Archive for category Healthcare communication
June 3rd 2015 Kaiser Health News reported the ACA seemed to cause more provider visits for management of diabetes “More Patients, Not Fewer, Turn To Health Clinics After Obamacare”. This is both good and bad.
The “good”: more attention to a patient’s condition is likely to result in better diabetic management, fewer complications, fewer hospitalizations and longer life.
The “bad”: since clinic visits can be billed to insurance, clinics make appointments and make money for each visit. The payment for visits rather than outcome is expensive and a known problem in US healthcare (fee for service). Diabetes can be managed over the phone in many, if not most cases — but there is no money for the provider in that approach. Phone care has a much higher value for the healthcare system and the patient; but, low-cost high-quality (high value) care is not getting the incentive.
The care of diabetics is further compromised by the pharmacy. A key piece of equipment for a diabetic is a glucose meter. The manufacturer almost gives away the meter so they can make huge profits by selling the disposable test sticks. The sticks are not interchangeable, not generic, sold in small lots, each lot sold with a co-pay, each lot requiring a visit to the pharmacy, and the use of gasoline to make the trip. If you don’t have much money the speed-bump turns into a mountain.
The solution: every few years mandate a generic test stick that manufacturers of glucose meters must support. “Uncouple” the meter maker form the test stick maker. And, sell the sticks in lots that last for at least 90 days, and that are sent to the patient by mail. Adjust the payment to providers so that they must contact diabetics by phone to adjust medications at least 2 times per month in order to bill for a medium or high level clinic visit. Also, each provider must obtain patient satisfaction data to prove the adequacy of service.
Addendum: Here is a link to an interesting court case about glucose meters
Hospitalization is dangerous because of your illness and because poor communication increases the risks. The simple fact is: patients who speak up get better care than those who are quiet and unassuming. As Gomer Pile’s sergeant would say: I CAN’T HEAR YOU!
A recent article in Consumer Reports (CR) February 2015 “How Not to Get Sick(er) in the Hospital” puts a focus on communication in the hospital and is worth reading.
CR makes some good points:
- You should be treated as a partner with the health care team. As a partner you should expect explanations in language you can understand. You should expect to know the plan, when and why tests are done and what results mean. If x-rays or blood tests are done ask the doctor “what was the result”.
- You should not be a silent partner. If you are not getting information or do not understand what is going on you are risking your life. Be courteous but speak up and ask questions and get ANSWERS not platitudes like “you just need some rest”. Reasonable questions are things like: “why do I need a CT scan”, “why am I in intensive care”, “why do I have a fever”, “what did you find during surgery”?
- The doctors or physician assistants (PA) or nurse practitioners (NP) are in charge — the nurses are not. If you have questions about medical or surgical issues insist on talking the doctor or PA or NP. If you need an extra pillow or help getting to the bathroom talk to the nurse. If you ask your nurse about the result of a test expect a vague answer “it’s just fine, get some rest.” However, the nurses know what medications have been ordered and what is available “if needed or PRN”. If you have a headache ask “what has the doctor ordered in case I have a headache”? “nothing — well please call the doctor now since I have a headache”.
- You need “your people with you”. Family or friends should be present as much as possible and they should make contact with the health care providers both doctors and nurses — at very least each time they visit they should introduce themselves to the RN at the desk to see how things are going.
- Who is available day and night? It is a very reasonable request to know the name of the nurse in charge or the name of the doctor on call and to have them contacted if there is a problem. If you are under the care of Hospitalists they are in the hospital 24/7 so it is very reasonable to request to talk to one of them at any time if needed — even on the phone, if that is adequate. “They are busy” is sometimes true but not for hours at a time. The nuclear option is to ask to speak to the “hospital administrator on call” — a request that always gets their attention.
- In any healthcare setting: you are not out of line to point out that a doctor, nurse or therapist failed to wash hands or use hand sanitizer. “Please wash your hands”. You do not want germs from other patients brought to you on caregiver hands.
