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Tom Utecht, M.D., is responsible for maintaining high quality of care and patient safety at all Community’s hospitals. Dr. Utecht is an experienced emergency medicine physician and a faculty member for the UCSF Fresno Emergency Medicine Residency Program.
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Last week I was at the Epic (our new IS majority vendor) demo/kickoff. The event was notable to me for several reasons. First, I think that Jamie Franklin (our Chief Project Management Officer) has second career possibilities in stand up comedy. Second, it was great to hear and see what Epic has allowed other facilities to do and what our future holds.
Finally, I was impressed by Jamie's comments about what the "end game" is. His goal after 7 years is not to have a "successful implementation of a software product." Rather the goal is to make caring for our patients safer, more efficient, more timely, more equitable - in other words, meeting well defined clinical, operational, and financial goals.
It is good sometimes to reflect on our different goals and how we define success in attaining those goals.
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I was recently on an airplane sitting next to somebody reading something similar to the above title. There are loads and loads of books written about leading. The interesting thing is how few books are written about "following." And yet following is something that almost all of us have to do.
In healthcare, following is not always easy. We certainly have a chain of command and a physician who makes the final decision about patient care. At the same time, we have an obligation to our patients to speak up if we see something concerning regarding patient safety. The physician expects this which in turn allows him or her to deliver high quality, safe care. Expect to hear more about this concept as LifeWings training is on-going at CRMC in the surgical area. Our goal is to expand this training to all of our facilities in multiple other service areas. One of the mantras of this program is, "See it, say it, fix it." Perhaps this is a good place to start as we think about following.
Who knows – maybe Atilla’s followers had a similar mantra.
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At the YMCA where I work out, one friendly gentlemen always says goodbye to everybody ending with "Drive safe." When I asked him about this, he related that after driving a truck for 25 years he had seen some pretty terrible things on the highway. Having worked in a trauma center, I can relate. This also struck a chord with me as I read the below link about another highway tragedy that occured locally. This story speaks to loss and the great care/service we provided along with the CTDN.
Our most valuable resource here at CMC are our people - those who directly provide care and those who provide the support to do so. And so during the hectic upcoming holiday season I ask you to preserve this resource (you) and please.............."Drive safe."
http://abclocal.go.com/kfsn/story?section=local&id=5781160
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Going bare?
Sometimes (in fact a lot of the times) the best solutions to a problem are the most simple. Take for instance the issue of health care associated infections – the simple solution here is hand-washing - for more information about this go to the Hand Hygiene policy and procedure in the Infection Control manual.
Another interesting and simple solution may be coming soon in regards to hospital acquired methcillin resistant Staphylococcus aureus and Clostridium difficile. In the UK, next year they are hoping to decrease the rate of spread of this infection by requiring health care providers to go "bare below the elbow" as well as eliminate white coats, neckties, and jewelry. As you might guess, there has been some pushback, nonetheless, the Brits are moving forward.
We’ll see what happens in further research and wait until the Central Valley warms up again, but who knows – perhaps going bare is in our future.
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This is hardly considered professional dialogue. Unfortunately, it happens, even between colleagues in healthcare. However, this type of dialogue should not be tolerated by any of our staff. Whether RN to RN, clerk to PCA, or MD to staff, etc. - respect should be the cornerstone of all of our interactions. The more we understand that high quality, safe healthcare is a team sport, the better. As any of our risk management staff can attest, communication (or lack thereof) is a contributing factor in nearly all of our problematic occurrences. It is obviously difficult to have meaningful exchange of information if one is fearful of, or subjected to, being yelled at or chastised.
The Medical Staff is in complete agreement with this concept. Let me quote to you from the Medical Staff Policy regarding Disruptive Behavior, “It is the policy of the Medical Staff of CMC that all individuals within its facilities be treated with courtesy, respect, and dignity.” Incidents that are contrary to this policy are taken seriously by, and acted upon, by the Medical Staff.
The CMC Corporate Harrassment policy also has similar language. You can read both of these policies in their entirety through Lucidoc – and I encourage you to do so. The soon to be released Target 100 Standards of Service Excellence will also address this issue.
There is certainly a subjective element to defining “disruptive behavior.” Nonetheless, I would encourage you to follow the above policies anytime you believe your ability to care for one of our patients is hindered by another’s behavior.
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How many of you somewhat dated individuals remember the movie the above phrase came from? On May 22, 2007, "They're here" meant that CMS had arrived at our CRMC campus to do a for-cause Conditions of Participation survey. While I cannot divulge the specifics surrounding the survey, I would like to convey that at the end of the investigation the surveyors were very impressed with our facility and our care and had no findings. The folks that interacted with the surveyors did an awesome job - Laura McComb, Marge Beekman, Linda Bates, Berj Apkarian, and Jo Gehringer to name a few. But beyond that, all the folks that give care and document in the medical record (Nurses, Physicians, Ancillary and Clerical staff, etc.) are to be commended as many medical records were reviewed. Surveys (announced, unnannounced, for cause, etc.) have become a way of life for health care facilities. I am excited to work with folks who are putting systems into place that deliver and demonstrate the high quality care we give to our patients.
Btw - I believe the above line came from the 1982 movie, "Poltergeist."
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“Lot’s of ‘Discharge magnets’ available.”
For anybody who spent time in the VMC/UMC ED, the above statement is likely to have meaning. In the days that our ED’s had magnetized boards, this is the quote that Brad Isaac RN, ED Coordinator, would use to encourage docs to dispo patients. It is with a heavy heart that I write about Brad as he recently died in a car collision.
From his weekend potlucks to his unique way of answering the phone, Brad was one of the key ingredients in the glue that holds together our Level 1 ED. He was a stabilizing force in an often chaotic environment. Brad had a lot to do with building the concept of “family” in the ED. It was also obvious how important his own family was to him. I will never forget the pride with which he would bring out some of his wife Terri’s award winning cookies or carrot cake to one of our potlucks. Brad was also very proud of his service in the Navy – often reminding us of this background with statements such as “Belay that order.” I could go on and on about Brad and how his consistent leadership and the love he had of his work, our patients, and his fellow employees will be missed – but I’m guessing you get the point. There are many things we will not understand in this life – the tragedy of losing Brad at this time would be one of them.
Please join me in offering condolences to the Isaac family – including his wife Terri, and children – Marshall, Nicole, Brandon, and Jacob. A Celebration of Life service will be held Friday, May 18 @ 10AM in the Rose Garden located between the 10 Story and TCCB buildings.
For details regarding the service celebrating Brad’s life, please contact Deonna Villegas-McPeters @ 260-9168 or Chaplain Grimaldo Enriquez @ 488-8800.
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In my last blog I talked about operating in the “legal/illegal” AKA “illegal/normal” space. The concept proposed that there are times we, as healthcare providers, operate outside, or on the fringes, of policy and procedure, potentially comprising patient care, – because we’re too busy or we don’t understand the rationale behind the policy or we’ve just gotten used to doing it the ‘easy’ way. The other reason we may not follow policy (i.e. use a work around) is simply because the policy doesn’t make sense – maybe it is dated, overly complicated or written by someone unfamiliar with clinical realities. If this is the case in your world, I would encourage you to consider avenues to change/simplify any of our Policies/Procedures that are overly burdensome and/or do not reflect everyday practice. A long time ago, Dr. Gene Kallsen verbalized to me what a Policy and Procedure Manual should be – “a living, breathing document that guides care and is easily accessible to those delivering care.” So… every once in awhile, open up Lucidoc and review a P&P that is supposed to guide what you do. If this isn’t your reality, decide if you should change….or the policy should change.
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Many of us would answer that in a 65 MPH zone we choose to deliberately violate the legal limit and usually drive somewhere around 72 MPH. This routine rule violation is termed by researchers as "legal illegal" since so many people make this violation that while still illegal it becomes "legal" to the many folks driving at this speed. Our decision is made of balancing the pros and cons of doing this. Pros – get there faster, more time for something else, it’s fun to go fast vs. Cons – getting a ticket, increased danger (there is good data from the NHTSA that there is increased risk!!). There is also an "illegal illegal" area where most would say the cons clearly outweigh the pros e.g. driving > 85 MPH.
So what does this have to do with healthcare?
Where do you operate in the course of your day caring for patients? When you walk into a room to give a medicine to a patient, do you still check the armband if the patient answers to their surname? Do you wash your hands before and after each patient interaction? The pros and cons here (if you are taking shortcuts) might be – pros – save time – can take care of your next task sooner vs. cons – give the wrong med to a patient 1 in 100 or 1,000 times, cause a hospital acquired infection (probably the same odds).
