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What Happens When Doctors “Just Listen” to Their Patients

Posted on Mon, Mar 20, 2017
What Happens When Doctors “Just Listen” to Their Patients

“Just listen to your patient; he is telling you the diagnosis.”

This medical maxim is attributed to Sir William Osler (1849–1919), widely considered to be one of the greatest physicians and diagnosticians of all time. Although Osler’s advice might seem impractical in today’s healthcare environment in which clinicians face increasing pressure to deliver care faster and more efficiently, a recent experiment by a New York City physician suggests that letting patients speak about their health problems without interruption can be both practical and beneficial for both parties.

Studies have shown that doctors interrupt or redirect patients within the first 30 seconds after they begin speaking, and two studies found the average time to interruption was 18 and 12 seconds, respectively. Danielle Ofri, MD, a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, confessed to having been guilty of such interruptions and redirections in her recent essay in STAT (adapted from her new book, “What Patients Say, What Doctors Hear”). Like many of her peers, she feared her patients would “ramble on ad infinitum” if she didn’t home in on their top priorities quickly. But after reading a study by a group of Swiss researchers who found that when doctors did not interrupt, the average duration of their patients’ monologues was a mere 92 seconds, Ofri decided to do some informal research in her own clinic the next day.

Throughout that day, she asked each patient how she could help her or him, then quietly clicked on a stopwatch to time their responses. She encouraged them to keep talking until they had finished telling her everything they wanted to discuss. Her first two patients, who were basically healthy individuals, spoke uninterrupted for just 37 seconds and 32 seconds, respectively. Her third patient, who had unresolved back pain plus glucose, cholesterol and weight that were creeping up, spoke for two minutes.

But Ofri was understandably worried about what would happen with her next patient, Ms. Garza (not her real name). Garza not only suffered from a wide range of chronic, insoluble pains compounded by anxiety, depression and irritable bowel syndrome, she also had to care for her demanding, elderly mother, who had insomnia and routinely was up and complaining at all hours during the night. “Exactly the type of patient who can drown you with a list of complaints,” Ofri noted. In addition, Garza, who had been a teacher in her native Argentina, had a penchant for offering observations about New York City’s “pretensions of culture” and its lack of sophistication compared to Buenos Aires.

Ofri feared that if she allowed Garza to say everything she wanted to without interruption, “the visit would unfurl like a Borges labyrinth. We’d tumble down a dizzying path of her symptoms that would encompass every organ system of her body, plus a list of her mother’s medical woes and a stinging critique of the Metropolitan Opera’s soulless production of ‘Turandot.’” Nonetheless, Ofri understood that if she excluded “difficult” patients from her experiment that day, her data—informal though it was—would be flawed. So, despite her qualms, she encouraged Garza to keep talking until she had “fully, truly, absolutely come to the end of all that she had to say” while Ofri jotted down the long list of issues. When Garza had finally talked her fill and Ofri clicked off the stopwatch without looking at it, she estimated that between eight and 10 minutes had passed. Later, when she checked the stopwatch, she discovered that even Garza’s lengthy monologue had actually taken just four minutes and seven seconds.

Garza had already had an extensive workup, and all the results were negative. Ofri explained to her that something was going on and that “Medicine is very poor at explaining pain syndromes, but that doesn’t mean we can’t go ahead and start treating your symptoms.” She and Garza spent the remainder of the time reviewing the list of issues. They went through each type of pain, which included shooting pains in Garza’s gums, a painfully sensitive scalp and neck pain that radiated down her spine, and identified treatments that might help, including ice packs, local heat and massage, physical therapy and pain medications. They discussed how antidepressants could be helpful, how seeing a therapist could decrease Garza’s stress, how she might get help in caring for her elderly mother and the critical role of exercise in treating chronic pain. Then they put together a written plan based on those discussions.

