Monday, March 7, 2011

The Recipe Matters

I love a challenge, and recently I have taken to making cakes. I am not Duff or Carlos, but I am determined to conquer the cake. My weakness is I don’t like recipes – ok, so I don’t like being told what to do, and I feel a recipe is just Betty Crocker’s way of bossing me around. When cooking, her recipes are general suggestions, but unfortunately in baking, it’s an order.

The thing with a recipe in Betty’s book is someone experienced has documented it – it has been verified – and it has made it to the general public. A recipe is successful because the common language used in each step. We are taught in grade school the standard terms of measure – cup, teaspoon, tablespoon, etc. We are also taught time – minutes, seconds, or hours. We are taught by our moms how to “preheat”, and we are taught by the Food Network how to “fold” in an ingredient.

Documentation of anything requires standard terms and common language. In a recent revelation in speaking with others about my professional passion for clinical alarm data and the picture of patient needs hidden within it, I found that there is not a current standard terminology in the arena of clinical alarm design. Therefore, I am proposing one. Just to set the minds of my readers at ease – Patient Communications Platforms are in my blood. You could say my youth encoded a understanding of clinical alarms into my DNA. I went to my first “nurse call” training before I could drive a car, and had a doll house with RTLS. I am not a novice, however, I am not so proud to think that what I’m proposing can’t be improved upon. Actually, I’d be thrilled if this proposal sparked a debate. So,I challenge all of my readers (all 700 of you) to comment. Collaboration can only occur if we are not so prideful to think we are perfect – if we can agree that little companies have as good of ideas as big companies – if we can solidly stand by saying we must create things for the betterment of healthcare because it’s really about patients – not all about profits.

This is Sphere3’s proposal for common language for documentation of Clinical Alarms. Below is a cascade of action – reaction that can either be generated by a person or the configuration of the clinical alarm system.

Initiating Action:

This is the beginning of the call. It can be manual, such as a patient pressing a button or physiological, such as a telemetry alert. The initiating action can also be a system trigger such as an occlusion or a system creating an alert based on a malfunction or necessary service request. The easy way to remember an Initiating Action is “it’s gotta start somewhere”.

Example:

Patient Press a “Normal Call” button on their Nurse Call System

Patient’s heart beat indicates a “V-Tach”
Notification Action:

How do people know that a clinical alarm has occurred? A Notification Action is the ring, ding, buzz, text, etc. This is the way in which a caregiver knows that an initiating action has occurred – they way they know the patient is in need. There are generally multiple Notification Actions for every Initiating Action. Every Notification Action is an invitation for the Caregiver to interact with the patient or their device.
Example:

Initiating Action = Patient Presses the “Normal Call Button”

Notification Action 1 = The Dome Light is White

Notification Action 2 = The PCT’s Wireless Device buzzes

Notification Action 3 = The PCT receives a Text Message “Normal Call Room #” with the option to “dial back” to the patient room.

Acceptance OR Rejection Actions:
If the Notification Action is the caregivers invitation to interact with the patients need it forces an acceptance of that request or a rejection. Accepting the alert requires an interaction with the patient or their technology. A rejection is a “delay of response” while it could indicate that the call is being ignored, mostly it indicates that the capacity of the caregiver to interact with the workload is challenged.
Example:

Notification Action3: The PCT receives a Text Message “Normal Call Room #” with the option to “dial back” to the patient room.

Acceptance Action 1: The PCT presses “Accept” it “dials back” into the patient’s room, they communicate with the patient.

Rejection Action 1: The PCT is unable to answer the call due to being engaged with another patient.

Escalation Action:

A Patient Communication Platform (aka Nurse Call) has a feature called “always an answer” where it will bounce a call if it’s not handled within a set time frame. Anytime a call is rejected, it bounces either automatically based on timeframe or physically based on a button push. That being said anytime a call is “rejected” technology should be programmed to create an automatic escalation action. Similar to an Initiating Action the escalation action is the technologies methodology of moving the call to the next person or place in line.

Example:

Rejection Action 1: The PCT is unable to answer the call due to being engaged with another patient.

Escalation Action1: Since the call has been “ignored” the technologies internal timer has allowed for a wait time of 2 minutes after which the call is sent to the RN’s wireless device with a message “Normal Call Rm 320”.
Escalations drives additional Acceptance and Rejection Actions, based on time frame. Again, a Rejection Action will create an additional Escalation. The hospital has to decide when the patient request (physiological or physical) has gone on too long, and at what point a failure to respond will generate the final Mandatory Action.
Mandatory Action:

The hospital’s determination of the final phase of the escalation process is the mandatory action. This designation is generally linked to Overtime calls. When a mandatory action occurs, the technology should force a physical face-to-face interaction with the patient. Mandatory Action is a new Initiating Action with a required interaction from staff.

Example:
Normal Call has not been answered in 4 minutes.

