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Patient Interests Before Healthcare Finance

Conscientious providers get tied in knots balancing patient interests and healthcare sustainability.

We worry that Medicare won’t have money for the care patients need.

As the point of access for many patients, emergency providers feel pressured to manage system costs and make up for inefficiencies elsewhere, by putting costs before patient interests.

This has to stop.

Backup?

Those who congratulate your parsimony disappear when you get sued for not ordering enough tests, providing enough care, or making patients wait.

After a medical disaster, you get no official support acknowledging overcrowding created an environment for bad outcomes.

Providers experience heart-wrenching cases: mothers dying shortly after childbirth, toddlers who choke to death, kids clipped in traffic walking to school.

Sick patients create bad outcomes.

Sick patients require split second decisions that lie naked to dissection from the armchair of retrospect.

Emergency departments get ‘helped’ with hours of meetings and external reviews from one bad outcome, but no one – not one single person – wants to discuss egregious overcrowding and unconscionable waits that often play the major role in terrible outcomes.

No one.

Societal conscientiousness needs to be matched with our system leaders’ passion for change. If bureaucrats want decreased emergency department use, they need to work on system redesign such that patients are attracted to seek care elsewhere.

Emergency providers should not bear the responsibility of rationing care for the whole system.

Focus on Patient Interests

Paradoxically, abandoning obsession with system citizenship ends up refocusing providers on patient interests. It’s the first step to creating a more efficient emergency department. Costs per case goes down, patients’ length of stay plummets, and adverse outcomes decrease. EDs function best when we focus on patient interests and ignore fiscal/system peer pressure at the front line.

So, banish guilt. If it will help your patients, order tests liberally, welcome them back for care, and put patient interests first. It will improve the system for patients.

Have you tried to be a good citizen and avoided ordering a test? Have patients ever come to harm as a result? Please share your thoughts below.

(photo credit: network.mcmaster.ca Check out McMaster’s post on Geriatrics training.)

We Serve Patients Because It Is Hard

It’s easy to talk about customer service when patents are nice. Our real motivation surfaces when patients demand narcotics, CT scans, or useless antibiotics. Patient threats, intimidation, and entitlement wear down the fiercest advocates of patient service.

Unless we commit to great service for our toughest customers, we will start to question whether any patients deserve our attention.

In the 1960’s race to the moon, John F. Kennedy said,

“We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”

Why bother?

1. Patients matter.

Nurses and doctors entered training to help patients. Nearly 100 years ago, Peabody complained that new physicians relied too much on science and had lost “an interest in humanity”. It’s been said recently that medicine has become “far more interested in diseases than the people who suffer from them” (A. Miles, 2009). Cassell’s classic book on medicine advocates for ‘person centred care’. “The Nature of Suffering and the Goals of Medicine“ (Oxford University Press, 1991, 2004).

2. Great service improves outcomes.

Waiting kills patients; over 400 articles demonstrate increased morbidity and mortality from waiting, just in the ED. Qualitative aspects of service are harder to measure, but things like patients’ trust in their providers improves outcomes, too. Trust requires great patient service.

3. Medico legal claims drop.

Long waits increase the chance of being sued. Again, waits get reported because they can be measured more easily than qualitative experience. Virgin media found customers more satisfied with polite service that didn’t fix a problem than rude service that did.

Expectations

Some of us entered medicine thinking we would be textbooks of physiology, that we would have respect, and have grateful patients. Instead, we trained in a field with ineradicable uncertainty, a society that leans toward general disrespect for all kinds of title and authority, and patients we often cannot help.

We choose to care for patients, not because it is easy, but because it is hard…

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(photo credit: rice.news.edu)

4 Features of an Outstanding Clinic

Helping in new clinical settings over the past year, I find these core features in great clinics and hospital departments.

Outstanding clinics:

1. Remember Their Core Motivation

Most of us run from task to task without asking why. At some point, we chose to do what we are doing right now. Even with years of training, people don’t have to keep providing patient care; they could look elsewhere.

People need help to remember why they do what they do, and why they work in a particular place.

Most people who work in healthcare applied from a desire to help people. They looked for specific jobs that allowed them to help and serve patients.

Outstanding clinical groups never forget that serving patients comes before anything else.

2. Support Their Core Business

Especially in large groups, staff might think the clinic or hospital pays them. In a sense, that’s true, but also very wrong. Every business gets paid for doing something.

Although revenue flows through the clinic before it gets to the staff, employees must know that the clinic stays open if physicians see patients. Anything that slows, or stops physicians seeing patients results in poor patient service and less revenue.

Great clinics keep physicians working at what physicians do best: seeing patients.

3. Think About Governance

Governance refers to how organizations are governed and controlled, how decisions get made, and how decision-making units fit together. A solo physician deals with everything, or delegates to an office manager.

Problems arise as clinics grow. At some point, groups need to think about a formal, simple governance structure. Communication, authority, and accountability must flow in a line through the structure. If structure gets ignored and leaders start talking like customers expecting to be heard like owners, chaos ensues. (Check out: The Imperfect Board Member)

High performing clinics have an explicit governance structure that everyone follows.

4. Manage Performance

Once everyone remembers why they are there, knows how the clinic earns income, and understands how decisions are made, staff needs support to perform well. With clear expectations, most staff members excel; some do not. Even in a small group, staff needs performance reviews, incentives to improve, rewards for excellence, and follow-up on underperformance.

Outstanding clinics measure performance using explicit criteria supported by everyone. When members do not perform well after attempts to help them change, great clinics help low performers find work elsewhere.

Final Thought

Oppressive workplaces leave you emotionally exhausted at the end of a day, fill you with dread at going to work, and require you to tiptoe around icy colleagues. Dennis Bakke wrote bestseller Joy at Work suggesting that we embrace human values as ends in themselves, not just means to business ends.

Outstanding clinics foster uplifting, healing work environments.