Where Has All the Time Gone

time

 

This blogpost is an excerpt of a chapter I wrote in Collaborative Caring: Stories and Reflections on Teamwork in Health Care. a book I co-edited with David L. Feldman and Michael Leonard.

The other day, I had an amazing experience. I went to see my primary care provider, a physician named Jane Himmelvo, whom I have talked about in an earlier post, to discuss the pesky issue of my elevating blood pressure. As I age, it has gone from lower to higher – like 155/90 sometimes. Problem is, given what I know about healthcare, and a terrible experience I had with a complication following surgery (one that my surgeon tried to blame on me and for which I received no apology, which would have been much appreciated), I have developed white coat hypertension. So whenever anyone takes my blood pressure in a healthcare facility, zoom, it goes way up. Jane and I have been trying to figure out how to get an accurate BP reading and so I have been doing the readings at home.

So I was in Jane’s office to report on the data I had collected. We sat and discussed it for a few minutes and noted that my regimen of aerobic exercise, lowering salt, meditation and dealcoholized red wine was actually working and we decided – and I use the word “we” deliberately here –that I would keep up the regimen for three to six months to see whether it would continue working over the long term.

With the problem addressed – at least temporarily – in about ten minutes, I was about to jump up and leave, knowing that ten to fifteen minutes is all you usually get with your PCP these days. But then Jane started asking some further questions. They were not: “how’s your stress level, or let’s check that cholesterol one more time (mine it turns out is just peachey). She asked me how I found living in the Bay Area after having moved from Boston two years ago. When I told her I loved it, she asked about my kids. I asked about her’s. We began to segue into our different ethnic backgrounds and religions (I am a lapsed Eastern European Jew, she’s a Vietnamese-American sort of Buddhist). We talked about prejudice, films. I kept peeking at the clock. I had exceeded my 15- minute limit ten minutes ago. Shouldn’t I leave? But no, we kept chatting, getting to know each other. After 45 minutes, our time together seemed to naturally end and I left, feeling flabbergasted. Was she really a PCP? Was this really a doctor’s visit?

Of course, she is, and it was. This particular physician has arranged her practice so that she can actually spend time with patients. There’s never more than one person in the waiting room at a time (rather than four or five). She never seems rushed or stressed or staring at her watch. And she talks with her face to you rather than with her back toward you and eyes glued to the computer screen as she hurriedly types in notes so she can get you out and the next patient (who’s probably been waiting for an hour, because the doc has booked four patients for the same 15 minute slot) in.

 

I write about this because one of the things that is missing in discussions of teamwork, patient centered care and patient safety is time – time with the patiient. Physicians, nurses, pharmacists, pretty much anyone who works in healthcare at any level today, is working too long and too hard. They are taking care of too many patients, listening to too many histories, ascultating too many lungs, charting the rhythms of too many hearts. When I began writing about healthcare almost 30 years ago, the average primary care doctor had a patient panel of maybe 800. Now it’s up to 2500 maybe even 3000. At a major teaching hospital, which shall go nameless, some PCPs work from early in the morning till late into the night. Some actually sleep in their offices. This is not in India, but California. In North America, resident hours have been reduced – a smidgen – but doctors who have finished their apprenticeship training have no restrictions on how long they can work, how much they should rest, and how many patients they can see, operate on, assess etc.

The kind of stress people experience with these kinds of workloads and hours is, we know, a significant barrier to teamwork and a patient safety hazard. Stress makes people irritable if not angry, frustrated, and possibly even abusive. Similarly fatigue has a serious impact on teamwork because it does the same. When people are constantly interrupted, they can become slightly frustrated, particularly with the supposed team member — or patient – who is responsible for the interruption.

Yet once again, I ask, where are conversations about reducing patient load and increasing time with patients as central to patient centered care. I recently attended a conference at a prestigious medical center on the patient experience in which physicians discussed their efforts to teach one another to be more empathic. The aim was to increase patient satisfaction scores and thus hospital reimbursement. The hospital in question was putting its physicians through empathy training. What it was not doing was changing their workload or work hours. Indeed, the physician presenting at the lecture emphatically stated that productivity demands were off limits and that nothing was going to change in that regard.

So I ask you, how can we have patient safety, patient centered care and teamwork if there is no willingness to deal with the issue of time with the patient?

