Tag: patient benefit

Scope of Practice Cherry-Picking

scope of practiceStool can get so hard that clinicians need to pull on a glove and dig it out.  It happens most often in very old, demented patients.  They pull their knees up into their tummies, we slip ‘blue pads’ under the business end, and a nurse or physician starts working at the blockage.

It takes muscle.   You lean low over the bed, left hand on the patient’s right hip, and dig deep with your right hand.  Success brings relief for patients and makes a huge mess of the bed.

No one fights for bowel disimpaction on his or her scope of practice.

Nurses used to disimpact bowels in the ED. They know how. Now nurses usually say, “That’s not within my scope of practice”.

You never hear “That’s not within my scope of practice” for fun things.  Prescribing medications, discharging patients, applying splints, and patient education are aggressively pursued.

Premier Wynne wants to increase nurses’ prescribing scope.

Pandering to unions does not improve wait times or patient care.  If Wynne wanted to really improve patient care by changing nursing, she would call for increased after-hours care, productivity incentives, and a return to the unpleasant parts of nursing that now get pushed off as outside of scope.

Doctors cherry-pick, too.

Orthopedic surgeons love to delegate ‘simple’ reductions of wrist fractures in elderly patients.  But pods hesitate about letting others reduce simple hip dislocations in the same patients.  Hip dislocations take seconds to fix, pay hundreds of dollars, and require almost no follow-up.  Wrist fractures require 20 times as long to fix, pay a fraction of the fee, and often require complex follow-up.

Everyone wants scope of practice to suit their needs, not patient needs.

Providers cherry-pick attractive bits of patient care and try to sell it as better for patients.  It’s not better for patients.  It’s just  self-interest.

(photo credit: stellacreek.com.au)

Canadians Love Kaiser Permanente

kplogoCanada loves Molly Porter.  She gets invited to speak all across Canada, and for good reason.  Her enthusiasm for patient experience at Kaiser Permanente (KP)   shines through every time she speaks.

Canadians see Kaiser as the apotheosis of Medicare utopia.  We recognize similarities to our system and lust after great outcomes, but entirely overlook KP’s secret to greatness.

What We Love

  • Uniform care pathways
  • Uniform approach to preventative care
  • Uniform IT system
  • Community health programs
  • Healthy living services
  • Docs on competitive salaries
  • Nurses and allied health workers unionized
  • Generous pensions and benefits
  • Peer review and a probationary period for new physicians
  • MDs do not control office bookings – any clerk can book appointments

What We Lust For

  • Smoking rates < nation average
  • Over 10 national awards for service and excellence
  • Less costly than competitors in many groups
  • Lower malpractice rates
  • No or short waits in Emergency Department
  • Same day appointments
  • Rated in top 6% of 484 comparator plans
  • Shortest hospital length of stay (others are catching up)
  • Outstanding IT functionality
  • Patient online access to records
  • “Care Anywhere; Care Anytime”

What We Overlook

  • “Competition played a huge role in success…we almost went under in 1997-98.”
  • While most patients have co-pays for face-to-face visits and for prescriptions, there are no co-pays for secure e-mail exchanges with providers and scheduled telephone visits.
  • Physicians call the shots on medical care
  • Physicians have parallel leadership corporation with own CEO (Permanente Medical Group)
  • Physicians profit share
  • Many unions have performance measures for group outcomes
  • Care moves down to the least trained professional who can provide it safely
  • Outcomes drive process…relentlessly devoted to patient outcomes, service and convenience
  • Costs $53 billion for the services given to 9.3 million patients.  Ontario spends $50 billion serving 13.5 million patients, but with a different mix of services covered.
  • Serves 3% of US population
  • Pulled out of OHIO and Texas (losing money)

Canadian love Kaiser Permanente.  KP is cool.  It reminds us of ourselves, and Ms. Porter does an amazing job describing it.

Idealists ignore Kaiser’s secret to greatness.  Kaiser Permante’s radical devotion to patient experience defines their competitive advantage.

Kaiser must compete or die.  

Kaiser Permanente knows each operational decision risks the life of KP.  They must focus on patients.  Although Kaiser is nonprofit, it must have operational income to invest in its infrastructure and growth as it owns and runs most of its own delivery system.

Kaiser must succeed or close down.  They cannot raise taxes to cover deficits.  They cannot ignore patient satisfaction, ever.

Canadians can learn from KP.  But let’s look at the whole package instead of picking and choosing only the things that appeal to our Medicare sensibilities.

(Thank you, Molly, for reading this over and helping with the details!  Any remaining mistakes are entirely my own.)

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.)