The nurses and patient care attendants were unbelievably nice. So was the man who delivered the food, the woman who mopped the floors and the special duty attendant who kept a close eye on the patient. They could not have been more pleasant.
The bulletin board in the hallway extolling the virtues of joint governance in nursing practice, the morale boosting slogans and employee stars in promoting customer satisfaction, was also impressive.
Less so was the ongoing medication dosage error and the admitted miscommunication between the attending physician and this exceedingly polite care team. The atmospherics of the care were good but if you were paying attention, you could see the communication gaps. The nurses and PCAs were not consistently talking to one another. The physician said he was not told about certain developments even though the nurses said they called. Then there was the reference to not knowing if they talked to the physician or a nurse practitioner.
Other than experiencing some periods of extreme disorientation and some aggressive behavior, the patient apparently did not suffer any lasting harm from these little mistakes. The team’s “misunderstanding of the doctor’s order” probably did not extend his length of stay and certainly will not register even the slightest blip on patient satisfaction scores.
If they realize (admit) the error, it probably will go unreported. No one in the bowels of this hospital’s quality assurance apparatus will even know that it happened. In the grand scheme of things, given the thousands of medications administered to other patients over the couple days he was there, this situation clearly did not rise to the level of a tiny dot on a pinhead. No harm, no foul.
And that is one reason why healthcare is in the mess it is in when you talk about patient safety and, ultimately, preventable hospital deaths.
The good news is that this hospital is spending hundreds of millions of dollars implementing a state-of-the-art electronic health record, a Cadillac system apparently designed to replace several existing legacy programs.
That will probably solve these problems and ensure that the mistakes, big and small, are “kept to a minimum” which, by the way, is a dubious measure for performance in excellence and safety.
I do believe, however, if the patient had been a relative of one of the nurses, someone would have questioned the dosage or asked the physician to clarify his “vague instructions.”
But he wasn’t.
Being polite with a service oriented demeanor is not going to change the fundamental process of care flaws. When you treat the patient as just a patient, another butt in the bed in a hospital operating at full capacity, these little mistakes, and far too many bigger ones, will continue to occur. This seems analogous with a belief that teaching students to pass the standardized tests is the same as providing them with a good education.
© 2015 John Gregory Self
We all recognize the popular business cliche, bigger is not always better. It is a nice sentiment, especially if your organization is included in the small category.
To give “big” its due, there are certain advantages to using a big company for certain types of jobs where capital structure or geographic diversity are critical, such as a company that builds commercial jet engines for clients throughout the world or a nationwide restaurant or retail chain.
It makes less sense when you need a specific type of information or expertise. Whether the provider is a boutique firm or a nationwide behemoth makes almost no difference. Price may enter the equation — the nationwide firm probably charges more to cover their larger overhead — but in the end it is the quality of the expertise or knowledge, not price or geographic coverage, that should win out.
Being a big company can stifle creative innovation in the name of efficiencies of standardization. It can limit flexibility in customization of process, pricing or the ability to be nimble to meet a client’s specific needs.
Small firms can have their own limitations but if you are purchasing expertise, size does not matter as long as the person you need to solve your problem, or provide the guidance you require has that knowledge or experience and will be available to personally do the work. Engaging the world’s top thought leader on an issue is not much of a benefit if a less experienced, junior associate does the critical part of the work.
So, if your goal is to get a package from Houston to Seattle overnight or in a day or two, using Sue Ellen’s Courier Service is probably not a good decision. FedEx has a few more resources for that kind of work.
For legal advice on physician contracting or to help an executive you are terminating successfully navigate to a new job, the size of the firm need not be a factor. In the case of the outplacement firm, your departing employee will probably thank you later for going small.
© 2015 John Gregory Self
A friend, an accomplished and respected Hospital CEO, has seen health care from the other side. Recently, a beloved family member died. He took early retirement so that he and his wife could offer full support.
This heart wrenching ordeal offered him a unique perspective on what healthcare in the US has become — a business model that is more focused on policy, process and reimbursement with less attention to how all of these “smart” business decisions impact the patient and family members. Prices and policy got in the way of making it personal.
A highly successful CEO came to healthcare leadership after spending much of his early life in hospitals as a chronically ill teenager, sometimes not knowing whether he would live or die. He spent much of his career talking about putting the patients first, about treating them as a beloved family member. During his tenure, his hospital’s quality and safety numbers soared. He made it personal.
A respected healthcare consultant, someone who lived his values, lost his wife, the victim of repeated medication and standard of care errors. He was stunned by the inefficiency of the delivery system — that the policies and procedures designed to prevent catastrophic breakdowns, actually led to the environment in which his wife, his best friend, fell victim. He travels around speaking to healthcare groups, trying to make these mistakes and needless loss of life personal.
The grandmother, scheduled for discharge, fell during the night. She never recovered. The hospital was more concerned about lawsuits and risk management than ensuring it never happened again.
Bad things happen. Good compassionate care givers make mistakes. Things go wrong, even in the best of hospitals. I get all that.
What I don’t get is how we arrived at a point where business processes all too often have become more important than the patient. I also get that healthcare in the US is way too expensive when compared to all other modern industrialized nations and, on average, the results/outcomes for US patients do not equate to the high costs.
Why is our profession not more outraged at what has become of our industry?
This is not a political or policy problem. It is a personal problem. We should all try to make this more personal, and less about making Wall Street happy.
Financial analysts and investors may think that I am a Pollyanna for my steadfast belief that patient care, safety and compassion for the family is more important than an unrelenting, unforgiving focus solely on sterling business results – meaning profits, but I have made it personal.
© 2015 John Gregory Self