Sunday, October 05, 2008

Buzz...*click* Buzz...*click*

Manglement has rolled out a New Plan for us.

It involves, as do so many things that Manglement thinks up, Customer Service.

See, Manglement recently discovered the Intertubes. They learned, much to their shock and awe, that people go online on the Innerweb to see what sort of ratings hospitals and doctors get. It's not just which hospital is covered by your insurance package any more, no sir; it's the Customer Service rating of said hospital that might just determine where you go.

So Manglement came up with a way for us to improve our Customer Service Performance. Wait for it: it's going to knock your non-skid socks off:

The members of The Healthcare Team are to make hourly rounds.

No, no. I'm not joking. Doesn't matter who does it: nurse's aide, nurse, physical therapist, respiratory therapist, occupational therapist, wound care specialist--you name it, they can round. And when they round, they have a script to follow. I'll give you mine, as I am the Nursing member of The Healthcare Team:

"Hello, Mr/Mrs/Ms Blankety. My name is Jo. I will be your nurse for the day/night. My goal for this shift is to provide Outstanding Patient Care. In order to provide Outstanding Patient Care, I or another member of Your Healthcare Team will be making Hourly Rounds to make sure All Your Needs Are Met. (Here I am supposed to sit by the side of the bed; on what, I'm not clear. Perhaps, given the dearth of chairs at Sunnydale General, I am supposed to carry my own from room to room.) What are your goals for today? Do you need help to the bathroom? Are you comfortable? Would you like assistance in repositioning? Thank you. I look forward to providing Outstanding Care to you today."

Note that I have Capitalized Some Words in this script. Here's where the fun begins:

Manglement of Sunnydale General has dragooned certain poor sots in middle management to go 'round to various folks' rooms during the day and night shift and read questions to them. The questions are meant to show the Level Of Satisfaction With Customer Service. The questions read something like this: "Did your nurse or another Member Of The Healthcare Team perform Hourly Rounds?" "Did your nurse Provide Outstanding Care?"

Remember that script and those questions. It becomes important later.

Being the sort of outcome-driven little person that I am, I asked during our staff meeting if Customer Service initiatives like this one had shown any impact on quality of care. In other words, *good* nurses, aides, and therapists are already making hourly or nearly-hourly rounds, asking about pain control, and taking folks to the bathroom; has mandating that shown any decrease in, say, preventable falls or bedsores or the like? What's the measurable outcome in terms of quality of care?

First answer: "That's not what this is supposed to measure. Falls and bedsores are measured by the Joint Commission's Core Measure standards."

Okay, but my question remains: Has this business of the scripted rounds shown any increase in quality of care?

Second answer: "Well, we imagine it would. After all, if you're rounding on your patient hourly, you're more likely to notice their skin color and stuff like that."

Okay, great. But still, have there been any studies to show that this scripted rounding increases quality of care?

Third answer: "No. But we know that it increases Customer Satisfaction."

Customer Satisfaction, that is, as measured by the scripted questions that middle managers have to ask the patients--questions that we, as nurses etc., have trained them to answer correctly by using key phrases in *our* scripts. That way, Upper Manglement can take the raw data collected by the middle managers and point out that Sunnydale General has incredibly high Customer Satisfaction scores, simply because we healthcare providers have trained our patients to respond, like Pavlov's dogs, to the ringing bells of "Hourly Rounds" and "Outstanding Care".

Now, I have lots of problems with the idea that a hospital patient is a customer. Not all of those problems spring from a condescending, paternalistic worldview, so save your angry emails. Many of those problems spring from this simple idea: 

If you treat a patient as a customer, you are treating them for the wrong reasons.

Let me say that again: If you treat a patient as a customer, you are treating them for the wrong reasons.

I doubt--seriously doubt, having done it for years myself--that retail clerks or waiters get up in the morning filled with glee at the thought of going to work again. As cynical and grumpy as I can be here, I really and truly do look forward to working nearly every day. 

I look forward to it because I have patients: people I care for, in multiple senses of the word. I can educate them, learn things from them, make them happier or more comfortable or help them to heal. They are not my "customers"--if they were, what would be the point of actually giving a damn? I could provide a service for pay, sure, and could take my heart and brain out of the equation.

