Another Satisfied Customer?

Do you believe in patient satisfaction?  For the majority of my training, I had my doubts.  As an impressionable intern, I remember a conversation between 2 seniors discussing a patient complaint about the wait.  The conclusion was something like this: "This isn't Burger King.  In the ED, you don't get it your way, right away."  For a long time, I believed that good care comes first and satisfying the patient comes second.

I'll also admit that my opinion was further skewed by the wealth of poor data collected by various "satisfaction" surveys that using a sampling that would be laughed at by any respectable researcher.  We see  more than 200 patients per day.  One month our sample was derived from a sum total of 14 patient responses.  Hard to make valid conclusions with data that is derived from <1% of total patients.

Needless to say, as I mature in my practice, I have come to realize that there is a lot of truth to the statement, "They don't care how much you know until they know how much you care."  With that in mind, I want to share some key points from a nice review of customer satisfaction that I stumbled upon from the Emergency Medicine Clinics of North America.

So why pursue a goal of having more satisfied patients?

There are multiple demonstrating benefits from hospitals which perform better:

-Staff morale improves
      (Turnover decreases, work is more enjoyable)
-Malpractice risk decreases
     (Happy patients sue less frequently)
-Patients respond better to treatment
     (Patients follow instructions when they believe that they received good care)
-Hospital finances improve
     (Patients recommend the facility and will come back)

The list is pretty impressive.  I'd be happy with improvement in one of those categories!  So we know that happy patients can bring us happiness, but how can we improve the current quagmire that is emergency medicine?

Obviously, you know your local environment best.  Each department will need to tailor a program to its needs.  The first step is figuring out those needs: what is the goal you want to strive for?  If you already have a program, great!  Hopefully you've been keeping tabs.  The data gleaned from your surveys can highlight areas in need of immediate attention.  What if you haven't kept tabs?  Look at complaints, get staff input, administrative input, and use good ol' common sense.

Leadership will be vital.  You'll be attempting to change something fundamental about emergency care: our culture.  First, get the key players on board: administrative, nursing, and physician leaders.  Don't forget the "leaders" within the ranks who may not formally hold a title.

As the leader, you'll be tasked with the following:
-Setting goals
-Modeling and insisting on specific behavior
-Monitoring the behavior and progress towards the goal
-Delivery of rewards and recognition for good performance

Goals take on two forms: philosophic and specific.  The philosophic goals helps set the vision for the change, the specific gives the down and dirty expectations and guidance for attaining the vision.  Remember to involve the staff.  Using goals that they create will help promote buy-in.

Some specific examples:
-Answer all phone calls within X rings
-Door to Doc of X minutes or less
-Door to discharge of X hours or less
-Door to bed of X hours or less
-Each patient will be re-evaluated by a provider every X minutes

Once you choose your goals, it will be up to the leadership to hold people accountable.  Some people will resist.  Giving that person an exemption will deep six any cultural change before it even has a chance.

Educating the staff will be important.  Everyone will need to learn to modify their behavior: physicians, nurses, registration, techs, transporters, housekeeping, etc.  The success of your program will depend on universal participation.

Remember to reward the people who contribute.  Publicly acknowledge them, give bonuses, a parking spot, etc.

Remember the need for a scoreboard.  Even if you missed the first half of a game, you know who's winning by looking at the board.  So it is with the staff: they need to know where they're at in order to improve.  Publish your results widely: newsletters, emails, bulletin boards, etc.  Let patients know too.  Success is contagious.

Invariably, there will be some people who choose not to come on board.  Once they become obvious, they will need to be removed.  Letting them stay within the department will create a division amongst the staff and hurt your chances of success.

There are tools available to help you succeed:

Scripting: developing specific comments for registration, nursing, and even docs can help diffuse anger and demonstrate an attitude of caring.

Patient advocate: This person can make sure that patients who are waiting are up to date with an explanation.  They can also help keep the patient comfortable while waiting.

Surveys: You can't change without data.  Develop your own, and distribute them widely.  The more the merrier.  Don't forget to allow family members to fill them out as well.

Call Back System: This tool can help to salvage what may have been a negative impression.  You can target specific conditions: Against Medical Advice discharges, left without being seen, etc.

Patient Satisfaction is a worthy goal to persue.  It's not easy, that is obvious from our day to day practice. Start by being honest with yourself.  Would you want your mother, father, spouse, or child to receive the same care given to the majority of the patients waiting in your waiting room.  If you answered no, then step up, become a leader, and promote the improvement that is within your reach.

Reference:
K Worthington. Customer Satisfaction in the Emergency Department. Emerg Med Clin N Am. 22; 2004: 87-102. PMID: 15062498

Better Consultations

A while back a reader asked the following question:

"How do you get them to buy in? as a resident in a surgical specialty, I'd love the EM residents to give better referrals, but often they want nothing more than to sell the patient and move the meat."

