Is There a Leader in the House

mlm-leaders-Leader-In-Me-BookHealthcare is steeped in  hierarchy, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower/team member(but more on that in a later post), and very preoccupied with chain of command, as in not breaching it.  Problem is, many people who insist they are the leader of the team (which, in most places are teams in name only) want to be in command, not  in charge.  Consider the following story which an experienced RN at a major teaching hospital recently recounted.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to have abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service  had prescribed a regimen of pain medications, which had been effective.  On the day in question, Smith came on to her shift.  She learned that the pain service saw the patient in the morning and the patient’s pain was well managed.  Three hours later, the patient had a significant spike in her pain and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything new, the pain service physician said she felt that the patient should be seen by the GI team since the pain level had altered.  Nurse Smith called the GI team but they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team.  She told  Smith to call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 repeated that she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst.  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and write off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

One of the things this story also spotlights is the fact that in too many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, or from intern, to resident, to attending, or a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – it seems that everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital.

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues’ refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in nominal charge of the patient refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a  story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  The story, which we recounted  in our book Beyond the Checklist, went like this.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly developed complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Holding his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.” Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hopkins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a meaninful two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discovered that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not only to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then rather than numerous  self-declared leaders we’ll actually have some real leadership in healthcare.

 

 

 

 

 

 

 

 

Healthcare is deeply hierarchical, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower (but more on that in a later post), and deeply preoccupied with chain of command, as in not breaching it.  Problem is, even though physicians insist they are the leader of the team, in actual practice, most health care teams are not only teams in name only but also leaderless.  Everyone, it seems, wants to be in command, but in many situations, no one seems to want to be in charge.  Consider the following story whichh an experienced RN at a major teaching hospital recently told me.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to her floor for abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service was also involved in care and had prescribed a regimen of pain medications, which were working.  On the day in question, Smith came on to her shift and the pain service saw the patient in the morning.  Three hours later, the patient had a significant spike in her pain, and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything else, the pain service physician said she felt that the patient should be seen by the GI team since the pain seemed to be new.  Nurse Smith called the GI team and they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team and that Smith should call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 said she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

 

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst (http://www.gme.medsch.ucla.edu/chiefresidents/Eradicating_Medical_Student_Mistreatment___A%2099583.pdf).  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and right off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

What this issue really highlights is the fact that in so many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, to a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress, did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital. (http://www.nytimes.com/2003/03/22/nyregion/mount-sinai-may-resume-a-liver-transplant-program.html)

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in charge refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a terrifying story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly de- veloped complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.28

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Hold- ing his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.”29 Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hop- kins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discover that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then maybe we’ll have some real leadership, rather than just a bunch of unattached leaders, in healthcare.

 

Healthcare is deeply hierarchical, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower (but more on that in a later post), and deeply preoccupied with chain of command, as in not breaching it.  Problem is, even though physicians insist they are the leader of the team, in actual practice, most health care teams are not only teams in name only but also leaderless.  Everyone, it seems, wants to be in command, but in many situations, no one seems to want to be in charge.  Consider the following story whichh an experienced RN at a major teaching hospital recently told me.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to her floor for abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service was also involved in care and had prescribed a regimen of pain medications, which were working.  On the day in question, Smith came on to her shift and the pain service saw the patient in the morning.  Three hours later, the patient had a significant spike in her pain, and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything else, the pain service physician said she felt that the patient should be seen by the GI team since the pain seemed to be new.  Nurse Smith called the GI team and they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team and that Smith should call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 said she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

 

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst (http://www.gme.medsch.ucla.edu/chiefresidents/Eradicating_Medical_Student_Mistreatment___A%2099583.pdf).  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and right off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

What this issue really highlights is the fact that in so many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, to a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress, did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital. (http://www.nytimes.com/2003/03/22/nyregion/mount-sinai-may-resume-a-liver-transplant-program.html)

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in charge refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a terrifying story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly de- veloped complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.28

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Hold- ing his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.”29 Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hop- kins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discover that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then maybe we’ll have some real leadership, rather than just a bunch of unattached leaders, in healthcare.

