Bomb disassembly 101

As the story goes in my husband’s family his brother was sent by his employer Uncle Sam to go help write or edit a bomb disassembly manual. Why? Because he knew nothing about the assembly or disassembly of bombs. He finds himself observing the process of disassembly while trying to follow the manual in its current incarnation. He finds the experts to have missed steps (e.g. disconnect the red wire only after ensuring...) Steps that matter when the expert isn't there to do the thing.

I often think of this when I send patients home with teaching for...whatever. My mind goes to the high risk things. Medication teaching. Wound care. How to know when something is okay versus when to call the clinic versus when to go straight to the ED, do not pass go, do not collect two hundred dollars. If my eyes aren't there, theirs needs to appreciate what is important.

"Just" is a four letter word

I sit in any random training and I throw out the concept that for all the cuss words I know, "JUST" may be the nastiest of the four letter words.

I look around me and I see good clinicians becoming increasingly burnt out. I have a theory that Electronic Health Records (EHR) should be click neutral (if you add clicks, you should subtract clicks elsewhere) otherwise you fall into the trap I call "Just is a four letter word". 

Technology has been brought to the bedside - but there really hasn't been proper time or space made for it. Of course back in the day, there was angst and gnashing of teeth about paper charting. Still, it seems to be worsening. 

Often in training we hear a feature was added and you "just" have to click this box, bar or link and you can find the order set and you "just" need to complete these _______ things. No one capped the click burden for people giving care at the bedside. No one thought to remove anything when they "just" added these extra boxes.

 
The increasing requirement for more and more standardized tools does not provide additional time to complete all the standardized tools.

In the sphere of value based care and tracking metrics, payers also seem to add requirements without taking other things off. It seems no one sees keeping screen time capped as a priority. As screen time increases, patient time decreases. How can this be good care?
 
I think the healthcare industry is racking up a tremendous technological debt. I think it is going to take an effort from payers, electronic health records manufacturers, hospitals and clinicians to prioritize and clean up the workflow. Of course, who do you convince of this? Likely most people working directly with patients agree. If you hear patients complain about how clinicians were "looking at the screen and typing" you know the patients would appreciate more face to face interactions.

I think the system has bandwidth to permit clinicians to get back to doing what we expect them to do - provide care. Someone "just" needs to see that as a priority.

Learn one, do one, teach one.

 

As nurses we are often taught "Learn one, do one, teach one." I learned it. I practice it now in my profession, however teaching isn't really the end. I want to make sure my patient or their carer can also do the thing safely and with good practice without me there.

This comes to the idea of demonstrating competency or "teach back." The higher the stakes the more I want to have my patient or their carer teach me how to do the thing. It is imperative they can do the thing successfully. It gives us opportunities to iron out the areas that matter, but also to build confidence that that can take the thing home and be successful.  I also find I learn a lot. In nursing we need to hold some things to a certain standard but other stuff is what I call "style points." I learn a lot by looking at different people's styles and it makes me a better nurse as I have adopted their techniques because they are legitimately good.

Look around at the folks around you. They have a lot to teach and when you think you know something - don't say "Oh, ok" or "I know" say "Teach me how you do that."  I promise you will be amazed at the things you learn!

Sometimes second-best is number one

I had a patient who kept being admitted for high blood sugars. They were known to the hospital. They would routinely be admitted with blood sugars from 800-1,000. The term “noncompliant” rakes over my last nerve and this patient is one of a list of reasons why.

Through the day, I learned the patient had housing insecurity (no home). They lived in their vehicle. They said they tried to manage their diabetes, but they couldn’t. People under stress have different reactions. This person’s reaction was to the problem completely. I looked at the chart. The diabetic regimen given to this patient after multiple admissions had them visiting their diabetes SIX TIMES PER DAY across multiple insulins. Think about that.

In my mind, I thought the patient may have lacked education or understanding. What I found was that the system was busy providing the “best” care with the most current protocol – despite it being unsustainable for the patient. One of the insulins prescribed was probably the most susceptible to temperature changes. Not great for someone who has no home to put it. Can you imagine carrying around supplies to check your blood sugar and medicate yourself six times through the day while you are trying to merely survive? Me either.

I asked the patient how often they may be able to reliably visit their diabetes? They said they could visit it twice. We could work with that. I called pharmacy. I explained the situation. I didn’t want to upset anyone, but maybe we could consider what would be the second-best treatment for this patient? We got buy in from the team. We updated teaching and I had them teach me how to draw and inject their insulin.  They benefited from the practice. They also suggested they could get a small cooler for their glove box to help protect the insulin from the temperature fluctuations in their vehicle. Wow! The patient who’d disengaged from their treatment is back in the game! Ultimately, prescriptions were reduced from 90 day to 30 day to protect the integrity of the medications. The patient could get to the pharmacy. This process delayed discharge by one day. It also stopped the readmissions for hyperglycemia immediately.

This is why I appreciate the value of the second-best treatment.

Healthcare is racist and not serving those who need it most. We can do better.

Harriet Tubman, nurse, spy, bad ass <3

The Tuskegee experiment was coming to light and being ended around the time of my birth.  I have deep gratitude to have worked for a nurse researcher (before I was a nurse) who helped open my eyes to disparities in care. 

Still, in the past year we hear news about racial bias in healthcare algorithms. This is unacceptable.

In my own practice, I see how the system is not fair for people every single day. People of color, people who are poor, people who have mental illness. People with disabilities (visible or not visible). Anyone different.

At the end of the day, I can only be transparent in my own behavior with patients and be accepting that patients may still harbor mistrust for me. I continue to educate my patients in the ways that work for them and I continue to advocate to keep the system from losing the folks that may be under served. The faces of the people who are under served, I can tell you they are beautiful, brilliant, resourceful and kind. We can do better.

Anecdote: How to get (then keep) a research department from being shut down

I took a job in 2004 where the federal purchasing was so out of compliance, they were threatened with shut down and mandated to create my role. My job started off with a deposition early and I was asked how I was going to address the problems.

BTW: Don't ever read your own deposition. Just take my advice on this. I know they want you to read it for corrections and you should do that, but if you can separate your emotions from how bad you sound - do it. 

It was federal purchasing - so much had been done incorrectly. For a long time. No more than $2,500 per transaction. Hundreds of thousands of dollars (or more) were insufficiently accounted for.

The system provided to researchers was DOS based. This system required entry of a proper purchase order and later reconciliation in that DOS based system.

Well duh! They handed credit cards to researchers and trusted they would be able to enter a purchase order and reconcile in DOS. Oh, this also had to adhere to all federal purchasing regulations.

These were researchers doing cellular level research. Purchasing was not in their skill set, purchasing was the necessary evil to get the supplies and equipment they needed to do their science. For me, it was a straightforward fix. No, I didn't know all the rules or the system but I was able to figure it out.


Hell, after digging through all the ways someone could inadvertently do something wrong it was easy to forge a system to get and keep them in compliance.  Added bonus, I found ways to purchase on and off contract that saved obscene amounts of money and still followed all appropriate rules. 

I worked with the individual researchers, helped get all the prior financials reconciled and set up a centralized system that was still being used 14 years later. It was simple, it worked. I like stuff like that.