Patient Centered Care

 Patient Centered - or Not

Patient-centered care supports active involvement of patients and their families in decision-making about individual options for treatment.

We all believe in patient-centered care, or do we?  Maybe there is another side to this we, patient safety advocates, patient safety healthcare professionals and anyone who says that they support patient centeredness hasn’t heard.

A dear friend and physician has been a long- time supporter of patient’s involvement in their care.  This doctor is well known for spending more time with patients than the average office visit.  Patients have this doctor’s cell phone number and there are handouts in this office with information about Ask Me 3, Patient Safety Tips and other patient safety literature. But, in a recent conversation, this physician tells the story of a patient who decided to not receive a procedure that the physician agreed could wait.  After all, if the patient doesn’t want to have a test or procedure, that can probably wait, isn’t that patient centeredness?


What happens when that test might have been a life-saving?  Should a physician be expected to spend extra time trying to convince a patient to have a procedure or take a test that  is important but can wait because that's what the patient wanted?  There must be a yearning for some medical professionals to go back to the days when a doctor says what a patient should do and the patient does it.

Choosing Your Medical Team

Patient Safety is Not About Bad Medicine

When friends or family choose a clinician or hospital, I find that they often try to convince me how wonderful their choice is.  They will tell me that the doctor is great or the hospital is the best. That usually means that for whatever the reason, the patient and the patient’s family are happy with their choice.  Whether it’s bedside manner, a gentle personality or a clinician who has a large practice of patients who work in healthcare, the choice is personal and meets the needs of the patient.  Choosing a medical team is a personal choice and I don’t need to be convinced as to why someone chooses their team.  I too choose my team for what may be important to me, not others.

SILOS

Patient safety is not always about good or bad medical care.  Even in a hospital where everyone is treated like a special guest and patient centered care is apparent “things” can go wrong.  A nurse who is rushed or distracted may forget to wash her hands, pick up the wrong medication or forget to check the patient’s identification.  Mix ups, miscommunication or human error can happen in the best facilities and by the most experienced medical professionals.  The reasons how errors or unplanned outcomes may happen is not about incompetence.  Maybe in the “better” hospitals errors may happen less.  Maybe when choosing a physician who comes well recommended the outcomes may be better but a medical team is made up by many more people than one clinician.  It is made up of teams, working within systems where many things can go wrong.  My role is to educate the public and break down those silos (a term used to describe a business that lacks team work) to keep the patient and family aware how something might go wrong and be part of the medical team – that prevents anything from going wrong. 

Our team will be doing that again this May 19 and 21 from 5:30 PM to 9:30 PM . Register early – classes fill fast  Family Centered Patient Advocacy Training

Don't Let Curiosity Destroy Good Care

Curiosity Killed the Business

Could you imagine a medical professional saying to a person with HIV/AIDS, “You scare me so I would rather not treat you”? What about telling a person with disabilities that they are a “bother” and take up too much time?

You wouldn’t think that it could happen, but even if such things are not said out loud, only thought about, the care and treatment of the patient is compromised.

I recently gave a presentation about the work PULSE of NY does with community groups and vulnerable populations. I finished with a brief discussion about patient safety and my work with a variety of populations — one being patients who are transgender. As I was walking away, a man stopped me and wanted to have a private conversation. “What do we call these people?” he asked me. I stopped to think about this question and the words he used: “these people.” I know that if I were transgender, the hair would stand up on my neck. Instead I sat down with him, gave him my biggest smile and said, “I’m so glad you asked. I just wish you had asked earlier so everyone could hear the answer.”

I asked who he was, because earlier when I was with senior leadership I got the impression there wasn’t much interest in this topic, but now he was asking a very basic question. He was calling them “people,” and although it seemed a bit cold, his intentions were good.  It seems he was the head of the transportation team in this large community hospital and he explained that he conveys plenty of people who are transgender — people whose names don’t match their looks. He was grateful for my response and was taking notes. I was grateful that he cared enough to ask. But would he ask someone who is transgender?

Years ago when teaching a gathering of senior leadership in a small hospital about working with people with various physical disabilities, a nurse in charge said, “They take up so much time.” As an advocate for this community I had to catch my breath. I thanked her for her comments. “Now,” I said to the group, “what can be done to fix this?”

When we don’t acknowledge the hidden feelings, the stigmas or our fears of the unknown, it puts a burden on the people entrusted with the job of caring for people they don’t know enough about.

