Quality of Care

QUALITY: Lessons in Communication from Ski Patrollers and Navy Men

Elena Harman — Mon, 23 Jun 2008 13:55:00 -0400

What’s the difference between a 15-year-old volunteer emergency responder and a doctor? Well, lots of things, but here’s one you might not expect: until recently, only the 15-year-old practiced a standard protocol of communicating with other health care providers.

This is big news to me. I was trained as a volunteer ski patroller back in high school, completing both my Outdoor Emergency Care and Wilderness First Responder certifications. In both courses, my instructors emphasized clear communication from day one. There was a strict protocol for each dialogue, and although we were all medical novices, by the end of training we were pros in reciting a SOAP Note: Summary (age, sex, chief complaint, etc), Observations (patient exam, vital signs), Assessment (what you think the problem is), and Plan (what you think should be done about each problem).

It never occurred to me that doctors did not all follow a similar protocol. If first responders—even teens on skis—are trained to streamline communication to get patients the best care as quickly as possible, shouldn’t doctors be too? Now, thanks to Doug Bonacum, VP of Safety Management for Kaiser Permanente, such standards are becoming more common. In an Institute for Healthcare Improvement: Profile in Improvement, Bonacum describes his experience with suboptimal communications between providers in the perinatal unit, and how he applied a communication strategy he had used in the Navy to improve patient safety:

I was sitting in a perinatal patient safety training […] in 2002, listening to the doctors and nurses sort of talking at each other about how disappointed they were with each other on their communications. And the nurses would say, “You know, when I call the doctor in the middle of the night, I tell the doctor what’s wrong and I really think I’m making a strong recommendation but I don’t get the sort of response that I would hope for.” And our physicians were saying, “You know, when they call me in the middle of the night, they tend to ramble, it’s not very clear what their assessment is, I don’t know what they want most of the time, and most of the calls, quite frankly, are of no use.” And I recognized that the patient was at the middle of all this and it didn’t need to be that way and that a more structured communication might help both the receiver and the transmitter of that information
So I reflected on how we would make similar conversations in the Navy. … And we used a technique that I later labeled as SBAR, which was just to describe the Situation we were seeing succinctly, give a little bit of a Background so the person hearing the information had the context to provide an Assessment … and most importantly to provide a Recommendation…

We quickly developed some training around it, allowing people to try to test it out and to give them feedback in a classroom environment. And I didn’t really think it was going to go much further than perinatal patient safety and soon it was sort of everywhere. And now we’re using it to write e-mails to each other and people are using it during handoffs in transitions in care, so it really has caught on.[…] And both the receiver and the transmitter of the information actually benefit from it, so it’s a win-win for everybody and, I would say most importantly, for the patient or the family.

After Bonacum’s 2002 initiative, the Joint Commission added communication protocols to their list of patient safety goals in 2006, and since then, hospitals have begun to adopt SBAR or similar models of their own. Fixing health care is going to require big things from Washington, but also littler ones from health care providers themselves. Things like clearer communication, whether on the ski slope or when caring for a tiny sick baby, can add up to make a big difference.

WORLDVIEW: Evidence-Based Medicine vs Russian Salt Dust

Joanne Kenen — Wed, 18 Jun 2008 17:30:00 -0400

If you think we've got problems here in the U.S. developing evidence-based medicine, just think about the challenge in a place like Russia. Health writer and blogger Merrill Goozner just spent two weeks reporting in Russia, and we were fascinated by his piece on the Scientific American website.The problem, he writes, begins in the medical schools, where "young doctors receive almost no instruction on biostatistics, epidemiology and methods of decoding the evidence generated by clinical trials." Russian doctors make about $800 a month, meaning getting access to western medical literature is often out of reach (besides, it's in English). So while neither our health system nor our lawmakers have yet figured out how to stimulate more comparative effectiveness research (and how to get the research acted on), at least we aren't treating pulmonary patients with aerosolized salt dust in "cave-like rooms"—a practice that's been common in Eastern Europe for two centuries, but according to Goozner, never systematically studied.

