The Service of Health Care

Hospitals are, and always have been, service providers. Patients have a choice-in spite of some insurance restrictions-where they go for Emergency and elective procedures and care. Yet, some administrators still believe the patient needs the hospital, therefore, to concentrate on customer satisfaction is a mote point. Isn't it more accurate to say, though, that health care is a co-dependent relationship between provider and patient? Each needs the other. The patient needs what interventions the hospital is able to provide in a crisis and the facility needs the financial gain from disasters to fund their expenses. Health care is a booming business and for some, it is easy to shift the focus from placing the patients first, to capitalizing on profits. Sadly, in some hospitals, profit-driven mentalities has become an obsession.

In the July 2010 edition of Good Housekeeping, Melody Petersen hints at the profit driven reason behind the overuse of CT scans in her article Over Exposed. "Could there (be) a profit motive at work? The researchers raised that possibility in their report. Certainly imaging centers have become profit centers for many hospitals and physicians. Even doctors who aren't radiologists-cardiologists, gastroenterologists, orthopedists, and others-have installed CT scanners in their offices. And, having spent upwards of a million dollars on a device, they're going to find ways to cover their investment. Indeed, many physicians now count on the hefty fees they earn from scans for a significant portion of their income."

It seems as if the secret is out-not all procedures are ordered for the patients welfare or best interest. Hospitals and health care facilities are financially happy as long as the patient needs-or believes they need-the prescribed pill, procedure or treatment. It's an unsettling fact that to stay out of the red, hospitals need flu pandemics, accidents and acts of violence.

On the other hand, how awesome is our current technology that we no longer die from dehydration, a cut to the finger, or high blood pressure? Coming back from a shopping trip recently, I pulled over to the shoulder of the road to allow an ambulance to pass. Seeing the lights flashing and hearing the siren wailing as it passed reminded me that we don't lay in pools of sweat anymore, dying of fevers. High blood sugar doesn't automatically progress to comas, and a severed limb doesn't become gangrene overnight. To be able to bring medicine to the consumers front door is a luxury, even if the reason requires mandatory treatment.

The health care field has taken customer service above and beyond what Florance Nightingale envisioned. In the process and along the way, we also accumulated a lot of debt. The focus can't shift from patient care to debt elimination, though. By maintaining high service standards, repeat customers and reputation still remains the greatest asset to a medical facility.

There are some administrators that believe great customer service means getting to the bottom of a crisis in a timely manner, and treat ASAP. But as Scott Louis Diering states in his book Love Your Patients, "Quality care is more than excellent technical care. Good health care can only be delivered when we treat each patient as a person, not just some disease or complaint or injury." It's admirable to treat in a timely fashion. Your patients in the ER would really appreciate that endeavor. But along with that goal, remember they are people first, illnesses second. Don't talk down to the patient, or about them to another health care provider in their presence as if they don't exist. Learn to be passionate about showing compassion.

When I was in retail many years ago, a co-worker was having a rotten day and had no qualms taking it out on the customer. One feisty lady told her, "If you don't like what you're doing, get another job." In the same token, if as a health care worker you have a hard time treating the patient as a person instead of just a technical puzzle to figure out, get another job. At the end of the day, hospitals are customer service providers and need patient satisfaction to maintain their business. You can talk about profit margins and productivity all you want, but you won't have those problems to manage without a promising patient flow.

Compassion vs Productivity

It's a monumental job overseeing the financial aspect of a hospital, as well as the productivity and morale of your employees. Sometimes, it becomes an impossible task. If you haven't learned the delicate act of balancing and prioritizing, you will most likely play catch up through out the day instead of blazing trails. For those that want to blaze new trails, thinking new thoughts becomes a daily endeavor. Here's a thought to mull over. Most health care facilities name patient satisfaction as one of their core values. Are you ensuring that your employees get the proper encouragement to take the time to be compassionate towards their patients to secure satisfaction, or are you making a statement for good public relations, yet pounding the importance of productivity in behind closed doors meetings? For many managers, it becomes an either/or situation. They argue taking the time to show compassion takes from the time of productivity.

I was insulted to overhear a conversation between the "coat and tie men" of one hospital. Though not word for word, the one sided conversation went like this.
"What am I suppose to do? Encourage a chat fest every time my nurses enter a patients room? Impossible. We need to concentrate on eliminating medication errors and the precise recording of vitals. I can not in good conscience give my nurses an excuse to be slack by saying it is ok to talk to their patients."

