I'm just gonna give you the top level here, our improvement package is really very simple if you break it down. There are three things that have to happen in ambulatory settings to get good high blood pressure control. One is you have to be dealing with the right number. There are huge problems in getting accurate blood pressures done. And if I don't have an accurate blood pressure handed to me, I am, I'm gonna have to repeat it. And if I don't believe my own blood pressure, I'm unlikely to make a change in therapy. And we know that the quality of the measures we're getting are not very good at any of the sites we're working with right now. No one is doing a great job of consistently, reliably doing accurate blood pressure measurement. It's a very simple thing. And yet it requires standardization and so on. Oh, sorry. The other two are once you have the number, you have to do something about it. So in sites that have poor blood pressure control, the number one reason they have poor control is because the patients who have bad blood pressure numbers didn't have anything done about it. This is called therapeutic inertia. So therapeutic inertia is the number one problem when you have low blood pressure control numbers. And you can get up to 70% or so control just by overcoming therapeutic inertia. So getting the clinic to do a better job in its role. The problem here is this is not like a lot of inpatient quality improvement where we're in control of everything. A lot of management of hypertension, 99.9% of managing hypertension takes place outside of the clinic. It's the patient and the family and the environment in which they live, work, learn, play, right? So engaging patients and families to support self-management is the third leg of what we call a MAP, M-A-P, MAP for Optimal Hypertension Control. So team-based care for hypertension control works. And I, again, I'm skipping over a lot here. There are people who know this, probably in this audience, much better than I do. But I'll just point out a couple of the sort of big sort of meta-analysis looks at team-based care and hypertension. Team-based care, effective team-based care is equivalent to one or two drugs in terms of improving hypertension control. So this is looking at a variety of different quality improvement interventions. And team changes is the one I've circled at the far end there. It's one of the few quality improvement interventions that across a variety of studies has really consistently shown that it works to improve hypertension control rates. So this is the Cochrane review from 2010. The Community Preventive Services Task Force did a similar review just last year, maybe two years ago now, finding a similar thing. Relatively consistent findings that implementing team care can improve hypertension control rates. And this is a terrific, the top box here is from Barry Carter's work. Really interesting study where he looked at essentially different aspects of team-based care and what you can expect from different aspects of team-based care in terms of demonstrated decreases in systolic blood pressure when those things are implemented. So if you give people free medications, you get about a 10-point reduction across your population in systolic blood pressure. If the pharmacist is empowered to call the doctor and make recommendations about what the medication change ought to be, you buy a 9.3% reduction in systolic blood pressure. If the pharmacist is empowered to make those changes themselves, you get an 8.4-point reduction in blood pressure. So it's actually a little better if the pharmacist and the doctor are talking about these things than it is if just the pharmacist is empowered to do it. But both are good. And by the way, I put the bottom box on just so you can see as compared to, say, hydrochlorothiazide, which buys you a 7% to 10% reduction in blood pressure or point reduction in blood pressure. So team-based care is about like adding a drug. Why is that true? Well, there are a lot of hypotheses about this. I think it's likely that we're overcoming therapeutic inertia by having people talk to each other better. Pharmacists are more likely to be well informed about guidelines and so on. And they will notice things in call, right? So things get brought to your attention. Once teams form, they tend to give explicit thought to things like process. And what's the pathway that someone takes? When they walk into our clinic, where do they sit? What happens if, right? Who does the next blood pressure? If a confirmatory blood pressure is needed, who's going to do that? So they start thinking through processes and making those. It's possible that team care provides an increased dose of information because the patient is not only talking to one person. They end up having reinforcement of that information from several people. And maybe one of those people connects better than one of the other people did. So there may be a dose effect in terms of information. So it works, but it isn't happening all over and it's not easy, frankly. And some of this is the culture of medicine, the sort of I'm the person who sits with the patient and makes the decisions and everyone else just carries those out. And some of it is natural to teamwork, period. Outside of medicine, inside of medicine, anywhere you go, teamwork is hard because when you're working without, this is the old trope about managing people