Friday, August 20, 2010

Customer delight equals medical quality. Right?

   In my hospital, one of the ways we measure quality of care is to look at patient perception of care.  A nationally known polling agency sends questionnaires to patients, and from them we learn something about whether patients are impressed by the care they receive.  We treat patient satisfaction scores with great reverence.  Our goal is to produce at least as many satisfied patients as comparable hospitals surveyed by this agency.
   The larger health system of which my hospital is a part has for several years exhorted its employees to remember AIDET – perhaps the most awkward acronym every devised in service of a noble purpose.  AIDET stands for Acknowledge, Introduce, Duration, Explanation, and Thanks, or something close.  The acronym is meaningless, the construction isn’t parallel, and the actions are listed out of order to create the acronym.
   Nevertheless, the fundamental idea is sound.  It fits with the customer service principles I learned in business school.  We want everybody to ensure they’re talking to the right patient about the right procedure. We want each patient to know exactly who we are and what our role in their care will be.  We want each patient to fully understand the procedures we’ll be doing.  We want patients to know how long their care will take, and we want them to know what to expect when delays arise.  And, finally, we want to thank patients for coming to us.
   This week I accompanied a close friend to my hospital for an endoscopic procedure. I sat by her side as a series of people readied her for care and returned her to her room.  Overall, she says her experience was entirely pleasant.  People were friendly, reassuring, and competent.  Everything proceeded briskly, nothing went wrong, nothing hurt, and the outcome was perfect.  She left feeling that she’d had a good experience.
   But not a great experience…  She didn’t come out singing the praises of the hospital and its employees.  We really didn’t surpass her expectations at any point.  We simply met them competently.
   Did we remember AIDET? Not entirely. Everybody reviewed her full name, birth date, procedure, and allergies – so consistently that my friend began to question whether anybody believed her or was paying the slightest attention to the work of others.  It would have been useful to mention that everybody who is about to provide care would review this information.
   On the other hand, few people did an adequate job of presenting their names and roles. She met one admitting clerk, two hospital assistants, one admitting nurse, two nurses from the endoscopy room, the anesthesiologist, and the endoscopist himself, whom she had met previously.  Few introduced themselves by name. Almost nobody except the anesthesiologist was introduced by role.  Even the anesthesiologist did not introduce himself by name.  Although he and I knew each other, he didn’t know my friend, and he didn’t carefully check her ID and procedure or introduce himself. None of this occurred as rude, exactly.  Neither did it say, “You’re an important person.  Before we touch you, we want to be sure you know who we are and what we’ll do.”
   Almost everybody gave a good explanation of what would be happening, and how long it would take.  The endoscopist himself had her sign a consent without additional explanation in the procedure room right before she went to sleep.
   Surprisingly, although everyone was polite and cheerful, nobody specifically thanked her for coming.  Even on a small island, she does have choices. It might have been impressive if one or more people had thanked her sincerely for choosing us for her care.  She was dismissed with a friendly wave and a warm smile, but not much thanks.  In fact, she points out that she wasn’t even actually formally welcomed.
   A further observation: our hospital looks at hand-washing in a variety of ways in order to promulgate pervasive hand sanitation.  Patients are asked whether personnel caring for them cleansed their hands all the time, some of the time, or seldom (or something like that).  The only person I actually saw using the hand-cleaner dispenser in the room was one of the nursing assistants.  My friend saw two of the nurses and the anesthesiologist use the dispenser. Everybody may have had clean hands, but by the questionable measure of whether their cleanliness was witnessed, we didn’t surpass 50%.
   What if everybody had done the good work they did AND paid attention to AIDET, with or without the silly acronym?  Would my friend have come away with the sense that all these people really cared about her experience with them, even more than she did?  Would she have come away with an experience that left her enthused and delighted, not just satisfied and relieved?  I think so. Almost certainly we could have improved an already-good patient-satisfaction score.
   Would that have been better quality medical care? More health, less disease, more result for less money?
   Everybody knows the story of the fellow who comes upon an inebriate crawling on the ground under a street light.   Asked what he’s doing, the inebriate replies that he’s looking for his car keys.  The newly arrived good Samaritan drops to his knees and begins searching too.
   After several fruitless minutes, the new man asks, “Are you sure you lost them here?”
   “No,” replies the inebriate, “I lost them crossing that field.”
   “Well, then,” says the Samaritan, “why are you looking here?”
   “The light’s better here.”
   If we did improve customer satisfaction, would the quality of medical care be higher?  Or are we hoping that we can find medical quality by looking at customer satisfaction just because the light’s better here? 