 

 

Healthcare is deeply hierarchical, obsessed with leadership (as in everyone wants to be a leader and no one wants to be a follower (but more on that in a later post), and deeply preoccupied with chain of command, as in not breaching it.  Problem is, even though physicians insist they are the leader of the team, in actual practice, most health care teams are not only teams in name only but also leaderless.  Everyone, it seems, wants to be in command, but in many situations, no one seems to want to be in charge.  Consider the following story whichh an experienced RN at a major teaching hospital recently told me.

The nurse, we’ll call her Joan Smith, was taking care of a gastroenterology patient who’d been admitted to her floor for abdominal surgery.  Nurse Smith had taken care of the patient for twelve hours the previous day.  The patient had problems with chronic pain and the pain service was also involved in care and had prescribed a regimen of pain medications, which were working.  On the day in question, Smith came on to her shift and the pain service saw the patient in the morning.  Three hours later, the patient had a significant spike in her pain, and was in agony.  Smith knew the patient and that she was not “acting out,” or trying to “put anything over” on anyone – accusations which patients face all too often if they happen to have the misfortune to suffer from chronic pain.  Nurse Smith called the pain service to advise them of the change in the patient’s condition.  Rather than prescribe anything else, the pain service physician said she felt that the patient should be seen by the GI team since the pain seemed to be new.  Nurse Smith called the GI team and they did not return her numerous pages.    She then called a third year resident (R3) on the GI service and asked the physician-in-training to come and see the patient.  The R3 said that she was not on campus and that it didn’t seem like something for the GI team and that Smith should call the pain service.  Smith said she had just called the pain service and they said to call the GI team, which she did, but the on-call didn’t respond and the patient was in serious discomfort.

The R 3 said she was not even on campus anymore and said Nurse Smith should call the on-call resident.  Nurse Smith explained that she had just done that, several times, and did not get a response.  Nurse Smith tried to maintain her cool and kept repeating that the patient was in pain and that the priority should be to take care of the patient.  She said she would try to call the on-call again but again there was no response.

About twenty minutes after Nurse Smith talked to the R3, the young woman came in the room.  She examined her abdomen, assessed her condition, asked the patient some questions and then insisted that there was nothing she could do and she told Smith that she was leaving and was going to turn off her pager.

 

There are many possible morals to this story and if one did a root cause analysis, there would doubtless be many issues to highlight.  One is the widespread mistreatment of medical trainees, which impacts their ability to empathize with their patients and makes them cynical at best and callous at worst (http://www.gme.medsch.ucla.edu/chiefresidents/Eradicating_Medical_Student_Mistreatment___A%2099583.pdf).  Another is lack of sleep, which is still a problem despite significant changes in resident hours.  Another is the long-standing problem between physicians and nurses which I have written about for years.  Then there is the tendency of physicians and nurses to disbelieve and right off patients who experience both chronic and acute pain.  There is also the issue of no team training in healthcare (there has been none at this major teaching hospital, in spite of its reputation for promoting patient safety and its many well known patient safety physicians.  I am sure there are countless other issues to highlight.

What this issue really highlights is the fact that in so many instances there seems to be no leader on the healthcare team willing to take charge of the patient.  Whether in a teaching hospital where accountability for the patient is passed from one service to another, to a community hospital where an RN calls an attending physician in the middle of the night and is told to call cardiology, or pulmonology or oncology – anyone but me, the one who is on the phone now – everyone wants to be THE BOSS, but no one seems to want to be in charge in the moment, particularly if it means more work for either the weary or the otherwise occupied.