This immediately made me think of a lecture given by Emergency Medicine Superstar Chad Kessler.  He actually has a research paper on the way studying the effect of his approach that I'm looking forward to reading.  In the mean time, I'll settle for listening to him lecture, repeatedly, again and again, on consultation skills.  In his lecture, he offers up some consultation pearls that we would all benefit from learning:

The Five "C's" of Consultation

1. Contact: This is where you call your consultant.  Before picking up the phone, make sure you need the consultation.  I'm currently a dedicated night doc.  When admitting a patient to a medical service, the accepting physician will often ask me to "consult" service x,y, or z.  Knowing when to simply write an order for a "routine" consultation versus calling each service in the middle of the night goes a long way towards improving your relationship with each service.  When you call appropriately, they begin to recognize that when you call, you need them.

When first making contact, make sure to identify yourself and get their identity as well.

2. Communicate: Once you've made contact, tell them about the patient.  The level of detail will vary by specialty.  Surgery often needs a one liner while medicine wants a thorough review of the patient.

3. Core Question: Here's the money issue: What do you need?  Be as specific as possible.  "I need you to admit this patient for fluids and antibiotics," or "I need you to take the patient for emergent cardiac catheterization."

4. Collaborate: Let your consultant digest the information presented and respond with their needs.  They may need you to order additional tests, call in the cath team, etc.  I've found that this are is where the consultation can quickly break down, especially with the uber-specialists.  Their plan may deviate from what you believe the patient needs.  You may need to take a quick time out and engage in some shared problem solving.  I find this to be most true when they're asking for a test to "stall" the need to see the patient.

For example:
"I have a patient with a fever, back pain, and loss of sensation in the L4 distribution who I think has an epidural abscess.  I need you to come and evaluate him for operative drainage."

"Order the MRI and call me back after the results."

Unfortunately, this behavior delays the needed evaluation.

Shared problem solving allows you to advocate for the patient and get them to the person they need to see.  For example: "How about you send your resident or PA down to get a quick baseline neurologic exam while I order the bed, the MRI, and antibiotics after a set of cultures."

5. Close the loop:  Take the time to repeat the plan back.  Letting them hear it allows for correction of errors or the addition of something that they may have forgotten.  Make sure to take the time to document the date, time, name, and nature of your conversation.

Another important point that Dr. Kessler makes is the need to practice.  Just like intubation or suturing, consultation is a skill.  To improve this skill, we need to take the time to practice.  As teachers, we can help our residents with a "practice run" so that they don't end up frustrated on the phone.  With luck, this short list will help to ease the frustration felt with difficult consultations.

A Practical Checklist?

It seems like checklists are the "in" thing in patient safety right now.  It makes sense; follow this list of things and you won't hurt patients.  The problem is, they only work when you use them.  

While doing some background research on checklists in prehospital settings, I found this gem in the open access Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine.  The article is the print version of an oral presentation, so it isn't "science" but it is practical.  Prehospital airway management is a hotbed of controversy right now.  The data seem to point to worse outcomes, delays to definitive care, and decay of skills.  With all of these problems, anything to make the procedure safer is a welcome addition.  Enter the "checklist."

This group of prehospital providers created a novel approach to their airway management.  They took a disposable plastic sheet and printed it up with the following graphic:

Notice anything cool?  While it still has a text driven checklist (on left), the visual representations offer a rapid and convenient way to prepare for intubation.

Their checklist approach is broken into  the following areas:

Pre-anesthesia checklist

Monitoring:

Equipment:

Drugs

Staff

It would be easy to replace their text with the more familiar "P's" of intubation:

Preparation

Positioning

Preoxygenation

Pretreatment

Push the Drugs

Placement with Proof

Post-Intubation Management

On the far right you'll also notice a box for induction medications and maintenance medications. 

The thing I really like about this list is the visual representation of the equipment.  Just looking at it, I believe that it would really decrease the time in the "preparation" phase.  Look at what it includes:

Equipment for bag ventilation: oral and nasal airways

Drugs for the procedure (I would like to see these boxes include dosing guides for the common medications)

Equipment for intubation:

2 laryngoscope handles and blades

2 different sized endotracheal tubes

syringe

tube holder

qualitative end tidal CO2 detector with BVM connector

Backup Equipment: 

Bougie

LMA

This is HUGE.  How many of you out there really take the time and get your backup equipment out before you need it?  This demonstrates true foresight.

The only thing that I see missing is the suction.   

When working clinically by myself or with the residents, I'm constantly running through a little mental checklist that includes most items on the above list.  Being able to pull out a little plastic sheet that has the list already prepared would free my mind up to think ahead and address other important issues with the sick patient in front of me.  I can easily see how this has potential to really make both prehospital and emergency intubations safer.

