Sunday, October 24, 2010

Canadian Patient Safety Week - Welcoming our second-degree guests

Canadian Patient Safety Week is next week, but its theme – Ask.Listen.Talk - was on my mind a lot this week. And it made me think about a party we held last New Year’s Day.

We invited several friends over for brunch. At the last minute, one family called and said they wouldn’t be able to come. Weather conditions had prevented their visiting relatives from returning home, and they didn’t want to leave them alone. Of course, they were welcome to come to the party, so we set a few extra places at the table.

If you’ve ever been a “second-degree guest”, that is, accompanying someone who was invited by the host, you know it can be awkward. You may not know the host. You would rather suffer in silence rather than put the host out by asking for something. You don’t feel comfortable.

We recognized that our second-degree guests felt that way. All the other guests had been in our home previously and knew their way around. They felt comfortable with helping themselves to cutlery or serving themselves drinks. They made themselves at home, and we invited our new friends to do the same.

But that wasn’t enough.

If I’m visiting someone’s home for the first time, and am told to make myself at home, I won’t. Because I don’t know what “making myself at home” means in that home. Can I poke through the fridge looking for leftovers? Can I flick on the TV and watch the game? I don’t know what their micro-culture accepts, and so I will err on the side of sitting quietly on the couch.

Recognizing that our second-degree guests felt the same way, we did what any host would do, and made sure to pay extra attention to their needs. Would you like another drink? What do your kids like to eat? Like any host would, we wanted them to feel welcome and comfortable.

CPSW’s theme - “Ask.Listen.Talk.” - suggests that communication between patients/families and caregivers, and among caregivers, improves patient safety. No argument from me. But I think we need to consider how we implement Ask.Listen.Talk. in our practices.

Patients and their families are like second-degree guests visiting the healthcare system. Everything from our facilities to the language we use is unfamiliar and intimidating to them. While healthcare workers bustle about around them, visitors worry that even a wrong turn in a hallway may take them into an unauthorized area. They feel awkward.

And then, next week, we want them to “Ask.Listen.Talk.” Maybe we’ll put up some posters, or hand out a brochure. That will be the equivalent of saying “Make yourself at home!” Patients/families won’t know what is acceptable in the healthcare culture. Is it OK to ask the doctor whether or not she washed her hands before examining my mother? Will she be upset with me for asking? I don’t take a red pill at home, but I’m sure it’s OK here at the hospital, because the nurse must have checked it before she gave it to me. She looks too busy for me to bother her.

It’s nowhere near enough just to publicize our belief that communication improves patient safety. We need to actively seek out patient and family comments and participation, like we would for second-degree guests in our home. And when those comments arrive, we need to receive them positively and consistently. A sour look in response to a voiced concern speaks much more loudly than an Ask.Listen.Talk pamphlet on a bedside table.

Last week, I spent some time with a medical student, and we observed what we considered to be a breach of a patient’s dignity. We talked about it after we left that care area, and I asked him how he would address that with the caregiver responsible. He laughed. I laughed too. We both realized that I was being absurd. It would be a rare medical student who would comment on a breach of patient privacy, dignity or safety. At best, they would be ignored. At worse, they would be excoriated for their impertinence. How dare you…

He felt – undoubtedly correctly – that the caregiver would not accept such a comment from someone who was without standing in their culture. But we did explore possible approaches. I thought that he would need to test out – role-play – some options with like-minded colleagues before “going live”. Perhaps the old just-trying-to-be-helpful gambit: Would you like me to pull the curtain around the patient’s bed while you examine him?

I used a similar approach with our second-degree brunch guests. I wanted my 10-year-old son to find out if our guests needed anything, but I realized that giving him that vague instruction would be useless. It wasn’t that he didn’t want to help, or that he is unfriendly. It’s just that it was a new situation for him, and he felt uncomfortable. He needed some coaching and a specific script.

“Ask them ‘May I get you something to drink?’”, I suggested.

“’May I get you something to drink?’”, he repeated.

And off he went.

Coaching and scripting to encourage dialogue around patient safety will help us demonstrate to patients and families that we are serious about engaging them as active participants in safe care.

The day after my student and I had discussed impediments to his commenting on the breach of dignity, he joined me in the operating room. As I introduced him to the personnel in the room, the anaesthetist said this to him: If you see anything going on in here that you think is unsafe, please speak up. We value your eyes on what we’re doing.

That was a big step in the right direction.

Monday, October 11, 2010

Joy at work

It’s not often that I have a moment of joy in the middle of a cystoscopy clinic, but I had one last week.

A cystoscopy clinic makes for a busy morning. Over the course of 4 hours, I’ll see 12 to 14 patients. Each visit involves – at minimum - an endoscopic bladder examination, discussion of the findings, and sending the results to the referring physician. It may also involve meeting a patient for the first time, asking about their medical history, arranging further testing or scheduling surgery.

I’m constantly aware of wanting to stay on schedule so as not to keep people waiting. Unfortunately, that time pressure will sometimes make me feel rushed, and that can affect my patient’s experience.

Why not schedule more time for each patient, you may ask. For some patients, rather than the standard 15 minutes, I will allot 30, especially if I anticipate that someone may require additional procedures. However, each extra time slot assigned to one patient means that another patient waits longer for their cystoscopy. And, wait times are already lengthy. It’s a difficult balance to strike.

But, during one examination last week, I found myself in the unusual situation of being ahead of schedule. Even though it was my first meeting with this patient, and I needed extra time to ask about her medical history, discuss test results (she had a tumour in her bladder) and recommend surgery, I wasn’t rushed. In the middle of that discussion, I had my moment of joy.

While explaining to the lady about what I had found, and the recommended treatment, I realized that I felt relaxed and confident. I was paying attention to her reaction to my explanation. Was she upset? Was I using medical jargon? Had she understood? Did she have any questions? I wanted to reassure her.

This was how I wanted all my consultations to go. Not only because it made me feel good about myself, but because I’m convinced that I’m a better doctor when I feel that way. I may provide the same technical results regardless of my mood (maybe…), but I think patients have a better experience when I’m relaxed.

As I thought about this, I began to wonder why I couldn’t feel this way, and offer my patients a better experience, on a regular basis. I think there are internal and external factors. Internally, I may allow myself to become flustered. That’s a habit I can work on. Externally, it comes down to an access problem. Long wait lists translate into pressure to fit in as many patients as possible in a given clinic. That increases the chance of running late, and forces me to rush, leading to an unsatisfying experience for both me and my patients. (And for any staff who may be unfortunate enough to be in the vicinity…)

So, if we work on improving our cystoscopy access problem – applying the same principles of managing capacity and demand as we have in our office practice – patients may benefit not only through shorter waits, but also through the quality of their experience. And our doctors may be more satisfied.

I think we’ve found our next access project.

And a selling point: Bring the joy!