Not all patients are ideal patients. Some have many questions, some come to the hospital after a bad experience. Some patients will take extra time for a variety of reasons. This often can’t be helped. Allowing staff to explore their feelings about unwed mothers, people addicted to or dependent on pain medications, people with disabilities or people who are transgender is important to making a fully rounded medical team. Some medical professionals will say, “I really don’t care: a person is a person.” Wouldn’t it be great if they all did?

True Story in the Emergency Room

The Emergency Room Dilemma

As I walked into the emergency room to visit a patient, I saw the halls filled with equipment and beds.  No matter where I walked there was staff rushing by me – no smile, no eye contact, no one was aware that I was even there.  As I went down the pathway to see the patient I was there to visit, each tiny cubicle that had room for a bed and a chair, was divided in half for 2 beds.  The nurse standing next to the bed, talking to a patient couldn’t do so without her back pressing up past the curtain and into the next patient’s space.  How dirty is that curtain I thought to myself, to have it handled by visitors, staff’s clothing brushing up against it and so close to the bed, the patients are touching it. When I saw a man about 3 feet from the curtain, lying on his side continually coughing, I was sure that the curtains were full of germs.

My first thought was that if animals were caged like this there would be a public outcry.  How is this acceptable?

A patient on a gurney was only feet away from the patient I was visiting.  One of about 5 beds lined up at a wall because there were no cubicle’s left.  I heard the doctor asking the patient questions about her drug use and recent surgery.  For sure I would not be having an honest conversation with my doctor if I knew my business was for everyone to hear.  When I turned around, the doctor was pressing on her belly.  An exam usually done in private.

The sink was behind the patients head blocked by the bed and an IV stand so no one could wash their hands. 

I knew someone who worked there who invited me to see a nurse in charge.  “She really is concerned” he said and took me back to meet her.  I had the opportunity to listen and learned that there are just no beds and physically no room.  She explained; we have to move patients out faster and safely but if patients come, they need to be treated.  I knew she was right.  She said that there is on-going conversations about moving patients out more timely, getting more staff but “it takes time”. 

A complaint to the state would cause additional delays in care.  Resources would be used talking to state surveyors.  A call to the Joint Commission would also cause additional stress and further slow-down of care.  They know what’s wrong and don’t need to be told.  They need resources to fix the problem.

At a recent emergency room visit, cubicles were so tight the
patients bed took up the entire space .  The sink is hidden
here behind the patient's bed, blocked by equipment

I want to help – not blame. How do we all help ensure safe care for these patient’s.  The building is only so big.  Every bed is full.  Staff is being hired and trained to move patients out faster.  Would the hospital CEO be treated as these patients are treated?  Would the family of the CEO use these beds?   There are numerous opportunities for errors here.  Staff morale must be low.  I can’t imagine any medical professional would come into this business to work in these conditions.  A supermarket would never be run like this.  A gas station, post office, hotel or restaurant would never be this crowded or chaotic.  What are the answers?  Before an injury or death from staff working too hard, too long and being rushed we need to stop this craziness.   Any ideas?

Patient Safety Awareness Week - Some History

The History of Patient Safety - Patient Safety Awareness Week March 8-15, 2015

 

Some say patient safety started in the late 1800’s with Dr. Ignaz Philipp Semmelweis who was a Hungarian physician now known as an early pioneer of antiseptic procedures.   He was born July 1, 1818 in Hungary and lived until 1865 where he died in Austria.

Seimmelweis was best known for his discovery that the incidence of puerperal fever, also known as childbed fever, an infection following childbirth, could be reduced by use of hand washing standards in obstetrical clinics. 

Puerperal fever was common in mid-19th-century hospitals and often fatal, with mortality at 10%–35%.

During a research on the autopsy of his friend who died because of a fatal dissection wound, Semmelweis noticed symptoms similar to those of childbed fever. This observation prompted him to connect cadaveric contamination with puerperal fever. Soon after he declared that medical students carried infectious substances on their hands from dissected cadavers to the laboring mothers. This also provided the logical explanation for a lower death rate in the second clinic, operated by midwives because they were not involved with autopsies or surgery.

 

Seimmelweis introduced chlorinated lime solutions for interns who had performed autopsies and this reduced the incidence of death of mothers following childbirth.

 

His discovery was not supported by his colleagues. At a conference of German physicians his ideas were rejected.  The years of controversy gradually undermined his spirit.   