When I heard this story – which is only one of many similar ones I have heard in the past – I was struck by several things.  First, I was stunned by how short our system memory seems to be.   Apparently the resident who blithely announced she was going to turn off her pager in the face of a patient in distress, did not perhaps remember the terrible incident that happened in 2002 at Mount Sinai Hospital in New York. reminded me of the horrible incident at Mount Sinai when a man donating a liver to his brother died of an infection in part because no one could reach a resident who had turned off his pager when he left the hospital. (http://www.nytimes.com/2003/03/22/nyregion/mount-sinai-may-resume-a-liver-transplant-program.html)

I was also struck by the lack of recourse of nurses, and even some doctors, in the face of their colleagues refusal to address significant patient suffering or safety issues.  Nurses constantly report this kind of issue.  But nurses aren’t the only ones who seem to have little recourse when the person in charge refuses to take charge.  In his book Safe Patients, Smart Hospitals, world renowned physician Peter Pronovost recounts a terrifying story in which he was forced to be a bystander, seemingly powerless to force the surgeon in command of taking charge of his patient.  An otherwise healthy twenty-nine-year-old woman had been admitted for laparoscopic removal of a kidney. She quickly de- veloped complications, and the surgical resident called Pronovost, who was at the time on call at home as an ICU attending. He told Pronovost that the surgeon in charge had requested that the patient be admitted to an intermediate care unit for extra nursing monitoring in spite of the fact that the surgeon insisted the surgery had gone well and the patient would be fine. Four hours later, at 2:00 a.m., the same resident called Pronovost to request the patient’s admission to the ICU with life-threatening problems.28

Pronovost understood that the patient’s problems could only be a result of a surgical complication and that she needed to return to the OR or she could die. The surgeon, the resident insisted, did not agree and refused to take the patient to the OR. Because the surgeon was in charge of the patient, neither Pronovost nor the resident could get the patient to the OR immediately. Pronovost called the surgeon, who continued to insist that his surgery had gone without a hitch. Hold- ing his temper, Pronovost argued his case, and the surgeon finally retorted, “I am not going to the OR. I have to leave town. From now on talk to the surgeon on call.”

After additional delays, the woman was taken to the OR, and another surgeon discovered that during the first surgery the trocar, a harpoon-like rod used during laparoscopic surgery, had accidently punctured her intestine and pancreas. “Acci- dents like this happen: surgery is not a perfect science. However, if this had been discovered quickly the patient might have suffered less harm.”29 Because the surgeon did not tolerate cross-monitoring and was allowed even by a world-renowned colleague to refuse it, the patient who weighed 110 pounds on her arrival at the hospital ended up weighing 80. Instead of spending three days in the hospital, she spent six months and an additional year in a rehab facility. In addition, she lost both kidneys, was on dialysis, and needed a kidney transplant.

This incident did not happen at some remote or tiny hospital but at Johns Hop- kins Hospital, several years after the Josie King incident when Hopkins had be- come a leading example of an institution devoted to patient safety.30 Josie King was a toddler who had suffered serious burns and was admitted to the hospital and died because of dehydration—something that could have been prevented by bet- ter teamwork and communication among staff and between the family and staff. The problem here is not a single medical institution but, as Pronovost himself explains, the “toxicity” of the medical system itself. In this kind of hierarchy, there is no two-challenge rule so that someone else can take charge of the patient when the captain of the ship is on a deadly course. Nurses who are concerned about patient safety in an urgent situation have to go up a cumbersome chain of command—charge nurse to nurse manager to clinical director and then–which rarely happens—to chief nursing officer, which could take more time than the patient has. She cannot call in another physician to oversee the case. In fact, even famous physicians like Pronovost cannot wrest a patient in danger from a surgeon or other physician’s control.

One of the things all of this points to is the need to have a two-challenge rule in healthcare in which nurses or physicians or anyone else can challenge the person in nominal charge when they see a patient safety problem that is about to cause serious or possibly catastrophic problems.  This is true in aviation and has prevented many disasters.  A first officer or someone else can challenge a captain who is about to endanger passengers and plane and can take over command of the aircraft if necessary.  Although such take overs are rare they do happen and have prevented tragedy.  In fact, if there is a crash or accident, or even near miss and it’s discover that the subordinate did not speak up or take charge, they can be disciplined for having remained a passive bystander when it comes to safety.  When they do take over, they are thanked.