Reducing patients to "customers" undermines the mission of medicine: to assist the person who's sick in healing. However, reducing patients to "customers" does something lovely for Manglement: it boosts their scores in patient satisfaction and means they get more money, because they can publicize those boosted scores and bring more patients in.

Don't I care about my patients' happiness? You damn well better be sure I do. But I do it without scripts and without mandates from Manglement. I do it because it is the right thing to do. Dammit.


Anonymous said...

Good grief. Your job is to help these people get better. If you can make them happy and provide Outstanding Service in the meantime, great. But if you have the choice between making them feel properly served and, oh, I don't know, keeping them alive...

I've heard of cases where a nurse gets in trouble because the patient wasn't happy. Why wasn't the patient happy? Because he threw out their loud relatives after 9 pm because it was impossible for the other patients to rest.

Joy K. said...

As a patient, I think I'd be irritated at the scripted question. What a great way to make yourself appear distanced from the patients!

Anonymous said...

We have had hourly rounding and scripted conversations for about a year now. I'll bet your management has been Studerized as well. It's a joke around my hospital. Sometimes its a race to see who can finish their hourly rounding checkoff sheets that are attached to the doors. Long term pateints just tell me that they will call if they need anything and not to come by every hour.

Anonymous said...

If I were in the hospital trying to recuperate from some serious illness/injury and Manglement came by in the middle of the night, I'd tell them to go take a flying leap and let me get some rest.

OTOH, if they offered to come read to me or (level of consciousness allowing) play some Scrabble during the daytime, that might increase my patient satisfaction.

Even better, they could come bring me water to sip or take me to the bathroom instead of hassling the nurses about it. Wouldn't that be more efficient?

I'm so glad that horses can't fill out Press-Ganey surveys.

I'm also glad that the director of the horsepital where I work is still a practicing vet who sees patients himself. Likewise, the nursing supervisor pitches in and gets her hands dirty when things are busy or someone is out sick. I love my job!

GingerJar said...

Good lord. Does that leave any time for passing medications, changing dressings, charting, and doing the mandatory in-service (on the computer) training and tests??? By the time I round, turn, clean patients, give meds and chart, I barely have time to check the next days mar's, put in all the new care pathways (individualized for every patient you understand) and print out patient teaching every night. Oh, and don't forget it's the nurses responsibility to check the vital sign sheets and do the EKG'S, check the tele strips and intervene and call the physician's if anything is going on.

Anonymous said...

I'm with Joy. If I'm sick enough to be in the hospital, chances are I want to be left the hell alone. If there's no medical reason for you to come into my room, I'd rather be left to my misery.

Jo said...

Waitaminit. Horses can't fill out Press-Ganey surveys (I guess 'cause they can't hold a pen) but they can play Scrabble?

Anonymous said...

Heh. The tiles are easier to manipulate than pens. They suck at keeping score, though.

I work part time (now that I'm back in school) at a teaching horsepital. I guess you could call me a nurse for horses, but I don't have any kind of degree and the division of labor in equine medicine is very heavily weighted towards doctors doing most of the procedures (setting catheters, passing NGTs, changing bandages, etc.). I don't know a lot about the human system, but I guess I'm something like an ER tech (and tech is the term used in vet medicine) -- I mostly take vitals, reconstitute and give drugs, hang fluids, take blood, and administer general TLC. Oh, then there's my favorite, refluxing horses with anterior enteritis (the doctors pass the NGT and it stays in). (Horses can't vomit, so it's up to us to help them toss their cookies, er, I mean, decompress the stomach.) My previous job gave me more leeway due to being in a different state with different veterinary practice laws.

H said...

For me, one of the big problems with referring to patients as "customers" is that some people (not all, of course) take the customer title to mean that the hospital--like the hotel, restaurant, grocery store--is yet another place where they're "always right" (as the old saying goes). But in the hospital, the patient is not always right, nor should the healthcare team be expected to cater to his/her every whim. For instance, the woman who wanted to push vodka through her alcoholic husband's IV? NOT RIGHT. The diabetic who wants to eat the candybars his family brought for him? NOT RIGHT. The elderly woman who thought I should get her some lotion for her freshly stapled incision site? NOT RIGHT.
I'm all for patient autonomy/involvement in care, but there is also a limit. Medicine is simply not a field where the "customers" are always right. It just isn't. And letting people think otherwise is dangerous. Not to mention extreeeeeemely frustrating for those trying to take care of them.

Lisa G said...