would be easy if people weren't involved. It's hard to work with people because you end up, especially people who are serious about what they're doing and think they're trying to do a really good job. They take this very seriously. They're trained to do what they do. Tensions are inevitable in teamwork. So that's outside of medicine aspect of teamwork. We as the ostensible leads on these teams need to recognize that tension's gonna happen. It's part of the job. It's part of what we do. So if it frustrates you, then you shouldn't be the leader of the team. We also in medicine have problems with language. And I've mentioned this a couple of times already, but this is a study to sort of back it up. Many of you have probably seen this study because it made a pretty big splash when it initially came out. In the OR, nurses describe good collaboration as having their input respected and surgeons describe good collaboration as people doing what I tell them to before I tell them preferably. So that's a different understanding of what teamwork means. And it's a different understanding of what collaboration means. So what does a collaborative practice arrangement mean to you? I can tell you, the AMA has been struggling with this for over a year now. A resolution was brought to the AMA House of Delegates about 16 months ago, asking for us to make a statement on whether non-physician practitioners should be allowed to basically prescribe orthotics. Yeah, tiny little, and it was gonna pass. Everyone was on board, this was no problem, of course. And then someone said, well, wait a minute, we're saying that this should happen within the context of a collaborative arrangement. What's a collaborative arrangement? How would you define a collaborative arrangement? And no one had a definition. And the same thing happened when we started our work on team-based care for the IOM. We put together a little list of what I called hot button terms and sent them around blinded and asked people to say, what do you think this term means to you? And I'll tell you, these things generate heat, not a lot of light. Physician-led is a very negative term to a lot of people. And yet, look at the ACP statement on physician-led care teams, look at the AAFP statement on physician-led care teams, we are all about physician-led. Boy, if it's not physician-led, none of those organizations, as of today, has a definition of what physician-led means. None of us have said, here's what it means to be a leader of a healthcare team. So we're working on a report on this now, on what is the definition of leading a healthcare team. And without giving you the report, which hasn't been passed yet, so this is not AMA policy as of today, it explores a little bit this notion of a nuanced understanding of what leadership in a high-functioning, multi-disciplinary team where everyone has very good training, high-level training, to do different things. And the notion we're starting to get at is the one that I mentioned earlier, which is leadership is the most important thing and leadership of teams is not a clinical skill set. It's a management skill set. So we need a new metaphor, right? The captain of the ship does not work in a high-functioning healthcare, team-based care environment. So this is where I turn to the leadership in teams that we get now to talk a little bit about the business literature. So this is a terrific book. If none of you, if you haven't read Amy Edmondson, it's a really fun read. And all of these business management books, by the way, have tons of examples from healthcare because healthcare is a fascinating environment for business thinkers for whatever reason. We're a really interesting organizational environment. So in teaming, she talks about what the new skill set is for the type of work that is increasingly common in the American economy. And healthcare is a terrific example of this. She splits the work of teams up into three different types of work. And I just want you to think, as I described these, what type of work you do mostly with the teams that you work with? So one type of work is routine work. This is largely technical work where the answers are relatively obvious if you're an expert. And where the answers, you know, the main problems are sort of process problems, making sure things get done that need to be done in a routine way. You expect for routine work to have zero defects. This is work that is highly amenable to six sigma type thinking. And it is what you might call assembly line work. Another kind of work is complex work. In complex work, the focus is actually, because you know this is complex, there are factors here that you can't adapt for all of the complexities that are gonna happen. So bad things will happen. Failures will happen. So the task here is to build in redundancies and processes to ensure that communication channels are open and so on. And this is where she puts most of clinical care in the hospital, in the clinic, as being more like complex work than assembly line work. But the third area is also happening a lot, I think, in medicine. And this is what she calls innovative work. So here, it's not that failures are gonna happen. You gotta deal with it. You gotta try and avoid it. In innovative work, you are looking for failures.  