Tom's scrotum The pastor asked if anyone in the congregation would like to express praise for answered prayers. Suzie Smith stood and walked to the podium. She said, "I have a praise. Two months ago, my husband, Tom, had a terrible bicycle wreck and his scrotum was completely crushed. The pain was excruciating and the doctors didn't know if they could help him." You could hear a muffled gasp from the men in the congregation as they imagine the pain that poor Tom must have experienced. "Tom was unable to hold me or the children," she went on, "and every move caused him terrible pain." We prayed as the doctors performed a delicate operation, and it turned out they were able to piece together the crushed remnants of Tom's scrotum, and wrap wire around it to hold it in place." Again, the men in the congregation cringed and squirmed uncomfortably as they imagined the horrible surgery performed on Tom. "Now," she announced in a quivering voice, "thank the Lord, Tom is out of the hospital and the doctors say that with time, his scrotum should recover completely." All the men sighed with unified relief. The pastor rose and tentatively asked if anyone else had something to say. A man stood up and walked slowly to the podium. He said, "I'm Tom Smith." The entire congregation held its breath. "I just want to tell my wife the word is sternum."
Thursday, September 30, 2010
Humor...essential to this journey
Wednesday, September 29, 2010
Sunday, September 26, 2010
My post to one of last week's discussion questions
What are the strategies that have worked in getting physicians and nurses to adopt evidence based practice?
“Resistance to adopting evidence-based practice is not a modern phenomenon. In his extraordinary treatise on disseminating innovations in health care (JAMA 1969;289:75), Dr. Don Berwick notes that after the discovery that sauerkraut and limes prevent scurvy, it took 147 years for that simple measure to become a matter of nautical policy” (Rubin, 2005, para. 2).
Most humans do not embrace change readily. We seem especially reluctant to do so when the change threatens to alter our personal philosophy or increases the effort needed to accomplish a task. We are creatures of habit and follow “the way we’ve always done it” as the path of least resistance regardless of the evidence presented. One need only look at the evidence between smoking or food and health issues.
Healthcare is no exception. Historically, when confronted with evidence both physicians and nurses have avoided or ignored it. That has changed somewhat in recent years. Information is more readily disseminated and new entrants to the profession are taught to value and practice according to the latest evidence.
Pham & Ginsburg (2007) frame the roots of the explosion of the use of research and EBP in healthcare to the “quiet revolution that began in the late 1980s, fueled by an expanding volume of health services research and influential reports from the Institute of Medicine on the suboptimal quality of much of the medical care in the United States” (p. 1588).
Physicians
Cultural barriers have contributed to physician opposition to evidence based practice. Historically, physicians learned under an apprenticeship model that led to a great deal of autonomy. They viewed themselves (and were viewed by the public) as “heroes” who miraculously resolved problems, much the way that current television shows such as “House” do. Physicians opposed what they perceived to be “cookbook medicine” that potentially questioned their judgment and decisions through the application of standardized procedures or protocols that took away their autonomy – and importance.
Accountability for physicians to use current evidence comes from multiple sources. First, educated consumers demand it. Online referrals and “ratings” of physicians are now more available for consumer review.
Evidence based practice has been emphasized in the training programs of the latest generation of physicians. In addition, there has been a proliferation of evidence based practice guidelines and accompanying electronic tools readily available to practicing physicians.
Physicians have been called to accountability by board certification exams that have increasingly emphasized knowledge of evidence based practices. The increased professional expectation that physicians attain and maintain board certification, has forced physicians to stay abreast of the current evidence.
Performance measurement systems and incentive programs have impacted physicians and their willingness to accept evidence based practice guidelines. Government plans, private purchasers and accrediting bodies now require physicians to practice according to current evidence or risk a reduction or loss in payment.
Finally, the health care industry is learning better how to effectively engage physicians in improving quality, i.e., IHI’s Framework for Engaging Physicians in Quality and Safety (Reinertsen, et.al, 2007). This learning is helping to drive a culture change in practitioners using the latest evidence in their practice.
Nurses
Nursing also has its barriers to implementing evidence based practice. Traditionally, nurses practice according to how they learned in nursing school (Koehn & Lehman, 2008) and lack research knowledge, skills and understanding simply because it was not taught in nursing education programs (Pravikoff, et.al., 2005). It’s hard to use research/EBP when you have to first learn how to research, on top of all of your other duties.
Institutional barriers such as financial limitations and lack of prioritization by the organization have also contributed to nursing’s slow adoption of EBP.
In addition to the regulatory push for adoption of EBP described above, I believe a major force in the adoption of evidence based practice has been Magnet designation. Magnet is seen as increasingly desirable for an organization and has some recognition as impacting an organizations bottom line through enhanced marketing. Magnet requires nurse involvement in research and EBP. The Magnet program is such that it’s not possible to merely give lip service to EBP, but it has to be instituted as a critical element in an organizational culture through the allocation of appropriate funding, leadership and time to make the practice a reality.
Today’s nurses are pursing more formal education than in prior decades. BSN education is becoming the norm in many parts of the country. With this increase in education, has come broader exposure to research/EBP concepts.
