Community Health Systems

Joseph G Seay

My Mother had a stroke.  It is serious.  It is scary.  Mom takes really good care of herself but her physical condition is complex and fragile as she is in her eighties.  The care she and we have received has been excellent.  From 911 and Emergency Medical Tech response, Emergency Medicine and Neurology service in those critical first hours of care, ICU, Neurology service floor, now rehabilitative care.  Everyone has been well trained, focused, attentive, responsive and genuinely caring of Mother and all of us, her family.

This is not my first experience of hospital care, as patient, family member or friend of someone encountering “the system”.  My advice to family members “handling” a medical event has become:

• Advocate for your loved one. Be engaged with nurses and physicians from every service.

• Be respectful and appreciative of clinical professionals, but ask questions, request services, pay attention to medications, tests, orders, therapy visits and all the rest.

• Make sure that everything intended for your patient is done, ideally in a timely manner. Respectfully, of course.

This is a lot to ask of a patient’s family.  There may not be a family member to assure that the patient receives expected treatments.  Even in our best facilities, with well trained, motivated, caring professionals, gaps can and do occur.

As I have said, Mom’s care was and has been excellent.  However, our experience of care often felt random, chaotic.  I found myself anxious that some order, therapy or evaluation was going to be missed.  Tests which required transport could result in Mom disappearing for hours without clear response from Nursing about status.  Doctors stopped in randomly to review her condition, adjusting medications or therapies.  Sometimes expected clinical data was fresh, current and available but sometimes not.  Sometimes therapy services (swallow, speech, physical, respiratory) showed up at the same time or not at all. If a physician was with Mom, therapy staff usually went to their next patient.  Understandable perhaps, but when asked, Nursing would reassure that the rapists would return before end of shift.

Remember, this is a quality facility.  There is clear evidence of organization, process and procedure in practice displayed by every service we encountered.  But this is where sound, organized operations ends, within each service.

Services are on their own schedules.  Team members are provided lists of patients, locations, and orders.  Maybe there is a cyclical nature to certain therapy services, as with Nursing. Perhaps established by order (three times per day). Practitioners attempt to “walk” their list in the sequence patients will be encountered with minimal walk arounds.  As the day goes on, this practice must become increasingly inefficient.

So how does care look from the patient’s perspective?  Uncoordinated? It is, across multiple services: lab, imaging, respiratory, dietary, housekeeping, nursing medications/vitals/general care, physician visits.  The only service “dedicated” to a patient is Nursing.  While nurses know what was ordered, they did not have a precise schedule of care for Mom for the next 4, 12 or 24 hours.  If we did not want to miss a physician consult or therapy session, someone must be in the room at least 7 AM to 9 PM. 

Hospital operation demands flexibility to respond to urgent events and needs throughout the day.  I get it.  But many services are really not that exposed to disruptive demand.  They may be disrupted by those that are.

Today’s facilities are well supported by automation.  Every patient service is a digital event tracked for delivery, cost, and outcome.  They are or can be assigned, scheduled and tracked for performance.

What if scheduling were taken a step further?  Imagine a “view” of house wide activity for each patient.  Publish a patient’s “availability” to all care givers and service staff.  Alert scheduled care givers of a change in patient availability status to enable proactive coordination of care.  Enable Nursing to see every unit patient’s schedule: who is expected, when they are expected, what they are doing.  Nurses can respond knowledgeably and confidently to questions from family or patients.  Quiet time can be scheduled so a patient can get rest! Talk about real “patient centered” care.  The experience of care might catch up to the great intent of every care giver.

Let’s talk about doctors. Most patients, and virtually all seniors like Mom, are complex, presenting challenges for several specialists.  Mom has cardiac, pulmonary, and neurological issues to contend with.  She had three different services actively engaged, each focused on their “system”.  They share her chart: tests, results, orders, medications and vitals.  They visit and comment on Mom’s status, prognosis and course of treatment for heart, lung and brain function individually.  There is some inference they consult about Mom’s overall course of treatment and interdependencies of various options across specialties but you better listen hard and ask questions to understand.  This is not a complaint; just how physician engagement can “feel” from the patient/family perspective.

Three days into the stay, I asked to meet with all three service physicians.  Our nurse agreed to make the request, but was not confident that it could be organized.  There had been individual discussion of treatment options that were aggressive, complex, confusing and interdependent from each specialist.  Here is what we got: Mom’s pulmonary physician, a great nurse practitioner from Neurology and no one for cardiology.  We had a focused (tight schedules) 20minute discussion with most family members.  We heard answers, judgement with context and assurance that everyone was on the same page, at the same time. We left reassured that Mom was getting the best, appropriate care, taking all her conditions into account.  What a reassuring outcome!

Physicians have huge demands on their time.  They, more than anyone, can plead a case of being at the mercy of patient needs.  However, might it be possible to schedule a physician team consult for shared patients to discuss treatment plans and options with families?  This is the sort of practice “name clinics” like Mayo and Cleveland have built reputations on.  If team based care is truly a best practice, institutions should strive to promote it.

By any standard, Mom’s care has been of high quality, delivered by caring professionals.  We are having a great outcome, given the nature and seriousness of the event.  There was a LOT of patient care in evidence.  Patient centeredness still can use some creative leadership and development from all of us.