After reading an article written by Dr. Sanjay Gupta in the New York Times I was left shaking my head –AGAIN. While the spirit of his article was noble in its intent, this was a chance for Dr Gupta to highlight the importance of focusing on multidisciplinary patient centered care as a means of cutting back on errors that reach our patients. As a nurse what I appreciate about Dr. Gupta’s article is that he clearly wants to motivate the medical discipline to start thinking about what needs to change in order to improve patient care outcomes. He proposes that doctors cut back on practicing “defensive medicine” and incorporate more “M and M” proceedings as avenues for change to reduce patient care errors. While these ideas are great on paper and in theory, they miss the mark in targeting the root cause of patient care errors—that cause is “ALL OF US.” That “US” includes patients and families. Part of our jobs as healthcare providers is to empower people to take the responsibility of advocating for themselves and their family members. The patients’ responsibilities are just as important in the partnership we share.
People are unique, complex, multifaceted beings. Why on earth should their healthcare be any different? We’ve come to rely too much on algorithms and protocols, we’ve come to a point where we try and put every patient into some kind of “box” that determines what treatment course they will get. Call me crazy (many have), but I think that approach in and of itself is where some of our patient care errors lie. Not all pneumonia patients should be treated the same, just as not every heart failure patient should be managed the same. While the medical management of these patient populations may be “similar,” more often than not there are other underlying issues that should be examined that have the potential to make the difference between a poor outcome and a good one. Enter the interdisciplinary model of care.
The purpose of an interdisciplinary model of care is to facilitate seamless healthcare delivery to the patient and family at the “center” while encouraging an open, respectful, and team oriented environment by which all disciplines interact. To get a picture of the model imagine a circle and label it “patient and family,” then imagine a circle around that and label it “direct care providers,” and finally—imagine one more circle around the other two and label that one “indirect care providers.” J. Quintero, MSN, further elaborates on the spirit of the “IMOC” in an article he wrote entitled “Developing an Interdisciplinary Model of Care in a Progressive Medical Care Unit”: “The purposes of the model were to promote interdisciplinary collaboration, eliminate redundancies of work, improve communication skills of all professions, and develop standards of practice that address the role of each healthcare professional.” Quintero further emphasized the need for the model to be adopted from the “top down” (administrative figures) as a foundation for successful implementation. Therein lies a problem, and quite possibly one of the biggest barriers to optimal healthcare delivery.
To put it simply, healthcare is one big messy ball of yarn—and we are all caught up in it. From the patient, to the CEO of healthcare franchises, there exists many views and variations of what healthcare “should look like.” (like many hues of the same color) Three things need to occur for patient care to become a safer, team oriented, and respectful process that keeps the focus on the patient instead of on the “us versus them” mentality: “Buy in” at the corporate level, a “just culture” in *every* healthcare facility, and an interdisciplinary model of care in *every care environment.* Unfortunately, all those lovely initiatives and recommendations everyone keeps coming up with won’t make it very far if healthcare corporations don’t see their value and adopt them as part of their culture. CEO’s and administrators can’t adopt the mentality if they aren’t shown what’s in it for them, how they will benefit financially, or how their cooperation and implementation of these things as mandatory components of their organizations will contribute to future success. So it actually works both ways—we at the provider level must use our advanced education to gain the buy in of the higher ups, and the higher ups must incorporate a “just culture and an interdisciplinary model of care” in order to gain improved patient care outcomes that will lead to increased patient satisfaction, successful brand imaging, maximum reimbursement from payers, as well as improved recruitment and retention of talented staff.
Prevention of “never events” requires so much more than increased M and M proceedings or extra classes for physicians that practice in hospitals. Responsible use of human capital in the corporate healthcare environment is a great place to start. There are so many talented providers out there who possess creative and powerful ideas which have the potential to change the face of healthcare into something we’ve never imagined….. We must all be open to new and innovative ideas that lead to transformational changes in healthcare delivery. Sadly, the key word these days is “silence.” I’ve learned first- hand that hospital management figures don’t want ideas from staff members and that advanced education means nothing on nursing units. I’ve tried submitting well researched ideas and suggestions (at all three hospitals I worked at) to improve patient care outcomes and the environment we all practice in and was greeted with either silence or with a prompt response indicating “your ideas don’t fit with our culture so don’t submit them anymore.” Newsflash—Improved patient safety and better patient care outcomes involve the people who are at the bedside.
Instead of feeling empowered to go back to school to get advanced degrees, nurses have been taught by their workplaces that their voices don’t matter— Hence the response I have heard uttered by many a colleague: “Why bother to go back to school, it won’t make any difference.” Nurses have also learned that reporting safety violations or unethical activity yields devastating personal results, so the new norm is protecting themselves first by saying nothing at all to advocate for the safety and well- being of patients. Nurses are now learning that it isn’t the art and science of our profession that is the important part of the picture, it’s all the resort like extras we are pushed by management to provide patients as a means of boosting patient satisfaction scores. I remember learning in school that the concept of “caring” was front and center in all things nursing….but what I have seen today is that everything but “caring” comes first. Want patient satisfaction to improve? Want patient care outcomes to improve? Want less sentinel events? Well then, nurses must be allowed to do what nurses do best without an overload of demands on their shoulders, without fear of losing everything…..they must be allowed to just be “nurses.” They must be given the time, the space, and the autonomy to be creative critical thinkers, teachers, mentors, leaders and advocates. Do this, and watch the magic happen.
