In December I received a patient grievance about a series of unfortunate events that occurred to one of our patients while in the hospital. The events ranged from issues of cleanliness, to delays in treatment, to team members not practicing appropriate hand hygiene and infection control. While none of the individual events that occurred were acceptable, if only one had happened it may have been able to be forgiven or overlooked. However, when these events were strung together they take on a whole new level of concern. We responded swiftly and appropriately addressing each concern with an action plan, education, and auditing, as hospitals typically do, but all of these things can't change the fact that these events happened in our hospital to this particular patient.
While not a typical practice, today I drove to this former patient's office to follow-up with him personally and to discuss our actions and results to date. As a local businessman, he realizes that it is easy to make empty complaints that all too often fall on deaf ears. To the credit of this gentleman, he has volunteered to not only inform us of his experience, but to get involved in the fix. Over the past several months, he has been diligent to stay in contact with me to understand how we are making good on our promise to ensure that these events are not repeated. Today he has also offered to donate his personal time and service to assist us in finding new ways of perfecting our service to our patients. I have to say that this is a first for me, and I genuinely appreciate his belief and interest in giving our hospital a second chance and the help to make it better.
As humbling as it is to understand that we can always be better, it is comforting to know that there are always people out there who care enough to take the time to help us do so. Today, on behalf of this gentleman and all of our patients, I have reaffirmed that our commitment to achieving excellence and improving lives has to be stronger than ever and I look forward to leading our hospital on that journey....more to come on that topic!
5 comments:
Hi Marty,
I enjoy your blog. I think this post is a great example to learn from. I am not sure if you can answer this, but generally speaking, what types of audits would you perform in a sitaution where there is a patient grievance? And how would you measure the results of those audits? And how would you hold people accountable if they fail to meet the expectations?
Thanks
Interesting...this is my first time to read your blog, and I'm doing so because I wanted to ask if you'd consider explaining the value of and reason for our surgical antibiotic prophylaxis protocol. (Core measure). I just finished explaining it to 5 nurses in one of our surgery areas - they were appreciative, because they didn't know much about it. Kinda concerning.... thanks. From one of the pharmacists...
Mike, I like questions, glad I peaked your interest!
Generally speaking audits of this nature could come in many different forms depending upon the situation. First a thorough investigation and understanding of the problem is in order followed by a determination if the problem was systemic (meaning a broken process or policy), or if it was a problem related to individual non-compliance.
If systemic, revising the policy and procedure to fix the issue at hand is in order, followed by education of the affected groups of people that are charged with carrying out the policy. From there, depending on the significance of the practice being carried out, checklists, additional supervision, creating dashboards/scoreboards, or secret shoppers are all methods that might be utilized to ensure compliance with the new process.
If it is an issue of personal non-compliance, again it depends on the nature of the issue. Issues related to scope of practice or licensure have to be taken with the utmost seriousness. For lesser infractions, remedial education is typically the first course of action, followed by an HR disciplinary process for habitual or willful repeated non-compliance.
Again without violating any patient or organizational confidentiality it is difficult to give specific remedies to specific situations, but I hope this gives you a sense of the tools we have to work with.
Anon Rx - thanks for the idea and information, I will try to cover that issue in a future post. Thank you!
What you did by involving the patient is a great idea! Reminds me of something Best Buy did. They asked their customers to get involved in the creation of a new computer, from ideal screen size and weight, to features, finish, etc. They then worked with Hewlett-Packard to build that computer for them and created a series called "Blue Label" computers. These are the top selling computers at Best Buy today. They are not the biggest or "flashiest" computers. In fact, IT types would have chosen some different options. But the setup of those Blue Label computers are just what the customer wanted to have! Kudos to you for going to meet with that patient!
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