Wednesday, August 11, 2010

A Spinal Shouldn't Hurt

            I saw part of an episode of the TV series “House” the other day.  In it, a young man required frequent lumbar puncture for daily injection of an anti-infective agent.  I don’t remember the story line, but I remember that the spinal tap was presented as an agonizing event during which the young man sweated, gritted his teeth, and bravely pulled through with the sympathetic help of the medical staff.
            Here’s news, America!!  A spinal tap should not hurt.  A spinal anesthetic should not hurt.  An epidural should not hurt.  If it hurts, somebody is doing it wrong.
            Under most circumstances, once skin is anesthesized (one big pinch or sting), there’s nothing else in the midline that hurts as a needle traverses bone-free space on its way to the epidural or intrathecal space.  I tell patients that I want to be in the midline where it doesn’t hurt.  If something bothers them, it means I’m not where I want to be.  Tell me it bothers you, and tell me which side, and I can easily correct to the midline. It did take me a while to learn that if I listen to my patients, they’ll tell me exactly where I am and guide me to a successful midline puncture.
            Patients who have to endure great pain during a spinal procedure are, I believe, receiving incompetent medical care.  There’s no reason for it be painful, except operator carelessness and indifference.
            Even a paramedian technique should not be painful, once the needle track is anesthetized (a little more painful than midline).
            So why do patients so frequently think a spinal procedure will be miserable?  I suppose in part it’s the idea, but it’s also based on real experience.
            I had a patient recently who was to have a total knee replacement, for which we usually do a spinal anesthetic with enough added sedation (propofol infusion) that patients sleep painlessly through the procedure.  He’d had a terrible experience with a myelogram 40 years ago, with painful repeated punctures, and for 40 years he’d refused to let anyone touch his back.
            I told him why I’d prefer a spinal myself if I were having the procedure, and told him that I didn’t expect a spinal to be a painful ordeal.  He decided to go ahead with a spinal, which proved easy and uneventful.  I just received an e-mail detailing his parking-lot encounter with a hospital administrator in which he talked about what a good job I’d done with his spinal.
            And that’s the sad part.  I did a very ordinary job, the sort of job every person having an anesthetic or a spinal tap has a right to expect every day.  That we continue to send the message that spinal procedures are by nature painful is a continued failing, I think.
            And while I’m at it, I think starting an IV without local anesthesia is another unnecessarily barbaric procedure.  Digging around to find a vein without local is thoughtless and insensitive.  Tell ‘em I said so.

Anger and Volcanic Energy

            Anger and I have a history. I have related to anger as a character defect, something wrong with me, for at least the last 20 years. But that’s not the truth.  That’s just a conversation, something people say.
What if we said something different? What if anger is not only normal for all of us as humans, but useful as a source of power?
            “DON’T TOUCH ME!!” That’s the last phrase a large, intimidating male working in a mostly-female workplace wants to hear, especially out loud in front of witnesses. In my reality, I had touched the shoulder of a nurse anesthetist as she turned to leave a conversation about inadequate patient care before it was clear that she could fix her error.  In her story, I had struck her, severely injuring her shoulder and requiring that she be off work for months undergoing therapy.
            The district attorney contemplated an assault charge.  The Board of Medical Quality Assurance contemplated lifting my license. (I learned that BMQA investigators carry badges and guns, as if the power to take a license were not intimidating enough.) The hospital board contemplated suspension of privileges.
            None of these punishments came to pass.  Instead, I experienced my first anger management counseling in the upscale home of a woman who had previously run the hospital’s employee assistance program. Anger, she said, rises from fear – most commonly from fear of loss.
            The workplace became less and less accepting of anger as I had experienced it. I was loud, I was foul-mouthed, and I looked intimidating.  I was no better at home on our ranch, where displays of temper were common and bad language frequent.  Though I never actually injured anyone, I broke my toe kicking a cow in anger during veterinary work, and I recall with shame brandishing a length of pipe at a teenager from the neighboring nudist colony when I caught him riding a dirt bike (fully clad) on our property.
            I would have said that I was seldom directly angry at my first wife,  but I learned after our divorce that she had had a different experience.  I had been angry in her vicinity so frequently that she had felt virtually controlled by my anger.
            I married again, this time a woman whose own anger was nearer the surface. She had little tolerance for any expression of anger from me.  Overt anger, a stern-sounding voice, an upset expression, cursing – all were unacceptable. There were no mitigating circumstances.  Anger around kids was even more reprehensible.
Over years, personal development courses and counseling have made a difference. I’m less and less volatile, less blaming, more aware that my world evolves from my own choices, more able to be with what’s so – and yet the goal of perpetual placidity and optimism continues to elude me.
            Now in the midst of a second divorce, my men’s group said a few days ago that I seemed angry. I’d been denying that, generally saying that things are fine. 
But they’re not fine.  I’ve lost my second marriage, my relationship with my stepchildren, my access to easy retirement, and some freedom of choice about how much I need to work.
The woman with whom I spent a dozen committed years decided last summer that she didn’t want to be married any more.  She said she’d like to end the marriage and be friends.  The friendly divorce that we first anticipated disappeared into failed negotiation, failed mediation, and wholly baseless suspicions that I must somehow have squandered or hidden our assets.
We do have much less than we once had, but our money isn’t hidden. It’s gone. We consensually spent it, lost it as our equity-based retirement account fell to half, or lost it in the real estate decline as our new mortgage went under water.  We’ll split what remains, with each of us a loser.
The children to whom I’d been stepfather for fifteen years seem to be pulling further and further away.
            So I’m angry.  So what? What if anger isn’t wrong, isn’t a failing, isn’t a character defect?  What if anger is normal and natural, part of everyone’s emotional makeup?
What if we were able to treat anger as a form of power or energy? 
If anger were volcanic energy, it might be instructive to look at the difference between Mount St. Helens and Hawaii’s Kilauea.  In one, energy is held in until it’s too powerful to contain.  Explosive release destroys the environment, rendering an area unlivable for years.  In the other, energy is constantly released, explosions are unthreatening, and the resulting lava flow creates an expanding island.
            What if we could channel anger into constructive action rather than explosive displays?  What if we went running, or tore out a wall for reconstruction, or wrote a piece on anger, or focused on legal strategies that would end a stalemate?  What if we let anger power life-improving actions instead of destructive explosions? What would it take to keep anger constructive, positive, and unthreatening all the time?  Now that’s a worthwhile inquiry… 

