Wednesday, October 14, 2009

Why patient care shoudn't be treated like a business (Or why I hate Press Ganey)

Well, it was bound to happen that there would be a disruption in my perfect work world- other than the swine flu panic that is sending our census through the roof and as a result, making a lot of our patients kind of act like assholes- that I can kind of deal with- but recent management changes- do not want. Our hospital has had not such a great reputation in the past- whether this was deserved or not I can't say, but both our reputation and our patient satisfaction scores- in our case, based on something called a Press Ganey survey, are going up steadily since I've started.
I'll be frank- I think Press-Ganey is pretty much a bunch of bullshit. Scores are calculated based on a card that is mailed out after the patient is discharged, and added together based on the ones that people send back. I learned even in elementary stats that this is a really unreliable indicator of anything- generally the only people that take the time to fill out a survey like this are the people that are pissed off and want to complain. The people that are satisfied are much more likely to tuck it away and deal with it later (never)- I can say this in my own experience- I still haven't filled out my survey for our outpatient radiology department, even though they were super cool and I had a good experience. I put it away to fill it out later, and I lost it. Now, if in my mind I had been disrespected somehow, you know I would have sent that in immediately. We get very few surveys back in relation to how many patients we actually see. And among the few we do get back, some of them are from crazy ass mofos- we actually got a really horrible score from one patient whose only complaint was that the sandwich tray she got in the ER didn't have mustard on it. Seriously.
Some of our administration- at least our awesome night manager- acknowledges that this isn't accurate. He's actually started calling people at home randomly to follow up, or going to visit patients who have been admitted, and find that most of them loved how they were taken care of in our ER and have little or no complaints about their care. So do we change our indicators? NO. What do we do? We hire a consultant to be our interim manager who's whole career is based on improving Press-Ganey scores. To a certain extent by actually making improvements in patient care, but also in a large part coming up with canned lines to feed patients that correspond with Press-Ganey questions. For example, if the survey has a question about whether the staff was respectful of your privacy, we're supposed to say things like "I'm going to pull this curtain for your privacy" every time we leave the room, so they'll remember and check the "excellent!" box.
This makes me ill. I am not selling Avon. I am not promoting a brand. I am taking care of a human being to the best of my ability. The idea that I should be trying to manipulate them into giving me better feedback is disturbing. I may alientate some people with this, but that's fine- this is why I have a big objection to running healthcare like a business as opposed to a social institution. There are many other reasons that I won't get into because it isn't relevant, but patients, especially ER patients, cannot and should not be dealt with in the same manor as hotel patrons. Function and need outweigh satisfaction for me. As much fun as it would be to listen attentively and contact my charge nurse and manager for a patient with a suspected GI bleed who isn't allowed to eat, I can't, because I, frankly, have more important shit to do. I often need to check on the person in the next room to make sure they aren't dying. I may need to help a teammate with a procedure. As nice as it is to build rooms with fancy matresses and new floors, it would probably be a better move in the grand scheme of helping humanity to have plainer rooms and take on more cases for charity care.
Sometimes we have to accept that some people are perpetually unsatisfied. That we could call in the freaking CEO of the hospital to personally thank them for choosing us, and they would still be pissed off about the temperature of their coffee. Sometimes we have to take a kind of paternalistic approach and acknowledge that sometimes, what may satisfy the patient is not in their best interest. Our Press Ganey scores among drug seekers would probably be through the roof if we passed out Dilaudid like candy! Would that actually help anyone? No. I realize that's an extreme example, but treating our hospital like a competitive retail chain is not a comparable model.
The best example I can think of to illustrate this is a patient who came in for tooth pain from a dental abcess who, during my assessment, revealed to me he had taken an entire bottle of Motrin in the last 24 hours because his tooth hurt. He immediately got admitted for observation to make sure he hadn't just made himself a transplant patient, and then promptly spent 20 minutes arguing with me about whether he would allow me to draw blood or start and IV if he wasn't immediately going to get pain meds for his tooth pain. I tried being gentle. I tried being rational. Finally, I had to close the door and tear him a new one- in short- go ahead and leave AMA if you want to, but that would be another pretty damn stupid move- and it got through to him. I then went back to caring nurse mode, and stayed late to adminster his pain medicine while smiling and joking with him. He ended having some damage to his liver, so cussing at the guy was probably the biggest favor I could have done him.
I try to, but don't always live by, the idea that you should treat every patient like it's a member of your family. And I like that approach much better than treating them like a customer. When I worked retail, I would smile through lots of ridiculous bullshit to keep my job. I could have cared less about my customers. By treating my patients like family, I'll put up with a reasonable amount of bullshit, but I refuse to be walked all over. I refuse to kiss ass, I refuse to smile and get my manager when someone acts like a bully. I will give that person the business in the most caring manner possible- just like I would for someone I know and love- and if they still want to talk to my manager, I'll get them. But it usually isn't necessary.
Reasonable people can generally recognize when someone is being real out of genuiene care and concern versus being fake to improve a number on a piece of paper. And I'd like to quit my damn job before I do the latter.


  1. Amen sister! That's my hospital's philosophy...treat them like you would a family member. Now we've got hourly which we're supposed to ask the 4 P's...pain, potty, positioning, potential needs....every freaking hour...all day, all night. I don't nor will ever treat my family that way. I think it's overkill & I'm tired of being told to basically recite a script. Let me be a nurse...not a puppet.

  2. Ugh. Do they have those stupid pieces of paper in your rooms, too? I do my "hourly rounding" at 6 am, even though I'm usually in the room every hour for something anyway- there's usually a family member parked against the thing, asleep against a wall.

  3. Holy cow. It reminds me why I moved back to Canada. Ya we care about the patients, but it is less about what they want and more about what they need....and most hospitals here aren't fancy shmancy and I can tell u that the celebrities I cared for got the exact same nursing care from me as the drug addict that came in....and the short time we had the "patient satisfaction cards" - we used them as our comedy reading...I am sure they weren't taken seriously since we got them back on our unit for our perusal...and, as much as we try and be polite and reasonable...we are certainly allowed to give the patient a reality check... ;)
    Would u consider moving to Canada? U sound like u would fit right in..... :)

  4. I agree!! I recently got talked to regarding a "minor complaint" from a patient I bent over backwards to do everything for...apparently I had made an offhand comment about it being a busy night, and she interpreted that to mean she was not going to get the level of care she deserved, so she reported it to my manager, who then decided I needed a lesson on "good customer service." Give me a break people!!

  5. Giving health care professionals the amount of responsibility they have and then taking away their decision-making capability for using that responsibility is a form of emotional violence of the worst kind. That is what these "customer service" programs do. It is more than just wasteful. It is unethical.