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!
Canadians take pride in having non-American healthcare.
US healthcare makes millions by driving activity: patient visits, tests, and procedures. American lawyers take money back with lawsuits. Canadians have a very similar legal system, also based on English common law.
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If healthcare is a commodity that can be bought and sold, patients should be able to sue for bad product.
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But, if healthcare is a public offering paid for with tax dollars, patients should have rigid limits on lawsuits, or not be able to sue at all.
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Here’s why:
Threat of suit changes behaviour, but not for patient benefit. Providers change behaviour to protect providers, not patients. Physicians order tests far beyond what’s needed, just in case.
Defensive medicine is expensive. Providers know that ordering more tests protects them in court. More testing also fits commercial interests: sell more. So, commercialized medicine and medio-legal activity benefit each other: more tests and more law suits!
Extra tests put patients at risk. Every test carries some inherent risk: radiation, discomfort, etc. Tests also carry the risk of false positive results that can lead to useless surgeries (with risks) and more useless tests.
Publicly funded healthcare was designed for necessities, not to generate more business. It never existed to create work for itself. Doing more in a system designed to cover only the necessities eventually leaves too little to cover the basics.
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We need legislated legal reform. Our publicly funded system will go bankrupt if it exists with our current, American-style legal system.
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Benefits of reform:
Improved quality of care. While you’d think that keeping all healthcare providers in perpetual fear of punishment and lawsuits would improve care, it doesn’t. Instead, it creates a culture of covering up, or denying errors at all costs. Medicine, like life, is full of errors. Errors present an opportunity to improve quality, not something to hide or run-away from. Quality improves very slowly in a system that crushes speaking up.
Patient experience. Patients do not want to go through useless tests. Most want what’s necessary medically, not what’s necessary to protect providers in court.
Efficiency. If providers didn’t have to practice defensive medicine, we would see a drastic change in ordering behaviour. Huge numbers of imaging tests and lab investigations would be dropped in favour of clinical judgement.
Capacity. If providers only performed tasks that directly added value for patients, we could care for more patients; wait lists would disappear.
What do you think? Does it make sense to have a US-style legal approach to a publicly funded healthcare system?
Docs spend more time with electronic health records than with patients. Many blame electronics. True, bad systems eat hours of nurse and physician time, but the biggest waste is fat charts.
If bigger is better for patient charts, then medical students make the best charts; staff physicians the worst.
Every year, trainees get better at sharpening details. Expertise leads to focus on critical information: everything that does not add value gets left out. Charts get shorter…until providers start padding charts for other reasons.
Modern patient charts aren’t just about patients.
Charts get longer to:
1. Protect against Lawsuit:
A long chart makes it tough to prove providers weren’t thorough. You can prove you thought about all sorts of things by listing all the negative responses you found even though the negatives don’t help the patient.
2. Protect against audit from your regulatory college:
The overseers/authorities/police believe they know what makes a great chart. They support #1 above and enforce it, and they (groups of lawyers and lay-people mostly) define ‘best practice’.
3. Protect against billing audit:
Long charts look like lots of work was done.
Value Added?
Would an informed patient willingly pay for long notes that were created to protect providers?
Do long lists of ‘pertinent negatives’ add anything for patients? Sure, they ‘prove’ providers considered a differential diagnosis, but considering a differential diagnosis is core medical practice; why should they prove they did it?
The whole medical decision-making heuristic rests on a differential diagnosis approach; why prove it over and over on every single chart?
As a provider, if you just wrote the diagnosis, does that mean you suddenly became anti-differential diagnosis? Even if you recorded pages of negative findings and came up with the wrong diagnosis, does that help the patient any more than just writing the wrong diagnosis in the first place? All it proves is that you were thoughtfully wrong.
Two types of Complaints
A. You know what’s going on:
This chart needs positive historical points and physical findings, diagnosis, and treatment. That’s it. Nothing else adds value for the patient.
B. You have no clue what’s going on:
This chart needs more. You should write a book: everything you thought about and why it doesn’t fit. In fact, long charts define clinical uncertainty, not clinical excellence.
If patient charts should be about patients, we need to:
1. Change expectations:
Focus only on what adds value for patients.
2. Change charts:
The whole process could be done with macros and tick-boxes. Only critical findings (positives, diagnosis, treatment plan) need manual entry.
When physicians and nurses go back to review a chart, they NEVER need all the information in it. NO ONE DOES, except non-providers! Clinicians look at old charts to find 1-2 critical pieces of information that have meaning for their patient.
How short would your chart be if you weren’t worried about lawsuits and audits? What needs to be in the chart if only patient benefit mattered?