Saturday, August 7, 2010

The Keen Eye of the Retrospectoscope

            A version of this blog appeared in 2009 on a coaching website I’d created with my wife.  Then life happened.  I took down the blog and let it marinate in a vat of good intention.
I’m a physician and a life coach.  The original question for this blog was whether I could write as a professional about my own humanity.  Could I be open, vulnerable, in touch with fears and failings as well as strength and wisdom? When I began my life work four decades ago, it would have seemed unprofessional to put personal thoughts in a place where they could be read by anybody who happened by.  Now it seems not only permissible, but valuable.  I learn daily from blogging physicians and coaches who speak without fear.
Not a single feature of my current life could have been predicted four years ago.
In 2006 I was working per diem as a clinical professor of anesthesiology at a major medical school in the Pacific Northwest, looking forward to creating a life coaching practice that would have me out of the operating room in a few more years.  I anticipated that we’d either stay in the Pacific Northwest or move back to central California to be near my middle son and his wife.  I planned to research and write a book on greatness, interviewing prominent people who seemed unafraid to let their light shine in the world.  I was happily married, eight years into a second marriage with children in their teens. 
The first never-gonna-happen surprise is that I now live in Hawaii. Four years ago I had never spent a minute thinking I might live here.  I loved the Pacific Northwest.  Then in 2007 after a period of family inquiry, we chose to radically reshape our lives and move to the Big Island. I said I’d do whatever it took to make the Hawaiian adventure possible.  That turned my work life in an unexpected direction.
The second surprise is that instead of moving out of the operating room to be a life coach, I now practice anesthesiology full-time as chief of a high-quality rural practice on one of the outer islands. I thought I was burned out, done, tired of the whole thing.  I was increasingly afraid of the operating room.  I couldn’t have imagined practicing full-time and being responsible for a department, and I couldn’t have imagined loving this practice, its people, its challenges.
The third surprise is that my marriage has ended. I live by myself in a condominium on Kauai, not in the family home on the Big Island.  In the summer of 2009 my wife said that she no longer wanted to be married.  She wanted us to end the marriage and still be friends.  A year later, negotiations have failed to produce a simple or friendly agreement, and an appointment in divorce court seems likely.
Finally, and most surprisingly, I looked briefly on last summer when it seemed that my marriage would soon be over.  I asked for a woman who was warm, loving, wise, kind, good-humored, sexy, and willing to love and be loved.  To my immense surprise that woman appeared, and we’ve been “together” for almost a year now despite my failure to finish a divorce as quickly as I’d predicted.  She’s exactly who I was asking for.  Once again, my experience could never have been predicted.
            I’m guessing that the blog will be another unpredictable experience.  Stay tuned. Where once I thought I had many of the answers, I now have mostly questions.  This is where I’ll explore them.  I welcome comments.  Without dialogue, I’m simply in my own head…