References
Koehn, M., & Lehman, K. (2008). Nurses' perceptions of evidence-based nursing practice. Journal of Advanced Nursing, 62(2), 209-215. Retrieved from CINAHL Plus with Full Text database.
Pham, H., & Ginsburg, P. (2007). Unhealthy trends: the future of physician services. Health Affairs, 26(6), 1586-1598. Retrieved from CINAHL Plus with Full Text database.
Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of U.S. nurses for evidence-based practice: many don't understand or value research and have had little or no training to help them find evidence on which to base their practice. American Journal of Nursing, 105(9), 40-52. Retrieved from CINAHL Plus with Full Text database.
Reinertsen, J.L., Gosfield, A. G, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. Retrieved from http://www.ihi.org/NR/rdonlyres/A30445C0-6DA6-40C0-AB12-D2592A9EF1C7/0/IHIEngagingPhysiciansWhitePaper2007.pdf
Rubin, K. R. (2005, July). Resistance to evidence based practice. Emergency Medicine News, 27(7), 3, 43. Retrieved from http://journals.lww.com/em-news/Fulltext/2005/07000/Resistance_to_Evidence_Based_Practice.5.aspx
Thursday, September 23, 2010
Sunday, September 19, 2010
Sunday Dance Routine
Spent all day at the computer writing school related stuff.
Got up from desk chair thinking I was done for the day.
Walked down the stairs to see what LJ was up to this afternoon. About half way down the stairs I noticed a black string. My first thought was "what pair of drawstring shorts has Yoko (the dog) ruined now." I stepped over the string and continued on down the stairs. And then something registered in my brain. At the bottom of the stairs I flipped on the light and voila.......MR. SNAKE.
Pardon me now....I need to go change my undershorts....and burn the pair I had on.
Got up from desk chair thinking I was done for the day.
Walked down the stairs to see what LJ was up to this afternoon. About half way down the stairs I noticed a black string. My first thought was "what pair of drawstring shorts has Yoko (the dog) ruined now." I stepped over the string and continued on down the stairs. And then something registered in my brain. At the bottom of the stairs I flipped on the light and voila.......MR. SNAKE.
Pardon me now....I need to go change my undershorts....and burn the pair I had on.
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Discussion Board Process
Some people have asked me about the weekly discussion board process. Here's how it works:
a. All weekly discussion board questions are provided to the student via the Course Syllabus at the beginning of the course. There are generally from 1 to 3 questions posed for the week.
b. Each student is expected to post a response to the week's question as well as respond to any questions asked by other students based on what I post. Finally, each student must post a response to at least at least 2 others student posts during the week.
c. All posts to the discussion board must be cited and referenced using APA format.
d. My routine is to do the reading during the week, outline my responses to the questions on Saturday, finalize and post my responses on Sunday.
Below is an example of what I posted in response to one of last week's questions:
Question:
With the advent of insurers successfully tying reimbursement to both cost and (more recently) clinical outcomes, health care providers are learning the results of their quality measures will influence their future success. National regulators, i.e. Joint Commission (Joint Commission [JC], 2010) and CMS (HCAHPS, 2010), are working to develop measures that compare providers fairly. Private for-profit services such as HealthGrades ("Healthgrades", 2010) have seized on the quality comparison movement and are successfully using their formulas to rank both hospitals and physicians based on a 5-star point system. HealthGrades promotes their website to consumers to help them identify the “best” providers in their areas. Hospitals with 5 stars purchase the rights to use the HealthGrades brand in advertising.
The general consumer is obviously a key audience for broad based quality messages. A coordinated public relations strategy built over years of positive promotion is key to building general awareness of the quality of care a hospital and its’ medical staff offer them when they need it. Internal risk managers and hospital attorneys advise against using descriptors such as “best” in messaging as those messages come back to haunt them in litigation. Instead, hospitals use awards and external recognitions such as HealthGrades, Magnet accreditation (Magnet, 2010), and J.D. Power (JD Power, 2010) customer satisfaction results to promote the quality of the organization and its services.
The availability of diagnostic and treatment technology can influence a consumer’s choice of provider and potentially defines the quality of the organization even further. In addition, the availability of physician experts as well as the expertise of staff providers are important components of building the quality image of the organization. My own organization regularly includes physicians/surgeons in advertising promoting the latest technology such as the DaVinci robot. We also have touted the high percentage of advanced training credentials held by our nurses. Obviously, any report of a quality measure must be defined well and accompanied by an explanation of why the measure means that the organization offers quality services.
Patients and their families may choose a provider based on the foundation built by quality messages they have heard or seen over time. After the time they enter the system, though, quality is judged moment to moment.
Do the televisions in the waiting room work? Are there a variety of magazines to read? Is there internet access for those waiting? Are the restrooms clean and stocked with supplies? Are coffee and refreshments available without having to venture far away from waiting rooms? Is there adequate and convenient parking available, and is the parking lot sufficiently lit to make people feel comfortable at night?
