Saturday, August 29, 2009

The lessons from one of the best hospitals in the world...

During the past month at MGH, arguably one of the best hospitals in the US, if not the world, I looked for subtle, innovative ideas that outsiders might not notice from simply taking a brief tour around the hospital. Health care is a complicated beast, and it really was the little things that made a big difference, not the obvious surgical robots or shiny buildings that meet the eyes of visitors.

1. The Get-to-know-me chart
In the room of every patient who cannot communicate for various reasons (stroke, delirium, intubation, whatever prevents a person from communicating), there was a Get-to-know-me chart, which consists of:
- Name AND "Likes to be called"
- Important people in my life
- Favorites
- At home I use (patients check all that apply): glasses, contacts, hearing aids, dentures
- I understand information best when...
- Achievements
- Things that stress me
- Things that cheer me up
- Others
Some of these charts are filled by the patient before surgery expecting that they might not be able to communicate post-op. Others are filled by their family members. We can imagine how important these answers are when a patient is unable to communicate well with their providers, when they may only be conscious enough to respond to the names they are called everyday, when their world tumbles in times of sickness and the important people in their lives or things that usually cheer them up can make a huge difference, when they are thrown into a new environment and things you usually rely on to function (like hearing aids, glasses) are taken away.

2. The ED observation unit
It is the limbo between the ED and the floor. Many times ED patients await beds or lab results to determine whether they need to be admitted, at which time they no longer need the specific sets of skills and services from the ED staff. The ED observation unit houses these patients so that the ED can triage new patients that need urgent care.

3. Radiology consult
Any physician in the hospital can walk into radiology reading rooms (all of which are located in the same area: neuroradiology, CT, MRI) to review imaging of their patients with a radiologists in person, in order to ask field-specific questions that are usually not answered by the broad comments in the final read. Every time we walk in, the radiologists say with a smile, "How can we help you?," as if they were greeting customers. It is definitely a far cry from Elmhurst hospital, where you can't get a hold of radiologists at whom you need to yell and argue to have them approve the study that you want. Asking them for a personal imaging review would be asking for insults coming your way.

4. Location, location, location
At MGH, all microbiology labs (virology, parasitology, etc) are grouped together, next to the Infectious Disease offices and team rooms, and that is no accident. Whenever a test result is positive, the teams walk down the hall to review lab findings in person, ask questions and get rapid updates as soon as a culture turns positive. A neurosurgery ward is across the hall from the neuro SICU - crashing neurosurgical patients can be rapidly whisked across the hall to be stabilized in the ICU. The CCU is next to the cardiac step down unit - cardiac patients can move rapidly between the two units depending on their cardiac status.

5. The Bigelow service
In most hospitals, interns on a team split patients - one intern does not know anything (or care) about another intern's patients. On the Bigelow service, all the interns share all the patients on the floor. This requires the interns to communicate among themselves regarding all development and treatment choices for each patient. It fosters a foreign concept of teaching physicians to work together and communicate with one another regarding a shared patient, which above the intern level actually happens everyday and everywhere. It also makes sense that an intern knows all the patients on the floor, since all of them are only cared for by one intern on call each night.

6. Communication
On the consult service, I learned to uphold utmost politeness in communicating with other doctors. At the end of every consult we write - thank you for this interesting consult, we will follow along with you. We also make it a point to always communicate recommendations verbally to the primary team, ON TOP OF recommendations written in the chart. At Sinai, I inched gingerly up to the consulting team and before I could ask a question, their first comment was whether I had read the chart, as if we were meant to talk to one another through pieces of paper deprived of personal cues that enhance our grasp of a message.

7. The staff
Most of the hospital staff (nurses, in particular) were there for the grind to earn money - many took no interest in the medicine or in their patients. They clock out right at the end of their shift. Many refuse to do anything other than the required lab draws and vital checks - they refuse to assist others looking for information on the status of their patients, which arguably nurses know best. Others do not care to learn what the patient has and what treatments are coming their way. None of this is true at MGH - nurses ask to be present when doctors explain treatment plans to patients. They suggest care alternatives that improve patient outcomes or reduce costs.

MGH may have flaws that plague other hospitals across the nation (commercial-driven hospital policy, budget cuts in times of depression), but it has merits that sure make for a special place for the lucky patients that can afford it.

1 comment: