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  • Potholes are usually something to be avoided. But now (click) they are also a mnemonic for things we would always like to include in our interactions with patients, especially at admission and discharge (or at the beginning and end of episodes of care [for those residents who do not have primary responsibility for hospitalized patients]). These are our Always Events – [read list]
  • Analogous to a surgical time-outa "time out" immediately prior to all invasive procedures with active verbal communication between all members of the surgical/procedural teamReview the written instructions with the patient and make sure the patient follows along with youAsk patient to repeat important instructions back to youAsk patients if there are questions (see Test Understanding)
  • - May also include nursing and social work
  • - How do you reach your doctor(s)?
  • - Among the most frequent patient dissatisfaction comments were those that reflected distress when team members gave patients different or conflicting information

Slide set for pothol es always events Slide set for pothol es always events Presentation Transcript

  • HEALTHCARE IMPROVEMENTTRAINING (HIT)PATIENT-CENTEREDCARENicholas Fiebach, MD (Columbia)Lia Logio, MD (Cornell)Maria Oquendo, MD (Columbia)Richard Liebowitz, MD (NYP)Alan Lee (NYP)Emily Marcelli (NYP)Aubrie Swan, PhD (CERE)
  • Supported by:GMEChallengeGrant
  • Patient-centered care Understanding and responding to the needs and preferences of our patients Challenging a national dilemma  an NYP issue  sometimes daunting for house staff Requires a collaborative response
  • POTHOLEs in patient-centered care P PAY ATTENTION ORIENT PATIENTS O AND FAMILIES TEST T UNDERSTANDING HUMANISM – BE H KIND O ON-TIME CARE LET PATIENTS L EXPLAIN EXPECTATIONS – E WHAT SHOULD PATIENTS EXPECT?
  • Is there time to do this? Possibly Famous study by Beckman, et al. (Ann Intern Med 1984;101:692-696): on average, physician interrupted patient 18 seconds into the encounter For the minority of patients (23%) able to complete their initial responses to the physician, the longest was 2.5 minutes Small investments in time spent with patients may have enormous value to them, may improve clinical outcomes, and might save time later
  • PAY ATTENTION1. Meaningful listening  Giving the patient your full attention  Eye level, eye contact  Sit when you can  The opposite of multi-tasking
  • PAY ATTENTION2. Discharge Time Out  Protected time with patient (and nurse if possible) involving active verbal communication about discharge plans, meds, follow-up  Be clear with details  Gauge patient understanding
  • ORIENT PATIENTS AND FAMILIES1. Introductions  Include everyone: glossary of providers and who’s in charge  Medical student: student doctors in their 3rd or 4th year of medical school who help us to take care of patients as they learn  Intern: a doctor taking additional training in _____  Resident: a doctor taking advanced training in _____  Attending: a senior (faculty) doctor in our department who is in charge  Fellows, consultants  Nurses, social workers “Ranking of physicians is very confusing - should explain what resident does, senior resident, attending. Also where fellow fits in. Also who is what. Also medical students.”
  • ORIENT PATIENTS AND FAMILIES2. Rhythm of the ward/service  Who does what with patients when  e.g. the medical student and the intern will check in on you first thing in the morning, usually about 7 am; then we’ll come by as a team for a few moments to assess you and your progress between 9 and 10; Dr. Xx will stop by at other times to check on you; and we’re all available if something comes up
  • TEST UNDERSTANDING1. Explain without jargon “Her crit was falling; it could be dilutional but we’re not sure, so we want to give her 2 units of packed cells.” Better: “Her hematocrit value dropped; it may be from the fluids she received, but just to be safe we want to transfuse 2 units of red blood cells.” Even better: “Her red blood cell count decreased. This may be due to intravenous fluids we gave her to maintain a safe blood pressure. I’m making sure she’s not losing blood, but to be safe I’d like to give a transfusion of 2 units of blood.”
  • TEST UNDERSTANDING2. Solicit questions, understanding  Does that make sense?  What questions do you have for me?  I want to be sure I was clear and explained this to you  Can you tell me in your own words what you understand (or will do… or how you will…) [called a teach back] “They started explaining a few days before discharge to make sure I felt ready.”
  • HUMANISM – BE KIND1. Adult-to-adult amenities or age appropriate, for Pediatrics  Common courtesies – knocking on door, may I come in?, introductions/reminders  Greetings – Good morning, Mrs. Smith  Providing privacy and modesty – closing doors and curtains, arranging bedclothes and sheets  Providing/restoring comfort and convenience – e.g. call button, lights (on/off), bedside table, phone, TV, food tray in reach “Didnt love the wake up call by a group of residents. They need to learn how to knock on a door.”
  • HUMANISM – BE KIND2. Empathize  empathy: understanding another person’s viewpoint, and appreciating that person’s feelings  practical steps to empathic communication:  awareness and inquiry: what is the patient feeling?  acknowledgement: you might feel…, it may be…, it seems that…, I wonder how…  appreciation and affirmation: I know that…, I appreciate that…, you are…  not intervention or remediation of feelings
  • ON-TIME CARE Understandably, often challenging for house staff who may themselves be at the mercy of hospital staff and the processes and the delays they cause But, several strategies may mitigate these effects for patients
  • ON-TIME CARE1. Realistic timelines  don’t be vague  try to provide timely visits, interventions and care to patients, but provide them with realistic estimates, often involving a range of times “Doctor said he would visit before discharge. He didnt visit and then discharge was extended for hours without being seen.”
  • ON-TIME CARE1. Update, empathize  keep patients informed of delays (they are reassured if they know you know; more reassured if they know you’re trying to expedite)  if you cannot expedite, acknowledge their frustration, re-affirm your commitment to their care
  • ON-TIME CARE1. Update, empathize  keep patients informed of delays (they are reassured if they know you know; more reassured if they know you’re trying to expedite)  if you cannot expedite, acknowledge their frustration, re-affirm your commitment to their care “Doctor said he would visit before discharge. He didnt visit and then discharge was extended for hours without being seen.”
  • LET PATIENTS EXPLAIN1. Open-ended inquiries  What do you think is going on? …causing this?  What do you think would help?  What are your preferences? …goals? …plans?2. Is there anything else? “getting the patients to feel comfortable that they have the right to ask questions and confirm whatever the doctor is saying within their own mind that this is what is supposed to happen”
  • EXPECTATIONS: WHAT SHOULD PATIENTSEXPECT?1. What happens next Short-term previews, e.g.  You’ll get an intravenous antibiotic and we’ll check your blood counts and your lung exam over the next couple of days  We’ll arrange for a CT scan of your abdomen and if it shows XXX we’ll discuss the need for surgery with you  You should fill this prescription to continue prednisone for another week, continue the other medicines you were taking at home, and you will see Dr. Doomuch next week on Tuesday. “Doctor visited me early in the morning before my discharge. He was very informative & friendly!”
  • EXPECTATIONS: WHAT SHOULD PATIENTSEXPECT?2. Coordinate/corroborate/explicate/equivocate  try to coordinate plans with attendings, nurses, social workers, etc., before briefing patient  if the patient (or other team members) have a different idea or preference for what will happen, try to check it out without dismissing the patient’s perspective  try to be specific in outlining plans, especially at discharge (and test understanding with teach back)  if you’re not sure (about diagnosis, interventions, discharge plans), it is okay to say so