Wednesday, October 8, 2014

InQuickER - Thats what she said

A new marketing tool has made its debut in many local Emergency Rooms. Most notably, at Dignity Health. The Human Kindness folks. Its called InQuickER. Its a web based tool to allow one to make appointments in their participating Emergency Department from the comfort of their own home via their Smart Phone.

The theory goes like this. You have an urgent issue, but not something life threatening, and you do not want to wait in a crowded Emergency Room full of coughing Ebola patients. You pull out your Smart Phone and make an appointment in your local ED and are assigned an appointment time. You wait in the comfort of you own home and when you arrive you get right in, supposedly. The program will kick you out if you put in key words such as "Chest Pain" or "Stroke". and will advise you to call 911. It contains disclaimers that your appointment time is not guaranteed if there are real emergencies to deal with. The ED will receive a fax that your on the way and the staff is instructed to accommodate your arrival. If your time cannot be accommodated due to department acuity or volume the ED can push your appointment back in 30 min increments. You will get a message if your appointment time is altered.

Just a few problems other than the obvious question of Appointments in the ED, Really! The keyword recognition is really not that smart. There was a sentinel event at one Human Kindness facility that involved a pediatric death shortly after going live with this program. A mother had a sick child, made her online appointment and waited at home with her child. Her complaint description did not trigger the key word trigger and the fax to the ED did not set off any alarm bells. When the patient was brought in at the appointment time he was in severe shock and expired after resuscitation. Would the outcome have been different if she just brought the child in without waiting at home. Who knows. No problem. The RCA determined that a few tweaks of the Key Word sensitivity would prevent a further occurrence. I'm not so sure.

Thoughts, comments on your experiences with InQuickER or like programs. Is this program helpful or just a cheesy attempt to market Emergency Department services?


Tuesday, May 12, 2009

How to tell if you have been Studerized - or something that sounds similar

You’re a seasoned ED Nurse. You are respected by your peers. You are up to date with the latest medical advances, you treat your patients well, you’re a strong patient advocate and actively advocate for patient safety and the nursing profession even if it conflicts with some of your organizations priorities. You probably feel your operating at or near the expert level and have been evaluated that way for a number of years but I have news for you. Nurses are no longer graded on the Novice to Expert scale. They are now being categorized as Low, Medium, and High performers. So how do you know where you fit in and what’s behind this new evaluation system? Hold on, if you haven’t already you’re about to be Studerized or something that sounds similar but is much more painful, at least from what I’ve been told.

How can you tell if you’re on the road to Studerization. It starts out when your managers, CNE, CEO, ED MD Director, among others leave for a few days to a conference or management retreat. The retreats are usually held in resort places like Las Vegas, Phoenix, or Florida but have been branching out to other cities and even webinars. You are not told what it’s all about and you don’t care, you’re just happy to see them gone for a few days. When they return you notice an immediate change. They are using new lingo and talk like they have been indoctrinated into some sort of cult. They are very scripted. They use terms like “Hardwired”, “Fire Starter” “Best Practice” “Taking the organization to the next level” “Low Performers” and “Rounding.” Some of these I wrote about in a previous post titled annoying consultant speak They also talk about some charismatic character named Quint Studer. From conversations with a number of people who’ve attended the programs they sound like a combination of a Amway multilevel marketing seminar, manager training seminar, and Kool-Aid drinking cult gathering. There usually is an inspirational speaker to pump up the crowd. There are various levels and once students are immersed in the philosophy they are considered “Studerized”. A more advanced level is the “Fire Starter” which has a 15 point litmus test called “15 Sparks”. Hospitals can even win the prestigious Fire Starter Award after a visit from one of the Studer troopers.

Hospitals thought-out the nation are trying to improve their patient satisfaction scores and marketing share. I have written about that in a post on patient satisfaction scores out of balance and How has the patient satisfaction push effected your practice. They have turned to groups like Studer who give them the nuts and bolts of turning patients into customers and strategies to bump their satisfaction scores. I have listed my own strategies here.

Not long after the retreat new concepts start appearing into the work area. Some are founded in good ideas but are being done for marketing reasons and means to boost patient satisfaction scores rather than any interest in patient care. Some measures include.

Scripting: Nurses are no longer free to communicate the way that feels natural or based on the situation at hand but are given scripts to communicate with their patients. Coincidentally, or not, the scripts prompt the patient to answer their discharge surveys by injecting key phrases into the scripts that correspond with the questions on the survey. Would you like Fries with that?
Managing up: Encouraging staff to positively portray services and co-workers, doctors, ect during conversations and hand offs regardless if it is true or not. Hi, this is your Doctor, He is one of our best physicians, The patients really love him. Wink Wink
Hourly rounding: Rounding every hour and every half our for ER utilizing your best scripting language. Staff are required to fill out rounding documents and some facilities play the beach boys music “I get Around” every hour on the hour to remind staff. Even the Manager, CNE, and CEO round once a day and ask patients directly if your Nurse has been doing their rounding. I hope my patients are not sleeping when I round, I might get a write up for not performing my hourly’s.
Discharge Phone calls: Generally a good concept if done to check on patients but these calls are timed and scripted to plant answers to survey questions with the specific purpose of boosting patient satisfaction scores. Expect a call the day before your survey arrives provided you were not admitted, transferred, mental health, or someone who really needed to be in the ER.
Peer review: Having staff fill out 1 to 5 rating scales on each other in 5 different categories. Used to help classify people as low, medium, or high performers. If you dont participate your immediatly classified a low performer. Nice way of turning the staff against each other.
RME: Marketing measures disguised as ED through put measures that focus on turnover and catering to low acuity patients, oops, I mean customers. I have written on RME and similar programs here and here. The common thread it that they de-emphasize Triage and limit the practice of Nursing.

So where do you fall, Here are some characteristics of low, medium, and high performers from the Studer site. Funny thing, you could be a effective employee and Studer still recommends you be fired


“..In fact, I would even suggest that you terminate employees who get results but do not role model your organization’s standards of behavior, because they are so damaging to overall employee morale”.

One Chief Nursing officer at a Sutter Health Facility learned the hard way about the dangers of email. It exposed how managers are using groups like Studer target their staff following a quota system. She instructs each department manager to identify 3 low performers per unit “You know who they are” for moving up or out to improve Press Ganey scores. Read her leaked memo here. CNA gave a great response on the same memo.

So are you ready to be Studerized. Bend over.

Tuesday, September 30, 2008

Drinking the RME Kool-Aid at ENA’s annual conference

Just got back from the Emergency Nurses Association’s annual conference in Minneapolis. Overall a pretty good conference if you avoided the Keynote addresses. A disappointment was the numerous presentations and posters touting the wonders of the process being pushed by several ED groups and Hospital bean counters called RME. Rapid Medical (Mediocre) Evaluation which also goes by several other names such as Triage Bypass, Provider is Triage, Door to Doc, among others depending on which ED Physician group is pushing it. All are basically the same thing. While pieces of the process can streamline care (immediate bedding, bedside registration) here are the claims that are made by the RME’ers that any thinking Nurse should question.
If we adopt RME we will be able to pay for more Nurses with the all the money we Save. Right!!!!! Well, that’s not my experience. I work in one of these facilities and staffing has stayed the same and the moment there is a lull the manager is trying to send staff home because the census is low. So, reduce your standards to move people through, stack them in chairs to utilize more space, pressure the Doc's to do a substandard exam, and as soon as you discharge them go home your not needed. Now that’s efficiency. Remember, work smarter not harder. I have an idea. How about not counting patients who dont get a Nurse in the Nursing hours of care. Most patients are alotted around 2 hours of care credit for budgeting. What if they never get a Nurse. No, that would be way to honest.

Patient should not have to tell their story more than once. Don’t trouble the patient with having to repeat their story more than once. This is team Triage and we get all the facts on the first try because the Story Never Changes!!!!! More Kool-Aid please. What do you call the Nurse in Team Triage? Scribe

You don’t need to have a Primary Nurse assessment. What the heck for. They don’t do that down at the Wall Mart Clinic, why should the ED. And what a wonderful way of dodging the Nursing ratios in California.


Patients do not need to get undressed. What the heck for. You never find anything when you examine the skin, back, or any other covered part. What a waste of time. Yum, Good Kool-Aid. I cant wait for our next round of survey results. Can you say Bump!!

Nurses are more satisfied. Which ones? The ones who view Nursing as a series of tasks rather than a process and don’t assess their patients or understand a Nurse Patient relationship probably will. You know them, the ones who make up discharge vital signs and always have their chart complete even though you never heard any of those questions asked. Yep, that’s them. There are certainly plenty of them around. Managers will also like it. Nothing makes them tingle like good numbers.

Patients can be quickly categorized with minimal or no triage. Put on your Blinders and only focus on the complaint they tell you. It keeps the problem simple. Patients always articulate an accurate complaint and totally understand their symptoms. Easy Peasy. You have an ear ache – Done, Your back hurts – take these, Done. Our Door to Provider times are awesome. Wow, why didn’t we think of this model 20 years ago.

Patients are more satisfied. Some probably will be. Most don’t recognize crappy care as long as its delivered with a smile and done quick. The Customer is always right.
So there you have it. Our professional organization (ENA) pumping up a process that shortchanges patient assessment and treatment from both Nurses and Physicians and cuts out important parts of the Nurses role to make the numbers look good. Brilliant recruiting strategy. I am so thrilled I think I will join for life right after I finish this Kool-Aid.

Tuesday, August 19, 2008

Annoying Consultant Speak

In the past week I have sat through several process type meetings and must reflect on some of the most irritating consultant speak. Here are a few examples.

Rapid cycle process improvement
The model of improvement is applied in short test periods, using small samples of patients, and measures the effectiveness of the changes being tested. Based on what is learned, successful interventions are applied to other patients or other organizational activities or settings and unsuccessful ones are revised and tested again for effectiveness. You usually hear it when a new manager or director takes over from the outside or your existing manager goes to a conference. Murse’s Translation. I went to this cool seminar and heard this great idea and since I don’t really know anything about statistics or study design and we don’t have time to do a real study were going to implement this new process and if by the end of the day it works were going to do it throughout the hospital. Then were going to put it in a power point and present our great success to the CEO. I love the smell of a bonus in the morning.

Perfect is the enemy of Good Enough
The origins of this phrase are from the French Philosopher Voltaire. In modern times it seems to appear during crunch time of hospital IT projects. Go-Live is just a few months out. The team is feeling nervous and wants changes. The CIO calls a big meeting and gives a power point pep talk to get everyone "on the same page". Then it comes out, “You know, when it comes to rolling this out, Perfect is the Enemy of Good Enough. Murse’s translation: “Lets put some lipstick on this pig and roll her out. Stop you’re bitching, the users will just have to deal with the issues”. Ok, we know its never going to be perfect but can I ask: Did you use that same term when applying for your job when asked to describe yourself? How about when you proposed to your significant other, or do you say it to your kids just before finals or the big game? Doubt it. I’ve decided that at the next EMR Go Live that I support I will wear a team t-shirt that says, Perfect is the enemy of good enough! How about that on a team shirt. The users will be impressed.

Studerized
Being Studerized is similar a baptism in the Studer Group philosophy. I suspect there is Cool Aid being served at this baptism. Hospitals thought-out the country are sending their staff to various vacation resorts for $1200 a pop, not counting lodging and travel for the 2 day Studerization. By the end you are a customer service expert. Patients become Customers. You become experts in scripting the survey and how to change the patients perception of the visit. You are eager to go back to your hospital and implement the Three Levels of Studerizaiton. When you get back you will be filling out report cards on each other and identifying your departments high, middle, and low performers. Hope I’m not in the low group. Wow, I’m pumped. Pass the Cool Aid.

I'll update this list from time to time, shouldn't be hard I have more meetings this week.

Monday, July 28, 2008

Spike in medications deaths. Could it beeeeeee ……. Satan – or perhaps “The Fifth Vital Sign”

In a article to be published in the Archieves of Internal Medicine next week an alarming spike in the number of accidental deaths from prescription drug use related to “medication errors" is reported. The Article by David P. Phillips, a sociologist at the University of California, San Diego is the most recent in a series of research he has done on the subject of drug abuse, suicide, and societal trends.

