Saturday, April 29, 2006

The importance of listening

“When [going into] an examining room,” said Dr. David Ruben, Chief of Geriatrics at UCLA, “you’ve got to be ‘out there’ for the patient. It’s very much like going on stage. It’s not that it’s insincere, but you have to be optimistic for patients. You need to engage them completely with your attention and be observant of everything that’s going on with them.”

That comment is from a story broadcast recently by National Public Radio. “On stage” was the phase that struck me because, although we are not “acting,” we in health care certainly are at center stage for patients and family members. Patients and family members study us, as if we were performing at a recital, giving a reading at our place of worship, or making a speech in front of our social group.

They watch closely to discern clues about what’s going on with their care or with their loved ones. Are we excited about something? Are we confident? Distracted? Are we sensitive to the patient’s discomfort or anxiety? This is the way we human beings communicate, by closely watching others to see if actions match words. And the more important something is (such as hospital care), the more closely we observe.

This year the federal government will start observing us – through the eyes of our patients. Surveys will be mailed to the patients of CGH and all other hospitals across the country. This is called the HCAHPS survey (pronounced “h-caps” and meaning “Health Consumer Assessment of Healthcare Providers and Systems”). The results of these surveys will be reported publicly, starting in 2007, by the federal Centers for Medicare and Medicaid Services (CMS). Eventually CMS intends to use the hospital patient satisfaction scores to determine how much they pay us for the care of Medicare patients.

CGH will voluntarily participate in a test run of the new HCAHPS survey this summer. The official survey process begins this fall.

Press Ganey Associates, a professional polling organization that already surveys CGH patients, has worked with the HCAHPS survey to determine what patient values are most correlated with high hospital satisfaction. According to Press Ganey, patients who give hospitals high marks well feel they have been listened to by the nurses and other staff.

“You need to engage them completely with your attention and be observant of everything that’s going on…” is the way Dr. Ruben put it, an excellent definition of effective listening.

The experts say that how we perform our jobs is as valued by patients as what we do in the jobs. “Scoring highly (on patient surveys) does not require [hospital staff] perform any additional tasks or duties but simply conduct their existing activities in ways that build relationships with [patients and families],” according to the experts at Press Ganey. Examples? Greeting the patient by name, and asking for help to pronounce the name correctly. Making eye contact with the patient and family members when speaking with them. Asking about a patient’s comfort and helping make the patient comfortable. Explaining what you are doing – and why. Using those most-important words consistently: “excuse me,” “please,” and “thank you.” Before leaving the room, ask, “Is there anything else I can do for you?”

Health care workers are hardly actors in any theatrical sense, but we are clearly stars to our patients when we listen to their needs, when we show concern for their comfort, and when we demonstrate courtesy in the many things we do every day.

Saturday, April 22, 2006

I had no idea

Two months ago we heard shocking reports about several individuals who were arrested for illegally harvesting body tissue in New Jersey funeral homes. [1] The tissues were provided to a legitimate medical supply company where they were properly processed and distributed to hospitals around the country – including to Community General Hospital.[2] The investigation into these matters is continuing, most recently with a probe of a Philadelphia funeral home.

We saw an entirely different kind of story in our local paper recently. For the 26th consecutive year, students from SUNY Upstate Medical University gathered at Weiskotten Hall for a memorial service to honor individuals who donated their bodies to science.

All of us benefit directly or indirectly from the gifts of bodies and body parts from voluntary donors. For many years the New York State driver’s license has included a short form allowing each of us to “make an anatomical gift to be effective upon my death.” This prompts a story about anatomical harvesting at CGH several years ago.

A young adult died in our Emergency Department as the result of a neurological event, and the spouse agreed to organ harvesting. The couple had been married only a few years, and they had discussed with each other their willingness to donate their bodies “to help others if something should happen.” When the patient was pronounced dead, the spouse readily gave consent, and the deceased patient went to the OR for harvesting.

Six months later the surviving spouse called me one morning and asked to meet with members of the Emergency Department and OR teams who cared for the patient who had died. “I want to thank them,” the spouse said, “and I have some unanswered questions, some things I am wondering about that I would like to ask.”

I did not know what to make of this request. The spouse was certainly heartfelt, but what were the “unanswered questions?”