QUALITY: What Patients Think of Patient-Centered Health Care

Joanne Kenen — Mon, 19 May 2008 13:30:00 -0400

"Patient-centered medicine" is one of the buzzwords in health these days, so it was refreshing to hear from patients who actually had a voice in finding that center. Four spoke at a panel this spring sponsored by the Institute for Healthcare Improvement. Four patients. Four very different experiences. All had some success in creating a more responsive health care system. And when we at New America talk about reforming health care, we don't just mean insuring people. We want everyone to be covered so they can be part of a system that delivers high-quality, cost-effective, patient-responsive care.

(If you are interested in the difference between "patient-centered health care" which involves how we deliver care that patients need, and "consumer-directed medicine" which is a market-oriented approach to financing health care, read this Healthbeat pos t . They are not necessarily mutually exclusive, but they aren't synonymous.)

* * *

Twenty years ago, when Richard Scholtz, was not quite 40, he needed surgery to replace a defective heart valve. Grateful for excellent care, he showed his appreciation by coming in every Friday to play music in the doctors' waiting room. Twenty minutes into his first "performance," one of the physicians came out and declared: "Everybody's blood pressure is lower!" It became a steady gig. They offered him a job, but he declined payment, although he later accepted a barter arrangement. He serenaded. They kept his heart ticking.

The experience did propel Scholtz, who is from Bellingham, Washington, into more activism about patients and health care, and he was able to help his aging mom learn to take care of her heart disease in a community that was part of a Robert Wood Johnson Foundation-funded "Pursuing Perfection" initiative. Among other things, the program helped patients create secure electronic medical records that they controlled. They could monitor their own chronic diseases, and share information at their own discretion with doctors, pharmacists and other practitioners, as well as family or friends who were part of their care team.

At the time his mother was already a bit confused—not suffering from dementia but having trouble dealing with a complicated medical condition. "Self-managing for congestive heart failure was tricky," he recalled. "But the care specialist spent time listening to her, understanding how she learned. So she was able to self-manage." The personal health record "has become a place where the patient has to make sense of their own situation," he said. The record contains both treatment instructions as well as the patient's own goals, how he or she stays well. Now that his mother is well into her 90s, he is less of a health-sidekick for her, and more her health navigator. He has also gotten deeper into "health mapping," which is both a literal map and a metaphor for understanding the context of good health in the life of an individual or a community (More on that later this week).

* * *

Patient two was Ashley Peterson of Minnesota. Actually Ashley is the mom; the patient was her seven-year-old daughter, Camerynn, who has cerebral palsy, developmental delays and a rare brain disorder. Camerynn now has a "medical home"—another new term in health which basically means she is treated by a primary care practice that coordinates all her care, that knows how to manage chronic disease and cares about doing it right. "Our experience before the medical home," Ashley recalled "was we were really rushed at our appointments. And with a complicated child, you need time to talk to the doctor." Ashley was invited by Camerynn's pediatrician to help create the medical home to serve special needs children and their families.

Camerynn no longer has to wait more than an hour for her frequent appointments. Her complex condition is flagged in her electronic medical record, so when Ashley calls, the schedulers automatically book Camerynn for a longer appointment—20 to 40 minutes instead of the standard 10. The clinic doors finally were adapted to handle wheelchairs; special scales can accommodate disabled children.

Ashley doesn't have to give her daughter's complicated medical history over and over and over again to 13 different specialists; they have her record on the computer "and they know what's normal for that child." The electronic medical record is even accessible at the emergency room if Camerynn or other children in the program end up there (and even in a medical home model, where complex conditions are well-managed, E.R. visits may be reduced but not completely eliminated). And the doctors now use "picture boards" so young children or those like Camerynn who can't speak well can point to images to communicate—what hurts, and how much.