 

 

 

Just Published New Book Collaborative Caring

CollaborativeCaringI am very happy to announce that I, along with my two co-editors, David L. Feldman M.D. and Michael Leonard, M.D. have just published our edited volume Collaborative Caring: Stories and Reflections on Teamwork in Healthcare.  The book is a collection of 50 rubber-hits-the road stories about what it means to implement teamwork, work on teams, or to work in settings in which there is no teamwork.  The wonderful people who contributed their essays include physicians, social workers, bedside registered nurses, psychologists,occupational and physical therapists, nurse practitioners, pharmacists, dentists, and hospital administrators.  The book also includes essays by healthcare professionals who write as patients who find themselves either the center of a team or exiled to the periphery when healthcare professionals function in siloed isolation. The book begins with an introduction (part of which is included below) and  is divided into eight sections, which cover the following topics:

Playing on a Real Team; The Dangers and Damage of Poor Teamwork; Is the Patient on the Team or Not; Psychological Safety; Teaching What We Preach; Patient Advocacy as a Team Sport; Barriers to Teamwork; Taking Teamwork Institution and System-wide.   The essays in it are not journal essays preaching about what to do but rather talk about real life experiences and show people how to do it — implement teamwork and play on real teams.  I have included in the blog-post an excerpt of the book’s introduction.

From the Introduction of Collaborative Caring:

“These days, teamwork is all the rage in health care. No matter where you look, there is talk of teams. There are interdisciplinary or interprofessional teams, medical teams and nursing teams, patient-centered teams and patients at the center of the team. We constantly hear that there is no “I” in the word “team,” or else we find out how to put it back into the team through leadership. Listen to the buzz and you find that teamwork today isn’t only for elite players— the quarterbacks and pitchers of health care—but is all-inclusive. Housekeepers, transporters, patient care assistants, and elevator operators—everyone is supposedly on the team, and it supposedly takes everyone to deliver patient care and enhance the patient experience.

“In 1999, the Institute of Medicine launched the contemporary patient safety movement with To Err Is Human, which reported that each year almost 100,000 people die and 1.5 million are injured because of medical errors. Its subsequent report in 2001, Crossing the Quality Chasm, argued that better teamwork and communication among all those who work in health care could vastly reduce that toll of injuries and deaths.2 In 2013, the World Health Organization published its “Framework for Interprofessional Education and Collaborative Practice” and the Lancet its “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World.”

“Given the rhetoric about the importance of teamwork, one would think that health care institutions of every kind would have taken up the challenge to move from the traditional model of parallel play among intimate strangers (known in the trade as “siloed care”) to a genuine teamwork model. One would also think that this paradigm shift in the rhetoric would be reflected in both the facts on the ground and the statistics. When one looks at the statistics, however, there is barely any positive movement in the number of patients harmed or killed in health care today. In fact, new studies document that the IOM’s original estimate of 98,000 people killed each year from medical errors and injuries was a dramatic underestimation. Recent Medicare data tells us that more than 200,000 patients per year die as a result of avoidable medical harm, and we know one in three patients admitted to a US hospital suffers an adverse event there. Yet another report esti- mates the number of deaths to be between 220,000 and 440,000.5 As for the facts on the ground, anecdotal reports reveal that—some pockets of excellent teamwork notwithstanding—teamwork in most health care settings is more of a dream than a reality. What explains this con- trast between rhetoric and reality? We believe it’s a failure to understand what teams are, how they are built, how they are led, how members on teams should really behave if genuine teamwork is to be realized, and how they are sustained over time.

“There are many theoretical and conceptual books and countless articles that have explored issues of teamwork in general and team- work in health care in particular. The editors, and many of the authors in this book, have read most, and have even written some of them. To tackle the issue of teamwork, we have, however, taken a different approach. Rather than write a theoretical book about what teamwork is, what it is not, where it exists in health care, what barri- ers prevent its implementation and how they can be removed, we have chosen instead to address these questions through narratives and reflections that vividly describe good teamwork as well as problems in creating, leading, and working on genuine teams. What we believe is too often lacking in the literature is a clear and compelling picture of what teamwork looks like on the ground, in the institutions where health care work is delivered and where teams play well, or don’t play well, on a daily basis. The question we ask here is thus: What is the state of play in most health care institutions?

“To describe the state of play, we have asked clinicians to write what we think of as “where the rubber hits the road” stories or reflections about the nature of teamwork in their own particular work setting. To gather these stories, we talked to many people in different health care disciplines.

