Patient-Centred vs. Provider-Centred

Patient-centeredWhile discussing over-crowding and ‘safe, quality care’,  a retired nurse manager said, “It’s all about doing what’s best for the patients.”  She told me, “People try to call it patient safety, but it’s just covering your butt.”

Motivations to help patients versus protect ourselves start to compete when Medicare runs short of money.

With enough resources, providers can protect themselves and focus on patient benefit.  When resources get scarce, providers often have to choose between patient benefit and self-protection.

For example, no one gets criticized for providing ‘really great care’ inside an emergency department or on an inpatient ward.  They’re patient-centred.  But providers can spend as much time as they want with patients only if they make other patients wait for hours (days!) in the ED waiting room or admitted in ED hallways.  Providers can champion ideal care settings – proper rooms, great infection control – only by forcing other patients to endure no bed, no quiet, and no infection control in an ED hallway or waiting room.

No one will fault a nurse or physician for working ‘really hard’ and doing a ‘really good job’ with his patients.  Discharge excellence, thorough education, exploration of psychosocial factors; no one can criticize a provider for ‘working hard’ to be patient-centred.

Are We Patient-Centred?

Are we really working hard for patients or are we just covering our butts?  Are we avoiding the risk of having to see a new patient in a less-than-ideal setting?  Are we aiming for ‘faultless’ care for our patient because we want what’s best for patients, or because we want what’s best for us?

But we’re already at the 25th percentile for length of stay!  What more can we do?

Even if care gets trimmed down to the shortest possible, leaving patients to languish in hallways and waiting rooms goes against everything healthcare believes in.  Both emergency departments and inpatient services do the same thing.  EDs leave patients in waiting rooms; wards leave patients in the ED.

Our system does not have resources to allow providers to give ideal care all the time.  Even if you don’t have enough to give patients your best, you can still give them something; letting them languish in the waiting room or ED is egregious.

Healthcare providers can describe their concerns in terms of quality, professionalism or patient benefit without being patient-centred.  When we make these comments in the face of unconscionable waits and suffering elsewhere – suffering that we could do something to alleviate – we are just “covering our butt.”

What do you think?  What role does self-protection play in our refusal to get patients out of the waiting room or up to the wards?

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(The photo comes from an MSF page about Patient-Centred care for TB patients in Armenia.  Check it out, too.)

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Improve Quality, Efficiency, & Communication with Physician Navigators

executive-assistantEmergency physicians spend more time looking for charts, finding lab reports, and checking if treatments are done, than they do caring for patients.  After continual interruptions from allied health providers, patients, and other physicians, doctors have little time left for patients.

Some say scribes help.    But after trying scribes, we found navigation to be our greatest need, not transcription.

Physician navigators (PNs) do 2 things:

Direct physician-patient traffic

Manage information

They do not:

Make clinical decisions

Give clinical advice

Order clinical care

PNs improve:

Patient experience.

Physician efficiency

Team communication, especially between nurses and physicians.

PNs perform non-medical tasks that MDs do when working without a PN.  They do anything doctors do that does not require a medical degree.  

We use Physician Navigators to

  • Keep informed of patients waiting in all areas of the department
  • Find out which patients are waiting to be seen next
  • Accept and photocopy patient handover lists from the physician handing over —
  • Make sure all these patients are reviewed and looked after by the accepting physician
  • Keep track of all the patients the doctor has seen and when patients are ready for reassessment
  • Obtain chart for “next available MD to see”
  • Access electronic charts; print out reports
  • Prepare chart for MD reassessment: blood-work, x-rays…printed and ready to hand to patients at discharge
  • Update MD data in the ED information system (tracking board)
  • Page and receive specialist phone calls
  • Receive and manage other incoming calls
  • Hold non-critical calls for MD when MD is with a patient
  • Assist RNs locating MD for urgent needs
  • Inform patients about wait times and purpose
  • Direct patients in and out of examining stations
  • Update RNs on MD work plan
  • Receive RN requests for patient reassessment
  • Work with the team (e.g., RN and RT) to gather equipment for procedures
  • Handout patient information sheets and referral forms to patients when instructed by MD
  • Assist with paperwork to ensure proper completion
  • Create handover list at the end of a shift

Physicians Navigators do this, and more, with good humour, a positive attitude, and in a polite, semi-invisible way.  After a few shifts with a PN helping out, physicians never go back.

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10 Commandments for Great Patient Flow

Follow these rules to improve patient flow, quality, and efficiency.  We made most of the list in a recent ED meeting, but it applies anywhere patients present.

1.  Add value for patients first, always, and without compromise.

2.  Never make patients wait unless it adds value for them.

3.  Triage means sorting, not primary nursing assessment (see 1 and 2 above).

4.  Time is Quality for most care.

5.   Nurses and physicians must pull in the same direction at the same speed: ED team = 2-horse chariot.

6.  Professionals must do what they do best: RNs do RN work, not clerical work.

7.  Remove or unload bottlenecks.

8.  Always design parallel processes, not sequential.

9.  Design for unlimited capacity; you cannot turn people away.

10.  Patients need humanity with every encounter, especially when ‘there’s nothing wrong’.

Do you have any to add?  Please share them in the comment section.  Thanks!

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