I read a blog response to Dr. Gupta written by one Paul Levy (former President and CEO of Beth Israel Deaconess Medical Center (BIDMC) in Boston) who felt that the scientific process was the answer to figuring out where mistakes happen in healthcare, and that most mistakes don’t even involve doctors: “OMG. Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm — hospital acquired infections, falls, failure to rescue, pre-39 week induced labor. Many of these are not even reportable as harm. “
The above perspective is what holds us all back from progression. I’d like to respectfully disagree with Mr. Levy’s presumption by recalling instances where physicians failed to call me back when a patient was crashing and in septic shock, when they have yelled at me for asking why a patient was on dual iv antibiotic therapy for three weeks without any documented evidence of infection in the chart, or the many times I saw doctors at one facility coming in to the nursing station early in the morning and charting assessments/progress notes on my patients when I knew they never stepped foot in the room to lay eyes on the patient. “Patient awake, alert, states he feels better.” Really? Hospital acquired infections don’t just appear out of nowhere because the patient is on the wrong diet or because a nurse wasn’t able to get to the foley catheter care on day shift. Falls don’t happen just because a nurse is in another room and didn’t answer the call light quick enough. “Failure to rescues” aren’t just a direct result from a nurse’s oversight. We are all involved in the process, we all have a part to play, and we all have the responsibility of examining and discussing poor outcomes in an open, respectful, professional venue that supports two major activities: “Listening and Learning.” Mr. Levy appears to need a refresher course in Root Cause Analysis.
Dr. Gupta may have missed the mark in presenting a broader approach to improving patient safety and reducing errors but the key here is that he sees the need for change, the desire to see better outcomes, and the insight to look within his discipline to examine ways that medical practices can improve. Conversely, Mr. Levy presents his views from an “old school” way of thinking that is no longer conducive or productive in the complex healthcare world of today. Inserting the “it can’t possibly be our fault” response to any root cause analysis is, to put it simply, like trying to fit a square into a circle—there can never be a positive outcome because the two just won’t fit together.
Regardless of what was lacking in Dr. Gupta’s solution, he’s promoting a “call to action” of sorts in the mainstream media. He’s shedding light on a persistent problem that pervades healthcare delivery on a global scale. As a nurse who wants to see change in healthcare delivery I respect that.
It’s a start.
Resources:
Quintero, J. (2004). Developing an Interdisciplinary Model of Care in a Progressive Care Medical Unit. Critical Care Nurse, 24(4), 65-72.
Love this post. Listen and Learn. Our day WILL come.You are a terrific writer with many gifts. I believe in nurses. I believe in you.
I agree. An excellent critique of the state of healthcare, and of the potential for nurses to play an important role in meeting the very real needs of the individuals we serve. I believe that another important way to promote safety and prevent harm is to reduce the risk of harm in the first place by avoiding unnecessary healthcare encounters.
We should adopt an approach that always questions the appropriateness of tests and treatments in light of what patients and their families REALLY want and need, looking at the big picture of how these things will benefit the individual in the long run, rather than just protecting the provider and organization from liability. Everything we do costs the patient and family in some way. Sometimes the cost is financial, other times it is the pain of a procedure, the worry of what a test might find, and always the time of the healthcare encounter. In some cases, the encounter results in a complication for the individual, the family or both- a complication may be from the procedure itself. It may be from being in the healthcare environment. Or, it may be from the long-term financial impact of a decision that we make.
Case in point: a cardiologist put a pacemaker in an individual with complete heart block to save his life. The device was the top of the line at the time, costing $80K. The cardiologist figured, no problem, the patient has insurance. I also wonder if there was a financial incentive for him to use that expensive device. Add to that, the costs of a week-long life-saving ICU stay, and the grand total was $225 K. A few months later, this individual who is now a cardiac cripple, unable to work because of his heart problems, finds out that his insurance company was not going to cover the hospital stay- his heart failure was a pre-existing condition caused by the cancer treatment he had over a decade earlier. The insurance company got out of paying, and the person is bankrupt, living with a family member to avoid being on the street.
No test, treatment, procedure or healthcare setting is without some kind of risk, especially for vulnerable individuals, and nothing in US healthcare is free. For many individuals with complex chronic illness, trying to manage their health is a full-time job. Decision-making that considers the long-term, big-picture risk and benefit of what we do with the patient and family as the focus is a good thing. By doing this, safety indicators will improve, healthcare costs will be reduced, and we may even improve people’s quality of life.
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