There's a map for that
How often do you work in
auto-pilot mode at work OR do simply as you were taught? This is scarily common
across major health systems, and after shadowing/observing various processes
and staff, we are certainly no exception. In fact, we have never created
any such process flow or diagram of sorts to visualize just exactly how/what
care delivery is across the hospital, including variance by service and unit.
So for the last 2+ months, I've lived in scrubs (getting up 10 min prior to bus
arrival has been heavenly), with the primary intent being just that-- getting a
baseline of how exactly we are delivering patient care. Most of the time a hospital's
focus is how to increase the profit margin, speed up throughput, decrease
waste, reduce infections, etc. My focus has been quite simply "what are we
trying to accomplish and how are we currently doing that?" Aside from
observing the actual process steps, I've evaluated the technology/communication
means, owner(s), and issues, risks, and gaps. My findings in one sentence?
Duplication, omission, delays, entry error, disconnects... to name just a few.
It's been fascinating to observe what seem to be basic processes become complex
and ineffective process steps for multiple reasons. My findings – in the form of detailed process maps – support a risk profile proof-of-concept
release, which aims to essentially "catch the bad stuff before it
happens." A solid first step is understand what you have. Only time will
tell, but I'm thinking that these observations are going to do soooo much more
than simply identifying patient risks. Stay tuned...
Higher on the food chain... or redesigning the food chain?
As with any large organization,
working at a major health system has drawbacks to go with the numerous perks
such as flex time, tuition reimbursement, and telework. One challenge I've
found in working at a large AMC is that, in addition to it being very
bureaucratic, many people are placed in positions based on tenure or simply
because they are "next in line". But take a step back and look at
today's most successful organizations, and you see something completely
different – a structure based on
meritocracy. I experience this on a daily basis and in all forms, from the
wretched, death-by-PowerPoint presentations with small essays on every slide to
even the most basic time management skills or perhaps an unwillingness to stretch and learn a new skill. I find it interesting that
calendars are always so full for senior management yet frequently so little
actually gets done. On a daily basis, I see (or experience) inefficient meeting facilitation, presentations that totally miss the boat, or worse yet, people who simply don't effectively manage daily operations or even have no clue what the underlying objective is of their project. A large part of being a leader is breaking down barriers and empowering your team; it's not a secret sauce, but it's surely absent for many. If you look today across all job markets, yes you will see a considerable gap in the 'on-the-job experience', from college grads to seasoned, tenured professionals. However, I've frequently asked myself what happens when the younger employee is significantly more talented and/or capable of doing a job than a more tenured or senior employee, and all that separates the two is time? As is the case at our hospital, the younger "new guy" typically gets that pass to "wait your turn". The result? An organization misses out on tremendous potential to capitalize on raw talents and disruptive innovation.
Work at a rescue mission
Andre has encountered some hiccups over the last few months, and it all came to a head two weeks ago. After stealing money from me on numerous occasions, I confronted him and he denied ever stealing anything. Knowing that he was definitely the culprit (after marking the bills), I decided that volunteer hours would be the best way to teach him a lesson. Coming from a double-incarcerated family, he is at a pivotal age (13) for learning right from wrong, before it's too late. So I asked him-- at 18 do you want to be sitting next to your parents in prison or walking across the stage graduating from high school? Because I want the latter. Ending on a positive note, I said that we can do this together, but he's got to want to change and learn from his mistakes. This past Thursday, we volunteered at a men's rescue mission for the first of many weeks to come. We served food in the cafeteria for 2 hours; more than 400 meals served! He got to see first-hand that no matter how bad you think life is there are always 2 things constant... someone is worse off than you, and you can learn from your mistakes. He actually said this to me when driving him home, a sign that I think we're headed in the right direction. I plan to have Andre sit with some of the participants there at the mission to hear their story-- how they got there and what they have learned.
Sunday, June 2, 2013
Monday, May 20, 2013
Role play
The last 6 weeks have been incredible. At the first of April, I began observing various services and units across our hospital in an effort to baseline current care delivery. I have been documenting things such as AM/PM rounds, rounds and action items by position, orders, issues, risks, bottlenecks, confusions, patient flow, technology, communication methods, culture, and duplicative process/entry. Thus far, I've completed assessments for 5 areas/services, 2 of which support our project in the short-term. The long-term impact will be HUGE, as this is the first time the med center has ever documented its care delivery processes, by owner and communication means. It's also uncovering much of the 'so what's causing this problem' factor-- for instance, the managers (nurse practitioners) in trauma spend an avg. of 4-5 hours of their total 12-hour shift simply updating and handing over between shifts (both outgoing shift and incoming shift). That means that approx. 40% of the manager's time is simply updating someone else!!! When I used this as a concrete example during a briefing to our vice-chancellor, he was completely floored and is very eager to see where this goes. Observations will continue for the next month or so... and it's sure to provide many more shockers. I'll update you on specific findings and provide more context (why are we doing this?) in my next post, once i've identified more themes and connected more dots.
