Leaders of the inpatient psychiatric unit in the University of Virginia Health System—a large academic medical center with about 7,500 faculty and staff—recognized that too many of their patients had psychiatric deterioration after being discharged and ultimately were readmitted. Those inpatient leaders also believed better communication and collaboration with community service professionals who took care of patients after they were discharged could improve the situation.

Instead of focusing on the negative things happening during the transition to outpatient care, inpatient psychiatric leaders chose to focus on the positive things already happening and build from there. They did that with guidance from the University of Virginia Center for Appreciative Practice, which helps people use “appreciative inquiry.”

The approach, detailed in an AMA STEPS Forward™ module, was developed at Case Western Reserve University in the 1980s and uses unconditional positive questions to identify what is working. For example, physicians and others in the organization are asked to think about a colleague who went beyond the call of duty and to then think about what happened because of the extra effort, or to think about a recent successful team project and offer perspective on what made it successful.

Faculty from the Center for Appreciative Practice began tackling the problem by bringing the right people together. They facilitated a two-day event for 50 people, including physicians, nurses, representatives of community services groups, members of a mental health advocacy group and people who had used the health system’s inpatient services.

Together, the diverse group used the first day to reflect on the positive aspects of current mental health care services in the community and the current care transition process. They told stories that showed commitment, collaboration, empowerment, empathy and perseverance.

Then participants again focused on the positive: They described their ideal plan to transition inpatients to the outpatient setting. On the wish list were improved access to substance-abuse treatment services, additional face-to-face and electronic networks for providers, and a transition clinic staffed jointly by inpatient and outpatient participants.

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Recognize the positive when changing your practice

On the second day of the event, facilitators helped the group outline an ideal transition process and helped them form a plan to implement it. Those gathered agreed on a common format for care plans that would travel between sites and a common form for shared documentation.

Ultimately, the appreciative inquiry process led to smoother transitions for patients and patient satisfaction scores improved for psychiatric services.

In addition, there was a better connection and improved communication between the inpatient care providers and outpatient community groups. People who attended the event learned more about services that other groups had available and many who had worked together virtually for years met in person for the first time. Inpatient clinicians began volunteering at a homeless shelter where patients sought help. Community mental health groups hosted educational sessions for inpatient staff and created a listing of community resources.

Once staff has experience with appreciative inquiry, the STEPS Forward module encourages physicians to embed the technique into the practice’s work during events such as daily huddles or staff meetings. Some appreciative inquiry activities include:

  • Appreciative check-ins at the start of meetings
  • Introductions: Ask people to respond to an appreciative question
  • Shout-outs: Ask team members to share something positive that they observed recently about another member’s actions or performance
  • Appreciative debriefs: Ask an appreciative question relating to the strengths of a meeting
  • “Positive gossip” such as favorable vignettes or inspiring patient quotes
  • Assuming positive intent
  • Taking a barrier and turning it into an opportunity
  • Finding the value behind a complaint

The STEPS Forward module offers more concrete information to help practices learn about the appreciative inquiry process and outlines how they can apply it to their health care setting. The module takes doctors through the five steps to build and maintain a positive organizational culture and answers frequently asked questions about the approach.

The STEPS Forward module may be completed for continuing medical education credit. There are seven new modules now available from the AMA’s STEPS Forward collection, bringing the total number of practice improvement strategies to 43; several thanks to a grant from, and collaboration with, the Transforming Clinical Practices Initiative.

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