That statement told me a lot about his facility. I guarantee you the employees were miserable and when his name was brought up in conversation, it was not in a favorable way. It also spoke volumes in regard to how the patients were viewed. They were clearly liability to him and a mere responsibility. It was very clear his management style was not adaptable to a health care facility. When you work with patients while they are in the middle of a health crisis, it is inconceivable to treat them as robots and ignore the emotional impact this event has on their overall chances of recovery. It is obvious he had no clue the drama that unfolded on each floor of each wing or what his employees experienced on a day to day basis.

For an employee to be able to show compassion does not indicate an automatic drop in productivity-in fact, I argue, it may increase productivity. When a patient feels validated, safe, and unafraid, they cooperate more. What if the nurses had totally cooperative patients, followed by families that conceded to the nurses suggestions? Talk about a relaxed environment. The wheels of the hospital would rotate without much coaxing.

My Mom spent the last 18 days of her life in a hospital. Her time was split between the floor and the unit. (ICU) The first night she was taken to the unit was a scary time for her. New procedures and protocols went into effect after she had somewhat learned her nurses and adapted to their schedule on the floor. When I visited her the following day, the first thing I noticed was a red ribbon in her hair, tying back her long strands, preventing them from the annoyance they had previously caused while falling into her face. I knew the activity surrounding a transfer. During the production of getting her settled in, one of the top priorities was getting her long hair off her face for her comfort. It had nothing to do with reading charts, ordering tests, or starting new lines. Her comfort-and style, I might add-was one of the things her nurse capitalized on. Did that small gesture take away from her productivity? I doubt it, yet it made a giant statement regarding where the priority of my Mom's nurse was. She was there to treat the whole person-the woman-not just a disease.

Dr. William Mayo-one of the Mayo brothers responsible for the health care giant-penned three conditions that were essential to the success of Mayo clinic. One of those conditions is continuing primary and sincere concern for the care and welfare of each individual patient. That doesn't sound like a leader that believed demonstrating compassion was detrimental to productivity. In fact, it appears to be 33% of the reason Mayo is the commanding voice of health care today.

In his book "The Florance Prescription", Joe Tye points out "At the organizational level a core value should define your non-negotiable expectations regarding how your people behave, the goals toward which you direct your collective efforts, and how you work together." You can't say patient satisfaction is important-so important it is a core value of your hospital-and then discourage compassionate interaction with your patients. If you have a team in place that desires to have more interaction with the patient, or you are hearing from the rumor mill that the Nurses would like to be able to spend more time with their patients, you have engaged the values in your employees that can not be taught in a classroom. Productivity can be taught. Compassion can not be.

A smart leader will look for characteristics in his employees that promote compassionate exchange, and encourage that as much as productivity. It is near impossible to build patient satisfaction on productivity alone. The patient has to feel as if they were priority-not the mundane tasks involved in their care.

There is a balance that needs to take place in hospitals today. Managers can't be afraid to give the go-ahead for their employees to take time to care. Multi-tasking is one of the primary elements involved in direct patient care. Your Nurses and other employees can handle meeting your demands for productivity while making a positive impact on their patients if you give them permission and the freedom to do so. If you trust them to apply their knowledge to keep the patient alive, trust them with a flexible understanding that the patient comes first-both in medical treatment and in building an environment of trust and empathy. Sometimes, loosening the iron fist merits the greatest rewards.

Non-Verbal Communication Studies Recommended for Those in Direct Patient Care

A patient presents in the ER fidgeting, so nervous that they can't adequately describe their symptoms or otherwise express themselves in a halfway helpful manner. The OB floor isn't sure if the patient in labor is a difficult patient, anxious regarding the delivery, or showing signs of abuse from her significant other. A child on the Medical floor is restless, whiny, and unable to settle causing the nurse to wonder if the pain meds are not enough or is it psychologically related?

Changing Minds.org reports that half of our communication is non-verbal and by studying body language, listening for certain vocal tones, and understanding common behavior clues, it is possible to discern the emotional aspect of another person even when they are trying hard to camouflage it. In the health care setting, this tool could prove to be an invaluable resource when treating a patient. Naturally, there would be limits and restrictions. A trauma patient or one that is unconscious would not be a good candidate, however, most of the presenting patients in the ER, or those recovering on one of the floors would give sufficient clues that would guarantee integral and thorough treatment.

