What is the cost of poor service in hospital delivery systems?

Presently, slower deliveries from Pharmacy could result in a patient waiting longer for pain meds and slow delivery of blood samples to the lab could result in the need of a re-test… or even result in postponing a scheduled procedure.  This slower than “expected delivery” would negatively impact the hospital’s effective and efficient execution of their care plan for the patient.  However, how do you identify these negative impacts and associate a cost to them?

Patient safety: What if you can’t speak up?

Everyone in healthcare has stories of being silenced with a look or comment.  You need clarification, or think something might be wrong, and when you try to tell the physician, s/he snaps at you, or is sarcastic, or condescending.  In some cases, the physician may even be verbally abusive or threatening.  You quickly learn, at least with that physician, to keep quiet.   This can happen in any communication where there is a strong power differential:  between nurse or doctor and patient, between senior and junior healthcare professionals, between managers and their staff, etc. 

Still worse, many people have pointed out this situation to their manager or someone else in authority, only to be told to just deal with it, or to become labeled a complainer.  Or the manager may respond attentively and with concern, but then nothing changes. 

All of these situations work to stifle concerns healthcare professionals have about the quality and safety of patient care.  This is demoralizing:  your perspective is unimportant, you are not worth listening to.  You come to understand that the organization in which you work is not committed to quality and safety, but that the organization often chooses to protect the egos of powerful people (like physicians who are not employees but control a large revenue stream) over the safety of patients (and of other healthcare providers).    You are in a double-bind situation, and feel increasing stress and frustration. 

Yes, physicians are under tremendous pressure — but that’s when they are more likely to make mistakes, and more likely to need the situational awareness of the others on the care team to prevent these mistakes from harming the patient.  In a complex adaptive system such as healthcare delivery, where error-proofing is often not possible, we need to rely on the dynamic awareness of everyone involved in patient care to catch mistakes before they cause harm.  

Most physicians, and most managers and administrators, do not habitually intimidate people or dismiss their concerns.  But anyone can be under so much stress that s/he sometimes or occasionally responds this way. 

According to The Joint Commission, in Sentinel Event Alert Issue 40,

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.  Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.  All intimidating and disruptive behaviors are unprofessional and should not be tolerated.
. . .
Several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors.
. . .
Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it.

Lucian Leape, in an article about problematic physician behavior, notes that:  “Performance failures of one type or another are not uncommon among physicians, posing substantial threats to patient welfare and safety. Few hospitals manage these situations promptly or well.” 

So what can we do?

At the organizational level, the Joint Commission has already required that hospitals set behavior standards and implement a process for managing disruptive and inappropriate behaviors.  It has also made a number of further recommendations, including training, contractual provisions, non-retaliation, and leaders modeling appropriate behavior.   

At the individual level, Maxwell et al. use positive deviance to identify what enables some people to successfully speak up in spite of an environment that is less than fully supportive.   These include:  work behind the scenes if the situation is not urgent;  avoid provoking a defensive reaction; keep your own frustration and anger in check; explain your intention to help the caregiver as well as the patient. 

As the organizational culture begins to change, scripted interventions may be very helpful.  In one hospital, “Doctor, I have a concern…” was used as an indicator that something might be going wrong, and requesting the physician’s attention.  If that didn’t work, the same person would follow up by saying, “Doctor, I have a patient safety concern.”  Regardless of whether the concern is founded or not, perspicuous or misguided, the physician or other caregiver who is being questioned should always thank the person who raised the concern, in order to encourage this behavior in the future.  (This can be very hard to do when the concern is unfounded, and the caregiver is irritated — but it is crucial to remember that this is how we prevent our mistakes from causing harm.) 

In your organization, do all staff members have the skills they need to speak up tactfully?  Will they be encouraged to speak up, and supported when they do so?  Are the behavioral standards applied equally to everyone in the organization?  “Respect for people” is a pillar of the Lean approach.  Are hospitals that have adopted Lean more likely to encourage and support speaking up? 

Reflections: CT Radiation Risk and Informed Consent

By Alina Hsu

Perhaps as a result of the body of research documenting physicians’ ignorance of CT radiation risks, Richard C. Smelka, MD, author of a Medscape blog on radiology, reports that a “plethora” of physicians have contacted him about improving the way they inform patients of the risks.  He provides three samples of new imaging informed consent forms in this post

Among  those physicians who are aware of the risks, some worry that giving patients accurate information would be too scary, and patients would avoid needed diagnostic scans.  There is some anecdotal evidence that this is not the case:  patients are quite capable of understanding the small incremental risk and comparing this with the diagnostic value of CT or other imaging tools.  Even if it were the case that patients judged the diagnostic scans to be too risky, that is no reason for physicians to fail to disclose the risks:  physicians must respect the patient’s judgment.  And the second sample in the above post, from Steven Birnbaum, MD of Southern New Hampshire Medical Center is a stellar example of frank, respectful, understandable, and accurate information.  (It is also non-scary.) 

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NEJM’s $640 Billion Question

By Alina Hsu

Why does cost-effective care diffuse so slowly?  Because of various kinds of resistance and countervailing forces across many stakeholders:  insurance companies, large employers, the public (largely influenced by inaccurate media reports), legislators, hospital administrators, physicians, academic health centers, and the manufacturers of drugs, medical devices and equipment.  The article is available as a free pdf, which I encourage you to read.

The authors, Victor R. Fuchs, Ph.D., and Arnold Milstein, M.D., M.P.H., are insightful in their analysis of these stakeholders and forces.  The road ahead is indeed daunting.  They end by calling on physicans to take the lead:

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Failure Demand

By Alina Hsu

There’s something of a war going on between John Seddon and the Lean community (see comments on this post in Mark Graban’s Leanblog), but I credit Seddon with defining the concept of failure demand:

…demand caused by the  failure to do something or to do something right for the customer

Failure demand occurs in many types of hospital  contexts:  errors, lack of coordination or communication, workaround processes, delays in getting needed tests or other  services, readmissions – all create extra work and increase the burden on hospital personnel who are often already overburdened.  One difficulty in dealing with failure demand is that the process that caused it is often different than the process that has to deal with the consequences, which requires cross-functional collaboration.  (If you introduce this concept in the context of value stream mapping, you’ve already got your cross-functional team in place!)  Many hospitals are making great strides in reducing or eliminating these kinds of failure demand.

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