I attended the American Academy of Communication in Healthcare Conference in New Haven. The AACH is the professional home for all committed to improving communication and relationships in healthcare. About 200 people attended from US, Canada, Israel, Brazil, Belgium, Australia. Although most attendees were physicians, I met nurses, therapists, coaches, office managers, patients, sociologists, medical students, and researchers. A couple of very low-key sponsors but no vendors present. A pleasant relief. The conference was designed to maximize interaction, learn from each other, and build skills within work groups and special interest groups. Met several venerable experts. Very open and quite humble: We have a lot to learn. Especially about patient centeredness. Most exciting for me was a presentation by Sharon Schindler Rising, a nurse midwife, talking about Centering Groups – facilitated groups of 6-10 young moms/couples preparing for the impending birth of a child. A wonderful example of people-centered design with participants directing much of the flow of the monthly small groups. Professionals and services came to them. Groups often kept meeting on their own after the children reach one year old, sometimes for 8-10 years. New groups have been starting for decades. Evidence over that time showed significant increase in proportion of pregnancies going to full term and decrease in the proportion of low birth weight babies. One sad piece of the presentation was the description of the barrier caused by the advent of the electronic health record. One participant-generated practice had been for moms and dads to enter their own health data into the paper record: instant empowerment! Not so with electronic record. People could no longer enter their own data into the health record. Shadow records had to be created. Lord, I was crushed when I heard this. I participated in several subsequent discussions about the infrastructure and skill set that would be needed to spread the Centering Group model to other settings. Instant learning!! Read More
Still exploring communication across transitions. This week speaking with clinicians. First, with case managers in an acute, short-term rehabilitation center serving people with recent strokes, heart conditions, or surgeries needing less than a month of intensive therapy. The transition points between nurses shift to shift, between physicians and between case managers, between patients, families, and primary care clinicians at discharge worked the best because they’re well documented and standardized. Tools are in place for the sharing of information. Either the hand-offs between clinicians are routine or patient education notebooks are completed the same for every patient: not the same contents but the same workflow. Since it’s not acute care (short stays) there is more for hand-offs and to develop relationships with the patient and their caring network and time for patients and families to absorb the instructions. A considerable volume of paper is generated, resulting in lots to read and lots to fax (everything by fax!). Maybe too much to read. Information coming in with patients was less complete than information going out with patients. Communication was better in general and more complete if a person received all their care within the same health system. The biggest risk? Not receiving information about critical medications, such as blood thinners, steroids, and antidepressants.
Next, a community Primary Care clinic. Again, communication best when a person is discharged from a hospital within the same health system as their clinic. Then a nurse knows when someone is going to be discharged or has been discharged. The nurse calls the patient at home and can let the doctor know that the patient has their prescriptions filled, knows what to do, or if anything needs attention. For the patient discharged from a hospital outside the health system, the clinic often doesn’t know the patient was even in the hospital and has to scramble to gather information so they can support the person. The transition from home to office works least well. Someone calls the office needing an appointment or has a question or needs a prescription filled. The quality of screening, triage, and information gathering varies widely The more the patient or caregiver takes charge, the better the communication with the call center the better the clinic visit goes. Transition communication with specialists outside the system seemed quite a challenge without a common EHR for communication. Read More
I’ve spent the week immersed in this communication dilemma in healthcare. As I’ve said before, I’m amazed that any communication occurs in healthcare – a constant unfolding Tower of Babel. Way too big of a topic. Let’s narrow (as the solar system is a narrowing of the universe) to communication across thresholds and boundaries. Some examples:
- Between clinicians (same profession, same agency, same department): such as nurse to nurse, doctor to doctor, shift to shift, day-to-day
- Between professionals (different profession, same agency, same department): such as nurse to doctor, therapist to doctor, counselor to nurse, paramedic to nurse)
- Between clinician and patient or family caregiver (within a hospital stay or clinic visit or community setting)
- Across departments or levels of care (inpatient, rehab, home, clinic, emergency, intensive and long-term care, are all levels of care) within a hospital, clinic, or system: such as clinician to clinician, direct care or support staff to anyone
- Across levels of care (everything in 4. above plus jail, homeless shelter, community residence, supported living) sometimes called discharge planning, care management, consultations, questions involving just about anyone in the center of care.
