The first difficulty for the physician was to determine whether the patient was asking for the medication because he was an addict and wanted it to get high. This situation is not uncommon. The second difficulty was a situation that, while not surprising, should not have happened. The physician felt pressured to prescribe the substance in order to please the patient. Why would that matter? The hospital administration had been pressuring staff to work hard to improve patient satisfaction scores on the CAHPS Hospital Survey. Turning the patient’s request down might lead to a poor response on the survey if the patient was asked to take it.
It is my opinion that the quality of the service to the patient as measured by a satisfaction survey should not impact the clinical decision process of the physician, nurse, or any other clinician. Any quality program should measure the quality of support services, such as hospital environment, waiting time for the patient, access to service, etc. This point of view is emphasized in The Toyota Way to Healthcare Excellence by John Black. It seems that this confusion of clinical decisions with quality improvement is not all too uncommon. When clinical staff hear of standardized work in quality improvement confusion about what is to be standardized can occur. In all of the quality programs-Baldrige, Six Sigma, TQM, Lean-the quality efforts focus on processes, not clinical decisions. It is assumed that clinical staff will make the best medical decisions that benefit the patient and that the patient should be involved in the decision making process.
Effective communication is a necessity at a healthcare site in order to avoid ambiguities such as described above. Two elements required for effective communication are quality leadership and structures that enable communication to occur. Involvement by the leaders of a healthcare site, both administrative and medical, are necessary for communication to occur and for quality to improve. Leadership means being present routinely in the work environment. When Mike Rona, president of Virginia Mason Medical Center, started leading the executives of Virginia Mason on their journey to enhance quality by eliminating waste and focus on the patient with the Toyota Production Model one of the first things he and his staff did was tour the various sites of Virginia Mason. He was very surprised by the atmosphere and work in the emergency department. He had not realized the challenges the staff there faced. He related that he became more aware of changes that were necessary from his walkabouts. It made the problems real rather than merely abstract numbers and prose in reports.
Leading by being involved in the daily routine of the staff and patients makes the processes and challenges at any healthcare more concrete and understandable. It fosters interaction with staff which can lead to trust and improved moral. In fact, these elements are very necessary if there is any major shift in processes or provision of care at a site, such as may occur when new centers are opened at a hospital or new directions in quality improvement are undertaken.
An acquaintance of mine who is the owner and CEO of a auto parts manufacturing company told me one morning at breakfast that he makes a point of putting on overalls once a month and go to work on the factory floor. He says that by doing so he has avoided many problems and has been able to find solutions to challenges with insights shared by employees. He stated to me that one of the keys to successful communication when he is on the factory floor is that he works hard to follow the fifth principal of Stephen Covey in the 7 Habits of Highly Effective People-Seek first to understand then to be understood.
Besides effective, visible leadership, another necessary element for effective communication are vehicles that provide opportunities for interaction of healthcare site leaders and staff, both clinical and support. Quality improvement teams provide an arena for discussions about improving processes and focusing on the patient. All the quality improvement processes mentioned above involve the use of teams comprised of representatives from each of staff involved in the process being improved. John Black in The Toyota Way to Healthcare Excellence describes permanent teams comprised of a clinical leader trained in Lean Process Improvement and staff from his model line in the healthcare structure-surgery, cancer, clinic, administration, in-patient care, etc. These teams are called Kaizen Operation Teams. These teams report to the Kaizen Promotion Office. The Kaizen Promotion Office works with the leadership of the hospital, including the chief medical officer.
In the story in the opening of this newsletter, the physician who was unsure of what to do about prescribing the narcotic could have brought up the conflict between the administration’s emphasis on patient satisfaction as measured by the survey instrument and his right to make clinical decisions. The team leader could then discuss the problem with appropriate leadership along with recommendations from the team involved. In general the advice of the team should be followed unless leaders perceive that the recommendations strongly conflict with the hospital’s strategic plan, which should be patient centered.