- Doctors will spend more time with you and answer more questions if they are comfortable — ask them to “have a seat”. A room with no seats is unacceptable — that, you can tell your nurse.
- Choose the right hospital in the first place. Check the ratings of hospitals on the CMS website called “Hospital Compare”. Driving a hour to a better hospital is absolutely worth your time and may save your life. This is not like going to a fast food restaurant. At this point in 2015 there is still a huge difference between hospitals — advertisements do not mean a hospital is good.
- Keep a written record — if you have a test write it down and leave a blank to fill in the result. You really don’t need all the details — “you had a blood count and it was normal” is a fine answer. If asked about your notes just say you have some difficulty keeping track of what is going on since you don’t feel the best — if you felt your best you would not be in the hospital!
The U.S. Navy Submarine Service is attributed with the development of a communication technique for critical situations. The technique is to standardize a message from one person to another in the order of Situation, Background, Assessment and Recommendation. For example in a submarine:
- Situation: Captain this is #1, we are having difficulty maintaining our speed
- Background: We are near a fishing fleet
- Assessment: I think we may be entangled in a fishing net
- Recommendation: I recommend we surface and cut away the netting
The captain says “make it so” or perhaps he says “no, all stop, send out divers”
About 15 years ago the method came to the attention of patient safety experts. It had several great features: 1) The person on the front line (like an ER doctor or nurse) could make a report quickly 2) the method was easy to learn and was consistent even when emotions were running high 3) It leveled the hierarchy so the person on the front line made a recommendation with situational awareness that the person receiving the message might not have. In a medical situation SBAR might sound like:
- Situation: Doctor this is the ICU nurse, your patient John Doe has become comatose and is breathing very slowly.
- Background: He has lung disease and was just admitted 2 hours ago
- Assessment: I think he is in respiratory failure
- Recommendation: I recommend we intubate as soon as possible.
The critical care doctor says: “Get me a scope and a tube, I will be right there”
Those health care professionals who embraced the method found it very helpful and it is still being used at many institutions. But, the idea has not had universal success for reasons that were not clear at the outset:
- Fear. Recommendations might be rejected.
- License: Some felt their license did not allow an assessment which was the equivalent of a diagnosis.
- Semantics: The word assessment means physical exam to nurses but it means diagnosis to physicians.
- Litigation risk: Some felt if a recommendation was followed and later proved to be an error they would be blamed and possibly sued.
Improved communication in critical health care situations is very important to the patient in distress, in fact, poor communication is responsible for many in-hospital errors. The SBAR technique is more difficult than one might think. And, implementing it requires more than just saying “wow, this is great, do it”. Techniques for implementation include some of the following:
- Audio or video recordings of the technique in use
- Practice sessions including both doctors and nurses.
- Role playing — the doctor giving the nurse a report and visa versa.
- Explanation of why the technique works
- Examples of errors in communication and how patients might suffer
- Emphasis on teamwork and not blame. A single negative comment by a physician or supervisor can take a great deal of effort to correct.
- Understand a critical assessment is not a final diagnosis but just a step in the right direction. The assessment is made at the training level of the person stating it. Some might say “breathing difficulty” some might say “respiratory failure”.
- Continued education and reinforcement. All new members of a medical team need to be instructed. This is an ongoing process.
Good communication improves patient safety especially when quick action is needed. SBAR is a framework for communication. Other methods may do the same thing but the history and success so far suggest it has wide applicability. Users of the technique express satisfaction (1). Communication always involves two parties — both must be accepting and well trained to use the technique. The World Health Organization has included SBAR in some of its publications (2) so wider use of the technique is expected.
Personal experience with SBAR
(1) Beckett, C. D. and Kipnis, G. (2009), Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes. Journal for Healthcare Quality, 31: 19–28. doi: 10.1111/j.1945-1474.2009.00043.x
(2) Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32 (3), 167–175.
(3) Anonymous (2007) Communication During Patient Hand-Overs. WHO Collaborating Centre for Patient Safety Solutions,Patient Safety Solutions,volume 1, solution 3, May 2007