They are welcomed. This is research work. But it also, I think, fits a lot of the quality improvement work that people are doing today. Where you're actually, trial and error isn't actually the right paradigm. It's more like trial and failure. Try and fail, try and fail. And the aim is not to not fail. The aim is to fail smart, to fail fast. And you hear this a lot in the business literature. The best businesses fail fast and fail often. That's what they do, because they're doing rapid cycle improvement all the time. Another great book, if you haven't ever either seen it or put it in the context of medical care. This is an older book, but terrific, because he splits these types, the types of problems. Largely, by the way, this is about politics, although he also uses healthcare as a set of examples throughout the book. He talks about technical problems.  Technical issues. And then, again, where he's focusing on is complex adaptive challenges for societies. So these are things like drug use in society, or improving education systems, or dealing with racial disparities in outcomes, whether it be in education or healthcare or elsewhere. These are complex adaptive challenges that we face as a nation or as a community. And in complex adaptive challenges, the people with the problem are the problem and the solution. And again, you'll hear this from these business speakers, that complex adaptive work is not about giving people the answer. It's about getting them to ask the right questions. It's about getting them to see how they are contributing to the dilemma that they face. And the most common failure in business leadership, and I pulled this quote, but you'll find dozens of examples of similar sentiments. If you Google the most common failure in leadership, this will come up. The most common failure in leadership is mistaking a complex adaptive challenge as a technical problem. So this is where we get to the work that we're doing with the folks at Hopkins. So when we decided that we were gonna do this improvement work, we thought, well, who's got legs? Who's got data? Who understands how to do improvement work? And Peter Pronovost and the group at the Armstrong Institute at Hopkins made a lot of sense because of their work in Michigan with the CLABSI program, which is now nationwide, very well documented, highly successful work. So we get in touch with them and we start this work. And one of the things to know is, this work has talked about a lot as checklist work. The checklist is sort of what became famous, but that is just the beginning of the types of changes that they made in order to allow the checklist to be implemented. The checklist is technical work. The checklist is figuring out what ought to happen every time. All that, it's hard. We have to be able to sit down at a table and decide this ought to happen every time. But once we've decided that, everything else is adaptive work. And so they break this up into what they call technical and adaptive work. And the adaptive work they call CUSP, their comprehensive unit-based safety program. And we're now adapting this framework, which has been proven in the inpatient setting to the ambulatory arena. Not easy, because I think I already mentioned there are big differences between an intensive care unit and an ambulatory clinic. In the ICU, if the patient got an infection, it probably wasn't the patient's fault. Probably. In the ambulatory setting, if the patient's blood pressure isn't controlled, it could very well be the patient's fault. And I use those terms advisedly, because how we interact with patients is proven to impact what they can and cannot do. So these are fuzzy borders. And it's where, again, we get back to this notion of teamwork. So when the ACP document came out last fall, which described team-based care, it received both praise and criticism. One of the criticisms was, I thought really well-phrased, Tom Huddle, this was one of the editorial pieces in the annals at the time, excuse me, the ACP paper came out. And he notes that the sort of ethical, as well as practical challenge in team-based care, and there are a few, but this is the one he focuses on, is that everyone is responsible, so no one's responsible. And I brought this up a number of times during our conversations at the ION, because I'm a parent, and anyone who's a parent has been at a park and been petrified, that there are 10 parents at this park, and 20 children, and the parents are all talking, because we all assume someone else is watching the kids. So when everyone's in charge, there's a risk that no one has responsibility and authority, right, has authority and responsibility. And this is related to the notion of professionalism, because professionalism is a lot about accountability, and personal and group responsibility for delivering on promises made to individuals and society. And the problem certainly in the ambulatory setting is, as Huddle points out here, there's such a wide spectrum of stuff we do in ambulatory care, we cannot count on regulators to tell us nurse practitioners are qualified to do these 10 things and not these other 10 things. Doctors can do these 10 things and these other 10 things. That is never going to happen to an extent that it actually works in the real world, because there are nurse practitioners who ought not to be doing some of these 10, and there are nurse practitioners who ought to be allowed to do some of these other 10, and there are doctors who shouldn't be allowed to do all of these 20, right? We