Even so, the visit didn’t run overtime by much. Before leaving, Garza said, “Just talking about all this has actually made me feel better.” To Ofri’s surprise, it had made her feel better, too. In fact, it was the first time she had ever felt good after a visit with a patient with chronic pain. “I was actually doing something to help, rather than just rearranging deck chairs,” she explained. “It’s a reminder that doctors sometimes need to zip it up and let the patient talk uninterrupted. Although it may feel like time is being wasted, it could actually make everything much more efficient.”

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Geographic Rounding – The Good, the Bad and the Ugly

Posted on Wed, Mar 08, 2017
Geographic Rounding – The Good, the Bad and the Ugly

Hospitalists have become vital members of the care teams throughout the United States. As healthcare organizations have welcomed this new physician role, many have been faced with the challenge of successfully integrating the role into their overall operations. One solution that has emerged over the past few years is geographic rounding.

Asim Usman, M.D., SFHM, divisional medical director for EmCare's West Division, led a panel discussion on geographic rounding at the 2016 EmCare Annual Leadership Conference in Las Vegas. He highlighted the experience and success Santa Rosa (Calif.) Medical Center (SRMC) had with geographic rounding. SRMC representatives Al Gore, M.D.: director of utilization management, Chris Stier, R.N.; nurse manager, Briana Rogers, EmCare’s division client administrator, and Carsi Padrnos, director of clinical services, joined Dr. Usman as panel members.

Dr. Usman explained that geographic rounding designates a system of hospitalist patient assignments by geographic location. He acknowledged that geographic rounding has become a buzzword in the healthcare industry: “It sounds cool, and it seems to make sense, so everybody wants it. But does a hospital really know what geographic rounding means and what it is asking for? Does the hospital understand the challenges that come with implementing it? Can the hospital’s culture support the successful implementation of the concept? This is the ‘bad’ of geographic rounding.”

What about the “ugly” side of geographic rounding? Recognizing that no one likes change, the concept is complex, involving several key stakeholder groups that are being asked to change their behavior regarding workflow. In addition, specific metrics and data will be used to hold individuals accountable for either supporting or hindering geographic rounding’s success.

To demonstrate the challenges of implementing geographic rounding and the resulting “good” aspects of the concept, SRMC’s experience was highlighted. SRMC has partnered with EmCare for the management of its emergency medicine and hospital medicine programs. EmCare’s Rapid Admission Process & Gap Orders™ (RAP&GO) solution is used to improve efficiency in the emergency department (E.D.) and to enhance patient flow by facilitating the movement of patients requiring hospitalization to inpatient beds as quickly as possible.

Dr. Usman noted that when EmCare started working with SRMC, the hospitalist program was disjointed, with only four full-time hospitalists on staff. With 200 beds, the hospital’s average daily census is about 120. Currently, six hospitalists cover the service daily, with one swing shift and one night shift.

In theory, geographic rounding should promote more positive experiences – timely, coordinated care and organizational efficiencies. The hospital’s goals for geographic rounding, created by the hospital medicine physicians, included:
 

  • Improved physician response time
  • Improved patient and family access
  • Limited physician movement in the hospital to facilitate team rounding (physician, RN, social worker)
  • Participation in discharge huddle
  • Building physician and nurse relationships
  • Improved consultant access
  • Increased patient satisfaction

To evaluate the success of geographic rounding, the hospital utilized the following metrics:
 
  • Average length of stay
  • 30-day readmission rate
  • Medical staff satisfaction
  • Patient satisfaction
  • Physician satisfaction

Stier’s nursing unit was selected as the pilot site for geographic rounding. He said the major objective was to locate at least 70 percent of a hospitalist’s patients on a single unit. Some of the first major challenges included a limited number of full-time hospitalists in the program – necessitating the use of locum tenens physicians who were not necessarily familiar with or willing to buy into the concept – as well as a high patient load, the existing method of patient distribution and “floor fatigue.” Huddles became a key component of the successful implementation of geographic rounding by creating a culture of accessibility and collaboration.