It has been known for decades that by treating the whole patient-emotional as well as physical-it speeds the recovery process and renders the best possible outcome. By teaching awareness of body language to those in direct patient care, the health care experience is enhanced for the patient. I'm not suggesting we view patients as crystal balls and begin analyzing their every movement from the time they present. However, it is important to be aware of universal behaviors and gestures so that when a difficult patient is introduced, the health care worker isn't without the needed knowledge and skills to competently do their job. Yet, this goes beyond just completing an employment task, it involves going one step further.


According to Mehrabian's communication study, in all communications:

7% happens in spoken words.
38% happens through voice tone.
55% happens via general body language.

"Watch the whole body, and especially gestures, as well as all parts of the face. When you are talking, don't get caught up in your own speech to the extent that you miss the subtle and constant feedback you are getting. When we communicate with others, we look mostly at their face. This is not a coincidence as many signals are sent with the 90-odd muscles in the face. The way the head tilts also changes the message. The eyes are particularly important, and when communicating we first seek to make eye contact. We then break and re-establish contact many times during the discussion. Eyebrows and forehead also add significant signals, from surprise to fear to anger. The mouth, when not talking can be pursed, down turned or turned up in a smile. The way that the body is held can communicate many different messages. An open body that takes up a lot of space can indicate comfort and domination, while a closed-in body that makes itself small can signal inferiority. Copying of the other person's body shows agreement, trust and liking. "

A deeper, in depth study can be done through many pieces of reputable literature, both written and on the web. Not long ago I picked up a copy of Poker Face-Mastering Body Language to Bluff, Read, Tells and Win to satisfy my curiosity regarding the urban legends floating around associating body language and the big business of poker. It didn't take long to learn that any serious card player not only studies but masters the art of body language. They know the stakes are high and will use any advantage to secure a win. Money, the bottom line, comes at a high price in the end for poker players.

In a hospital setting, lives are saved daily by the trained and gifted health care professional. The gifted part they were born with. As for their training, there is no such thing as reaching a point where enough is enough. If understanding body language gives the advantage needed in treating patients, the health care professional succeeds and the patient benefits from that success. The poker world is a serious business, but not as much so when lives are dependent on careful analysis and responsive treatment. If there ever was an environment where understanding basic human nature and non-verbal communication was fundamental, it is the health care industry.

Those on the front lines of direct patient care can determine to evaluate physical ailments only and treat any form of illness or disease associated with such, or they can commit to going one step further, and evaluate non-verbal clues when relevant. Sometimes, health care reform doesn't take the shape of massive reorganizations or multi-million dollar programs. Sometimes, the greatest advances and proof of genuine change becomes apparent in the facilities quality of patient care. While many other elements of the industry remain evasive and unruly, outstanding patient care is, and will always, be eventual and manageable within your organization. Learning the clues of non-verbal communication is one way to get the edge on your competition and satisfy even the most elusive of patients.

Lessons Learned From Bellevue and Newton Medical Center

If you walked into the EW-Emergency Ward-of Bellevue Hospital in New York in the mid-seventies, you would have seen a Declaration from the Nursing Division posted on the bulletin board. It listed 9 things that "In our culture the public has come to expect" and went on to name those patient rights. Nestled comfortably within those rights were the following:

*To be cared for with concern
*To decline and die in reasonable dignity
*To feel that someone cares and that they are not alone in their illness or dying

Bellevue placed importance on the patients emotional well being while correcting, curing, or compensating for their illness. In case you believe those ideals can't possibly compete with the significance of the financial bottom line, let me offer the 2008 statistics for Bellevue Medical Center:

Beds: 809
Clinic Visits: 472,110
ER Visits: 101,792
Births: 2,021


That doesn't happen by concentrating on dollar signs only. When I walked the halls as an employee of Newton General Hospital in 1993, the picture looked grim. Very grim. The hospital was in the red. There was a hold on all salary increases as well as a hiring freeze. The talk around the water cooler was the hospital would be a nursing home within a year and employees began looking elsewhere for work. That didn’t keep James Weadick, the administrator, from concentrating on the quality of patient care. He raised the standard with his “hospitable hospital” program. He determined that it was the responsibility of each employee to go out of their way to be courteous and friendly to not only the patient but their families as well, and went on to lead by example. At a time when most administrators would have pushed for stricter spending or raising the per nurse patient load, Weadick defined success by building on the level of care he offered his patients. The patient came first.