This week two of my readers described experiences of fractured communication with their clinicians. One reader, a person in acute treatment for overwhelming anxiety, found himself watching and feeling the effects of dueling clinicians with widely differing diagnoses, medication regimens, and styles of communication. A collaborative, listening, empathetic physician versus a paternalistic, blameful, arrogant physician. Both physicians practiced in the same organization but in adjacent levels of care (one inpatient and the other outpatient). They didn’t coordinate care – they didn’t even speak to each other. The person with acute anxiety had to muster energy to advocate for himself and seek help from his partner. To little effect. The other reader experienced a sickle-cell crisis in a hospital without a sickle-cell specialist. She couldn’t get pain medication known to work for her. She was classified as a drug seeker. The treating physician wouldn’t communicate with the specialist who had treated this reader successfully many times and managed her long-term care.
So many levels of outrage here. How is it that institutions, practices, and people working in these two programs don’t know about disrespect, poor communication skills and lack of coordination within? Does nobody raise a red flag? Where was the medical record? Where were the leaders? Read More
225 weekly blog posts. How do I do it?, a reader recently asked me. The health journey provides me endless material: fascination, intrigue, tragedy, empathy, frustration, wonder, curiosity, fear, and inspiration. As a nurse I’m blessed to participate in some of people’s most intimate moments as a guide, helper, ear, hand holder, and translator. As a team member and leader I study the puzzle of how people think, emote, decide, and relate trying to get anything done safely and ethically in the most consuming, illogical, nonsensical, complex system imaginable. My palette includes the desire and dilemma of habit change, the tangled web of cultures, the enticing potential and hype of technology, the flood and inaccessibility of data, the vital impossibility of policy change, and the insane contradiction of money surrounding, driving, tempting, confounding health. Can I tease out the simple and illusive filaments of the magic levers of best health? What works, how do we know? How do we find, share, and use evidence? How is uncertainty communicated, how does information about groups of people relate to me, a single person? I love sharing my broad and thin knowledge of health as a coach and a writer. As a person on my own health journey, writing this blog stokes my fire – feeding and renewing my pathological optimism. Actually, I start with a nut of an idea, sit down with that idea on Sunday and write. Takes about an hour. I used to read the drafts to my mom, now my wife. It never turns out the way I think it will. The post writes itself. I’m an old hippie – at the end of the day the health journey is a roller coaster of love. Thanks for the ride. See you next week.
This week my son, Mike Funk, would have been 40. Lord, I miss you, Mike. You still inspire me. You’d be proud of your seasoning family.
I taught this week at the Organization of Nurse Leaders’ Leadership Academy. My topic is Organizational Cultural – Change from Within. I love working with nurse leaders. Those who supervise the front line in healthcare have the most difficult job in healthcare be they nurses, therapists, doctors, support staff or other direct care workers. So much responsibility without commensurate authority or resources. Two issues stood out working with this week’s group: They often say, but it’s outside of my control. And they often feel alone. Read More
Here’s the reference I didn’t accept on LinkedIn:
He’s seriously annoyed with his disability, full of himself and his opinions and perceptions about life and health. Blogs every week whether or not he has anything to say. Can’t keep a job. Has the attention span of a gnat, flitting from one thing to another. Needs significant help focusing and limiting the scope of his work. Moves way too fast, going for the latest shiny thing, tested, proven, or not. A major joiner. Set some limits for Pete’s sake. Sits on expert panels without real expertise in anything. Has to keep lists of books he’s read so he doesn’t read them again, but forgets to check his list. We’ve always done it this way is a red flag for him. He should shut up and listen for a change. Has a loose relationship with the truth. Would rather tell a good story. Needs a fact checker. Loves to say, God willing and the creek don’t rise. Where does he think he is? W Virginia?
OK, he’s sort of disabled. Takes advantage of his get-out-of-jail free handicapped parking placard. After all, he can walk a couple of blocks. Frantically trying to stay healthy. Massage, acupuncture, chiropractic, counseling, meditation. Give it a rest already. Cut his foot with a chain saw when he was an ED nurse and paramedic. Then he went to his son’s second grade class to teach first aid Doesn’t know the meaning of safety. A truly strange bird. Was in the movie, Woodstock, when he was 17, calling his mother. Now 63, he’s still a momma’s boy. Was in a Life magazine cover story, You’ve Come a Long Way, Buddy. Men’s Liberation. For real? Can’t lie to save his soul. Don’t know about diversity, he’s prejudiced against stupid people who can’t get anything done. Can’t stop talking about his grandkids. He’s a boring Johnny one-note. Thinks he can play saxophone. Please! Loves to dance – in his head. Who is he fooling? Pokémon illiterate. Just ask his grandson. Does laundry and takes out the garbage, but doesn’t cook enough. Leaves the entry way door open when it’s freezing outside. Appreciates clean running water and weekly garbage pickup. Every week! Give it a rest already. Built a house with his wife without ever having built anything before. Lord, get some experience before you go off halfcocked. Won’t stop correcting lab technicians who ask him to confirm his birthdate that they read to him. Arrogant. Still hot for the same woman after 40 years – get a life. Balding, needs a hat. Any hat, doesn’t care.