Sure-- my observations as project manager for the above project have been valuable, but it's actually the role-play that has been the most fascinating experience. Ever seen the show Undercover Boss? Well, it's sorta like that. So over the last 2-3 months, I've played different roles in meetings and introduced myself in different formats, intentionally hiding my badge. My hope was to experience what it's like to be in various positions of an organization, from a surgeon to nurse, to admin asst. and intern. Think your job is bad? Do you feel like everyone hates you? Well, go role-play for a day. I can only speak from a hospital perspective, but I am absolutely floored from my experiences. The respect and overall demeanor of/from people when wearing scrubs and/or introducing as a physician and/or position of authority was not even on the same timescale as when introducing from the perspective of a traditionally unrespected position (secretary, intern, housekeeping). What's most interesting about the whole situation is that we typically view equality within the realm of ethnicity, but there's so many other aspects to equality, as I experienced first-hand. The sheer lack of respect, trivializing of input or roles, and even the frequent 'who the hell are you' or 'do you know who i am' look/phrase numbed me to the bone. Eye-openers like this are good for everyone, and I'm encouraging more senior leaders to do the same. On the flip-side, a quasi-role-play has worked magically for some departments, allowing "back-office" staffers (such as our call center, who schedule appts) interface with actual patients to accent their laborious job duties with realization of medicine, letting them all know that, even though they don't see patients' faces daily, they ARE making a difference. These staffers walk the halls and waiting rooms to meet patients and see first-hand that they are all indeed making a difference, one appointment at a time. So powerful....
Sure-- my observations as project manager for the above project have been valuable, but it's actually the role-play that has been the most fascinating experience. Ever seen the show Undercover Boss? Well, it's sorta like that. So over the last 2-3 months, I've played different roles in meetings and introduced myself in different formats, intentionally hiding my badge. My hope was to experience what it's like to be in various positions of an organization, from a surgeon to nurse, to admin asst. and intern. Think your job is bad? Do you feel like everyone hates you? Well, go role-play for a day. I can only speak from a hospital perspective, but I am absolutely floored from my experiences. The respect and overall demeanor of/from people when wearing scrubs and/or introducing as a physician and/or position of authority was not even on the same timescale as when introducing from the perspective of a traditionally unrespected position (secretary, intern, housekeeping). What's most interesting about the whole situation is that we typically view equality within the realm of ethnicity, but there's so many other aspects to equality, as I experienced first-hand. The sheer lack of respect, trivializing of input or roles, and even the frequent 'who the hell are you' or 'do you know who i am' look/phrase numbed me to the bone. Eye-openers like this are good for everyone, and I'm encouraging more senior leaders to do the same. On the flip-side, a quasi-role-play has worked magically for some departments, allowing "back-office" staffers (such as our call center, who schedule appts) interface with actual patients to accent their laborious job duties with realization of medicine, letting them all know that, even though they don't see patients' faces daily, they ARE making a difference. These staffers walk the halls and waiting rooms to meet patients and see first-hand that they are all indeed making a difference, one appointment at a time. So powerful....
Thursday, March 28, 2013
Curriculum 2.0 -- a new medical school curriculum
For the last 80 years or so, medicine as we know it today has been delivered to patients in the same fashion. You become sick or have abnormal health condition(s), you get treated, you get well (hopefully). Why? Look no further than the training itself. Why do you fold your shirts into thirds or wash your veggies before you consume them? Why that's how you were taught, so of course that's how you do it. And the same goes for physicians.
The old approach: For the last ~80 years, "traditional" medicine has been practiced in the same manner-- year 1 of core prereq's (bio, chem, anatomy), followed by year 2 of foundations, and a disease focus, namely pharmacology, immunology, microbiology. You want more bazaar? Some schools teach one subject at a time! Everyday, the same subject for 8-week blocks. It's your standard turn and churn routine. But how does that make any sense, given that all of the systems and functions of the human body are inter-related in every aspect possible? At the end of year 2, students take the USMLE to test medical competency. In years 3 and 4, students begin rotations in various units and specialties, with year 4 seeing greater responsibility. Toward the end of year 4, each student must choose a focus area for their residency, which more or less means "hey choose what you want to channel all of your attention on". Subspecialties (e.g., anesthesiology) require additional years of training (called fellowships).