Below is a video demonstration of the checklist in action:

Reference:

A pre-hospital emergency anaesthesia pre-procedure checklist R Mackenzie , J French, S Lewis and A Steel from Scandinavian Update on Trauma, Resuscitation and Emergency Medicine 2009 Stavanger, Norway. 23 – 25 April 2009 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26

Great Video for Those Beginning Academic Careers

I was perusing my stack of journals the other day and came by a "Dynamic Emergency Medicine" Article in Academic Emergency Medicine.  Typically this section contains useful videos about new procedures and has a very heavy ultrasound slant.

What I found instead in this particular journal was a link to a 40 minute video interview of some of the leaders in Emergency Medicine, people at the leading edge of the bell curve.  It's a goldmine of good advice for those with interest in becoming a better academic physician.

Take a look and let me know your thoughts!

Interviews with Leaders in Emergency Medicine from Academic Emergency Medicine on Vimeo.

So You Want More Feedback?

Learners, do you want the truth?  Can you handle the truth?  In order to receive better feedback from your teachers, you need to take an active part in the process.  Here's how:

1. Remember that not all feedback is positive.  You need demonstrate a higher level of maturity and self awareness in order to improve.

2. Create your own learning goals and share them.  If your teacher knows what you want to learn, they can provide more focused feedback.  Don't forget to ask your supervisor for input when creating goals in order to keep you goals realistic.

3.  If you're not getting feedback, ask for it.  Emergency physicians are action oriented and a passive leaner will get left behind.

4.  Clarify.  If your teacher says, "You did a great job today," don't be satisfied with your performance.  Ask them what you did well and what needs improvement.  You won't improve if you don't know where you need improvement.

5. If you get some negative feedback, understand that it is meant not as a personal attack, but an opportunity to improve.  Find out from you teacher what the issue is, why it is an issue, and what you need to do about it.  If there is an interpersonal issue (rare occurrence) with the teacher, ask your advisor to help you work through the issue.

6. Don't forget to discuss your success as well as what needs improvement.  You don't want to lose those skills that you do well.

7.  You are probably your harshest critic.  Don't be too hard on yourself.  Take the credit when you do something well.

8.  Be aware of yourself.  If you are feeling stressed, rushed, or simply tired, don't be afraid to ask to reschedule for a time when you have your mental faculties in line.

Your teachers want you to succeed.  Sometimes we're equally rushed or simply afraid of giving you the advice you need.  Following the above list will help us maximize your potential.

Reference:

Rider EA, 

Longmaid HE. 

Feedback in Clinical Medical Education: Guidelines for Learners on Receiving Feedback. JAMA. 1995; 274(12): 938.

Failing at Feedback?

In the last post, we discussed a some background and general tips on feedback, focusing on the  seminal article by Jack Ende, MD.  Unfortunately, despite all of the hype and hoopla surrounding feedback skills, learners still complain about not receiving enough feedback.

Problems with feedback identified in some studies include:

Too teacher-centered
Too much positive skew
Low cognitive level (fails to engage learner)

So why are we failing at feedback?  Perhaps the problem lies with the learner and not the teacher.  In a 2009 article titled "Why Medical Educators May Be Failing at Feedback" Bing-You and Trowbridge offer an alternate view on our failure and suggestions for improvement.  In their article, they highlight 3 key problems with the learners:

1. Poor ability for self reflection


2.  Overpowering influence of affective reactions to feedback


3.  Lack of adequately developed metacognitive capacities

Lets take a look at each of these.

Physicians are notoriously bad when it comes to self-reflection.  We tend to overestimate our abilities.  Just look at the difference between pilots and surgeons on the perception of the effects of sleep deprivation.  Even worse, the most deficient performers may be have the least insight into their incompetence.

So what happens when these learners are faced with negative feedback?  Pure emotion.  The feedback becomes a personal attack.  The feedback may trigger emotions such as guilt or anger.  The learners unconsciously fall back on ego defenses (denial, distorting information) that prevent a fair assessment of the feedback.  Knowing this, it makes sense that learners who have negative reactions to feedback find it less useful.

Learners also need strong metacognitive skills to appropriately process feedback.  Metacognition is a the process of "thinking about thinking."  Reflection is a valuable metacognitive skill that students can use to critically evaluate the feedback and apply the needed changes.  A lack of this skill probably accounts for some of the overconfidence displayed by learners.

So how do we overcome these barriers and get through to the learners?

We need to recognize the affective component of feedback.  Knowing that negative feedback will likely invoke some degree of ego-defense, we can use guided reflection to help our students process the information at a metacognitive level.  Using follow-up activities to reinforce the positive changes may also help overcome the negative emotions.

There is a growing body of literature about how to teach metacognition.  In emergency medicine, we constantly practice procedures.  Why not teach metacognition early?  Practice with the metacognitive skills students will increase their self awareness and, hopefully, their self-assessment skills.

We need to take another look at feedback.  Efforts to improve feedback need to take these learner factors into account.  We owe it to our learners and our patients.

Reference:

Bing-You RG, Trowbridge RL.  Why medical educators may be failing at feedback.  JAMA. 2009 Sep 23;302(12):1330-1. PMID: 19773569 [PubMed - indexed for MEDLINE]