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.

A Vital Sign with concerning unintended consequences

Great post over at Aggravated Surgery Doc about the on the Downside of the 5th Vital Sign on how the PC infiltration of pain management policy caused poor patient outcomes and placed patients at higher risk. He makes valid points that political pressure has lead to more aggressive use of IV narcotic pain management instead of IM or other management thus putting patients at risk.

“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”

“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“

In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.

The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.

I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.

“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.

I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.

If this practice has not hit your ER yet, consider yourself lucky for now.