“Deaths from medication mistakes at home increased from 1,132 deaths in 1983 to 12,426 in 2004. Adjusted for population growth, that amounts to an increase of more than 700 percent during that time. In contrast, there was only a 5 percent increase in fatal medication errors away from home, including hospitals, and not involving alcohol or street drugs”

"By 2004, fatal medication errors were responsible for far more years of potential life lost than were all accidents from firearms, falls, fire and flames, drowning and non-medication poisonings combined," Phillips said

So what type of medications are we primarily talking about here. You guessed it, Opioid pain medications like Methadone, Oxycodone, Vicodin, and Fentanyl. Throw in a benzo, an antidepressant, perhaps a glass of wine and out go the lights.

Similar data is being reported by the Centers for Disease Control. According to the federal Centers for Disease Control and Prevention, unintentional poisoning deaths – 95% of which are drug overdoses – increased from 12,186 in 1999 to 20,950 in 2004.

During testimony at a Senate Judiciary committee in March of 2008 Leonard J. Paulozzi, M.D., M.P.H stated


When these more specific drugs were tabulated, we found that street drugs were not behind the increase. The increase from 1999 to 2004 was driven largely by opioid analgesics, with a smaller contribution from cocaine, and essentially no contribution from heroin. The number of deaths in the narcotics category that involved prescription opioid analgesics increased from 2,900 in 1999 to at least 7,500 in 2004, an increase of 160% in just 5 years.[1] By 2004, opioid painkiller deaths numbered more than the total of deaths involving heroin and cocaine in this category.


He went on to say

All available evidence suggests that these deaths are related to the increasing use of prescription drugs, especially opioid painkillers, among people during the working years of life. A CDC study showed a correlation on the state level between usage of opioid painkillers and drug overdose death rates.[2] Perhaps because of differences in marketing or physician prescribing practices


What can be done

It is important that state prescription drug monitoring programs share data with law enforcement officials for the purpose of investigating the unlawful diversion or misuse of certain controlled substances. For example, some state prescription drug monitoring programs are administered by a law enforcement agency in conjunction with a state board of pharmacy


This recommendations falls in line with what California is implementing through the CURES program which will give providers instant online access to all scheduled drugs obtained via prescription by a patient. Law enforcement also has access to this data as needed. I recently posted about that program here

What is going on here is a direct result of politicizing medicine by the pain rights movement and the organizations (Joint Commission and others) that have mandated liberal pain management into guidelines and enforcement standards. More recently the push to promote patient satisfaction in Healthcare organizations has resulted in liberalizing of prescribing opioid medications to make patients happy. Whatever happened to do no harm? Medicine has lost its way. These numbers should serve as a wake up call and re-examination of pain management practices and the whole concept of pain as the fifth vital sign.

Wednesday, July 2, 2008

California takes a big step forward in fighting prescription drug abuse

In 2005 California expanded the CURES program to include all Schedule II-IV prescriptions dispensed. These medications have to be reported to the State Attorney Generals office who maintains a database of medications dispensed. This includes controlled substances directly dispensed from, Pharmacies, Doctors offices, clinics, and Emergency Departments that give out the to-go six pack of Vicodin when patients present after pharmacies are closed. Reports to the CURES program are done using a direct dispensing log that is faxed weekly to the CURES program.

Medical Providers and Pharmacist have been able to tap into this database by requesting an activity report on patients under their care. What they get is a print-out of every controlled Rx filled by the patient regardless of the source. In the past this report took several days to weeks to obtain. It was little use for the Provider who is trying to figure out if the person in front of them is filling multiple scripts from multiple sources. It worked well for ongoing care of repeat patients. I have seen it work well with some of our regular patients who return like clockwork to the ED several times a month. When confronted with the report of scripts they have filled recently and neglected to mention when listing their medications most give up knowing they have been had and you don’t see them again.

Soon the availability of activity reports will be online instantly via the California Attorney Generals web site. Instant access to a patients controlled substance prescription activity will give providers knowledge if they being lied to, used, played, to feed a habit or supply someone with an income who is reselling their meds. For those with legitimate pain conditions who are not seeking medication from multiple sources it should help them by removing the cloud of suspicion that follows them when seeking pain relief.

This effort is being funded partially by the Troy and Alana Pack Foundation founded by Bob Pack who’s 7 and 10 year old children were killed by a driver under the influence of prescription drugs obtained from multiple doctors. The Wall Street Journal recently had an article about the program.