I know it’s tough to get a job as a disabled person. But, hire this guy? Be very careful, count to 10.
The New York Times Magazine has an article this week about flexibility at work. Since I am a person with a chronic illness and disability and have been a boss to many teams, it seems like a no brainer to support flexibility at work. In fact, life requires flexibility at work. If you give care to yourself or anyone of any age you need flexibility at work. This can range from a haircut to periodic hospital admissions. I used to think that there couldn’t be flexibility if you worked on a shift, say in an ICU, when your absence would make it short-staffed and less safe. But then my teams realized that if we expected to need flexibility then we could design the work and schedules to accommodate the unexpected. Rather, the need for flexibility became the expected. In my first management job as a manager of an ICU I noticed that nurses didn’t stop for lunch, let alone take breaks or go to the bathroom. Crazy. We can design this work so we can take breaks!! This morphed into no one needs to be on call all the time and then, sure, you can go to your daughter’s recital. We can figure this out. I found that when flexibility was expected and given, people stepped up to allow it to happen for each other. No work was planned that required just one person, we always built-in redundancy and clear written descriptions so someone else could step in at a moment’s notice. Certainly, hiring the right people is critical. Flexibility doesn’t work if you don’t trust that everyone gives their all. Do you avoid hiring people with disabilities, chronic conditions, or full of life because you’re worried about getting the job done? I hope not.
I went to a meeting in Chinatown attended by parents with children on the autism spectrum going to Boston Public Schools. The attendees spoke Mandarin, Cantonese, Vietnamese, English, and Bureaucrat-ese. The parents helped each other advocate for services for their kids. Most only spoke one of those languages. After 2-3 minutes of speaking in one language, someone would raise their hand and there was cross-translation by the 2 or 3 people who spoke more than one language. This repeated for about an hour. I went home and my 7-year-old grandson tried to teach me to play Pokémon. I understood less than I did in Chinatown. Opa, you don’t understand this at all!! Read More
I want to be a good leader of my healthcare team. How would I know? Such a swirl of activity. This week my ophthalmologist wanted to refer to me another ophthalmologist. She said she’d email her to introduce me, send over my records, and have her scheduler arrange the appointment. I’ll follow-up if I don’t hear from the scheduler in a week. My chiropractor wants to hear what the massage therapist and physical therapist recommends and aligns his plan with theirs. My neurology nurse practitioner called me to say that the insurance company won’t cover the brand name injection I’ve taken for years because there’s a new generic medication. She doesn’t think it’s been tested enough on people before FDA approval. Instead she will prescribe a different dose of the brand name drug instead that’s still covered. Is that OK with me?
My healthcare team is like no other team in my life – not like family, not like business teams. It feels like a team in the clouds. They never gather together as a team. If they communicate at all it’s through me, or emails and snail mail reports, or if they’re in the same system through the electronic health record. I can think of once in 7 years that any clinician spoke to each other directly: my primary care doc called the neurologist when I fell and sustained a concussion. My wife has attended a couple of doctor appointments with me when I was first diagnosed with MS. Several times a year a prescriber speaks with a pharmacy or medical supply company to clarify an order. My family likes to stay current about my treatments, risks, appointments, and stress. They talk with me and among themselves.
Who is my team? Me, my wife, my sons and their families, my sister, my doctors and their teams, other clinicians (massage therapist, chiropractor, acupuncturist, physical therapist, optometrist, optician, pharmacist), medical supply companies, insurance company. I’m fortunate. I’m a good e-patient and I’m a clinician myself. I’ve selected this team (except the insurance and pharmacy benefit companies). One of my best barometers of team effectiveness is usually how the team operates when the leader isn’t in the room. Do they work better when she’s present or absent? Do the team members treat each other with respect? Is communication open? Are they clear about accountability, do they meet their commitments? But in healthcare there are so many other factors and power dynamics between clinicians, office staff, caregivers, insurance companies, administrators. It’s crazy complex – like being Secretary General of your health team. I wonder what Ban Ki-moon would advise?