Mandatory Action: Due to escalation past allotted time frame the technology changes the alert verbiage to “Overtime Room 320” and tones at the main console and duty stations in all caregiver work areas on the unit. Additionally, the PCT and RN’s wireless phone receives a text message “Overtime Room 320” with no capability to call into the patient’s room. The call can only be cancelled at the patient’s bedside.

Now, let’s get back to baking cakes. Here is what I’ve learned in my most recent experience. There is a certain amount of discipline that comes with baking. To try to get creative on the basics is the best way to really ruin a dessert. Getting the basics of a cake right makes for a great foundation. But, the real fun and creativity begins once you have solid knowledge of the basic fundamentals of a cake. You see, I’ve now learned how to take a basic recipe and make an exciting dessert for my family—its about the secret additives, the substitutes that have just a little more interest in flavor, the interesting style of presentation, and complimentary chemistries of toppings, sides and coffees.

Clinical Alarms is the same thing. You have to know the basics and assure the foundational strategies in clinical alarm design were applied. BUT, once that is accomplished, there is so much more that can be done to enrich the patient and caregiver experience with request and response.

The documentation above associated with each phase is laid out similar to a process chart used in lean, however Sphere3 has created a methodology that is easy to understand and see at a glance. I will create a blog series on each phase of the process if there is feedback on this, but if there is not then we will just leave it as one persons attempt to create some normalcy to the market.

Comment Back – Ask Question - Email me kgovro@sphere3consulting.com if you don't want to post a comment – join this conversation.

It’s not “IP” it’s about creating something we can all use. This shouldn’t be an uneven playing field - this is Sphere3 stepping up and saying it's about the patient - not about the technology.  If alerts are designed incorrectly in the extreme case someone could die – in the most likely case a patient is dissatisfied with their care.

3 comments:

  1. Danielle HutchinsMarch 8, 2011 at 2:49 PM

    It's funny that you have the same problem I have with baking! I can not bake and it's for almost the same reason...my reason is who is Betty Crocker and who is she to say this is the appropriate way to make a cake?
    Much of the alarm technology has evolved because there is not enough caregiver to spread around. In the early days of nursing, nurses spent time with their patients, they developed healing relationships with them. Relationships that allowed them to note differences in behavior, symptoms, etc. The initiating action was a noted palor or irratic behavior. No dinging, no buzzing, just a caregiver knowing their trade and their patient well enough to note the difference and take action.
    The geek in me loves healthcare technology but the caregiver in me trembles as more and more observation is conducted by machines. The recent trend in remote Telemetry is a notable example. Hospitals contract with telemetry monitoring to provide not only monitoring but also Intensivist recommendations. Some hospitals are even considering giving the Intensivist authority in certain situations to order interventions. The caregiver in me shutters at the thought of a person watching blips on a screen intervening in the care of a living breathing person. What if the machine was not calibrated correctly, what if the machine was not given the correct parameters for this particular patient?
    So does this mean we should throw out the machines? Of course not, diagnostic technology has greatly improved care. I am merely pointing out that in the business of healing sometimes technology is not the answer. In this case the answer may simply be allowing caregivers the time to assist in the healing process, rather than being managers of medications, charts, and beeps.

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  2. You have a way to taking the complex and driving to the heart of the issue. Technology can be a great thing but too often becomes a tax instead of a benefit for the caregiver...and patient for that manner. The challenge for us is as innovation drives new technology how does it become seamless in the delivery of care. Too often technology has driven workflow versus workflow empowered by technology. Our rush for the latest and greatest doesn't always deliver the best design. The goodness, like cooking, if we step back to focus on the basics we are not far off from delivering something great! I like this...'Collaboration can only occur if we are not so prideful to think we are perfect'...I also think a big hindrance to collaboration is fear...we are changing the eco system, there will be new business models, solutions and playbook...while this doesn't always feel good those living in what was, it is vital for us if we are going to delivery on a common vision of true workflow transformation.

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  3. Tom

    I always appreciate your comments because I know you are sincere about changing the way healthcare works. I started Sphere3 with a simple thought - we can make this better.

    I spent the first year figuring out the "how" - removing the tether of technology and looking into workflow. What I came to at the end of year 1 is the technology will change the overall goal will not. So creating some consistentcy in language is critical. This could've been copy written, trade marked, or "owned" by S3. However, without widespread adoption it means nothing. That's why it's put on a blog - for public consumption and use. I hope that powerful organizations like Cerner would consider the adoption and promotion of this language.

    I spent the second year finding a way to use the language in a meaningful way to help make life better - the goal of "improving patient care" is there but what does that mean? What's the tactics within the strategic goal.

    This year - my energy is going to be focused on the patient. How do we drive the needs of the patient to the surface - which starts with how they are ASKING to be cared for. Cared for is sooo much more than some cool flashy item we put in front of them in the name of improvement.

    Our new mission is to Make Life Better.
    Thanks for your post.

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Thanks for Posting on Clinical Transformation!

Kourtney Govro
kgovro@sphere3consulting.com