It was no small thing when a sign was pushed into the ground announcing the coming construction on what would be an adjoining 60,000 square foot Physicians Pavilion which accommodated three floors of new medical offices. The attached parking deck may have made greater news, though. This was not the direction of a medical center doomed for nursing home status. When construction was completed in 2001 on a 103,000 square foot Surgical Center that was connected to the main building, it forever silenced the skeptics. The state of the hospital was no longer lamented around the water cooler, but instead, great pride was established in the employees as they witnessed the expansion of success that was initiated by a minor detail-caring for the patient.

Defining success by patient satisfaction is not only admirable, it is required. After all, you can possess the most sophisticated equipment, brag that the best interior designers created the optimal environment to recuperate in, or claim your facility has earned prestigious awards. However, it doesn't mean a thing if the patient isn't satisfied with the care they received from the people they came in contact with. Everyone wants to feel validated, important, of value. That is multiplied in a crisis situation-especially a medical crisis. The people you hire to gingerly care for your patients will make or break the future of your facility. Success is not found in the outer walls-it lies within your employees.

It begins with the leaders. Don't demand, make rules, or otherwise place the burden of your growth on your employees only. Walk the hospital. Get to know the patients as well as your health care workers. Lead by example. Greet your workers in the hall as if they were potential financial contributors-from the laundry worker to the specialized surgeon. Create an environment of smiles, greetings, and genuine appreciation for your employees, and watch how they relate that to their patient care.

Take the advice from Bellevue-respect the patient, and then do as James Weadick did and make your hospital a "hospitable hospital". You can't argue with their results, and isn't a profitable hospital a win-win for everyone?

Much Needed Healthcare Reform Not Understood

On March 27th, Psychology Today ran an article blasting Americans that weren't fully supportive, claiming they were "biting the hand that could heal them". Political commentators were quick to point out the hypocrisy (and in some cases stupidity) of such protesters."

I wonder what it will take for politicians to grasp the real issues. Both former first lady Hillary Clinton and President Obama made it their endeavor to use public office to create a nationwide health care system. Clinton couldn't get it done, Obama did only because of the overwhelming support from his political party. If he would have cared about the American people, he would have listened when they opposed it. Some polls reported as high as 75% opposed, while others in the 50% range. Either way, that was a high percentage of disapproval.

Our current system needs a face lift but all this new reform did was further complicate a government program that creates long waits for the patient, a bigger burden in administrative duties for clinics and hospitals, and doesn't address the real issue. To place an enormous debt on future generations by creating another program when the one in existence (Medicaid/Medicare) is failing, was too risky.

The American people opposed because more taxes, enormous debt and invasion into the financial privacy of our lives is asking much to give in return very little. In the end, the strapped, over worked, over stressed employee would see even less of his wages to assist 3% of the population.

How does this affect the health care industry? On May 18th, Fiercehealthcare reported "71 percent of emergency physicians believe ER visits will continue to rise and that crowding will intensify. Further, 54 percent of the 1,800 physicians surveyed predict that the number of specialists such as neurosurgeons and cardiologists who will be willing to respond to ER calls, will drop. In addition, 61 percent of the respondents don't believe the new law will effectively address uncompensated care, which has closed hundreds of emergency departments in America, most recently St. Vincent's in New York City. "If the Times Square bomber had actually blown up his car, injured victims able to walk would have found the doors of nearby St. Vincent's closed and locked," Gardner said."

CMDA reports (concerning the health care reform) "It's going to damage right of conscience for faith-based health care professionals. We actually surveyed 2,800 faith-based doctors, nurses and other health care professionals, and 95 percent of them said they will leave health care if it came down to violating their conscience on abortion, human cloning, physician-assisted suicide, and other issues," Stevens reports. "And this bill provides absolutely no protection, even though it's guaranteed to us in the First Amendment of the Bill of Rights."

If the new reform was such a positive move in the right health care direction, the medical community would be backing it 100%. To have full backing from your political party and not from the citizens it is intended to serve, or the doctors and nurses that will provide such care, says a lot. This reform is not about health care reform at all. It is another political move that does little in satisfying the cause.

It's time to go back to the drawing board, and this time, we need a leader strong enough to listen to the American people and the health care community and give this nation what it needs. We need a leader that will listen, understand and then implement. We can't afford to lose gifted, moral, knowledgable experts in the medical field and my concern is that eventually, under the new plan, some of our countrys best will walk.