The new approach: Vanderbilt UMC and a few other med schools launched a new curriculum in the last 18 months, aimed at changing how students learn about medicine. Dubbed Curriculum 2.0, this new medical school model provides a deeper comprehension of the many scholarly fields essential to our understanding and practice of medicine. It more or less aims to instill a life-long learning model for all students, adapting to the every-changing shift in care practices and methods (based on research and outcomes data over time). After learning the core medical concepts (biochem, anatomy, etc), a personalized learning model shores up tailored course material as the student progresses. This aims to not only eliminate today's cookie cutter MD issue but also maximize the fit of clinician interest with both opportunity and curriculum. On top of it all, a longitudinal macro course ties is all together, helping to explicitly addresses the strengths and limitations of various diagnostic/therapeutic approaches and explain clinical reasoning as the student moves along on the journey called med school. This curriculum overlays onto the previous time span req't.
The gap: This new approach is eons better than the old approach. Doctors of old-- okay, let's be frank...all doctors in practice today-- learned on the archaic and ineffective legacy model or health care delivery, whereby students more or less are required to memorize the concepts and terminology in 40-50 2-inch text books, cram for exams/comps, followed up shortly thereafter with no recollection of what just happened. What did i just learn?! And if you are having a hard time relating to this, speak for 5 minutes in the foreign language you took in high school-- hell, even in college. Having issues? Yea, use it or lose it... that simple.
Although Curriculum 2.0 is a major advancement in the format of the curriculum, it's the curriculum itself that needs to be totally revisited. What do i mean? Today's medical field is littered with amazingly brilliant individuals, making immense strides in treatment and patient outcomes. But we have become so specialized in our care delivery that we have pigeon-holed ourselves when it comes to delivering a consistent and effective macro-patient care continuum. To address the pain in our chest, we now have to see 17 different specialists, of which 9 order separate MRIs with contrast. Brilliant. I'm not saying specialists aren't necessary; in fact, they are essential to our continued advancements in medicine. However, doctors are trained to focus on one specific area and no more. It reminds me of the days in school where we put up dividers during tests-- no cheating. Who am i fooling, cheating?! Every hospital/provider claims they provide the best care, but when is that ever possible without working together and/or sharing information? Bottom line-- no one provider has all the answers... impossible, in terms of both human retention AND time. But knowing who to turn to and what to look for/ask is within reach. That's more like it, eh?
The old approach: For the last ~80 years, "traditional" medicine has been practiced in the same manner-- year 1 of core prereq's (bio, chem, anatomy), followed by year 2 of foundations, and a disease focus, namely pharmacology, immunology, microbiology. You want more bazaar? Some schools teach one subject at a time! Everyday, the same subject for 8-week blocks. It's your standard turn and churn routine. But how does that make any sense, given that all of the systems and functions of the human body are inter-related in every aspect possible? At the end of year 2, students take the USMLE to test medical competency. In years 3 and 4, students begin rotations in various units and specialties, with year 4 seeing greater responsibility. Toward the end of year 4, each student must choose a focus area for their residency, which more or less means "hey choose what you want to channel all of your attention on". Subspecialties (e.g., anesthesiology) require additional years of training (called fellowships).
The new approach: Vanderbilt UMC and a few other med schools launched a new curriculum in the last 18 months, aimed at changing how students learn about medicine. Dubbed Curriculum 2.0, this new medical school model provides a deeper comprehension of the many scholarly fields essential to our understanding and practice of medicine. It more or less aims to instill a life-long learning model for all students, adapting to the every-changing shift in care practices and methods (based on research and outcomes data over time). After learning the core medical concepts (biochem, anatomy, etc), a personalized learning model shores up tailored course material as the student progresses. This aims to not only eliminate today's cookie cutter MD issue but also maximize the fit of clinician interest with both opportunity and curriculum. On top of it all, a longitudinal macro course ties is all together, helping to explicitly addresses the strengths and limitations of various diagnostic/therapeutic approaches and explain clinical reasoning as the student moves along on the journey called med school. This curriculum overlays onto the previous time span req't.
The gap: This new approach is eons better than the old approach. Doctors of old-- okay, let's be frank...all doctors in practice today-- learned on the archaic and ineffective legacy model or health care delivery, whereby students more or less are required to memorize the concepts and terminology in 40-50 2-inch text books, cram for exams/comps, followed up shortly thereafter with no recollection of what just happened. What did i just learn?! And if you are having a hard time relating to this, speak for 5 minutes in the foreign language you took in high school-- hell, even in college. Having issues? Yea, use it or lose it... that simple.