I feel your pain. That craziness hasn't worked its way to SNFs yet, thank God. What's next, french maid's costumes on the nurses?!

I love "manglement" by the way.

Anonymous said...

It's "Outstanding" for you? It's "Excellent" for us. Every time we say it, they give us a cracker. *RAWK!*

shrimplate said...

"Everything is a commodity."

That is the key to understanding how manglement thinks. They have to think this way, because they themselves are commodities.

Anonymous said...

Lordy mine, that's ridiculous. I was hospitalized briefly earlier this year, and I was annoyed enough with the resident assigned to me constantly coming through (he was a lovely man, don't get me wrong, but I'd been up 'til three am in the ER and didn't fall asleep for a while after...) and the nonstop vitals-taking. Someone poking their head in to read a script every hour? I would have cried.

Also, no, we're NOT customers, and I can't stand people who think of themselves that way. This is not an instance of us being always right. Y'all, it's a HOSPITAL. Of all the places I'm not going to be arrogant enough to assume I KNOW WHAT'S BEST, that's gonna be it. Sheesh.

Anonymous said...

@ a particular hospital it was called 'hourly comfort round'. It was to ensure we were giving the very best care to our customers.. err uuhh.. I mean patients.
I know how you feel.

RehabNurse said...

Awww....I'm having flashbacks to my days at Saintarama (a large religious-owned hospital chain) which pushed hourly rounding out the wazoo. Only the nurses or the techs could do it though, since our rounding was based on following the three P's (potty, pain and I forget the third one--can you tell I skipped that inservice!).

Sure it's great to look in every hour or so, but sometimes, it isn't possible, or you get people who will corner you and won't let you out to do anything else.

We had to fill out little spreadsheets (I'm not kidding) for each hour. These were in folders on the door. We even did this when people were gone to therapy. If we didn't, the manager would tell us we didn't have enough rounds noted.

The nice thing was that before we left, we had a manager who would actually do rounds, and if someone needed to toilet, SHE would do it, no matter what. (She's also the CNE--chief nurse executive) She's not forgotten where she came from and I admire that.

I just really hated those d*&ned Press-Ganeys. They are so month your ratings are up, one month down, depending on the number of surveys returned and they're usually horribly low.

Penny Mitchell said...

This is not inspiring me to blast off to nursing school.

Bev said...

I agree with what Lynn said. In my previous life I was in retail management, and the customer was always right. The patient is NOT always right, otherwise they wouldn't be in the hospital and we wouldn't spend so much time teaching. Besides, if I were sick, and you came in every hours bothering me, you'd probably be wearing my fancy plastic water pitcher!

Unknown said...

No doubt compliments of the same mindset that brought us HIPAA...reminds me of old Latin proverb: Dum vitant stultia vitia, in contraria currunt. (When fools want to avoid evil they run to the opposite extreme).

oncology rn said...

We've been doing this bogus scripted rounding for about two years now at my hospital. The patient's aren't getting better quality of care because we don't have time to round on them because we're busy reading our scripts. Plus, they have common sense and realize we're all reciting from a script and then complain that we're all phony. If I had a nickle for everytime I explained to the patient that I was there to keep them safe and not be their BFF, I would be rich enough to retire. My last complaint when I was charge was that my tech wasn't a good tech because she didn't smile enough. Pul-leaze! Never mind that nothing was left undone on her part. She just didn't smile enough. How many times can you smile in 12 (the minimum number of hours in the shift) hours?

Anonymous said...

Having been an inpatient for 10 days, if the staff members had done that to me I would have been upset, knowing immediately exactly what was going on and that this was not a good use of anybody's time. So, if they're doing it now, next time, can I complain to the hospital ombudsman that I'm unhappy about it? Would it change anything?

But then, I'm a rebel who asked the Safeway grocery clerk if she weren't tired of the set script upper management had recently decreed must be said to each customer--and hey, I asked her, how ya doin', anyway? That got me a real conversation, short but just right, that was far more satisfying than anything the MBA's could foist. And it had exactly the effect they'd wanted: I wanted to come back.

ERMurse said...

Great post. The concept has come to emergency rooms. I just posted on it over at We've been studerized or something that sounds like it. Scripting just does not sound genuine or natural conversation. Are patiets really that stupid that they cant tell when the are being read a script vs true concern or assessment. I guess management thinks so.