“When we extended our invitation, we deliberately asked people not to focus exclusively on the dyad of doctor-patient, nurse-patient, PT-patient relationship, which is what so much of the pedagogy on communication in health care has addressed. Although we have included stories by patients, and patients are involved in almost every story, we are convinced that no system of patient-centered care—or that claims it wants to put the patient at the center of the team—can succeed if all the rest of the players are flying solo and there is essentially no team on which the patient can, in fact, play. While good communication and teamwork among different groups, professions, and disciplines does not necessarily assure good communication and teamwork with patients, it is a necessary but insufficient condition for the genuine inclusion of the patient on the team, and, thus, the creation of patient-centered care.

“Indeed, we would bet that poor communication and lack of team- work (particularly what Suzanne Gordon terms “total communication meltdowns,” or (TCMs) are the foundation of patient harm. Even if such TCMs don’t directly involve patients, if you look carefully, you will find that at the sharp end of such poor teamwork and communication is the patient who inevitably suffers from the existence of unresolved conflict, abuse, and other major and minor teamwork failures. Those who work in health care at every level often assert that their “professionalism” will somehow trump the fact that they have been told off, reamed out, ignored, or otherwise publically or privately disrespected and that they can function at an optimum level in spite of all manner of conflicts and problems. Health care managers and administrators are even more enamored of the myth that health care workers can just suck it up and perform with aplomb in spite of unmanageable workloads, fatigue, lack of support, simmering resentments, and outright conflicts as well as other assorted, unresolved problems.

“This is a long-winded way of saying that although this book does not focus squarely on the patient and clinician-patient communication, its every word, comma, and semicolon is dedicated to the proposition that excellent intra- and interprofessional teamwork and communication among those who work in health care is the only avenue for putting the patient first and making health care safer and more cost effective.

“People who work in many different areas in health care have written the stories in this book. Even the stories from the point of view of patients are written by patients who have a great deal of experience in health care, either as clinicians or researchers or both. Almost all the authors are identified by name. In one case, in which the author reported on a serious failure of teamwork, the author requested not to be identified, and we decided to include that anonymously written story. We can assure you that this is an expert practitioner who, for reasons that will be obvious when you read the story, worried about being disciplined if identifying details were printed.

“We deliberately solicited these very “real world” stories because we wanted to move beyond theory to practice to show—rather than tell—readers what it takes to make a team, lead a team, and be a team member. We also wanted to show, rather than tell, how easy it is for smart people of very good will to defeat—or create—teamwork and thus quality patient care.”

David and Michael and I are really excited by this new book. We hope you will consider looking at the book and letting other folks know about it.

Big Surprise! More Bad News about Patient Safety

MedicalErrorLast week the Boston Globe reported more bad news about patient safety.  In an article entitled “Mass Hospitals’ Mistake List Widens”, the Globe reported that, “Massachusetts acute-care hospitals reported 753 serious medical errors and other patient injuries last year, a 70 percent annual jump that health officials attributed mostly to expanded definitions of what constitutes medical harm.

“So-called serious reportable events in other types of hospitals, including those that provide psychiatric or rehabilitative care, rose 60 percent from 2012, to 206.

“Instances where patients underwent a procedure on the wrong body part, were burned by an operating room fire or a too-hot heating pack, or were subject to contaminated drugs or improperly sterilized equipment saw some of the largest increases in reporting since 2012.

“Hospitals also reported more patient falls, serious bed sores, assaults, and suicides and suicide attempts.”

The article did not delve into the reasons for these disturbing statistics, except to suggest that perhaps increased reports were due to increased reporting.  Is that supposed to be a plus?  Asked whether this report was a sign that things are somehow getting better because hospitals are reporting more problems, Allan Frankel, (former head of patient safety at Partners Healthcare and now Chief Medical Officer at the wonderful Safe and Reliable Healthcare, along with my colleague Michael Leonard), responded candidly and emphatically,”No!”

Frankel is right.  The questions that need to be asked when statistics like these are revealed are the following:

Are the hospitals in question doing team training in a systematic recurrent way?

What are their nurse to patient staffing ratios, the patient loads of their physicians, laboratory techs etc?

Who sleeps and when?  Do nurses routinely work 12-plus hour shifts.  Are resident physicians hour restrictions routinely violated?  Are people afraid to speak up when they see a patient safety problem– like when they think a surgeon is about to operate on the wrong body part?  Do hospitals use SBAR (see my last two blog posts) and other predictable patterns of communication?  Do they use use surgical checklists, time outs, not just sometimes but all the time, not just sort of but really.

The list of questions could go on and on.  The problem isn’t more reporting, the problem is less of the right kind of consistent systematic action on patient safety.