Although Curriculum 2.0 is a major advancement in the format of the curriculum, it's the curriculum itself that needs to be totally revisited. What do i mean? Today's medical field is littered with amazingly brilliant individuals, making immense strides in treatment and patient outcomes. But we have become so specialized in our care delivery that we have pigeon-holed ourselves when it comes to delivering a consistent and effective macro-patient care continuum. To address the pain in our chest, we now have to see 17 different specialists, of which 9 order separate MRIs with contrast. Brilliant. I'm not saying specialists aren't necessary; in fact, they are essential to our continued advancements in medicine. However, doctors are trained to focus on one specific area and no more. It reminds me of the days in school where we put up dividers during tests-- no cheating. Who am i fooling, cheating?! Every hospital/provider claims they provide the best care, but when is that ever possible without working together and/or sharing information? Bottom line-- no one provider has all the answers... impossible, in terms of both human retention AND time. But knowing who to turn to and what to look for/ask is within reach. That's more like it, eh?
Sunday, March 10, 2013
Rankings schmankings
Every spring finds hospitals (along with many other organizations) scrambling in search of numbers. What numbers? Good question. Over the last month I've shadowed the 2 people at Vandy who are responsible for responding to the US News survey for ranking hospitals, on a myriad of factors. This was a huge learning experience because, while i haven't ever had much faith in rankings alone, it really shed light on just how arbitrary rankings actually are. In fact, majority of the survey questions, for US New and World Report at least, are subjective and interpretable in a number of ways.
So this begs the question-- for all the clout that rankings bring, not only for health care but any other industry/area, how valid are they? Political response-- it varies. I can say that after observing the hospital survey compilation, i hold VERY little faith in going to a top-10 hospital over a top-40 hospital. This is because majority of the hospital survey questions are quantitative but can be interpreted in a number of ways. For example, it may ask for a specific metric, which seems to be cut and dry. But there could be 4-5 different ways to capture that metric.
Also, how many rankings are there? Yes. And who pays for these? Exactly. Majority of the rankings available have some degree of political clout associated, donations, relationships, or otherwise. (same with research findings)
Additionally, a blanket ranking for an entire hospital/system can't possibly represent the quality of service delivery in each department/specialty. IOW, just because a hospital is #5 overall, doesn't mean that it is the best option for your open-heart surgery. In fact, they could have a heart institute that just launched in the last 2 years but people often associate the ranking with all services being golden.
My recommendations:
So this begs the question-- for all the clout that rankings bring, not only for health care but any other industry/area, how valid are they? Political response-- it varies. I can say that after observing the hospital survey compilation, i hold VERY little faith in going to a top-10 hospital over a top-40 hospital. This is because majority of the hospital survey questions are quantitative but can be interpreted in a number of ways. For example, it may ask for a specific metric, which seems to be cut and dry. But there could be 4-5 different ways to capture that metric.
Also, how many rankings are there? Yes. And who pays for these? Exactly. Majority of the rankings available have some degree of political clout associated, donations, relationships, or otherwise. (same with research findings)
Additionally, a blanket ranking for an entire hospital/system can't possibly represent the quality of service delivery in each department/specialty. IOW, just because a hospital is #5 overall, doesn't mean that it is the best option for your open-heart surgery. In fact, they could have a heart institute that just launched in the last 2 years but people often associate the ranking with all services being golden.
My recommendations:
- ask the dept/unit/service how quality is measured in their area
- find out the readmissions rate and/or outcomes data; e.g., successful treatment of UTIs sans related complications as a result of the procedure/treatment; this is available at http://www.medicare.gov/hospitalcompare
- ask what service enhancements or changes have been implemented/incorporated over the last year; younger physicians and academic medical center clinicians (anywhere with a medical school) are usually the most "on top of the latest and greatest";
- seasoned clinicians (say a doctor with 20 years experience) often are averse to adoption of newer research findings into their practices; however, they're great for knowing about specific conditions and or treatments (in the age of "specialists"), so ask as many questions as your little heart desires!!!
- make the provider recommend several options of treatment (as necessary), with pros and cons of each; sometimes you find that a certain procedure is recommended b/c it's a higher bill code or will require 6 follow-up appointments; if the rec. procedure is done at a place where the provider receives financial benefit (owner or otherwise), that's... illegal (kickback statute).
Sunday, February 24, 2013
One word: autopsy
Feeling the lull of work this past week? Same here... joking. But i did partake in a fascinating process at work. As an AMC, autopsies aren't a common procedure; they only conduct ~35-40 per year. That said, the director of pathology invited us to not only explore the process but also observe an actual autopsy. Firstly, a disclaimer before divulging the details-- death is deeply saddening time for a patient's friends/family, and though I didn't know this person, much sympathy for his family.
