Archive for category Nursing quality
According to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care. This is important for two reasons:
- Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
- Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.
The tremendous building boom for hospitals is strange given this bit of science — are CEOs trying to improve quality by remodeling? Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.
Increasing the distance a nurse must walk to see patients results in decreasing nursing visits. This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients. The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.
The hospital that looks like a nice hotel seems to be the desire of hospital CEOs. This may be fine for obstetrics but may be wrong for geriatrics. A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly. 4 times the number of nursing visits makes it much easier to prevent falls. When nurses still wore those pointy white hats they had this figured out.
Progress marches on. American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.
Just calling a patient on the phone does not prevent patients from being re-admitted!
Hospitals are very interested in preventing a patient from returning to the hospital (called a re-admission) within 30 days from discharge due to the financial penalties from Medicare.
For example, if a patient is hospitalized with a serious problem called congestive heart failure (fluid retention that causes shortness of breath) the hospital will be penalized financially if the patient gets the condition all over again and has to return.
The government idea is to force hospitals to be more accountable — it’s like a 30 day guarantee from an auto repair shop! So hospitals are looking for ways to improve their performance (and avoid paying money).
There is no question frequent visits to a physician can reduce re-hospitalizations. However, a recent hospital study found that hospital nurses who talked to patients before discharge and who called them after discharge did not help the readmission problem — in fact there were more re-admissions!
a) How can this be?
b) Do well meaning nurses actually make the problem worse?
c) Does this mean hospitals should not be penalized?
The answers are: a) bad science b) yes and c) no, perhaps they should be penalized more!
The “bad science” part is because there was no intervention to adjust medications or treatments that might prevent readmission. A hospital nurse only has one option for a telephone intervention: “you better get checked at the ER”. The conclusion from the study should have been stated “chatting with a patient does not prevent re-admission” — brilliant deduction.
The outpatient care provider’s office is where action can be taken to stop re-admissions. That’s where medications can be prescribed. If the hospital wanted to prevent re-admissions they should have made an appointment and given the patient a coupon for a taxi ride to and from the outpatient office. This is not rocket science.
Saying “sorry” is the human thing to do. Doctors and nurses should say it when they feel it.
Saying “sorry” seems to have two meanings: 1) something bad happened and I understand your emotions 2) something bad happened and I had some connection with the event for which I feel partly responsible. Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.
Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things — neither said “sorry.” Sorry truly does not fix anything; but, the absence of “sorry” is infuriating.
The problem is ego. Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME. Absence of “sorry” is a sure sign of defense (a defense of self). Perhaps the health care provider was spanked as a child or yelled at by teachers. Who knows … ego has gone wild.
Quality health care depends on people believing errors are due to system failures. When providers fail to embrace that philosophy they fail to correct problems. No failure, no correction.
A fall in the hospital can be deadly. Recently, a family member fell in a room while no nurse was present and they died. The nurse did not say “sorry.” There was no acknowledgement of responsibility. No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths. The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.
Lawyers are not the cause of excessive health care ego. However, lawyers with the threat of suit are a convenient excuse. When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.
When Quasimodo answers your call light instead of the the nurse you know something is wrong. It probably has to do with all that paperwork — one third of a nurse’s time is spent doing clerical work either on paper or on the computer.
Laura Landro of the Wall Street Journal reported 7/21/14: “Nurses Shift, Aiming for More Time With Patients”. Ms. Landro highlights one hospital where nurses are getting more help from LPNs and CNAs so they can spend more time at the bedside.
More low-level helpers — where does that lead? Probably not to more Florence Nightingales at the bedside but rather fewer RNs who will mainly serve as supervisors. Nurses are getting expensive so the trend will save money for hospitals.
Nurses are hit from many directions. Shift-work is hard on family life and the educational requirements have increased. Highly motivated nurses often escape the shift work by training to become outpatient nurse practitioners — why try to climb the corporate ladder? Nurses aspire to be more like doctors at a time when doctors as hospitalists become more like nursing supervisors. And, hospitals don’t see much value to experience — they fire a 50 year old nurse so they can hire 2 twenty something nurses to save money.
Nurses are criticized for quality issues as well:
- Poor shift to shift communication — who knows what the guy at the end of the hall has?
- Collection of information that has no value 24 hours later — a huge waste of time. Unfortunately, the nursing model is focused on filling out forms or online queries. Always made worse by legal concerns.
- Training that inhibits drawing a conclusion. For example, if a nurse finds a patient is on the floor bleeding from a cut on the head … the conclusion is “deficit of patient comfort” rather than “scalp laceration and possible brain injury”. That’s the doctor’s job — too bad the doctor is not always there.
It’s almost a perfect storm. A general shortage of nurses, a background of quality problems, hospitals anxious to find lower cost employees, and nurses obtaining more training to command higher salaries. Nursing is not going away but the RN job will be different in the future.