We need to do this in healthcare.  In the case recounted above, the nurse has to have permission – indeed, be expected, not to call her nursing chain of command – a cumbersome and ineffective act in an emergency.  She – or he – has to be institutionally authorized to immediately go over the head of anyone she needs to to get to the person in charge, whether that’s the attending, the chief of service, whomever.  In the case of someone like Pronovost, the SICU attending has to be able to call another surgeon who can take the flight/patient to safety.  There has to be an accepted and expected procedure to do this and whoever does this, even if the call was wrong, has to be thanked.

I can hear the naysayers.  This will mean attendings, chiefs of service, CEOs, whoever, will be constantly being called by nurses and other underlings, woken in the middle of the night, interrupted at dinner, disturbed on the golf course.  Well guess what?  Maybe if a lot of attendings and chiefs and CEOS start getting disturbed more often they will do something to force the folks who want the power and authority to start using it in the service of  the patient.  Then maybe we’ll have some real leadership, rather than just a bunch of unattached leaders, in healthcare.

 

 

 

 

 

 

 

 

 

 

 

 

 

Showing 4 comments
  • Rebecca
    Reply

    Great post. Nurses need to be acknowledged as the voice of the patient. We are advocates aren’t we? Not acknowledging that advocacy is disallowing our ability to practice at our potential at the most basic stance, no matter where it comes from-nursing or medicine.

    • Suzanne
      Reply

      Yes you are one of the voices of the patient, but actually not THE only voice. What is interesting to me is that nurses are also part of the problem in denying the role of other healthcare clinicians and workers. So I totally believe we need to know more about nurses. I have spent most of my career trying to explain what nurses do to the public. But let’s all get real here and start talking not only about one other member of the team,RNs but of everyone on it.

  • Helen M. French RN, BSN
    Reply

    Hi….conferences, and talking…..and talking and conferences…talk is cheap! In 1991, there were over 98,000 deaths in our healthcare system….now it was recently reported that there are over 240,000 deaths in our system. I know the system problems and I know most of the solutions….and I will say IT till I die, “It is all about power and money and money and power by the elitists in nursing which have so significantly contributed to the carnage in our healthcare system…..nurses are great but nurses are not medically trained! The day nursing started trying to take over patients’ care and replace doctors, is the same day that medically educated and trained doctors/surgeons self respect went out the window therefore causing a confusion in job roles…..I have been an operating room RN since 1974 and I have never seen the likes of what is going on the last 10 years just in the OR arena! Every patient deserves the same standard of care i.e. care by doctors with his team and cohorts….not by proxy! I encourage everyone to read my book which also has suggestions for certain “executive orders” which should be signed into law by President Obama ….my suggestions will save lives stat…trying to go the regular legislative or conference route only allows the system to “kill” more patients! Secondly, my “check-off” list in my book is for patients to read, ponder, and fill out…it is the only check-off list that truly would save lives from needless harm due to non or mis-information. Bullying, lateral violence, mistakes, infections, retained OR hardware, wrong patient surgery, wrong surgery on wrong patient, med mistakes, incorrect counts, patient falls, the mandate for RN’s to delegate to UAPs or “its the highway” or the loss of their RN license, and etc , again, in my opinion, is all due to the nursing elistists attempting to take the seat of power….if a nurse wants to play “doctor”, then I suggest he/she go to medical school, do the internship, residency, fellowships etc….we all need to work together …..divided, our patients suffer or die! Regards, my opinions,
    Helen M. French RN,BSN

    Amazon Book: A book by Helen M. French RN,BSN: “FRENCHIES HOSPITAL
    SURVIVAL TIPS” @ http://www.amazon.com/dp/B0055LH5MU/

    Curriculum Vitae: Helen M. French RN, BSN

    As a Clinician Level III, Registered Nurse, at the University of Virginia Health System / Operating Room, Helen was a perioperative generalist in the operating room and throughout outlying units “floating” between all the operative specialties as a registered nurse circulator and/or as a registered nurse scrub. She was a member of the University of Virginia Hazardous Waste Sub-Committee since 1993, and chaired and participated on many perioperative and hospital committees and extracurricular activities at the “U” for over 20 years. She is especially known for The University of Virginia MERCI Program (Medical Equipment Recovery of Clean Inventory), which she founded and coordinated from 1991 to 12/2007. The MERCI Program still exists today and is now its own hospital department.