“Nurses want physicians there, consultants want to be able to reach the hospital medicine physician, and patients want to have their physician readily available,” Dr. Usman said. “When you go into a new facility and bring a new team of 16 hospital medicine physicians to interact with 300 nurses, how do you develop a geographic rounding program?” The five- to 10-minute daily discharge huddles, held in the morning with efficient delivery of critical information, helped to engage physician and staff confidence in the concept.

Ongoing feedback and communication among all care team members was key to its evolution. Participants identified what was working well and what was not. As the new geographic rounding program matured and discharge huddles involving the hospitalist, nurses and social workers became standard procedure, the hospital began to see significant improvements in organizational efficiencies such as pharmacy utilization, DME orders and delivery, reduced callbacks and a substantial decrease in the distance hospitalists traveled within the hospital to see their patients. Physicians noted that the volume of telephone calls also decreased dramatically, indicating that it was most likely due to more consistent physical presence of physicians, which resulted in fewer workflow interruptions.

Rogers noted that education and collaboration were necessary for a successful launch of the program. Aligning the hospitalists clinically with the mix of patient diagnoses also was important. The hospital set up financial models to ensure appropriate staffing practices were in place to meet patients’ needs. Flexibility also was paramount. When staff members were flexible, they were able to learn from their experience and make adjustments to improve the process.

Dr. Usman pointed out that timing is important for launching a geographic rounding program: “When you go into a new program with 60 percent locums, it’s probably not the best time to start most new initiatives. We waited about eight months to get appropriate hospitalist staffing in place before we began the program.”

Padrnos explained that the geographic rounding initiative at SRMC brought together three factors: a multidisciplinary approach, the opportunity to impact patients, and a multitude of challenges for presenting providers. One of the biggest challenges was the high degree of interest the hospital had in the program compared to the low degree of interest from legacy hospitalists. Padrnos and the team made sure that all of the providers were involved from the start of the initiative and throughout the entire process.
A variety of implementation strategies were employed, including:
 
  • Setting clear goals
  • Involving providers at every stage of the initiative through regularly scheduled meetings with all team members
  • Testing small changes to gauge effectiveness
  • Designing a mixed model of solutions
  • Implementing frequent and ongoing communications, including memos
  • Creating a daily distribution board that included the hospital’s current census and newly hospitalized patients, a list of the hospitalists’ admissions and discharges, a list of the hospitalists’ current patient assignments by unit, average length of stay for the previous month and month-to-date length of stay
  • Using surveys with multiple stakeholders to measure the initiative’s success and to identify opportunities for improvement

The results of the geographic rounding initiative at SRMC have been impressive:
 
  • Length of stay has fallen from a baseline of 5.83 to 4.44 days
  • 30-day readmission rate has decreased from a baseline of 14.6 percent to 9.8 percent
  • Patient satisfaction has increased from a baseline of 67.7 percent to 78.1 percent

In addition, surveys the hospital administered to providers 30 and 90 days post-implementation addressed the specific goals they originally established for the initiative. The 30-day survey showed that the 10 respondents had little to no interest in the program. After 90 days, 60 percent of the five respondents said they were satisfied with geographic rounding and 100 percent said they were satisfied with the discharge huddle.

Dr. Gore concluded by saying, “The keys to our success with geographic rounding came down to teamwork and patience.”

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Patient Satisfaction Must Start With Nursing Satisfaction

Posted on Wed, Nov 16, 2016
Patient Satisfaction Must Start With Nursing Satisfaction

By Alberto Hazan, MD

Ever since the U.S. government decided to link Medicare reimbursement dollars to patient satisfaction scores, hospital administrators have been obsessed with improving the quality of care for patients visiting their emergency departments. While the motivation may be partly financial, the goal of improving the patient experience during emergency department and hospital visits is an admirable one.

Unfortunately, many of the tactics used by administrators have done little to achieve that goal. Hiring national “experts” on customer service to give lectures to the hospital staff, or introducing catchy mnemonics to guide physicians in conducting more compassionate patient interviews, have been equally ineffective in markedly improving patient satisfaction.