as professionals decide, in fact, where within the broad scope of practice we are allowed by society, we are actually capable of practicing. I'm a physician, can I do neurosurgery? I don't think so, but the regulators haven't exactly told me that. Well, they have in some ways, but maybe that's a bad example. In any event, I am an internist. I can take care of people who are more complex than I ought to with regard to rheumatologic conditions. I refer people to a rheumatologist when I get out of my depth. That's part of what we do as doctors. We figure out what our depth is and we use each other as a team to take care of patients, right? So that same framework, that same notion of professionalism is going to have to apply across the board in healthcare, not just to doctors. We have to have a shared professionalism for all of healthcare, for all health professionals. And this is where I'm gonna finish. We have a piece coming out on this shortly based on a workshop that we held last fall. Again, as follow on to the Institute of Medicine's work where we talk a little bit, and I think because I'm running out of time I'm gonna skip a couple of these slides, but we talk a little bit about what a transdisciplinary professionalism would look like. And we use the word transdisciplinary carefully here because this is not interprofessional work. Interprofessional work means we've got a profession of nursing and a profession of medicine and a profession of podiatry and a, right? And we're all trying to figure out how to work together as separate professions. Each of us writing our own social contract with society and negotiating then amongst ourselves. We need a shared social contract where nurses, doctors, podiatrists, dentists, we all share the same profession. We are all professing the same stuff together because that's what our patients need. They don't need to be able to trust doctors and nurses and dentists. They need to be able to trust doctors and nurses and dentists and others working together as health professionals. This may be a road too far, but that's the aim is to start thinking about and thinking about what the infrastructure would need to be to have a shared professionalism for all of the health professions. And that would mean an infrastructure to create a new social contract across all of the current health professions to unify them. These are just a few examples, but I don't really need to show you this because if you've ever looked at anyone else's Code of Ethics, you know we all look about the same. We've got Codes of Ethics, which are largely redundant across the supposedly different health professions because we have different disciplinary expertise. I'll close with this quote which is worth noting not only because it is true, but because it was true in 1910 when William Mayo said it. We are dealing with such a complex environment, so much knowledge, so many complexities in the individual patients we're taking care of that we have got to learn to work better as a community of health professionals. So I will end there and just thanks to Shahid who helped me out with learning how to work prezzy among many other things. Thank you so much, ma'am. Dr. Winnie's talk is open for comments and discussion. Mention that patients should be an active part of the team. And I was interested in that. And in the last slide, the quote from Mayo, there was language about teamwork, but the patient wasn't part of the team. So I was really interested in the idea of this collaborative model where patients are actively involved. And I wondered if you could give me an example of what it would mean, either an actual clinical example of a patient, of a change where patients are conceived of and treated as members of the team, or something more abstract if that would make more sense. Yeah, so I can do both. This is ongoing work. There are two different work groups now looking at this at the IOM on what does it mean for patients to be members of health care teams? So the examples we have are from this work that we did earlier, but we're doing a series of interviews right now with both patients and practitioners on that specific topic. And just a quick anecdote. The first patient we called was the mother of one of the other people on the team doing the research. And we got about three or four minutes into the interview, and it seemed like she was really confused about what we were talking about. And then she said, oh, you're saying team-based care. I thought you were saying teen-based care, like care, you know, by teenagers, which didn't make any sense to me. So that, it's a worthwhile anecdote because not many patients think about what they get as teen-based care. They don't often get introduced to the various members of the team as a team. So one of the things that we saw within these what we called high-functioning teams, the ones that had really given a lot of thought to what does it mean for us to be a team? What does it mean for us to bring patients on board? Is that they had explicit onboarding protocols for patients, right? So, and there are a variety of ways that they would do this, but they all look like an intake visit, right? So in hospice, so hospice of the bluegrass was one of the teams we interviewed. And they described to us in detail what their intake visit was like. And it involved introducing the patient to every member of the team who was likely to touch them, describing to the patient who the other members of the team would be if they needed additional services. That was actually used as part of the process of eliciting from the patient what their goals were and then writing those goals down and saying, okay, these are gonna be the goals for your care team.  