The Wild West of Inpatient Care
Crash. Ouch! That’s my Mom falling in her kitchen in Florida in January. She’ll be 80 in June, so falling’s not an advisable activity. Crunch! That’s the sound of her left kneecap breaking. A neighbor gets her to the ER where they x-ray, diagnose, and schedule her for an office visit in two days.
My wife, a nurse practitioner, flies into Tampa from New Mexico. And the next day, Friday, they both go to the surgeon’s. No bedside manner, rushed, not a particularly good listener—pretty much stock and trade for this kind of thing, but he has an excellent track record in knee surgery and that trumps all else. Surgery is scheduled for Tuesday, and Mom is outfitted with an immobilizer to keep her leg stationary.
On Monday we go to a private (HCA) hospital south of Tampa to get Mom registered and prepped for the surgery. And this takes HOURS—long waits interspersed by two interviews, neither of which takes more than 10 minutes, and some vitals and blood work, which takes about 15 minutes. During the long waits, no front desker can give even a clue about when the patient—in pain—will be seen for the next step. But, after a few hours, miracle of miracles: registration and prep are completed! Here’s the point: while each individual seemed quite competent, the system and processes within which they work neutered that competence, and no process was patient-centered. A badly designed and orchestrated process makes everyone look less than brilliant.
The Tuesday surgical experience is schizophrenic. The anesthesiologist is personable and brilliant. He nails what’s required so precisely that Mom recovers from the operation within an hour without nausea or disorientation. Wow! And the surgeon, again with all absence of bedside manner, and significantly behind schedule, does do what he does well and puts Mom’s kneecap back together with a minimum of fuss and without complications.
But it’s the nurses who provide the other side of the schizophrenia coin. What is it with nurses, by the way? I know so many nurses and I respect their knowledge and experience but too often it is this cadre of professionals who seem too intent, even eager, to enforce silly rules, block access to information, and defend the system even when it is detrimental to patient care. This is a consistent behavior, and it is just the opposite of what the potential could be. Nurses, as a professional cadre, offer the best hope of crafting patient-centered care and offering sound day-to-day clinical judgment. But this requires sufficient authority, patient-centered processes, and a temperament allied with patients and families. Nurses must stop defending and protecting dysfunctional systems if they are to claim their rightful professional place in the healthcare world.
After being prepped for surgery, Mom waited in the pre-op area. A nurse informed my wife and me that we could visit my Mom one at a time. You’ve got to be kidding! “But there’s only two of us and we work in healthcare.” Nope, we could only see her one at a time “to protect the privacy of the other patients”. It’s easy to end run this kind of arbitrary rule: just ignore it. Mom is 80 and she’s being administered anesthesia and going into surgery for the first time in 50 years. What better way to prepare (and be prepared) for such a momentous event than be surrounded by loved ones? And what better way is there for both my wife and me to get first-hand information (rather than wait in the surgical waiting room for a volunteer to tell us what a nurse told her a physician said)?
The “rules” are always the product of the same, dismal mentality: Patients and family members are nuisances to be tightly controlled. Where’s the love? Our whole experience—which mirrors the stories we hear from patients and their families all the time—consistently fit this mold.
Here are some key suggestions for improving this all-too-typical patient care ambience:
- Managers get out of your offices and meetings! Any business that is operations heavy and successful, whether it is a restaurant, FedEx, or White Stallion Ranch in Tucson, has an on-the-floor top-management presence that ensures the customer experience is what top management wants that experience to be. At this hospital, as is typical at most hospitals, the administrators were nowhere to be seen, and the administrative corridor was as silent as a great library. “Management by Walking Around” would result in a lot of obvious problems getting fixed quickly. We’ve tested this a bunch of ways in our client projects and it has dramatic impact.
- Let’s put the “care” back into “patient care”. Healthcare professionals regard any work other than technical work to be unworthy of their time and attention. And everyone wants the prestige that comes with being a technical worker. Instead, anyone on the unit should respond to any patient or family request if they are qualified to do so. Getting someone to wheel my mother out to the parking lot ramp (which took all of three minutes, that’s how close it was) took numerous requests and as many staff mini-huddles because no one wanted to be seen as so unimportant as to have the time to simply push a wheelchair around. But that’s the “care part!” A patient’s discharge should be pomp and circumstance. What a way to capstone the care! Treat it as saying goodbye to an important relationship rather than as a useless task.
- Let’s move all the “care” back into the “patient care unit”. Here’s a simple example: I was stunned to see a hair-netted dietary aide wheel a cart of covered meals from the kitchen to the unit to distribute to patients just like 38 years ago when I began my healthcare career. There are two key ingredients indispensable for recovery from anything: food and sleep. Why don’t we manage “in flight” meals the same way an airline does (think Business Class)? We could easily provide a selection of meals that could be heated in a microwave right there on the unit. What’s more “caring” than feeding someone? Meals could be served when patients are actually hungry, the meals would be hot rather than warm, the caregiver connects meaningfully to the patient, and—within dietary restrictions—the patient would have a choice. And we’d eliminate the eerie interaction between the patient and the stranger from the basement. Why do we insist on converting the simplest of tasks into career paths?
- Let’s put nursing back on the pedestal. And here I’m talking about RNs, not nurses’ aides. These are the folks with the training and experience that gives them “bridging judgment”. They have the ability and knowledge to anticipate what will go wrong and head trouble off at the pass. For instance, our surgeon was awful at discharge plans—he didn’t even include the obvious: wheelchair, portable potty, and walker. But the nursing staff, they work with this guy every day and he does a lot of knees. They know his strengths and weaknesses. So when the obvious happens and we’re puzzled by omissions, we’re even more puzzled to hear “that’s all the doctor ordered and all we can do is follow…”, you know the rest of the story. This is absurd. We must design processes and systems so nurses are not put in this ludicrous position. And, we need nurses to no longer want to be in this ludicrous position. All too often, highly intelligent and skilled nurses become defenders of the absurd.
In my lifetime, I can identify three groups of workers that I’ve admired who have been in the middle and have proceeded to ally themselves with the wrong side, to their own detriment. The first is United Automobile Workers. (I worked in a GM factory in the late ‘60s). They had the world by the tail, making more and more money every year, yet they knew the cars they made were loaded with defects. They failed to ally themselves with customers and produce a sterling product, but rather allied themselves with management and accepted poor quality. With one exception: Saturn. In its heyday, Saturn customers returned to the Tennessee factory every summer for a Saturn cookout and reunion. The workers and managers were aligned with customers. It was the GM hierarchy and old guard that sunk Saturn—depriving it of capital and additional models that would have made it competitive.
The second group is that of flight attendants. I started traveling for business in 1984 and I’ve put in a lot of miles. In 1984, this was a bright, socially adept, professional, and admirable cadre of folks. But increasingly, airline management deteriorated—as you well know—and flight attendants allied themselves with management and did not protest the deterioration of quality and service for customers. They enforced the silly rules. Now, as a passenger, you merely hope your flight attendants are not hostile. With one exception: Southwest Airlines. In an era where almost every airline is going broke, in only one quarter over several decades has Southwest failed to make a profit. In general, flight attendants have lost status, pay, and pensions during the last decade.
And the third group is nurses. Will they protest the deficiencies in patient care for patients and families and therefore find the support for their rightful role in improving healthcare or will they continue defending the silly rules and defending the dysfunction and continue to suffer the loss of professional status?
Written by Roger Coleman, Founder (and thought provoker extraordinaire)