Patient Safety: Care of the Patient Requires Care of the Providers

What does patient safety mean to you? I was recently asked this question in advance of speaking at an upcoming National Patient Safety Foundation Conference. Below is my answer. I’d be happy to hear from others your answers to the question.

I believe patients get the safest care when 

  1. The patient is known as an individual
  2. The health care team gives the patient their undivided attention 
  3. The team is well-supported with efficient workflows and organized, easily accessible information. 
  4. The health professionals find joy in their work.

By being “known” I mean, that the nurses and physicians know the patient as a real person, what their life is like, who are their supports, what are their goals. Inherent in being “known” is continuity--the same medical assistants, nurses and physicians work with the patient at each visit and between visits. Relationship-centered care. 

By “undivided attention” I mean that the physicians and other providers can listen intently to the patient and think deeply, without being distracted by multi-tasking, and without being diverted by clerical tasks such as data gathering and data entry.

By “organized, accessible information” I mean an EHR that reduces the cognitive workload of information management; checklists that make it easy to do the right thing; and the supportive use of clinical metrics to empower front line workers to improve care.

I learned this guiding principles from Borgess Health in Michigan: “We will know who you are and we will be ready for you.” This is a powerful promise to patients; delivering on this promise requires knowing the patient, providing undivided attention, and being well-supported by efficient workflows.

And finally, and most importantly,  I believe the best way to achieve a safe and satisfying experience for patients is to create an environment that is safe and satisfying for the workers, an environment that nurtures the intrinsic professionalism of the physicians and other staff—where the health care team can experience joy in practice. In sum, I believe that achieving the triple aim is dependent on the quadruple aim; that care of the patient requires care of the providers. 

I believe that most health professionals come to work each day to serve their patients, to make a difference in their patients’ lives. If the environment helps people meet these professional goals, by making information easily accessible, by limiting the distracting burdens of regulatory compliance, by fostering relationships, then I believe the members of the healthcare team will give the patients their all, and the results will be safer, more satisfying care.


Is Replacing Transcriptionists with Physicians a Good Bargain for Health?

My general internal medicine practice is equidistance from three academic institutions and a Veterans Administration facility, and thus I have patients who receive primary, secondary and tertiary care at each of these institutions.

The notes I receive back from one of these organizations are hands down the best of the four. These notes are personal, concise, precise and clear. 

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Are We Measuring the Right Things? Is current measurement a production line solution for a “solution shop” problem?

We believe in data. We are scientists after all. And yet in this new era of Big Data is it possible we are measuring the wrong things?

Most measures of physician performance are process or intermediate outcome measures aimed at a production line model of care. Was an A1c done, did the physician use a computer to send an order to the laboratory, were antibiotics given within two hours of presentation.

Yet most physician quality is related to what Clay Christiansen calls “solution shop” work, such as diagnosing and solving undifferentiated problems, activities that require an amalgam of experience, intuition and problem solving skills, and for which good measures have not yet been developed.

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Healthcare is Ultimately a Social Enterprise: Building better systems through "Relational Coordination"

Healthcare is ultimately a social enterprise. We can reduce it down to a series of electronic steps and lose the humanity. Or we can leverage the professionalism among the people who come to work every day. When the oncology nurse talks with the family medicine nurse care is more tightly woven together for patients and families.  When the surgeon talks with the pulmonologist errors are less likely. When the internist talks with the pharmacist medication choices are optimized.

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Can “Slow Medicine” Hasten Healing in the US Healthcare System?

Dr. Dennis McCullough’s ideas about Slow Medicine for the elderly can be boiled down to three recommendations: regularly reassess the need for current medications/doses; pace decisions over time; and have another person in the room to listen and help explain. 

These commendable recommendations should be held up to the light of concurrent trends in the external environment. Physicians can't handle yet another mandate “Go slower, take more time with each patient, especially the elderly” without the environmental changes that can support this approach.

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MU2 does not Require Physician Order Entry.

The Meaningful Use 2 requirement, “Use computerized physician order entry (CPOE)”  is commonly misunderstood and warrants further clarification. Many organizations have misinterpreted this statement to mean only physicians or other providers can keyboard in test codes for lab and radiology orders, only physicians can send prescriptions to the pharmacy, and that all prescriptions sent by a nurse at the doctor’s direction require co-signature by the physician. This has placed physicians in a thicket of electronic busywork, and needlessly added hours to many primary care physician’s work day. 

CMS is very clear that keyboarding in orders for medications, labs and radiology tests does not have to be a physician function. 

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Unplugged and Reconnected

It started with a dead laptop. For the first time in more than 3 years I felt like a doctor again. I had forgotten what it was like.

Having neglected to plug in my laptop the night before, it was without power. (Without Power!) An opportunity for an uprising, of consciousness if not full revolt.

For the first 1½ hours of clinic I entered each exam room without the weight of the computer. I felt light, free and focused. 

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Take Back the Night

It’s 6pm and time to go home. The primary care physician, who still has several hours of work to do, packs up her laptop and heads out the door. I’ll have dinner with the family and then do my charting after the kids go to bed, she reasons. From 9p-11pm most nights her husband can find her typing up the day’s clinic notes and working down her seemingly endless worklist. He tells a friend “its nice to have her home, it would be good to have her present.”

Do you think this scenario is unusual? 

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Hazards of Poorly Designed Decision Support

Have you ever encountered an intrusive, insistent, but unhelpful pop-up decision support screen while trying to take care of patients? Found yourself stuck in a dead-end electronic hallway without egress? A situation where you had to choose an option that was inappropriate for your patient just to exit the screen?

This is the situation with Trinity Health’s “DVT Advisor,” a mandatory decision support screen for all patients. 

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Welcome to this new website and blog for physicians in search of greater efficiency, meaning and joy in their work.  

Why now? I've observed a growing sense of discontent among the physicians I encounter, and within myself.  This cannot be good for patients. And it cannot be good for the physicians who care for them.  

This could be the best of times for medicine. We can do more for patients, with less risk, then we ever could before. We can communicate with colleagues and patients by call, text, email or even (!) in person. We have information resources at our fingertips. No more lingering doubts about the workup or long searches through outdated text books for treatment guidance. Why then do so many of us feel our days are being drained of meaning? 

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