*#^&$ Seven-Layer Dip. *#$*@ being awake at night...

Grrrr.

Obviously, I have the night off. Also just as obviously, I've not managed to flip days and nights successfully on my nights off. This would not be a problem, except that the DMV opens after my bedtime tomorrow morning, and I have to get my license renewed.

*** *** *** *** ***

So I'm looking up recipes for Seven-Layer Dip and pondering the breakfast I had this--well, yesterday, now--morning.

Fellow Intern Anna and I met up for breakfast at a place where, no kidding and no exaggeration, the pancakes are a foot across and an inch thick. An omelette with all the fixings (potatoes, biscuit that's the size of a half a loaf of bread, gravy) will run you twelve bucks, but it's three meals.

Anyway, as I was plowing through a quarter of one of my pancakes, she told me about a minor procedure she'd screwed up the night before. It's one of those things that they didn't cover in the internship. The screw-up was tiny, not harmful to the patient, but got the resident annoyed and made Anna feel like a dope.

Turns out it's covered in the CCU protocol.

"There's a protocol for that?" I said.

"There's a protocol for everything, apparently." she replied.

"Well, that's a good thing to know. Better late than never. Where are the protocols?"

"Nobody knows."

I wish I'd been surprised. "You mean we have protocols somewhere in a three-ring binder, but nobody knows where it is?"

"Yep," she sighed. "And the CCU protocols are supposed to be online as well, but every time you click the link to the practice and protocol pages, it lands you on the page that asks for a password, then tells you that yours is invalid and kicks you back out. Nobody can access it."

"Seriously?"

"Uh-huh. *And* the only official protocols are the ones online, so even if we managed to find the binder where the old protocols are, we couldn't use those."

"Well," I said, "It's nice to know that there are standards of practice and ways of doing things, even if we're not allowed to see them. Makes me feel all warm and fuzzy inside."

Anna stirred her coffee and stared into the middle distance for a minute. "I wonder if my mom kept that decoder ring I bought from the back of a comic book when I was eight. Maybe *that* would get us in."

*** *** *** *** ***

This is, of course, Texas. The idea that anything associated with state government could actually work well (or at all) is pretty foreign. I mean, you're working in a research institution, you're trying to access the rules set forth for your practice by that State-funded institution, but you're not allowed to. That's pretty much how it goes here.

When I called about renewing my driver's license, the state DMV people told me that I had to bring a money order or cashier's check for the fee. They don't take personal checks any more; it was too hard for them to track down hot-check writers. Not enough information in their database, they said.

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.