    Helen French always received excellent university / state yearly evaluations. Her last state evaluation was deemed as “Outstanding” with a numeric score of 359 out of a possible score of 400.

    Helen French received her Associate Degree in Nursing from Piedmont Community College (PVCC) Charlottesville, Virginia and her BSN from the University of Virginia, Charlottesville, Virginia in 1991. She was nationally certified in perioperative nursing I.E. CNOR (certified nurse operating room) up to 12/2007.

    Helen received on May 08, 2009 the 2009 Distinguished Nurse Award from the University of Virginia Beta Kappa Chapter of Sigma Theta Tau International Honor Society of Nursing.

    Helen M. French initially worked at the Kings Daughter’s Hospital in Staunton, Virginia ( operating room) and later worked for the Waynesboro Hospital, Waynesboro, Virginia (operating room / now renamed Augusta Health) at which time she left to pursue her next step in her professional career i.e. her Bachelor of Science in Nursing and employment at a Level #1 Trauma Center.

    Helen had been an active member of AORN, the Association of periOperative Registered Nurses from 1974 – 2007 and subsequently, served on many district committees including the Board of Directors and Nominating Committee. She was appointed and served as the National Virginia Legislative Coordinator for the Association of Perioperative Registered Nurses (AORN) from 2001- 2002 and 2002-2003, was President of her AORN District twice as well as served as their Legislative Chairman from 1991-2006. Helen has received three AORN National Legislative awards.

    Helen M. French had served as the Virginia Nurses Association’s Director at Large and has held many other VNA positions in the past. As a longtime member of Sigma Theta Tau International Honor Society, she has also been listed in their “Media Guides” as an expert in “Hospital Medical Waste Management”, a topic which she has presented at a meeting at The National Institute of Health, “Healthcare Without Harm”, and other environmental conferences. Helen participated on a Federal EPA Task Force on Medical Waste Minimization for over three years per a Virginia congressman’s recommendation which culminated in a national MOU i.e. Memorandum of Understanding. AORN and Sigma Theta Tau published her MERCI (Medical Equipment Recovery of Clean Inventory) articles.

    In regard to MERCI, Helen founded and had coordinated the no-cost University of Virginia Health System MERCI Program (Medical Equipment Recovery of Clean Inventory) since August of 1991 to December 2007. By 2007, the program had captured and diverted over 500 tons of clean medical supplies at no cost to the hospital (valued at over 108 million dollars) just to missions who then shipped the supplies all over the world. Over 50,000 pounds of clean and sterile medical supplies were also diverted to UVA research labs and to those serving on short mission trips with the UVA School of Medicine, and etc. Another 500 plus tons of medical supplies and equipment had been received from donors and ‘directly” given to NGO’s (non-profit organizations). Helen still networks for medical supplies for individuals and for organizations. One example is a donation of supplies, from a Pennsylvania medical supply company, which she diverted for wildlife welfare. (Some recipients of MERCI supplies and from donations to MERCI were The US ARMY for a Workshop on Weapons of Mass Destruction, a American/Russian astronaut program, MERCY Ships, Operation Smile, Gleaning for the World, Equipping the Saints, RAM project at UVA Wise WV, Mission of Hope Bolivia, etc. and to such places as St. Kitts, Liberia w. Africa, Lithuania, Russia, Nicaragua, Paraguay, Philippines, etc. and to relief efforts such as Hurricane Katrina, to dental clinics for the under served, etc. etc. The donations from major medical supply companies was astounding and a blessing for all missions which networked with UVA MERCI.