Random side notes:
----
So I get an email saying 'yo we're starting like... now' or something similar. I get down there, fix myself with the "keep me sanitary and disease-free" garb, and then start asking the director questions about the process. He said there's not a specific step-by-step process for an autopsy, though the process has generally the same order of steps, working outside inward so as to preserve all body parts. As I approached the body, I took gradual glances at the body and eeeeeeeased into view. Being my first autopsy observation (obvi), i wasn't sure how my nerves and stomach would handle it.
Go! So they start and surprisingly enough don't do a full recap of the patient case or anything (as in 'this guy has _______, with ________... and he was _________). Communication fail. This patient had Spina Bifida, which turned into a urinary tract infection; however, the doctors weren't sure what the actual cause of death was. After measuring the scars, pupil size, and limbs, the residents began making incisions (taking turns) and pulling back the skin. To preserve the appearance for the viewing/funeral, the incisions are made in a minimally invasive manner. Then the blood/fluid was soaked up and the bones were cut apart. To keep myself together, I made sure to only view one part of the body at a time, say the arm, chest, or pelvic area. Something about the head that was a little tougher to view, so I limited looking there... perhaps the eye factor.
So the residents proceed with the cutting and resection of various tissue samples and organ removal. Each component is put in a separate bag or bucket for analyses. The toughest parts to remove were all of the organs TOGETHER-- (ridic!) as well as the testicles. Once the organs were removed, though, the process went rather quickly, because they were divided among the residents (and attending) for analyses. The only part that I had to turn away for was at the very end when one resident removed the brain (that's a G-rated adjective). He then casually put it in a bucket of formaldehyde like it was no big... right near the end of the procedure, the attending handed the heart my way and instructed me to hold it and i declined. Figured i needed to take this one step at a time. And let's be honest-- today I had skipped steps 2-76.
The most incredible takeaways from my autopsy observation:
Random side notes:
- pathology residents must conduct min. 50 autopsies for program completion
- tissue/organ donation helps ~80 people
- patient's spouse/family must agree to research use of samples/tissues (not opt-out)
- If you're an organ donor, those are removed immediately after death (as in prior to arriving at the autopsy station)
----
So I get an email saying 'yo we're starting like... now' or something similar. I get down there, fix myself with the "keep me sanitary and disease-free" garb, and then start asking the director questions about the process. He said there's not a specific step-by-step process for an autopsy, though the process has generally the same order of steps, working outside inward so as to preserve all body parts. As I approached the body, I took gradual glances at the body and eeeeeeeased into view. Being my first autopsy observation (obvi), i wasn't sure how my nerves and stomach would handle it.
Go! So they start and surprisingly enough don't do a full recap of the patient case or anything (as in 'this guy has _______, with ________... and he was _________). Communication fail. This patient had Spina Bifida, which turned into a urinary tract infection; however, the doctors weren't sure what the actual cause of death was. After measuring the scars, pupil size, and limbs, the residents began making incisions (taking turns) and pulling back the skin. To preserve the appearance for the viewing/funeral, the incisions are made in a minimally invasive manner. Then the blood/fluid was soaked up and the bones were cut apart. To keep myself together, I made sure to only view one part of the body at a time, say the arm, chest, or pelvic area. Something about the head that was a little tougher to view, so I limited looking there... perhaps the eye factor.
So the residents proceed with the cutting and resection of various tissue samples and organ removal. Each component is put in a separate bag or bucket for analyses. The toughest parts to remove were all of the organs TOGETHER-- (ridic!) as well as the testicles. Once the organs were removed, though, the process went rather quickly, because they were divided among the residents (and attending) for analyses. The only part that I had to turn away for was at the very end when one resident removed the brain (that's a G-rated adjective). He then casually put it in a bucket of formaldehyde like it was no big... right near the end of the procedure, the attending handed the heart my way and instructed me to hold it and i declined. Figured i needed to take this one step at a time. And let's be honest-- today I had skipped steps 2-76.
The most incredible takeaways from my autopsy observation:
- the residents have mastered the process like a car assembly line
- there is no timeout concurrent with the analyses and minimal information exchange as they investigate
- i find the whole process extremely intriguing, notably in how similar the process apparently is regardless of the case complexity/condition (gunshot wound or shortness of breath)
- how much "background info" there is from simply analyzing someone's organs
- how beneficial organ donation is to other people (you should seriously consider being a donor
Monday, January 14, 2013
Keep calm, carry on..
