An Audit and a Cup of Chai

Atul Gawande is an endocrine surgeon and a great writer. His 2013 New Yorker article Slow Ideas: How Do Good Ideas Spread is about the history of anesthesia and hypothermic newborns in India. Could this have relevance to Assertive Community Treatment? It does!Gawande

ACT is still very new. Well-studied and proven but still new. We need to press for more access to ACT services for only a few more decades I suspect. And that’s what Gawande is writing about – how do new ideas and new practices, take hold? Gawande writes of how trainers such as Sister Seema teach nurses in rural hospitals in India to better care for newborns. Initially, this process feels critical but over time, and over cups of chai, the conversation shifts.

“When Sister Seema pointed out the discrepancy between the teaching and the practice, the nurse was put out. She gave many reasons that steps were missed… At her second and third visits, disinfection seemed more consistent. A thermometer had been found in a storage closet. But the nurse still hadn’t changed much of her own routine. By the fourth or fifth visit, their conversations had shifted. They shared cups of chai and began talking about why you must wash hands even if you wear gloves, and why checking blood pressure matters. They learned a bit about each other, too… With time, it became clearer to the nurse that Sister Seema was there only to help and to learn from the experience herself. Soon, she said, the nurse began to change. After several visits, she was taking temperatures and blood pressures properly, washing her hands, giving the necessary medications—almost everything. Many of the changes took practice for her, she said… But, step by step, Sister Seema had helped her to do it.

“She showed me how to get things done practically,” the nurse said.

AG: “Why did you listen to her?” I asked. “She had only a fraction of your experience.”

In the beginning, she didn’t, the nurse admitted. “The first day she came, I felt the workload on my head was increasing.” From the second time, however, the nurse began feeling better about the visits. She even began looking forward to them.

AG: “Why?” I asked.

All the nurse could think to say was “She was nice.”

AG: “She was nice?”

“She smiled a lot.”

AG: “That was it?”

“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”

I like the image of ACT auditors and reviewers being like Sister Seema, looking carefully at what ACT teams do and being part of an ongoing process of quality improvement. How does change happen? Gawande writes (my bold): “… technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.”

ChaiFor those of you who have the important task of being an ACT reviewer/auditor, read the whole of Gawande’s article. I’d be interested to hear what it’s like being in that role – share a comment if you have the time.

Shalom Coodin

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