richard[WINTERS]md

ACEP Lecture on Wednesday

I will be giving a lecture at ACEP on Wednesday, October 10 at 2pm.

The title: "Service Excellence: Learn From My Mistakes."

Here's the introduction as a teaser:

Hi! I'm Richard Winters and I'm going to talk about service excellence.

I have a confession to make. I’ve been a provider of service mediocrity. I’ve always been an excellent physician…my patients just didn’t know it.

But I have seen the light.

I am through some effort moving from service mediocrity…to service excellence.

I was afraid I’d have to sell my soul…to the gods of patient satisfaction…and the gods of survey…the Press Ganey deity. A two headed beast…one head being the hospital CEO and the other head being an angry patient…clutching the sacred Scantron survey. But my soul remains my own.

It's from my vast repertoire of mistakes that I'll teach you the essentials of service excellence.

Facebook for Medical Conferences

I am currently in Seattle at the American College of Emergency Physicians annual conference. It's a great conference with excellent lectures about clinical and business topics in medicine.

One of the best things about attending the conference is being able to see people I trained with and people I trained. However, it can be very difficult getting in touch.

Facebook should work with professional societies to connect individuals at medical conferences. Who's at the conference? Where are people going for dinner?

They could target ads to conference attendees.

Simplify the Process

What is the probability of a patient visiting the emergency department not encountering an error of process?

Registration functions perfectly.
Labs are ordered correctly and return on time.
Vital signs, medications, transports, x-rays, exams…all performed without error.

Each step of each of these processes has its possibility of error. Every handoff of a task to another person has it's own risk of mistake.

Take the example of ordering and getting the results of an ankle xray.

Assume that getting an ankle xray takes 20 steps (it likely takes many more).
See the patient…
write the order for the xray on the correct ankle…
put the order in the clerks box…
have the clerk enter it correctly…
etc…

Let's say the accuracy of each of these steps is 98%.

In addition, the process of getting an ankle xray involves 5 different handoffs of information. The clerk, the radiology tech, the nurse, the radiologist, and the emergency physician are all exchanging information.

Let's assume that each of these handoffs has an accuracy rate of 95%.

Rolled throughput yield measures the predicted probability that an ankle xray will be ordered and completed error free.

Calculating the rolled throughput yield shows us that the probability of an error free ankle xray process is:

(0.98)²⁰ x (0.95)⁵ = only 52%

What happens if we reduce steps in the process?

We decrease the process from 20 steps to 8 steps.
Instead of 5 handoffs of information we have 3.

Now the probability of an error free ankle xray process is:

(0.98)⁸ x (0.95)³ = 73%

Every step and every handoff of information decreases the probability of an error free process.

An error the majority of the time does not result in a bad outcome for the patient. (eg "Can you re-fax that order?") However, it increases the time it takes to get through the system. It increases the frustration experienced by all involved.

Simplify the process.

Bacon Bandages

Available at Archie McPhee.
They have steak too.

Pattern of Patient Interactions

The same physician.
The same patient.
The same quality of care.
The same amount of time spent with the patient.
But there is a difference.

Visit 1: The physician spends all of her time seeing the patient at the beginning of the patient's visit.
Visit 2: The physician spends all of her time seeing the patient at the end of the patient's visit.
Visit 3: The physician divides her time seeing the patient into three separate interactions during the patient's visit.

After which visit will the patient be happiest?

Tour de Hospital: Don't show your sweat.

I sometimes sweat at work.

Capped, masked and gowned procedures under hot lights.
A difficult negotiation with a consultant.
Hungry. Must eat.
All certain to make me sweat.

I'm a big cycling fan and an avid cyclist.
July is a great month. The month of the Tour de France.

It's 107F in Fresno and I ride at 2p.
I wear an undershirt and it greatly increases my cooling.
It seems counterintuitive, more clothes in hotter weather.
A good base layer wicks away the sweat and provides a larger surface area to evaporate.

I wear a base layer at work.
I may be sweating, but you wont see it.
No wet shirts.
I stay cool.

I wear the 2007 Craft Pro Cool Base Layer.
There are many good base layers made by other companies.

A Better Patient Introduction: Smile and Handshake

Every time I walk into a room I make it a point to smile.
A gesture that shows happiness, humility, and a desire to please. I'm here to help.

This can be difficult.
I may have just pronounced a patient dead.
I may have just been insulted.
Perhaps the prior patient pointed out my crooked teeth.