    The MERCI program under Helen’s tutelage promoted actions for a cleaner environment, served as an educational program for students, provided fiscally sound suggestions to eliminate wasteful practices through out the hospital, and very importantly, benefited humanity by aiding various states in local need ( Katrina disaster, RAM Tennessee/Virginia Project, etc. ) as well as the less fortunate through out the world. MERCI was recognized by the State of Virginia House Joint MERCI Resolution #739, whose main legislative patron was Delegate Mitch Van Yahres as well as by a Virginia DEQ (Department of Environmental Quality) award. Helen has planted thousands of MERCI “seeds” through meetings and through emails.

    Some of her awards included a Volunteer Award by the UVA School of Nursing Alumni Association and from the University of Virginia Health System Community Service Award for “Extraordinary Dedication and Excellence in Volunteerism and Health-Related Outreach” as well as the University of Virgina Daniel T. Pesult Award.

    MERCI was honored to be included on The Luminary Project: Nurses Lighting the Way to Environmental Health. Earlier, even The Bill & Melinda Gates Foundation offered funds to MERCI.

    The story of Helen’s MERCI Program was included in the edition of LeeAnn Thieman’s , Chicken Soup for The Nurse’s Soul, Second Dose. Besides being a busy mother and nurse, Helen was also a Big Sister (Big Brother/Big Sister) to a young teenager for over five years. In 2012, Helen became a volunteer in the Virginia Medical Corps (emergency preparedness). She authors articles for healthcare and nursing blogs as well as sits on The Truth in Medicine Board of Directors. However, Helen French’s main passion will always be for “safe patient care”, I.e. Do No Harm, an aspiration which has been reflected in her long nursing career.

    ( Helen has letters from thousands of people from over the years which validates MERCI works, a no cost program which benefits especially not only humanity but all hospital & research financial systems, is bright green and sustainable, is an educational tool and one which Helen believes should be used as a working concept for state and national emergency preparedness for the generic public. A letter from Marilyn Tavenner, once the Secretary of Health for Virginia and now head of CMS, states that MERCI concepts have been implemented by many Virginian hospitals. It is also Helen’s belief that her MERCI concepts should be used by one group to set up a state/national clearing house program so all hospitals, especially the operating room/surgical clinics arena, work together with medical supply companies as one in order to assist all qualified NGO’s in all states to help the under served in all countries as well as be used for relief efforts in the USA. She has assisted OR RNs and etc. all over the United States to set up their own mission projects BUT feels that until everyone works together the results will never be effective. Helen knows through personal experience that there are enough medical supplies and medical equipment for everyone in all states to divert to their specific missions work. Helen set up the MERCI concepts to be simple, and able to be replicated, safe, and no cost. Being that Helen was born in Slovakia, which endured World War ll horrors, and being aware of emergency preparedness issues which would deplete the United States’ supply of medical supplies in less than three days, she has developed strong beliefs that the MERCI concepts should be incorporated into state and federal emergency preparedness programs in order to save lives of the generic population….a topic for another day.)

    (In 1991 the CEOs at the University of Virginia Medical Center placed their trust in me in regard to solving their excessive waste issues problems coming out of the UVA operating rooms and the hospital. With CEO backing, through my audits and identification of opportunities, nursing expertise on safe practices, networking and through eliciting cooperation of hundreds of UVA staffers, I was able to set-up and coordinate a total waste reduction program which I named MERCI (my acronym for Medical Equipment Recovery of Clean Inventory). My job description/role was that of an operating room RN circulator and scrub. However, under my tutelage, MERCI soon enveloped seven main facets: waste reduction, fiscal responsibility, and safe and green environmental, humanitarian, research lab, educational, and community endeavors (1991-12.2007). My goal is still to encourage others to adopt an eighth component i.e. emergency prepardness. (UVA MERCI Program is now its own hospital program)

    I just read an article which stated that there is now over 5 billion pounds of waste generated each year by hospitals! I purport that over 70% of this number is Gold Waste….a term, I coined many years ago. I also purport that it is this GOLD WASTE which will rein in hospitals’ waste issues as well as save staffers jobs….an issue which could be detrimental to patient safety if patient/staffing ratios are lowered.)

  • Maria
    Reply

    Excellent Suzanne. Thank you for bringing attention to this very important patient safety issue.

Leave a Comment