2 weeks ago i shadowed an MD in the emergency dept. (formerly called the "ER") while he was working the night shift. I was always eager to do so, given that i've never experienced the ED outside of my 2-3 personal unfortunate encounters, of which i'm of course oblivious to observing how the place operates (least of your worries, right?!).
Expected observations-- the ED staff sees a LOT of random crap. And of that, a large chunk of ED-fed cases are not "ED-worthy". Over the course of the night, we confirmed one pregnancy and investigated another woman's pregnancy issues (abnormal discharge). We also saw 2 patients who are quote "regulars", coming in weekly for the same condition, which is nothing at all (more of a mental health issue). Then comes the good schtuff. One dude comes in on a stretcher sitting up at 90 degrees after crushing a vertebra in a bad car accident. The kicker? He absolutely refused to lay down on a straight board and strapped in, so the EMTs kept him upright, strapped against ~8-10 pillows between his back/head and the stretcher. What a knucklehead! In doing so, they explained that he did risk being paralyzed... and he was okay with that. This is when you empathize for the shcrap that clinicians have to put up with. Another guy thought he had a heart attack and turns out he just drank enough for 3 people and was still feeling the lingering effects. One lady had CHF and was unable to breathe, so we had to put her on a bi-pap. And another pt had what the Dr thought to be a classic seizure, as per the description by his wife. This was a great example of the importance of communication and the risk of misinterpretation, as one person's language often means something totally different to another. The Dr had to decipher the wife's story amidst her excitement and put the pieces together. Turned out to be a textbook seizure. Another textbook case was a cold, which expectedly is a frequent case that arrives to the ED that shouldn't. This is a prime example of when a triage nurse is necessary to sift out the non-critical cases.
Unexpected observations-- So that was the pretty textbook side of the observations. But with that came a lot of surprises. First and foremost, where's all the chaos that comes with "emergencies" just like on the TV shows?! There was not a single person running or stretcher flying through that joint! Nah, probably a good sign.. or at least best practices. In fact, the MD i observed was calmer than a golf tourney announcer. He calmly rounded, at random, to see how patients were doing. Something that I was very surprised by, and also concerned with, is how arbitrary the case review process is conducted. In fact, there is (at least at this ED on this night) no "best practice" protocol for how patients are triaged, notably the order, acuity, room placement, MD/nurse assigned, or treatment status tracking. They pretty much just arbitrarily circled the halls and checked on various cases.
Per the MD i shadowed, the case/EMR updates were usually made at the end of the shift; he said he has no problem remembering the facts and never confuses patient cases (so he says..). When we had downtime he would make updates accordingly, though. The ED also has an e-whiteboard tracking case status, including incoming cases. However, i think it's used incorrectly... so much info not referenced or even collected that the board is capable of and could be a huge time-saver (and CYAer). It was also very interesting to see the MD never request or confirm a patient's insurance status or ability to pay. He treated every patient equally, which is above the minimum requirement of EMTALA. I also found the MD's "BS report" to be really interesting. Because patients often come to the ED complaining of symptoms that are either unrealistic, not true, or severely exaggerated, he would commonly barrage a patient with questions and intertwine/follow up with specific condition questions. If the patient had inconsistent responses, he typically concluded that their condition was either not true or low priority. He said that patient pain level and/or description of condition is frequently exaggerated or even invalid, in hopes of seeing a MD faster.
This was probably the kicker of the night... a gradual observation. With the recent rise in patient safety and cleanliness, i really expected everyone to be extra careful with hand hygiene. FALSE. In fact, the MD i shadowed didn't wash his hands even once over 4.5 hours!!! After each patient observation, he flicked the hand sanitizer lever barely making contact and surely not getting any sanitizer on his hands. And while he had the whole "be consistent" part down pat, he consistently failed to actually clean his hands. This is quite scary and makes me want to squirt my physician's hands with cleaner at my next dr appt. I mean, if you mess around with someone else's open wounds, genitals, and bodily fluids, i would like a clean slate. Just sayin'. Joking aside, this is a HUGE risk, liability-wise and something that probably needs to be further evaluated. Note to self..
By 3:30am the flow had slowed and it was time for me to bounce. I'll be back for more, i just know it..