So they felt like they had a process and infrastructure in fact, a room where this could happen for people to sit together with the patient and lay out the goals. And if the patient wasn't sure what their goals were, they would circle back around until they had some written goals. And it's fair to change your goals over time. We know patients change goals, but if we don't know what the patient's goals are, we can't help, right? And our role on the team is to help you achieve your goals. So that was the, those are some of the things, but the things that came up repeatedly were infrastructure needs for actually sitting down with patients in an environment that's conducive to that kind of conversation and writing it down. So having it be an explicit process for eliciting and establishing goals. Yeah. Well, we're getting Bob's question. What is the best way to measure blood pressure? Since you said that, we don't do it very well. So, you know, the things that, there are three things that we're looking at right now, three aspects of this. One is technical stuff, so technique. Like I went to the YMCA the other night because I almost didn't believe that this was true. But there are several studies that show that if you take blood pressure with feet flat on the ground versus with legs crossed, it'll raise blood pressure by five to 10 points.  And take, this is what I did. I did 30 seconds between measurements. I would take my blood pressure like this, 118 over 78, cross my leg, wait 30 seconds, 125. It was incredible that I could bump my blood pressure by six or seven points just by crossing my legs. So we've got a checklist now of, you know, six things that are very commonly done wrong. If you are talking during the interaction while you're having your blood pressure done, that will raise your blood pressure. Talking, if you are actively listening, that will raise your blood pressure a little bit. So you can talk and they can't talk. Which, now this is a process challenge, right? Because patients talk as do MAs. And they like to use the time when they're doing vitals to say hi, how's it been going, right? So now the MA has to figure out how do I articulate to the patient in a way that's acceptable that, okay, we've been chatting, but I need you to be quiet and I have to be quiet so we get an accurate blood pressure read, right? So there's the technical thing, but then there's also the culture change and the culture change isn't just about the MA. It's also about bringing the patient in to this process. So we've made some materials that you can put on the wall where you do vitals so that patients have right in front of them. Here's why we're asking you to sit flat on the floor, arm supported, bare arm, you know, not over your shirt. These are sort of basic stuff that MAs know. We all know this and yet it doesn't always happen. So individual physicians are one thing, but when it comes to the AMA, maybe I'm old and jaded, but I cannot see the AMA living with physicians not being the leaders. And for example, the shared ethics thing, this is a project being led by the AMA? Well, let's say it's a project that the AMA hasn't told me I shouldn't do and they were happy when the paper was accepted. So it's a provocative idea and it's a provocative paper and it's a conversation that needs to be taking place. And the AMA should be part of that conversation. And you're right. The AMA is a representative democracy, right? It's not the Board of Trustees. It's the House of Delegates. And the House of Delegates is representatives from every state society and every specialty and most sub-specialties. So there will be a diversity of opinion within the House of Delegates on how we should move forward with team-based care. And this is one of the reasons why physician-led, what you're articulating is one of the reasons. And just to be fair, it's not just the AMA, right? ACP is facing the same dilemma. AAFP is facing the same dilemma. They have not said, I'm okay, we're okay as a group with someone else being the lead of a healthcare team. So I think the path forward is to explore more what do we mean by leadership? How does leadership on a team play out in the real world? Because one of the things that was pointed out in the huddle piece, the annals piece, was that we don't have nearly enough doctors to actually do all the stuff we say we're supposed to be leading right now. So we're gonna have to figure out a manner of leadership that we're okay with that allows autonomy and so on for other professionals who work with us. Enjoy your talk. I led the development of a medical team training program in the VA from 0409, pardon me? No, medical team training for the VA. So we focused on surgical teams and some critical care teams. We had good data because we had NISCIP data and we also had all employee survey data which penetrated the, had a good response rates. And we correlated these things and what we learned was that surgical teams that were stable surgical teams and we defined that as people who worked with each other every day and the same kinds of procedures