 

The stories surrounding his being institutionalized are controversial.  From suffering a breakdown because he had no fight left or that he was showing early signs of dementia.  The stories surrounding his death are also questionable.  He was beaten by staff until he died or he died from an infection.  Either way, there is no question that infection caused many deaths in the 1800’s and it does so now.  There is also no question that 150 years later, hand washing in the healthcare setting can reduce infection rates – but it’s still not done enough. 

 

Today there are over 90,000 deaths from hospital acquired infection with a cost to the economy of $10 billion.

 

 

 

http://semmelweis.org/about/dr-semmelweis-biography/

https://explorable.com/semmelweis-germ-theory

http://www.britannica.com/EBchecked/topic/534198/Ignaz-Philipp-Semmelweis

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

The Talk on Joan Rivers Lawsuit

Joan Rivers and The Talk

I watched the show The Talk. It opened with the story of Joan Rivers death and a lawsuit her daughter Melissa is bringing against the doctors and facility where the procedure was performed that ultimately killed her.  

A host asked “If you were Melissa, would you be suing?” gives us the impression that everyone who has lost a family member sues.  They don’t and they often can’t.  Not every medical negligence case gets the media attention that Joan Rivers received helping to move it along.  

Sharon Osbourne tells the cheering audience that to make sure this never happens again she would not rest until they all lost their license and she had a “whole chunk of money”. 

Unfortunately,  Ms. Osbourne is leading people to believe that a big chunk of money is what will improve medical care in this country.  It won’t.  When the lawsuit is done and everyone is paid (and attorneys have every right to be paid for their services) what will the change be?  These doctors can go get a license in another state and though this exact behavior may not be the problem, these behaviors can happen again. 

Making Meatloaf

Can You Really Repeat Back Everything?


During a recent classroom of nurses I was instructing, one of them asked if she is the patient's advocate shouldn't she be able to explain to the patient what the doctor said if the patient doesn't understand?

I gave her the "Meatloaf" lesson I have been working with for years.   "Who here has a wonderful meatloaf recipe" I asked the group.  One hand shot up, so I then asked who wants to go with me for dinner and have meatloaf?  Another hand went up.

I set the stage that the two of us were going to dinner to have meatloaf at Jayne's house and it was so wonderful, I asked Jayne to share the recipe with us.  I would love to make that meatloaf!  Jayne gave us the recipe.  "I use some pork and beef and an egg some seasoning and mix it all together and bake it".

I then asked the other nurses if they can repeat it.  She, nor the rest of the class could get the recipe exactly as it was shared, nor could they remember everything that was said.

So the answer is "no".  If the patient or their helping family member doesn't understand the treating clinicians instructions, diagnosis or information, the advocate is responsible for having the clinician explain it again until the patient understands it.  Too much information can be lost in the explanation.

The teach back method also is important for the same reason.  If the person receiving the meatloaf recipe writes it down, or repeats back what she heard, Jayne can verify that she has the information correct.  If Jayne just asked if we understood, it's too easy to just say "yes" and when we get home, we forgot what the actual recipe is.

Medical errors happen too often because of miscommunication.  An important part of patient safety is understanding each other.  Patients should never feel embarrassed or intimidated when  not understanding what is said, its also hard to remember a meatloaf recipe.

Reports Give False Hope

Don't Let Reports Fool You

Don’t let reports of hospitals doing poorly cause you false hope that you are automatically safe if you use another hospital. Newsday December 23, 2014 

We know that as well as bad things happening in hospitals, lives are saved each and every minute of each day.  But, I don’t want to take away from even one life being cut short because of a medical error, hospital acquired infection or unplanned outcome.  Reports that a hospital has lower ratings than another gives reason for leadership to pat themselves on the back – but even in the “best” hospitals people have bedsores, die from infections and can be given the wrong medication.  Even if they don’t make the news.  To let our guard down even for a second is a cause for concern.  

Never had a car accident?  So should you stop wearing your seat belt?  Cancel your insurance?  No.  We must use these reports only as an opportunity to continue the conversation, recognize we aren’t where we need to be yet and continue the education and advocacy that was started long ago.  This report is screaming that PULSE of NY is important and patient safety groups need to step it up a notch and work closer where the problem is – in the hospitals and at the bedside.

