Friday, February 17, 2012

Who is in charge?

A few weeks ago I wrote about our improvement in patient satisfaction scores ("Better Care"). Our people have really been working hard to deliver wonderful care to those we serve and their families.

I am so grateful for how hard our physicians, nurses, other clinicians, and support staff are working. But recently I have gotten some feedback from staff that they are concerned that patients and their families are “getting their way” because of our desire to improve patient satisfaction. At least one person suggested that a test had been ordered when the clinicians knew that it would not help the patient but they ordered it anyway, for fear that the patient would be upset.

I know some people think that my response to this is trite but I am going to say it anyway: “What if it was your daughter?” If it were your daughter, you would not want her to get something where the evidence showed that it was not in her best interest. On the other hand, you would want your daughter to “get her way” if she were talking about comfort, respect, companionship, or anything that made her experience of the care better. It’s true; we want our patient satisfaction scores to be as high as we can get them. It is our duty to do this because that is what we would want for ourselves and our loved ones.

Another thing that I heard as an example of “patients getting their way” is that we are “letting a patient have 5 visitors at a time when our rule is 2”. What is the correct number of visitors at a patient’s bedside? I believe that the correct number is the number that the patient wants…..within reason. Sure, if the room is full so that the caregivers can’t do their work, or if they are disturbing others or if a visitor is clearly sick, we need to act to remove some visitors. We need to do this because of our commitment to improving the patient’s health.

I am concerned that talk about patients “getting their way” is really about some of us having a hard time letting go of a paternalistic view of care-giving.  I believe that the patient is in charge until the patient is asking me to do something that I know is not in his or her best interest because of the evidence; or if the patient is requesting something that prevents us from accommodating our other patients.

So, we should start from the premise that we want the patient to “get his way” until we know that we can’t or we shouldn’t. It is impossible to get to our vision of everyone, every time getting the care that we would want for our own loved ones if we don’t.

What do you think?


  1. I would add on..."or until the time involved in meeting the patient's requests interferes with the quality of care I am able to provide to other patients". Having been on the floor (in the trenches), I can clearly see THAT patient whose wants are far greater than their needs and who could potentially monopolize an entire shift. This leaves the other patients in my care with whatever time is "leftover". Many times THAT patient is still dissatisfied with some thing or another. Is this fair to the patient who got the "leftovers"?
    I would also encourage dialogue with providers who are not always understanding when called for things that seem insignificant. Trust me, calling the provider for something non-urgent is the LAST thing a busy nurse wants to do. But providers need to understand that what may not seem important to them IS important to the patient, and the nurse on the other end of the phone is striving for 100% patient satisfaction.

  2. I agree fully, Anonymous, thank you for your comment.

  3. I am really glad this issue is opened up for employees to respond. We are struggling with the visitor policy in the Peds department as it pertains to patient and family satisfaction. The policy was written by a group of committee members with patient and staff saftey in mind---and currently we make every attempt to uphold the policy as it is written---2 visitors per room. If an issue occurs our staff know that we can use "discretion." What does discretion mean?---not always the same for all staff----so we have defined discretion for our staff and that discretion must be discussed with our doc and charge RN before we bend. As a manager, I struggle with having policies that include using discretion. How can I say that one policy is meant to be followed exactly, for instance patient identification, and another is used with discretion.

  4. I completely agree with you valarie. I sruggle with this as well. I also have concerns with the time allowed for a patient to be late. Some Dr.s will allow 10 min others 45 min. This leaves other patients to wait long and throws off the entire schedule. I hear many patients asking why they are being seen after the patient who walked in 20min later then them. I think this should be an established policy as well.

  5. Great point, Valerie. Design is a critical component of continuous improvement. Our procedures are our designs to get us to our vision. A procedure that we don't follow is as bad as not having designed it in the first place.

    I think we need to rewrite our visitation policy. I don't think it ought to prescribe how many visitors a patient has. It should say that the caregivers will limit the number of visitors or prohibit visitors as the patient's care requires. I guess this builds "discretion" right into the policy. I know that our hard-working staff is smart enough to implement this. Having said that, I look to our clinical leaders to review the policy/procedure.

    Anonymous: As you may know, I was a practicing pediatrician for many years and I ran a busy office of 6 attending pediatricians. For every patient that was late for an appointment, my partners ran behind about 10 times as often. Should the policy also address clinicians who are routinely making patients wait?

    I agree with you that we should have a procedure (design) that specifies that the "late" patient will be accomodated (or not)but only after the on-time patients have been seen. Obviously, we must care for all significantly acutely ill patients even when they are late. These stipulations should be explicitly stated in the procedure.

  6. I agree totally. My wife had a difibulator implanted here approx 9 years ago. When she was inpatient the nurses allowed here to have as many visitors as she wanted (within reason) as long as we kept the noise down. They also did not make us leave at 8pm. She has never forgot that.

  7. In such a litigious society don't you think we also leave ourselves open to law suites for discrimination if we don't have a baseline policy that we bend?


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