Unfortunately, we may be judged not only on the quality of medical care, but also with regard to non-medical indicators that relate to the overall experience. You can have the latest equipment and the most qualified caregivers in the world, but if the bathrooms are filthy, THAT is what people will recall and talk about with their friends.
a. All weekly discussion board questions are provided to the student via the Course Syllabus at the beginning of the course. There are generally from 1 to 3 questions posed for the week.
b. Each student is expected to post a response to the week's question as well as respond to any questions asked by other students based on what I post. Finally, each student must post a response to at least at least 2 others student posts during the week.
c. All posts to the discussion board must be cited and referenced using APA format.
d. My routine is to do the reading during the week, outline my responses to the questions on Saturday, finalize and post my responses on Sunday.
Below is an example of what I posted in response to one of last week's questions:
Question:
Since customer satisfaction is a key driver in today’s healthcare organization, discuss ways that providers can educate patients and families about what is “quality care” and how they can play a role.
With the advent of insurers successfully tying reimbursement to both cost and (more recently) clinical outcomes, health care providers are learning the results of their quality measures will influence their future success. National regulators, i.e. Joint Commission (Joint Commission [JC], 2010) and CMS (HCAHPS, 2010), are working to develop measures that compare providers fairly. Private for-profit services such as HealthGrades ("Healthgrades", 2010) have seized on the quality comparison movement and are successfully using their formulas to rank both hospitals and physicians based on a 5-star point system. HealthGrades promotes their website to consumers to help them identify the “best” providers in their areas. Hospitals with 5 stars purchase the rights to use the HealthGrades brand in advertising.
The general consumer is obviously a key audience for broad based quality messages. A coordinated public relations strategy built over years of positive promotion is key to building general awareness of the quality of care a hospital and its’ medical staff offer them when they need it. Internal risk managers and hospital attorneys advise against using descriptors such as “best” in messaging as those messages come back to haunt them in litigation. Instead, hospitals use awards and external recognitions such as HealthGrades, Magnet accreditation (Magnet, 2010), and J.D. Power (JD Power, 2010) customer satisfaction results to promote the quality of the organization and its services.
The availability of diagnostic and treatment technology can influence a consumer’s choice of provider and potentially defines the quality of the organization even further. In addition, the availability of physician experts as well as the expertise of staff providers are important components of building the quality image of the organization. My own organization regularly includes physicians/surgeons in advertising promoting the latest technology such as the DaVinci robot. We also have touted the high percentage of advanced training credentials held by our nurses. Obviously, any report of a quality measure must be defined well and accompanied by an explanation of why the measure means that the organization offers quality services.
Patients and their families may choose a provider based on the foundation built by quality messages they have heard or seen over time. After the time they enter the system, though, quality is judged moment to moment.
Examples of items that might impact the public perception of the quality of an organization may include things such as: How long did they have to wait in the Emergency Department? Were the staff and physicians they encountered kind and supportive? Did they read the Joint Commission “Speak Up” posters and then count the number of times someone forgot to check their hospital identification bracelet? Did caregivers seem to give sufficient time to hear concerns and explain items, rather than rushing to get to the next patient? The list goes on and may include non-medical indicators that are easily overlooked by an organization, too.
Do the televisions in the waiting room work? Are there a variety of magazines to read? Is there internet access for those waiting? Are the restrooms clean and stocked with supplies? Are coffee and refreshments available without having to venture far away from waiting rooms? Is there adequate and convenient parking available, and is the parking lot sufficiently lit to make people feel comfortable at night?
Unfortunately, we may be judged not only on the quality of medical care, but also with regard to non-medical indicators that relate to the overall experience. You can have the latest equipment and the most qualified caregivers in the world, but if the bathrooms are filthy, THAT is what people will recall and talk about with their friends.
The bottom line seems to be that each person is an individual and brings perceptions of quality that have been built from exposure to a host of messages. Our challenges are:
- Arm staff with our quality messages including our focus on continuous improvement as our never-ending journey.
- Continuously improve our processes to ensure that our quality measures will be positive as we begin to report them.
- Include not only caregivers in the quality message, but also individuals who have supporting roles, and make sure that they realize that their contribution has an overall impact on a patient / family interactions.
- Perhaps most importantly, assure that every single patient and their family has a very positive experience every single time and views us as the best healthcare partner they could have chosen.
References
Saturday, September 18, 2010
Update
Have spent all day (since about 7 am) at my home office desk finding relevant articles for this week's discussion forum questions. Even after a really exhausting week, I continue to find these studies worthwhile and provoking. Without the structure of a formal education program I wouldn't push myself to be read and integrate as deeply as I'm finding that I am now doing.
Tuesday, September 14, 2010
Sunday, September 12, 2010
Monday, September 6, 2010
New Start
After 2 weeks of (that sure went by fast), the new course started today. The subject is "Quality Management Techniques."
I was able to get out of town for a few days this past week for some much needed rest and relaxation. Returned home yesterday.
Yesterday I drafted and posted my responses to the weekly discussion forum questions. Today (Labor Day) I spent drafting the first paper that is due in 2 weeks.
I was able to get out of town for a few days this past week for some much needed rest and relaxation. Returned home yesterday.
Yesterday I drafted and posted my responses to the weekly discussion forum questions. Today (Labor Day) I spent drafting the first paper that is due in 2 weeks.
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