If we aim to better the patient experience in the emergency department (and the rest of the hospital), we need to shift our focus from the patients to the nursing staff. After all, the people who spend the most time with patients are not the physicians but the nurses. If nurses are dissatisfied at work, patients will inevitably be dissatisfied with their experience.

Recent discoveries in the field of positive psychology have demonstrated that being successful in any endeavor (including improving patient satisfaction in emergency departments) requires happiness as a prerequisite. If we truly want to improve the safety, care, and experience of our patients, then we need happier people at work. In his book, The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work, Shawn Achor highlights the link between success and happiness: “Studies show that simply believing we can bring about positive change in our lives increases motivation and job performance; that success, in essence, becomes a self-fulfilling prophecy.”

Ensuring we have happier nurses won’t just improve patient satisfaction; it will, more importantly, improve the safety and well being of anyone being treated in the emergency department. Happier people are more aware of their surroundings, they take more pride in their work, and they’re less likely to make mistakes. In the ER, this is imperative. A happier, more engaged nursing staff will be able to recognize red flags (including physician error), identify septic patients, and stay on top of their workload.

Ultimately, success in the emergency department means many things: taking good care of patients, looking after their best interests, and ensuring they do not have a life- or limb-threatening illness. Being successful isn’t just about improving patient satisfaction scores. It also means taking care of patient anxiety, treating their pain, and making them comfortable. It means that nurses (and physicians) are in a state of flow, can handle stress, and are aware, in the moment, and conscious of what they’re doing. This will help them work better as a team. Being happy at work also provides nurses with self-confidence and self-esteem: “The more you believe in your own ability to succeed, the more likely it is that you will,” says Achor.

If our nursing staff is happy, they are likely to see working in the ER as a calling rather than a job. In other words, “people with a calling view work as an end in itself.” Achor makes a case that happy employees have different priorities beyond just earning a paycheck: “Their work is fulfilling not because of external rewards but because they feel it contributes to the greater good, draws on their personal strengths, and gives them meaning and purpose.”

When nurses view their work as a calling, they can see more clearly the benefits they provide to patients, such as alleviating pain and suffering, quelling anxiety, diagnosing illness, and providing compassionate care.

How to Engage Your Nursing Staff

I recently became the director of the emergency department at Desert Springs Hospital Medical Center in Las Vegas. As soon as I took over the position, my mind reeled with the changes I wanted to make to ensure that patients were adequately taken care of, treated with respect, seen in a timely manner, and that their pain, anxiety, and questions were addressed quickly and effectively. I soon realized the most effective way to bring about such changes is to make sure that the people spending the most time with those patients—the nursing staff—are adequately taken care of.

I’ve started asking nurses about their goals and frustrations. I don’t schedule meetings with a bunch of doctors to figure out how to best improve patient satisfaction, but rather I ask the nurses themselves, individually and in real time:
 

  1. What is your overall satisfaction working at our hospital?
  2. What is the most stressful thing about your workday?
  3. What can we do to improve your workday?
  4. Do you feel rested? Do you have enough breaks?
  5. Do you enjoy working with your colleagues? Is there anyone here who drives you down?

I’m not sure what changes will come out of this. Maybe we will mandate an 8-hour workday, or provide a better schedule. Maybe we will increase our staff, or make sure nurses don’t waste time on non-clinical chores like finding equipment. Maybe we will promote more social events, or have more discussions in real time, especially after traumatic experiences like the death of a pediatric patient or a major resuscitation, to ensure hospital staff deal with the grief inherent in treating dying patients.

Regardless, I’m starting the process where I should: focusing on the people at the heart of patient care.

Dr. Alberto Hazan is an emergency physician and the director of the Desert Springs Hospital Medical Center Emergency Department in Las Vegas. He is the author of the medical thriller Dr. Vigilante and the preteen urban fantasy series The League of Freaks.

This post originally appeared on KevinMD.com.

