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September 2013 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Listening and communicating = patient satisfaction and better care

Sep 18, 2013 | Comments (1) | 16391 Views

By Daniel J. Castillo, M.D., M.B.A.
Medical Director
The Joint Commission

In the middle of a busy shift, my hospital administrator approached, saying apologetically, “Could you answer this person’s letter, please?” If you practice long enough, eventually you must answer a complaint. One of my first grievance letters came from a 45-year-old man I had seen several months earlier for back pain. He was approximately 245 pounds, and other than being significantly overweight, he was generally healthy. He was initially upset at having a 3-hour wait in the waiting room, and then he had demanded an MRI and Norco, despite the fact that he had no other concerning signs or symptoms. I had ordered an X-ray (negative), given NSAIDs and a PT referral and spoke to him about losing weight, core muscle strengthening and stretching. I thought I had done a pretty good job. Apparently, the patient disagreed. After I discharged him, he went directly to another ER where he received an MRI that showed a very minor disc bulge, and was discharged on Norco. 

Now I ask you: Who gave better care? This question is going to become more concerning as the Centers for Medicare & Medicaid Services (CMS) continues to incorporate experience of care and patient reported outcomes not only into hospital reimbursement schedules, but physician reimbursement as well. Basically, the patient’s perception of care is going to directly affect your bottom line. 

So, how do we navigate this changing environment? How do we continue to provide high quality, safe patient care that is also valuable to the patient? Effective communication is the key. Communication can be enriched by incorporating the First and Second Laws of Service (created by David Maister):

  1. Satisfaction = Perception - Expectation 
  2. It’s hard to play catch-up ball

The First Law states that for patients to be satisfied, not only must they perceive the care to be excellent, but their expectations must be managed as well. I did a poor job managing my patient’s expectations in the example above. He had come in fully expecting an MRI and Norco, and I did not spend any time explaining why I was not going to fulfill either request. At the time, I remember feeling that I was just too busy to sit down and have a 5-minute conversation. Those 5 minutes could have saved me the 50 minutes I had to spend later meeting with the hospital administrator to construct a reply to the complaint. Had I talked with the patient about why I believed it was safer to start with NSAIDs and avoid opioids, he would likely have been much more satisfied with our encounter. I could have even printed out some of the recent literature and media articles regarding the side effects and increasing problems with abuse and overdose. Unfortunately, I did none of that. I provided high quality, safe care that left my patient utterly unsatisfied.   

The Second Law speaks to the importance of first impressions. Sitting down and spending time initially listening to the patient can both improve perception of care and avoid having to play catch-up ball. However, this can be difficult when waiting times balloon and nerves run thin. Every doctor knows that once a patient becomes angry, it is hard to turn the conversation back in a positive direction.   

Practicing medicine has always been challenging. Spending a few minutes with each patient using the First and Second Laws of Service early in the interaction can save many more minutes in the long run. Effective communication strategies, especially surrounding pain treatment, can significantly improve satisfaction scores, and even lead to better care. 

For more information about David Maister’s First and Second Laws of Service, see his article: The Psychology of Waiting Lines.

Health care’s dirty secret: Physician’s don’t wash their hands as often as other caregivers

Sep 04, 2013 | Comments (0) | 8578 Views

Ana Pujols McKee, M.D.By Ana Pujols McKee, M.D.
Executive Vice President and Chief Medical Officer
The Joint Commission

Admittedly, this is a “touchy” topic for physicians, but I will dare to ask the question: why do some physicians resist adopting and adhering to practices that improve patient safety? I am not talking about complex interventions; I’m talking about hand hygiene, the relatively simple act of washing one’s hands. As health care organizations monitor hand hygiene compliance, they consistently identify physicians as trailing woefully behind other health care workers. 

The evidence which supports how hand hygiene can significantly reduce the risk of acquiring a health care-acquired infection has been well established for decades. Yet the same physicians who turn towards the evidence-based methods for their practice, ignore the compelling evidence demonstrating that hand hygiene reduces risk. In some ways, this is incomprehensible. Why would a physician not want to protect their patients from these nasty infections during a time when the patient is most vulnerable and trusting their care in our hands? That is, unwashed hands?

Another missed opportunity is compliance among physicians in using two patient identifiers, which also falls behind other health care workers. The simple task of using two patient identifiers significantly reduces the risk of giving the patient the wrong treatment, procedure or test. Yet once again, a fundamental concept of probability is routinely ignored by some.

In trying to make sense of this, I can only conclude that these behaviors reflect a sense among some physicians that these safe practices apply to others. If so, our colleagues can benefit from some “just in time” coaching. The next time you see a physician colleague ignore the safe practice of hand hygiene, I encourage you to kindly remind them that hand washing is a data-proven method of protecting patients from health care-acquired infections, and  that patients expect their doctors to wash their hands. And if more needs to be said, pause, and then say, “Let’s talk over a cup of coffee, but first, let me wash my hands.”

Let’s help our colleagues get on board.