Working with the Nursing Division, I arranged for a small reception in the Personnel Lounge for the spouse at mid-morning one day. I invited those who had cared for the patient to stop and introduce themselves to the spouse. It was voluntary, and I told the spouse that CGH people were busy, and I could not be sure how many would be able to attend.

Many did. Employees shook hands with the spouse and introduced themselves. They said, “I cared for your [spouse] in the ED,” and “I was with [the patient] in the OR.” They said, “I am sorry for your loss.” The spouse said, “Thank you so much for all you did,” and “Thank you for coming this morning.”

One nurse from the OR had done homework. She arrived with a small piece of paper that had numbers written on it. “Let me tell you about some of the people who benefited from [the patient’s] gift,” she began. “There was a 15 year-old girl in [a Southern state] with bone cancer. She received your [spouse’s] long bones. There was a middle-aged man in St. Louis who received the heart. I was there when the harvest team arrived from St. Louis. A few hours later, as we continued to work on your [spouse], there was a phone call that was put over the OR speaker. The caller said, ‘The heart is in the patient, and it is beating.’ And we all cheered.”

The nurse continued, “I tried to count the number of patients who were helped by [the patient’s] gift – the eyes, the kidneys, the skin, the bones, the heart. There were more than 150 individuals who were helped by some part of your [spouse]. The harvesting took many hours, and at the end we were all exhausted. We all said a prayer for your [spouse] in the OR.”

I don’t think there was a dry eye in the room. “I had no idea,” the spouse said. “I had no idea that so many people were helped. Thank you for telling me this. You have no idea how much this means to me.”

This story has stayed with me all these years as a reminder of the good that we do – and how powerful it is when we explain what we do so others may share its meaning.

This CGH story – along with the annual memorial service at SUNY – are antidotes to the revulsion we feel at learning of the tissue scandal in New Jersey.

Please take out your driver’s license. Have you signed permission to be an anatomical donor “to help others if something should happen?”

[1] Two CNY patients got tissue linked to indicted supplier ,” Post-Standard, February 23, 2006
[2] “CGH opens info line on body tissue scare,” CGH Family Letter, February 25, 2006

Saturday, April 8, 2006

Thank you, 95%

Community General Hospital has seen an increase in the percentage of hospital people (that includes doctors and employees) who comply with proper hand hygiene. In the first three months this year, we are averaging 95% compliance, compared with a 90% average in the past two years.

Three weeks ago I quoted a newspaper obituary for David Williamson Milne, a man who died in Kingston, Ontario on October 30, 2005. “The surgery was successful,” read the obituary.

Dave’s recovery was preceding well, thanks to the care of the [hospital] staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.[1]

According to the Hand Hygiene Resource Center, “two million people become ill each year as a result of a hospital-acquired infection,” at a cost of some $4.5 billion. This week the Wall Street Journal reported “the rising alarm” that 90,000 hospitals deaths occur each year from these infections.[2] That translates to about 250 patient deaths each day! To put that number in perspective, last year CGH had an average daily census of 192 patients.

A review of 34 studies shows that “hand washing adherence among health care workers…varied from 5% to 81%” – with the average “only 40%.” Yesterday Sue Chamberlain, CGH’s Infection Control Program Director, told me there is a 1999 study by the Centers for Disease Control (CDC) that shows an average 54% of health care workers wash their hands as required. From this I conclude that the average hospital’s compliance is in the 40-50% range.

“‘It is no longer tolerable to accept noncompliance rates of more than 50% when we are dealing with critically ill patients,’” according to Dr. Don Goldman of the Institute of Healthcare Improvement (IHI) who was quoted in the Journal article. Dr. Goldman noted that computer-chip makers have better hand-cleaning performance than some hospitals.

At CGH nothing we do is more important than keeping safe the patients entrusted to our care. So I thank you for the increased vigilance that has boosted our hand hygiene compliance to 95%. We are at the very top of nationwide performance, ]something we should be proud of – and something very important for patients.

I do have a nagging question about the remaining 5%. Who would fail to wash hands and raise the risk of a potentially life-threatening infection for a patient in the next room, a colleague in the cafeteria …or for that matter, a loved one at home?

[1] “A Tipping Point,” CGH Family Letter, March 18, 2006.
[2] “Hospitals Get Aggressive About Hand Washing,” Wall Street Journal, April 5, 2006