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Develop Your ‘A Team’ to Improve Employee Engagement and Enhance the Patient Experience

Posted on Mon, Nov 16, 2015
Develop Your ‘A Team’ to Improve Employee Engagement and Enhance the Patient Experience

By Thom Mayer, MD, FACEP, FAAP

Providing clinical care at the bedside is a difficult job that seems to get more so every day. Nowhere is that truer than the physician’s interaction with the patient in the emergency department and on to inpatient services.  The fiscal demands for improved patient satisfaction scores only add to the pressure. But how can we motivate physicians for service excellence?

Developing an “A Team” culture is essential—so your staff understands the traits of excellence exemplified by the A Team, as well as the demoralizing effects of B Team behavior.

The intention of customer service is almost universal, but the execution of customer service is often lacking. Unfortunately, patient satisfaction initiatives typically mean more work for clinicians that may even interfere with the care of their patient. In my opinion, if it doesn’t make the job easier, it isn’t really customer service.

Excellent customer service only takes place in an excellent work environment. If people don’t love their work, any customer service push will be in vain. A great work environment is created by great people. Therefore, the only way to achieve excellent customer service is to recognize and reward “A Team” clinicians and get rid of clinicians who are unwilling to change behaviors that have an adverse effect on the team and on the patient.

“A Team” clinicians are intrinsically motivated to care for their patients and do a good job. They are usually described as:
 

  • Communicator
  • Compassionate
  • Competent
  • Confident
  • Does whatever it takes
  • Has a sense of humor
  • Positive
  • Proactive
  • Teacher
  • Team Player
  • Trustworthy

“B Team” clinicians have a poisonous effect on their work environments. Their behaviors are predictable and subject to statistical analysis. Characteristics that typify them include:
 
  • “Can’t do” attitude
  • Confused
  • Constant complainer
  • Late
  • Lazy
  • Negative
  • Poor communicator
  • Reactive

Service excellence is good for the patient, the family, safety, risk reduction, market share and, yes, customer service scores.  But the No. 1 reason to get service excellence right in emergency and hospital medicine is that it makes your job easier!

EmCare works with physicians and nurses to create an “A Team” mentality so hospital clients can achieve their goals of improving communication, reducing left-against-medical-advice rates and improving patient satisfaction.

For more information about how EmCare can improve satisfaction and performance, visit the Resources section of our website.



Thom Mayer, MD, FACEP, FAAP, is an Executive Vice President with EmCare. He also is the Founder and CEO of Best Practices and serves as a Medical Director for both Studer Group and the NFL Players’ Association. Mayer has published dozens of articles and book chapters and edited 15 textbooks including the definitive text “Strauss and Mayer’s Emergency Department Management.” He has been recognized as Speaker of the Year by the American College of Emergency Physicians. On September 11, 2001, he served as one of the command physicians of the Pentagon Rescue Operation. Emergency departments under his guidance have won awards from Press Ganey, PRC, Gallup, the Robert Wood Johnson Foundation and others. Mayer’s academic appointments include Clinical Professor of Emergency Medicine at the George Washington and Senior Lecturing Fellow at the Duke University School of Medicine.

 

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Physician Emphasizes Importance of Saying Thank You

Posted on Sun, Nov 01, 2015
Physician Emphasizes Importance of Saying Thank You

Doctor reports feeling deeper connection to his patients; improvement in patient satisfaction score

(HealthDay News) -- The importance of thanking patients for coming to see you, the physician, is described in an essay published online in Medical Economics.

The article discusses implementation of AIDET in a large multispecialty group practice. The acronym stands for the action words that comprise the patient visit: acknowledge the patient and associated family; introduce yourself; describe what you are going to do; explain what you did and what will happen next; and finally, say thank you.

The author notes that despite having good scores overall for the patient experience, after making an effort to say thank you, his scores increased further, reaching 90 percent. As well as seeing an objective improvement, the author describes the feeling of having made a deeper connection to more of his patients, noting their smiles as they left the exam room.

"To paraphrase Abraham Lincoln, you can please all of the patients some of the time, and some of them all of the time. But you can't please all of the patients all of the time," the author writes. "But you can try to thank all of them, all of the time, for coming to see you."

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