A recent email, from Stacey, one of our great ICU nurses, about a doctor with visiting privileges from an affiliated institution:
Paul,
I have been encouraging and supporting the hospital’s policy regarding hand hygiene. My understanding is that all personnel are to use Calstat when entering or exiting a patient’s room, even if they are not going to give direct patient care. I happened to notice Dr. X entering a room without using the Calstat. I went and politely reminded Dr. X to use the Calstat. Dr. X appeared quite annoyed that I requested him to do so as he said he had already examined the patient and was just looking at the monitor. This is not the first time I have had such encounters. How would you like this type of situation handled in the future?
My reply:
Thank you, Stacey,
You did EXACTLY the right thing, and I appreciate how uncomfortable that can be.
We have indeed asked everybody to remind everybody else about the importance of this matter. As you know, it is very easy to pick up germs from equipment and material near the patients and then pass those along to other patients and staff, even when the doctor or nurse has not actually touched the patient.
I am copying Dr. Sands, our SVP of Health Care Quality, who will now follow up with Dr. X.
Sincerely,
Paul
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27 comments:
The name of the game is team work, and empowering people to call foul on anyone and everyone. Nurses on doctors, patient transport on nurses, etc etc etc.
It's hard to instill that power in some employees.
It's a lot easier if you're willing to back up policy with real enforcement, at every level. No one should be dinged for doing his or her job right. But it happens all too often in these cases.
Good work.
Go Stacey! Paul, please share tips on changing from "no-blame" culture to culture of accountability and team work, especially when it comes to patient safety.
Thanks!
What I'd be curious to see is the follow up with Dr. X. I heard a story about another Boston hospital yanking privileges from MD's who didn't fill out post-surgical paperwork in a timely manner. That got their attention. Would you consider something similar with chronic non-hand washers?
People who persistently violate safety standards can lose accreditation. It is VERY unusual for that kind of behavior to persist, especially once it is pointed out to someone.
See my October 19 post called "Errors, Improvement, and Discipline" for more background on this.
It is great to see that nurses are empowered to do this, especially in the name of patient safety. Nurses who do this should be supported in their role and actions. I know it can be difficult to challenge the classic medical hierarchy, but like the previous posters noted, this is about teamwork and accountability.
As a palliative medicine physician, I appreciate and really enjoy working with nurses (and other disciplines) who feel comfortable enough to speak their mind, especially in the name of patient advocacy.
Would that be the famous Dr. Danny Sands, guru of patient e-mail?
Hospitals alway have great initiatives and great programs, I think it's the sustainability factor that is the key on any type of program. Once the initial (programs) effects subside (senior management is focused somewhere else) then things tend to go back to the way things were or not quite where they should be.
I saw on the news over the weekend then Medicare/-caid regulations changed. Now a hospital can't bill -care/-caid for extra care for followup infections and such. And they can't bill the patient either. So, I'm betting everyone should get used to being told to wash their friggin' hands.
does jcaho have to do it when they visit? does dr. sands call them to the carpet as well if they don't?
To ANON 12:05
I can say YES, Joint Commission was held to the standard of Hand Hygiene prior to entering and upon exiting patient rooms. If they had not, I would have issued a courteous yet firm reminder.
Anon 9:03,
No that´s Dr. Ken Sands, SVP for Health Care Quality.
I am interested in Dr. Sands' job description. Is he a "doctors' policeman" or does he chair your quality improvement committee overall? Do you have a Chief Medical Officer as well, or is he it? Just curious for comparison purposes.
And by the way, my experience is that OR, ER, and ICU nurses are rarely afraid of anyone, including Dr's. This is appropriate. (:
We do not have a CMO. The Department Chiefs really serve in that role for their departments. Ken has a coordinating role and chairs our quality improvement committee and in that capacity oversees all of the quality and safety programs and reporting. He is also our liaison with the state DPH (which licenses the hospital), the state Board of Registration in Medicine (which licenses doctors), the Joint Commission, and other regulatory bodies. He also is responsible for staffing the Board´s Patient Care Assessment Committee and for the quality and safety presentations and training for our Board.
Please let me know if that gives you the answer you were seeking. I am sure Ken would be happy to provide more details about how we organize things at BIDMC, and also to learn about the pro´s and con´s of how people organize their quality and safety programs elsewhere.
Finally, you are absolutely right about the nurses, and I´m glad of it!
I am the one who asked about your SVP. I like the idea of having a physician in this position; most other places I have seen either a QA type administrative person, risk manager, or nursing background. It helps to make the docs more aware and part of the process. I also like the scope of his responsibilities, from the staff up to the Board and externally. Is he also in charge of physician peer review? If not, he should be. (:
Some of the peer review occurs at the departmental level, i.e., at M&Ms. When it gets past that level, he gets involved.
Sister Stacey may be doing everyone a favour by her most noble attitude in focussing attention on the one-hygenic-drill she is conversant with and trained to meticulously observe. But surely the Hospital procedures must be having some system of heirerchy where this could have been discretely brought to the attention of Dr Sands to deal within the frame work of somekind of weekly in-house meeting/Discussion of medical issues by the Doctors/Residents.
Reporting deviant behaviour of a senior collegue on the Blog may lead to a deluge of similar complaints by disgrunteled elements.
It is possible that Dr X may otherwise turn out to be a extremely talented guy heading for the Noble prize in the near future except for this one fetish that He hates to wash his hands !!
Good points, Yogi. There are more subtle and/or discrete ways to do things, but sometimes - especially for a busy nurse - unless it gets done in the moment, it might never get reported or dealt with. So that´s why I don´t mind and tend to reinforce such behavior rather than discourage it.
BTW, Dr. X is a very talented person . . .
I do enjoy this blog, especially the way you handle challenging comments and situations. Good job and keep it up. I just might learn something about diplomacy.
Thank you very much. I try to keep things on an even keel, but there are times when I feel strongly and let it show.
OK, minor point but I feel strongly about spelling!! "discreet", meaning diplomatic, is the spelling you want. "Discrete" means a unitary thing, as in a "discrete point in time." I once had to write a letter to my secretary to make her transcribe this right.
You are absolutely correct. I can´t believe I let that one squeeze out of my keyboard!
My favorite one to teach people about is the proper use of comprise. It should never be "comprised of". It is either "composed of" or "comprises".
I am sorry for wrongly spelling the word 'Discreet'
I'm anon 7:02. Ya got me on the comprised. I have been guilty of that one myself; thanks!
This is why Dr's find nurses so annoying...they nit pick at insignificant details, as a way of trying to put some authoritative control in their own hands...they should maintain their role and know their place. Dr's write orders, nurses should follow them. If you just walk into a pt's room to talk after looking at a monitor, there is no need to rewash your hands...It is just plain silly to feel the need to approach and assert your idiotic "protocol based practice" that nurses may like to refer to as "thinking", blindly without looking at the larger picture.
Wow. Amazing set of generalizations and stereotypes in one paragraph. Your words say volumes, but more about you than the nurses.
eye see you md must surely have been a joke, right?
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