Expected observations-- the ED staff sees a LOT of random crap. And of that, a large chunk of ED-fed cases are not "ED-worthy". Over the course of the night, we confirmed one pregnancy and investigated another woman's pregnancy issues (abnormal discharge). We also saw 2 patients who are quote "regulars", coming in weekly for the same condition, which is nothing at all (more of a mental health issue). Then comes the good schtuff. One dude comes in on a stretcher sitting up at 90 degrees after crushing a vertebra in a bad car accident. The kicker? He absolutely refused to lay down on a straight board and strapped in, so the EMTs kept him upright, strapped against ~8-10 pillows between his back/head and the stretcher. What a knucklehead! In doing so, they explained that he did risk being paralyzed... and he was okay with that. This is when you empathize for the shcrap that clinicians have to put up with. Another guy thought he had a heart attack and turns out he just drank enough for 3 people and was still feeling the lingering effects. One lady had CHF and was unable to breathe, so we had to put her on a bi-pap. And another pt had what the Dr thought to be a classic seizure, as per the description by his wife. This was a great example of the importance of communication and the risk of misinterpretation, as one person's language often means something totally different to another. The Dr had to decipher the wife's story amidst her excitement and put the pieces together. Turned out to be a textbook seizure. Another textbook case was a cold, which expectedly is a frequent case that arrives to the ED that shouldn't. This is a prime example of when a triage nurse is necessary to sift out the non-critical cases.
Unexpected observations-- So that was the pretty textbook side of the observations. But with that came a lot of surprises. First and foremost, where's all the chaos that comes with "emergencies" just like on the TV shows?! There was not a single person running or stretcher flying through that joint! Nah, probably a good sign.. or at least best practices. In fact, the MD i observed was calmer than a golf tourney announcer. He calmly rounded, at random, to see how patients were doing. Something that I was very surprised by, and also concerned with, is how arbitrary the case review process is conducted. In fact, there is (at least at this ED on this night) no "best practice" protocol for how patients are triaged, notably the order, acuity, room placement, MD/nurse assigned, or treatment status tracking. They pretty much just arbitrarily circled the halls and checked on various cases.
Per the MD i shadowed, the case/EMR updates were usually made at the end of the shift; he said he has no problem remembering the facts and never confuses patient cases (so he says..). When we had downtime he would make updates accordingly, though. The ED also has an e-whiteboard tracking case status, including incoming cases. However, i think it's used incorrectly... so much info not referenced or even collected that the board is capable of and could be a huge time-saver (and CYAer). It was also very interesting to see the MD never request or confirm a patient's insurance status or ability to pay. He treated every patient equally, which is above the minimum requirement of EMTALA. I also found the MD's "BS report" to be really interesting. Because patients often come to the ED complaining of symptoms that are either unrealistic, not true, or severely exaggerated, he would commonly barrage a patient with questions and intertwine/follow up with specific condition questions. If the patient had inconsistent responses, he typically concluded that their condition was either not true or low priority. He said that patient pain level and/or description of condition is frequently exaggerated or even invalid, in hopes of seeing a MD faster.
This was probably the kicker of the night... a gradual observation. With the recent rise in patient safety and cleanliness, i really expected everyone to be extra careful with hand hygiene. FALSE. In fact, the MD i shadowed didn't wash his hands even once over 4.5 hours!!! After each patient observation, he flicked the hand sanitizer lever barely making contact and surely not getting any sanitizer on his hands. And while he had the whole "be consistent" part down pat, he consistently failed to actually clean his hands. This is quite scary and makes me want to squirt my physician's hands with cleaner at my next dr appt. I mean, if you mess around with someone else's open wounds, genitals, and bodily fluids, i would like a clean slate. Just sayin'. Joking aside, this is a HUGE risk, liability-wise and something that probably needs to be further evaluated. Note to self..
By 3:30am the flow had slowed and it was time for me to bounce. I'll be back for more, i just know it..
Tuesday, December 18, 2012
You can do it... we can help.
Have it your way... no, really.
A few weeks ago, I had the pleasure of connecting with an outpatient nurse, named Holly, for a day. It's hard to beat a richer experience than working alongside a nurse for the day. They remind me of Mr. Fix-it, the jack-of-all-trades pretty much. Knowing that my passion is in informatics, she geared the whole day in that regard. As we walked through Holly's daily routines, I reiterated to state the process as is, be 100% honest, and highlight all aspects of IT and informatics within these processes. And boy, did she ever! Before long i had 5 pages of process notes, many of which were highlights of areas for improvement. Many of her process, as I learned, were doing the trick, but it was extremely inefficient. This is because different teams were tasked with creating various widgets/tools, and they weren't interoperable in the end. The result? 378 IT systems across the university. Interface much? Sheesh. By the end of the day, I had a huge tally of process improvement projects to forward on to the hospital strategy and innovation council for consideration. As I've found in the past, some of the best ideas come from a newbie with a neutral mindset... who isn't afraid to speak his/her mind.