Unfortunately, many still do not understand the much needed healthcare reform-and I'm not talking about the "stupid" protesters either.

Profiling Within The Hospital And How To Offer Unbiased Treatment

It's kind of ironic. Thousands enter the hospital every year hoping not to die, and yet, there are mindsets that we, as healthcare professionals, need to kill. The old school term was judging. The new term, profiling.

It exists. Even those repulsed by it have to one extent or another, been guilty of prejudging a person. Something as simple as associating someone with a Latino heritage with tacos, or the Chinese with rice. Hey, Americans do it to themselves when they proclaim "Baseball, hot dogs and apple pie". It's part of human nature to draw certain conclusions because innocent generalities within races do exist.

The type of racial profiling that needs to die within society, not just our hospitals, is the kind of negative beliefs we presume about people we don't know, based on forbidden or immoral activities engaged in by one or more of that particular race. Ask Rodney King how it felt to be "punished" for what other young, black men did that proceeded him. Or how the white man feels about being profiled according to Civil War mentalities. And lately, Hispanics are afraid they are being stereotyped by those that enter the country illegally. There are certain generalities we would be better off not making in order to maintain peace and a positive working and treatment environment.

Those working on the front lines in the ER have the greatest burden when it comes to profiling. Watch as the healthcare worker fights to restrain himself as evidence of child abuse or wife abuse stares him in the face. Or how they must overcome emotional generalizations in dealing with a chained and cuffed prison inmate. Add profiling within a racial context and it becomes normal to view certain cases with a certain mind frame. The problem is not in having an opinion-you are free to believe as you wish. However, when your beliefs impact your ability to treat a patient with neutrality, it's interfered with your work. It's admirable to want to protect a patient that's been brought in beat up from a bully. It's illegal to with hold or change treatment that alters the best possible outcome.

Workers in the ER are at the greatest risk of profiling because they are the first to see the patient, with Physicians and Nurses coming in second as they orchestrate ongoing treatment. Yet, I can not overlook the power of emotion that rips through the x-ray tech as they peer into a lit box, shaking their head as they read a confirming film. I've walked by a few groups as they gathered around a lit up box, cursing, and I knew right away the patient was an abused child. Some things will passionately tug at you, but to remain professional, those emotions have to die to the greater cause-effective and unhindered treatment.

The list of obvious things not to do include:
*Referring to a patient by a racial slur or anything besides his/her name.
*Categorizing the patient in a group-learn to see a patient for who they are as an individual-not a certain race, or illness, ect.
*Determining to withhold, delay or alter treatment because you immediately dislike the patient.

Instead, when tempted to profile, spend a few minutes getting to know the patient. Learn one characteristic that sets them apart from the typical stereotype one may presume. Are they a mother, father, son, daughter? Try relating to one aspect of their lives and offer to momentarily place yourself in their position.

Lastly, even if your initial profiling proves to be correct, the patient is probably terrified to be in the hospital. They are unsure of their surroundings, intimidated by the tests and white coats, and fearful for what the treatment options may be. Try to be sympathetic to their emotions and particular injury and overlook their less than favorable qualities for the time being. If you are unsuccessful, and you find you can not overcome the emotions that threaten to overtake professionalism and fair treatment, turn the patient over to someone that can be objective. The patient deserves impartial treatment and that is something we can offer.

When all else fails, as you leave work following your shift, make sure to stop off at the gym and hit the bag an extra time or two. Don't carry the aggression home. It's not worth it.

Recommended Reading

NONFICTON
The Florance Prescription by Joe Tye
Healing A Hospital by David Herdlinger
Practice By The Book by Gene Rudd, MD and Al Weir, MD
Grady Baby by Jerrry Gentry
Patch Adams MD by Patch Adams, MD and Maureen Mylander
House Calls by Patch Adams, MD
My Eyes, His Heart by Ted Kuhn, MD
Angels In The ER by Robert D. Lesslie, MD
Angels On Call by Robert D. Lesslie, MD
The Hole In Our Gospel by Richard Starns
The Hospital By The River by Catherine Hamlin
Catherine's Gift: Stories of Hope from the Hospital by the River by John Little
The House of Hope and Fear by Audrey Young, MD.
Half The Sky by Nicholas D. Kristof and Sheryl WuDunn