As you think about this, consider that your decision to drive 72 mph has implications for you – and to some extent to the drivers around you. Your decision to live in the "legal illegal" realm of healthcare has implications for your patients – they did not consent for you to follow your own interpretation of our Policy and Procedures. While the ‘rules’ can seem cumbersome and not following them to the letter might not even result in a bad outcome the majority of the time, our policies and procedures are there for a reason. They are there to protect our patients, as much as possible, 100% of the time.
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Two weeks ago my mother was taken to an emergency department with abdominal pain. After a sleepless night, I was speaking with a surgeon who related that she had ischemia, or reduced blood flow, of her bowel and a high likelihood of necrotic, or dead, bowel. She would require emergent surgery. The surgeon also indicated there was a good chance he would find such extensive necrosis that he would just close and “let nature take it’s course.” I was soon driving to Los Angeles, thankful my mom was being cared for in one of the top hospitals in the US, as rated by US News and World Report. But, I was also very worried about her and anxious to see how she was doing. After driving straight for 4 hours, navigating a complicated parking garage and getting frustrated trying to find out her location, I was standing outside of the ICU. Like most ICU’s, this one had the obligatory phone outside a locked door. Picking up the phone I was notified that my mom was stable but that I would be unable to see her for at least 1 ½ hours because it was the during the time that nurses give report. So there I was stuck between understanding how important hand-off communication (National Patient Safety Goal 2E) is vs. a son’s love for his mother and wanting to see her as soon as possible. You can guess which concern won out. With a fair amount of discussion, I was allowed to see my mom.
As I reflect back on the incident, what strikes me the most was the callous nature of the ICU staff. I’m sure an ICU nurse reading this is thinking what a pain concerned family members can be during report. I’m also guessing that 98% of the time a family member would sit unobtrusively at the bedside during report. In support of allowing a family member access to their loved one, I would also offer two other thoughts. First, there is more and more adult and pediatric literature that speaks to the benefits of family presence during invasive procedures, including codes. Secondly, National Patient Safety Goal 13 requires that we involve patients and their families in their care – listening to report certainly helps in this regard.
BTW – my mom was discharged from the hospital 3 days ago and is doing OK.
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I recently listened to a presentation that speaks volumes to the "can do" spirit of our institution. One of the Joint Commission National Patient Safety Goals relates to handoffs. As a patient’s care is transitioned from one care provider to another, errors can happen. Several years ago residents at UMC developed a homegrown spreadsheet to communicate with each other as they sign out patients. Recently, Dr. Natalia Volkova worked with Jack Buchanan from IS to incorporate this spreadsheet into LastWord and markedly improve it. Using this tool, physicians are able to more safely and efficiently transfer information as they handoff a patient. Nurses will also be able check this information to understand the problem list identified by the physicians as well as quickly determine which physician to contact for care concerns. While we may not have the most recent technology in Clinical Information Systems (we’ll be fixing this soon), a bit of innovation and a can-do attitude go a long way.
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"He’s making a list,
Checking it twice…."
Christmas seems like a long time ago, but for some reason the above line from "Santa Claus is Coming to Town" has stayed with me. The connection to healthcare? The checking it twice part. This simple layer of redundancy that is used in many other industries (for you carpenters out there – "measure twice, cut once") is incredibly important for us in healthcare. Whether you are a phlebotomist checking two identifiers prior to sticking the patient or a nurse reading back a doctor’s telephone orders – this checking it twice piece takes a little more time but averts many medical errors. After all, if Santa takes the extra step – shouldn’t we?
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As we were transitioning from Hwy 168 onto Hwy 180, my eleven year old son asked an unusual question. "Dad," he asked, "have you ever killed anybody?" After a question or two to clarify, he meant exactly what I first thought when I heard the question - as a physician, had I made a mistake that contributed to the death of a patient? He was somewhat taken aback when I answered, "yes." I am guessing that many physicians and nurses can immediately think back to a case in which a different action or decision would have increased the odds of a patient surviving. I responded by asking him what he would do if this happened . He stated, "I would explain to them what they did wrong and how not to do it again." This is what drives me - my goal is to add layers of safety/redundancy to our care processes so that clinicians don't have to answer the above question in the affirmative.
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