Anything you can do i can do betteeeeer.
Working at a massive AMC, I never thought I'd experience stiff internal competition. I gotta tell ya--- things are pretty fierce around this joint. And while it sometimes can work to your advantage in creating innovation and constructive conflict, this definitely isn't the case. So i'm helping to manage a project on anticipatory patient care, and naturally, I took a scan of fellow projects across the health system. While none were identical to what I was partaking in, at least 5-6 were, in some way, shape, or form, related to or in parallel with our project. It's taken the last 3 months to convince the leadership to have these projects dotted-lined to one another! The result? Saving many months of duplicative work with potentially very similar outcomes. I've started a spreadsheet of both duplicative initiatives/projects and related/parallel projects, with plans to soon share with leadership in hopes of merging efforts. And we wonder why so many projects fail-- lack of communication.
Does that come in platinum?
Being a big bro has been eye-opening these last few months. I think above all else it's made me realize that many kids of Gen-Z have a defining sense of entitlement. An extremely generous donor gave us 2 tickets to the Titans game a few weeks ago-- on the 2nd row back!! We could practically touch the players. So as we left, I asked Andre if he enjoyed the game. He explained how it was okay, but in his thank-you to the donor (which i have him write to every donor/supporter) he was going to request that he get us box seats for next year because these weren't good enough. Wha?! The flipside of this experience has taken a while for me to build but i'm seeing it like so-- people of all types walk this green Earth. Regardless of upbringing, people have different desires in life. My goal is to teach Andre that nothing is free and he must work for it. I want him to see not only the value of a dollar for all people but also the importance of appreciation. A few weeks ago, he told me at the end of a trail hike that I 'am the best big brother ever'. That definitely makes it all worth it... over one hill and on to the next. I guess this is what 'making a difference' is all about...
A few weeks ago, I had the pleasure of connecting with an outpatient nurse, named Holly, for a day. It's hard to beat a richer experience than working alongside a nurse for the day. They remind me of Mr. Fix-it, the jack-of-all-trades pretty much. Knowing that my passion is in informatics, she geared the whole day in that regard. As we walked through Holly's daily routines, I reiterated to state the process as is, be 100% honest, and highlight all aspects of IT and informatics within these processes. And boy, did she ever! Before long i had 5 pages of process notes, many of which were highlights of areas for improvement. Many of her process, as I learned, were doing the trick, but it was extremely inefficient. This is because different teams were tasked with creating various widgets/tools, and they weren't interoperable in the end. The result? 378 IT systems across the university. Interface much? Sheesh. By the end of the day, I had a huge tally of process improvement projects to forward on to the hospital strategy and innovation council for consideration. As I've found in the past, some of the best ideas come from a newbie with a neutral mindset... who isn't afraid to speak his/her mind.
Anything you can do i can do betteeeeer.
Working at a massive AMC, I never thought I'd experience stiff internal competition. I gotta tell ya--- things are pretty fierce around this joint. And while it sometimes can work to your advantage in creating innovation and constructive conflict, this definitely isn't the case. So i'm helping to manage a project on anticipatory patient care, and naturally, I took a scan of fellow projects across the health system. While none were identical to what I was partaking in, at least 5-6 were, in some way, shape, or form, related to or in parallel with our project. It's taken the last 3 months to convince the leadership to have these projects dotted-lined to one another! The result? Saving many months of duplicative work with potentially very similar outcomes. I've started a spreadsheet of both duplicative initiatives/projects and related/parallel projects, with plans to soon share with leadership in hopes of merging efforts. And we wonder why so many projects fail-- lack of communication.
Does that come in platinum?
Being a big bro has been eye-opening these last few months. I think above all else it's made me realize that many kids of Gen-Z have a defining sense of entitlement. An extremely generous donor gave us 2 tickets to the Titans game a few weeks ago-- on the 2nd row back!! We could practically touch the players. So as we left, I asked Andre if he enjoyed the game. He explained how it was okay, but in his thank-you to the donor (which i have him write to every donor/supporter) he was going to request that he get us box seats for next year because these weren't good enough. Wha?! The flipside of this experience has taken a while for me to build but i'm seeing it like so-- people of all types walk this green Earth. Regardless of upbringing, people have different desires in life. My goal is to teach Andre that nothing is free and he must work for it. I want him to see not only the value of a dollar for all people but also the importance of appreciation. A few weeks ago, he told me at the end of a trail hike that I 'am the best big brother ever'. That definitely makes it all worth it... over one hill and on to the next. I guess this is what 'making a difference' is all about...
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