The Capsule
“We work with primary care providers and nurse care managers who are not thinking of technology-based home care. What will it take to have medical teams, patients, families, and caregivers embrace technology for home-based care?”
My colleague, a manager of a health system’s at-home care service, posed this problem to several of her peers on a recent call. Her at-home care service has started to use remote patient monitoring (RPM). RPM aims to increase capacity of the service, enhance quality of care, and reduce ED visits and hospital admissions. RPM has not taken off the way she and her team has hoped.
In less than 10 minutes, she got four ideas that her team hadn’t considered:
Pose the problem of slow uptake of technology-mediated home care to the customer group of primary care providers and nurse care managers. Get their solutions to guide the service use of technology.
Develop a champion primary care provider—choose one of the primary care providers who has spoken in favor of the service in the past, enroll one or more of the provider’s patients in the at-home service program, demonstrate value, and have the provider speak to peers.
Record the story of a couple who have been enrolled in the program, to speak to the benefits of remote monitoring in personal terms.
Begin to stratify the patient population more effectively to find patients and caregivers who can manage the service’s remote monitoring technology. Abandon the belief that every patient in the current population will accept the current generation of remote monitoring technology.
My colleague wasn’t simply lucky to get four new ideas in a few minutes. We used a structured conversation to generate change ideas likely to help her and her team.
The Conversation’s Structure
The conversation requires one or two members of a team to present a problem and an audience of peers and coaches to listen and reflect. The audience can be as small as five or six people or as large as ten or 12 people. You want diversity of views and experiences to generate suggestions while keeping the audience small enough to allow everyone a chance to speak. We include peer listeners because they will have insights based on similar challenges and experiences.
The conversation has four steps that take less than 20 minutes:
Describe the situation and the problem. A member of the presenting team has up to four minutes to describe their context and their problem. Remember that a problem is simply a gap between what you want or need and the current situation. The audience is asked to listen without interrupting the presenter(s).
Clarify the problem and its context, up to two minutes. The audience members ask questions to confirm or expand their understanding. For instance, in the at-home care example, a peer asked the presenter: “Have you talked directly to the providers about their reluctance to work with the technology-based home care?” The manager answered: “Yes, for example the Care Managers fear that we will take their patients. This is not the case; we are a short-term service and patients return to the Care Manager’s panel.”
Generate ideas, eight minutes. The presenting team now is silent and listens for new ideas. No interjections like “we tried that idea and it didn’t work.” The peers and coaches are asked to pretend to work on the team that presented the problem. They should use “we” rather than “you” in their statements. In the at-home care example, a peer asked: “Have we addressed the concern of patients that we’re not going to rely only on telemedicine and remote monitoring, it is in addition to face-to-face care?”
Identify take-home ideas, two minutes. The presenting team summarizes the ideas they heard that can help to solve their problem. The manager who presented the problem identified the four ideas listed at the start of this post.
One coach serves as timekeeper, typically using a smart phone with a timer that beeps. If the step 1 or 2 conversations takes less time than allotted, move to step 3. After step 4, a coach can ask the presenting team which ideas will be tested next week, to encourage the transition from talking to learning by doing.
We typically create capsule groups with three small teams of two to five members. In less than an hour, the three teams can each take a turn as the presenting team.
How to increase the impact of the Capsule Exercise
Require Skill in Plan-Do-Study-Act
I don’t use the Capsule exercise until I’m confident teams have basic skills in running Plan-Do-Study-Act tests. The Capsule exercise aims to generate ideas that the presenting team has not yet considered or tried. In terms of the Model for Improvement, the Capsule helps the presenting team answer question 3: “What change can we make that will result in improvement?” Change ideas by themselves do not solve problems. Unless a team has a method to test an attractive change idea, the problem will stay unsolved.
Repeat the Capsule Exercise
I like to use the capsule more than once with the same group. Teams take turns presenting problems, across multiple sessions. It takes practice by a presenter to share a problem succinctly. It takes practice by the audience to role-play the presenting team while generating multiple ideas.
In the home-care example, the teams have worked together for 18 months. We’ve repeated the capsule exercise five times. Teams always have new problems, there’s no danger of running out!
If teams have worked together for several months, they will know more about the presenting team’s context and be able to listen for nuances.
While there may be a risk that teams could become too familiar with each other’s situation and have nothing new to add, I’ve never had the exercise fail to deliver at least one useful idea.
In-person or virtual?
We have used the capsule for both in-person and virtual settings. The exercise seems to work equally well in either setting.
Why call the exercise “the Capsule”?
The presenting team is like a team of astronauts in a capsule or spaceship who identify a problem. The audience is like a larger team of control engineers and astronaut peers on the ground. After the ground team gets a bit of clarification, radio transmission from the capsule cuts off. The astronauts in the capsule can only listen while peers and engineers suggest ideas to try. Finally, radio transmission starts up again and the astronauts on board review the ideas and prepare to act to solve the problem.
Acknowledgement: I first learned the capsule exercise in 2017 from friends at the Institute for Healthcare Improvement.
Capsule Image: This is an image of a NASA Apollo capsule. The story of Apollo 13, popularized in the 1996 film by Ron Howard, centers around a life-threatening problem on-board the Apollo 13 spacecraft. Successful resolution of the problem required the ground team’s creativity and the Apollo 13 crew’s discipline.