Three parent representatives regularly meet with the medical staff and care coordinator—and the care coordinator actually coordinates. "It's a huge improvement. She'll make appointments for all the specialists. And instead of a three or four week wait, it's a quick turnaround," said Peterson, who now serves on all sorts of boards, councils and volunteer groups—in addition to going to school to become a special education teacher.

* * *

Jean Klein, who is in her 80s, played Mrs. Santa Claus for 25 years for her local business association in Colorado. She and her husband were in real estate, and they had a good life. When Al had a heart attack, he got good care. Klein always found that if she hugged the doctor, Al would get even better care. Then she got sick. She woke up on life support with double-pneumonia. She survived. "They brought me back twice." Her young doctor ("I'm old enough to be her grandmother," Klein said.) saw something special in the elderly woman and invited her to join a patient advisory group where patients could help the doctors see the treatment from the patients' perspective. Klein had a few simple suggestions that made a big difference.

"The doctor looks at the computer, he talks to you, you say yeah, sure, and then you go out. Your cell phone rings. You drive off. You remember you forgot to go to the lab. You have to call the office... We came up with the idea of letting him (the doctor) put everything he wants you to do in that computer. Then he pushes ‘Print,' and by the time you get out to the desk, you can see it for yourself." The "After Visit Summary" helps patients keep better track of tests, appointments, referrals and their medications, and if they are elderly it make it easier for them to share it with family members too.

"Think of all the old wimpy people who aren't going to be calling back," Klein told the doctor (whom she also hugged). "This will save you a lot of time."

* * *

Margaret Murphy, from Cork, Ireland, lost her son Kevin in 1999. He was 21. He didn't need to die. "Every aspect of his point of contact (with the care system) failed him," she told the IHI conference. His care in both Ireland and the United States was a comedy of errors—except that it was a tragedy not a comedy. His "patient journey," as she calls it, of misdiagnosis, mistreatment and miscommunication (potentially life-saving information slapped on a sticky note instead of in his chart) turned her into a dedicated international patient safety advocate, part of an international movement. The goal: to make sure there are no more deaths like Kevin's.

Stay tuned for more on Richard Scholtz and mapping.

QUALITY: For a Patient in Pain, Too Much Can be Too Little

Joanne Kenen — Mon, 12 May 2008 16:57:00 -0400

Maggie Maher, a health blogger we read regularly, has a poignant post today about untreated pain, inappropriately aggressive high-tech care, and the lessons that young medical students (not to mention some older doctors) still must learn about why "good care" and "cure" are not synonymous.

Maher spent some time with Dr. Diane Meier, a geriatrician and national leader in palliative medicine at Mt. Sinai Hospital in New York, and she watched Meier share with medical students some of what she has learned about how to help seriously ill or dying patients. I learned a lot from Meier and her colleagues at the Center to Advance Palliative Care last year when I was doing an extensive reporting project on palliative care and hospice. (Click here, here, and here).

Palliative care (which unlike hospice does not preclude curative treatment and which is not only for people expected to die within a few months), is better understood and more widely available than just few years ago. But the health care system, with its emphasis on a high number of elaborate procedures, still undervalues it—even though palliative care's emphasis on getting patients the most appropriate care can often save money. As Maher writes:

Clearly, we need more palliative care specialists like Meier. But this is another case where we don’t pay enough for “thinking medicine"—which involves talking to and listening to the patient—rather than cutting him or radiating him.

“When a three-person palliative care team made up of a doctor, a nurse, and a psychologist spends 90 minutes in a meeting with a family, Medicare would probably pay $130 to $140—for all three people,” Meier told me. “And Medicare is one of the better payers.” This explains why Meier earns $100 for every several thousand dollars that her husband, an invasive cardiologist, takes home. “Though,” Meier said mildly, “it would be hard to say that one of us is practicing more sophisticated medicine."

BMJ, the medical publishing conglomerate, recently got 4,000 responses to an online poll asking people to rank six areas where doctors could make the greatest difference to patients. Number one: more palliative care.