usually serve as specific, got to begin to trust each other and these were teams where if they had a pre-hop briefing the tool that Wandy talks about, which we did before they started doing it back in 03, sometimes the surgical engineers would lead that discussion because she would have the checklist, sometimes the attending surgeon, sometimes the chief resident. Throughout the course of the operation you could tell people who were used to work with each other and trust each other would do tasks and there was no question about who was gonna do that task. And when we studied this and correlated surgical outcomes with job satisfaction these surgical teams, these stable teams got had better outcomes and better job satisfaction primarily among the anesthesiologists and the nurses. My question is, are these lessons learned translatable to PACT or to medical home model primary care clinics? I absolutely think they're translatable and in fact I didn't draw the connection during this talk but if you remember back there are three focus areas at the AMA now one of which is improving health outcomes another of which is understanding and improving physician satisfaction. And we've been working with the RAND Corporation to study predictors of physician satisfaction in a variety of settings but primarily in the ambulatory arena for the last year, year and a half. And what you found in the surgical setting is what we're finding in the ambulatory arena which should be no surprise, right? People who are working in an environment where there's mutual trust where there are open channels of communication where they believe in the people they're working with those people are happy with their jobs. People who feel like they're operating at the top of their license and so are the people around me. They feel like they're doing good work and it actually gets back to I don't know if you guys know Tony Suchman, Jody Hoffer-Gottel, folks who've studied relational coordination but their work is based out of self-determination theory which is psych speak, I guess or bio psych speak for what makes all of us satisfied in our lives. There's three big buckets of things that make everyone happy.  There are people who talk about flow like when you're in the zone. Mike Segal. When you're in the zone is when you are feeling it everyone around me is clicking so basketball teams and so on talk about it. Like a symphony. Also these teams are more innovative because it now comes on a certain and takes courage and trust more trust than usual to feel the environment and the way of treatment and they're more innovative as well. Yeah, again I skipped over mutual trust but it is one of the five principles of high functioning teams and that's where much of this comes up. You talked about the issue of shared responsibility being something that's very difficult for teams to come together on and part of me thinks that that might have something to do with the perception that the accountability, the ultimate accountability which you also mentioned often falls on the physician. So in these high functioning teams that you worked with how did accountability and shared responsibility function in terms of sort of the ultimate legal responsibility and outcomes and making sure everybody did what they were supposed to do. Yeah, so this gets back to your point actually. The reason these work is because of mutual trust because the physician's license is on the line and it's your malpractice insurance but you must rely on these other people. So accountability in fact ends up being dispersed even though ultimate accountability comes to you the reality of being able to take care of people effectively and efficiently and being innovative and so on relies on mutual trust. It means it's a trust that has to build up over time which is why there's a formal onboarding process for new members of the team. I mentioned before onboarding for patients but it's an even more extensive process for new members of a team who are health professionals and there's sort of a probationary period typically. A lot of these teams said we give people six months and if we have a new member of the team and in six months they haven't figured it out and we don't trust them yet to do what they need to do in order for us all to function effectively we can't keep them. So we let people go. Your talk reminded me that 45 years ago in this room, Milton Friedman came over from the business school to argue in favor of team medicine and Milton said at that time, I invited him, I was chief resident, so it was 1969. Milton Friedman said at that time that licensure and regulation sort of out of this quote from Tom Huddle was not a sufficient protection for consumers and that consumers could only be protected by a team concept in which consumers had confidence in the group, in the team practice, rather than in the individual who was licensed. So he was actually arguing for the non licensure of physicians and he thought in terms of great institutions like this one in the Mayo Clinic and the Cleveland Clinic and 25 or 50 such leading institutions around the country where you could count on the institution to assure you a complete service in terms of your health care needs. So that was 45 years ago here but I see that that William Mayo was saying it back a name to it today. Yes. Well, it was a wonderful talk. Thanks so much. Thank you. Thank you. Thank you.