I've written before about my questions of why so many hospitals abdicate their leadership responsibility for quality and patient safety, or at least offload much of it onto the patients. I think it's wrong to put patients of the position of asking the providers if they've washed their hands. The hospital, the providers, the physician leaders, and the administrators need to take on this challenge. They need to fix processes and put better management systems in place. That's getting closer to fixing the real root cause of these problems instead of asking families to play the role of “quality inspector.”
The article and blog linked to at the top of the post give these recommendations:
Here are a few tips for taking care of a loved one in the hospital:
- Ask everyone if they've washed their hands.
- Ask nurses to read drug orders out loud and confirm that they match the patient's ID bracelet. If it's a new medication, ask what it's for and what to expect.
- During long stays, be alert for bedsores. Make sure the patient is moved often, and lifted rather than slid.
- Don't try and help the patient into or out of bed by yourself.
- Don't give the patient medications on your own.
I can understand asking families to not give medications or help move patients… but you want families to be the ones responsible for making sure the wrong drug isn't given? Seriously?
You don't see articles about “How to Be a Vigilant Airline Passenger” with tips such as
- “ask the pilot if they have done pre-flight maintenance checks” and
- “be sure to sit over a wing so you can see for yourself if the flaps have been properly set for takeoff.”
People wouldn't accept that when flying or when buying a car (“Be sure to check that the lugnuts have been tightened before driving away!!”). So why do patients and families accept this in hospitals? At best, it's a short-term stop-gap fix — a necessary intervention to make up for a bad system. But I'd feel better if hospitals also explained to patients how the system is being fixed (through Lean methods or otherwise).
In the WSJ article, Melinda Beck writes about a typical “vigilance required” tale:
Don't go to the hospital alone, if you can possibly avoid it.
A friend of mine slipped on the sidewalk recently and broke her hip. She had surgery in one of the best hospitals in the country.
But it was my friend's grown daughter who noticed that she was having an adverse reaction to a pain medication. And that her IV drip had pulled out of a vein and was pumping her arm full of fluid. And that the hot compresses to reduce the swelling in her arm had left blisters on her skin. And that the blood-sugar test she was about to be given was meant for her roommate instead.
Hospitals need to ask why these errors or oversights occur and how they can be prevented. Are nurses too overburdened with unnecessary administrative functions and are they dealing with “waste” and problems that keep them being being as attentive to patients as they could be?
Many hospitals are under financial pressures to keep nursing staffs lean.
As you might guess, I really dislike this colloquial use of the word “lean.” In this use, it might mean “less staff than we had before” or “less staff than we'd really like to do the work the right way.”
To me, “Lean staffing” (in the Toyota Production System sense) is about having the RIGHT number of employees. This is a topic I'm going to explore more in a future post — how DO we determine the right number of employees? If it's based on budgets or financial targets, that might not give the right answer. The answer should be based on a real operational analysis of the work that's required, not arbitrary targets or benchmarks.
When does short-term financial pressure to keep staffing low actually lead to higher costs? These costs might include poor morale (which leads to expensive turnover and hiring) or poor quality (the impact of which might be a lawsuit or incalculable loss).
While I'm leery of relying on families as “partners in quality and safety” (they're really customers), I do like the idea of including families (and the patient) in communication and handoffs, as some hospitals are doing:
“This is a huge cultural change,” says Mary Chatman, Chief Nursing Officer of Pitt County Memorial Hospital in Greenville, N.C., which is giving family and patient advisory groups a voice in designing new facilities and interviewing physicians.
Initially, some staffers worried that family involvement would take up valuable time, but in the long run, it saves time because doctors have more information, says Ms. Chatman. After MCG Health's neuroscience unit became more family-centered, average length of stay dropped 50% because discharge planning went faster. Patient satisfaction rose, and nursing turnover dropped.
Here's an example of a short-term cost (time and staffing) that pays off through lower costs and better service down the road. That's the type of systems thinking that the Lean approach encourages. Don't just micromanage your budget column, improve the whole system.
I can understand “partnering” with families in things like discharge planning, as shown above. But I still think it's ridiculous to think of the family as a “partner” instead of a customer. Any service provider has the duty to make sure their customer is taken care of and that quality is maintained. Don't offload that onto the family — they have enough to worry about.
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