If I'm not ready to smile, I wait.
I meet every patient with a smile...and a handshake.

To each person in the room, "Hi! I'm Dr. Winters."
Shake hands.

If they can't shake hands, I grasp their arm.
If they don't have arms, I grasp their shoulder.
If they don't have shoulders, they are likely very ill.

Patients don't come to the emergency department to be triaged.
They don't come to talk to registration.
They are not here to sit on gurneys in half open nightgowns.
They come to see the doctor.

Here I am.

This week smile when you meet every patient.
State your name and shake hands with everyone in the room.

Taking Compliments With Double Thanks.

I never knew how to respond when a patient said "thank you."

I might stand there with an awkward smile.
Sometimes I'd blurt "your welcome."
More often I'd try to come up with something graciously witty to say...and fail.

Each time I heard a patient say "thanks" I'd feel uncomfortable. I'm not wired to take thanks. It made me feel like a poser. "Why are you thanking me? It could be so much better."

I overcame my fear of thanks.

How did I do it?

I thanked them right back. Twice.

A patient says, "Thank you Dr. Winters."
I say, "Thank you! Thanks for letting us take care of you today."
Or "Thank you! Thanks for coming here to help your mother today."

I know longer have to think about the right way to respond. It is right there. Ready and waiting.
And it's true. I am thankful.

Wash your hands in front of patients.

My family and I are greeted and seated at a table in our local P.F. Changs restaurant. The server notices that the table hasn't been wiped clean. As she wipes the table she says "this wipe has a disinfectant, so it will get really clean."

"Great!" I think. Half the food my 2 year old daughter will be eating will have fallen onto this table.

You may wash your hands in between every patient. Do your patients know this?

Some rooms have sinks. Some rooms don't. Some have alcohol-based hand sanitizing dispensers.

When I use the alcohol-based hand sanitizing dispensers I tell my patients I am "disinfecting my hands." I whisper it nonchalantly...as if I'm talking to myself. Otherwise they think "why is he moisturizing his filthy hands?"

If there is a sink in the room I use it before and after the physical exam.

If there is a sink outside of the room I tell my patient I need to wash my hands. I do this after I take their history, right before I examine them. Then after I leave the room I again wash my hands. If they can't see the sink I make sure they see me drying my hands with the towel.

Sometimes I will also walk to the next patient as I am finishing drying my hands with the same towel. This can save one of the washings. "Ah...look at the doctor drying his clean hands."

It doesn't matter that I know my hands are clean. My patients need to know that my hands are clean.

A Better Patient Introduction: Knock and Name

I'm in my hotel room sitting in my underwear eating cheetos when the maid walks in the door unannounced. She screams. My body covered with powdered cheesy goodness shocks her. She agrees with my colleagues that I truly look my best with a mask and cap in full surgical gown.

It's polite to knock before entering a room. Yet how often do we do this in the hospital?

I've started knocking and stating the patient's name before I enter a room.

Knock. Knock. "Mr. Jones. It's Dr. Winters. May I come in?"

But what to do if there are no doors, only curtains? A quick shake of the curtain does the trick.

Patients are often sitting bare-bottomed on a hard gurney in a cold room. Give some privacy. Let them allow you to enter.

Stating the patient's name verifies that you are seeing the right patient. Bonus points are awarded if you pronounce a difficult name correctly. Have the first person who meets the patient get the name and write the pronunciation phonetically. I have my scribe help me with this.

Knock before you enter the room.
State the patient's name.
Ask permission to enter.

A Better Patient Introduction

At the beginning of each Fresno State basketball game there is a moment of music. Dry ice blows smoke. House lights dim. Spotlights flash. The resonant voice of the announcer shouts "Yourrrr Fresno State Bulldogsss!!!" and the players burst onto the court. The crowd gets on their feet. Everyone cheers.

Why not bring this to the bedside?

Lights down. Dry ice fog. Loud thumping music. My scribe shouts "Yourrrrr Doctor Winterssss!!!" The curtains part. I chestbutt my scribe and give everyone in the room high fives.

Might be effective. Might be awkward. Might kill grandma.

Sports teams understand that the introduction sets the tone for the whole game. A great introduction announces energy and intent. It brings the home team players and crowd together.

I used to walk into a patient's room and say whatever came to mind. Sometimes this brought the patient and myself together, sometimes it was uncomfortable and ineffective.

I've worked to make my introductions more effective.

It is work to change old inefficient ways. However, it makes work more enjoyable.