Understanding HIPAA

HIPAA, So Misunderstood

HIPAA does not mean your clinician cannot share information with your family.  HIPAA does not mean that a doctor cannot share your information with another clinician.  Many of us, as well as the people who work in healthcare do not understand HIPAA.

Health Insurance Portability and Accountability Act of 1996 (HIPAA), provides protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes. 

If I do not object, can my health care provider share or discuss my health information with my family, friends, or others involved in my care or payment for my care?

Answer:

Yes.  As long as you do not object, your health care provider is allowed to share or discuss your health information with your family, friends, or others involved in your care or payment for your care.  Your provider may ask your permission, may tell you he or she plans to discuss the information and give you an opportunity to object, or may decide, using his or her professional judgment, that you do not object.  In any of these cases, your health care provider may discuss only the information that the person involved needs to know about your care or payment for your care.  

Here are some examples:

·         An emergency room doctor may discuss your treatment in front of your friend when you ask that your friend come into the treatment room.

·         Your hospital may discuss your bill with your daughter who is with you at the hospital and has questions about the charges.

·         Your doctor may talk to your sister who is driving you home from the hospital about your keeping your foot raised during the ride home.

·         Your doctor may discuss the drugs you need to take with your health aide who has come with you to your appointment.

·         Your nurse may tell you that she is going to tell your brother how you are doing, and then she may discuss your health status with your brother if you did not say that she should not.

BUT:

·         Your nurse may not discuss your condition with your brother if you tell her not to.

You may want information kept private - but it isn't always about HIPAA.  Privacy and ethical behavior can’t be disputed, HIPAA can.

Before your next medical appointment, read about HIPAA here:

http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

Patient Safety Education; You Need PULSE of NY

Why You Need PULSE of NY

In a recent 30 minute presentation about patient safety I began to talk about the difference between a healthcare proxy and patient advocate.  A woman in her later years shot her hand up and said “you need to have a friend who knows information about you in case you can’t speak” she told a room full of her peers.  It was apparent as we continued the dialogue that she didn’t know what a healthcare proxy or advance directives are.  We often assume people know what we are talking about.  Patient care is a perfect example of language that is misunderstood and too often the receiver of the information is too intimidated to ask or feeling overwhelmed.  They also may think they know information but until it’s time to follow instructions of a care plan – possibly like taking medication, they realize they don’t understand.

“Do you think that a patient’s bed rail needs to always be up to avoid falls?” I asked explaining that falls can cause serious injury and may add as much as $13,000 to a hospital stay.  When most of the audience nodded, I explained how a patient, no matter their age, may try to climb out of their bed and this could be tragic.  When visiting a friend in the hospital, if you know they may have fallen in the past, be sure the nurses know.  “If you see a star or sometimes a picture of a slipper on the door” I explain, “do not encourage the patient to get up”.

The presentation I cover is about some basic topics costing healthcare billions of dollars each year.  Falls, infections, literacy, medication and surgery also known as F.I.L.M.S. is the basis of the presentation.  Other important topics are advance directives, communication for the best diagnosis and record keeping.

At one community program, audience members admitted that when discharged from the hospital, they left without understanding their next steps.  Should they go back to the surgeon, their family physician or not at all?  If they didn’t understand their medications they were given, some people have told me they wouldn’t get a prescription filled.  Understanding before getting surgery that there are people to help in the hospital with questions or concerns might keep someone from being readmitted because they didn’t understand their care plan.

Most people are annoyed that they are asked on numerous occasions their name and birthday.  When learning that this may help reduce errors, participants are encouraged to be sure every person who treats or transports them asks for 2 forms of ID and agree that now they will expect to be asked.

Choosing your advocate needs to be done before an emergency strikes.  Will your helper be non-English speaking, over 95 years old and unable to hear with limited sight?  Will your advocate or helper be someone who loves you so much they can’t think straight and cries continuously when your clinician talks to you about your cancer diagnosis?  

Listening skills, communication examples and fun interaction can turn patient injury into a celebration of care going right.

Patient safety is not about us – or them.  It’s everyone’s responsibility to be part of the team working around the patient for patient centered care.  We all need to work together to keep a patient safe; friends, family and medical staff.  It’s time the information about patient safety comes out of the hospital walls and lands in the laps of the public so changes can happen.  If you’re looking for a community presentation that can last 45 minutes to *6 hours, call (516) 579-4711

*The PULSE of NY 6- hour workshop is a certificate programs.  Fees may apply

http://www.pulseofny.org/