Its about time.

Wednesday, May 28, 2008

Technology protections for Nurses and why they are necessary

Recent employment contracts between the California Nurses Association (CNA) and a number of California Hospitals have contained model language to protect Nursing Practice from being degraded by the implementation of Technology, primarily Electronic Medical Records. When initially proposed this language did not receive much attention but as nearly everyone is in some phase of implementing an Electronic Charting system its getting attention now. I'm not a banner carrier for CNA as their positions are very much to the left of mine which I have noted here but on a few issues, ratio's and this language, they are right on. I am a big supporter of EMR’s if they are designed correctly. That’s a big if. Here are a few experts from one contract.

“Deployment of technology shall not limit the Registered Nurses in the performance of functions that are part of the Nursing Process, including full exercise of clinical judgment in assessment, evaluation, planning, and implementation of care; nor from acting as patient advocate”.

“Technology is intended to enhance, not degrade nursing skills”


Here are some of the ways that Nursing practice is being limited with the use of Electronic Charting.

Charting by Exception: The assumption of Charting by Exception is that patients follow a predictable course and unless there is deviation from the norm nothing needs to be charted. The is in direct contradiction to the “If it was not charted it was not done” assumption that many Nurses live by. Charting by exception is certainly not limited to computer charting but tends to creep in as systems are implemented to ease the transition by selling the point that look how much less you have to chart.

Limitations of access to key areas of the chart: All EMR systems have security settings that allow hospitals to determine who can see what. Some Hospitals have designed their systems to keep Nursing from viewing the notes of others or specific types of results. The most common examples are the limitation on the viewing of sensitive areas such as Psych notes or HIV status, all important information to the patients Primary Nurse.

Lack of basic Nursing Functions within the system: One of the major Hospital EMR systems, Cerner, does not even contain a Care Planning Module. Cerner has been around for years. Supposedly they are developing one. Nurses using the system either have to keep their Care Plans on paper, manually type them out every time, or use the Problem List function which is not a Care Plan. Some Cerner users keep Care Plan templates in word documents and cut and paste them into blank notes as their work around. Being an ED Nurse, I am no fan of care plans but they are a key Nursing function on the floors and a regulatory requirement by JCAHO and most boards of nursing.

Limitation of Nursing access to educational materials: One ED EMR System (T-Systems) is very role based which means your view and access to the application is very dependent on your role. Not a problem in theory if the system designers know all the complexities of the various roles. The problem is the developers over at T-System (and the hospitals that purchase their product) do not recognize that one of the main professional responsibilities of Nurses is to provide good discharge education. This education goes beyond what the ED Physician may select in the system as the discharge instructions for the patient. Nursing does not have access to the Exit Writer instruction module that is a part of T-System.

Limited generic charting choices: Some forms of charting limit the Nurse’s ability to document in a coherent way. An example is Flowsheet documentation or Templated charting with fixed choices, many that are very generic and difficult to fit into complex patient situations. The underlying issue here is the desire to make all data reportable, actionable in alerts, or graphable. Its also the way programmers think. Structured data can be reported off and trigger alerts while free text data is very hard to report off of. Some data needs to be structured such as the Patients Medications, Allergies, Height, Weight, I&O’s, ect. Other data such as observations of patients behavior, patient statements, or responses to procedures are better left to free text and make little sense when forced into fixed choices.

Compromising Triage in the ED: When a patient enters the ED the first contact should be with a Triage Nurse who will determine the patients acuity and disposition. Many EMR systems require the patient to be registered in the registration (ADT) system prior to them being visible in the EMR system. So, until the patient see’s a registration person the Nurse cannot document. Most facilities do not allow the Nurse to create the patient in the EMR system out of fear they will create duplicate patients or otherwise get it wrong. It’s a battle with nearly every EMR implementation. While a quick registration can be very quick there is an interface that the data must cross from the ADT to the EMR and most ADT systems are prone to downtime.

CNA sees the move to Electronic Charting as part of the deskilling of Nursing by reducing Nursing to a series of tasks rather than a process. Whether that is one of the intents of some EMR's or just a result of poorly designed EMRs is not very clear. CNA’s technology contract language provides important protections and deserves a serious look to any Employee Organization that represents Nurses during contract negotiations.