"The Immediacy Conundrum"

Question #4 “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” Answers: Never, Sometimes, Usually, Always, and I never pressed the call button.


“after you pressed the call button”

Patience is not in abundant supply at Gate’s BBQ. When you walk in the door they shout at you - “Hi May I help you?” you must know to yell back very quickly – there is no patience for Umm or questions – by either the counter staff or the patrons behind you. You must shout back – quickly with full confidence - “Yes, I want a burnt end sandwich, fries, and a Ice Tea.” The food arrives to the counter very quickly – you can watch the man through the cook window constantly chopping and slicing meat to serve – you know it will be good, hot, and fresh.

The Gates atmosphere creates an expectation for an immediate response to questions, there must be no hesitation. I have reviewed reams of data from nurse call systems and 4 years ago when we started – the average wait time before exit of the bed for a patient was about 1:13. Now we see a majority falling under the 30 second threshold. Are people getting more impatient? Maybe…

We live in a world where as soon as I want to be connected my expectation is to have connection. The problem with “after you pressed the call button” is many patients expectation is immediate. Geeky techy stuff – if you have a nurse call system older than 2 years and you are functioning in decentralized – there is a lag time. Depending on the specific system – it can be an “eternity” in terms of immediacy. This is not a reflection on caregivers, it may actually be a reflection on the implementation of technology. Yet, caregivers are under pressure. Just like Gates, the health system and government is creating an atmosphere around hospitals that require immediacy. By its ever- more acute care criteria for entry, there is an equal expectation for immediate response?

Let’s talk solutions to the immediacy conundrum. The Decentralized Nurse Call craze of a few years ago is beginning to subside as hospitals realize the limitations of moving the patient call to an individual who is mobile and has variable task responsibilities on the unit. Decentralizing or sending the “Normal” patient call to a wireless device does not solve for immediacy – it’s actually the most difficult methodology for nursing to utilize because there is no immediate feedback on volume of requests or the “queue”. Immediacy requires the “queue” to be low and the person answering the call to interact and disconnect quickly. Think Economics - Basic Supply and Demand Theory – if you have too many nurses and not enough calls then you are fine. However, what is generally the case at documentable specific periods of shifts, if you have too many calls and not enough staff then you are going to get low scores on question 4.

The trick is the patient has a need and since they are not in their home environment and have very little control of their surroundings – many “wants” become needs. Not to mention the variation in expectation. The patient requires an immediate interaction – not an immediate solution. This is a really important point – so don’t miss it – the patient needs an immediate interaction and a sense that their need has been identified and help is on the way. The second key to this is you must deliver on the promise. So, if you have pushed your button and someone has quickly told you “help is on the way” then help must really be on the way. The only way to manage that is to develop a methodology to alert the needed caregiver with a specific request – data rich. Then Mobilize AND Monitor their action towards delivery. What does this mean – the person interacting with the patients request should be air traffic control – they should be able to monitor the total quantity of requests and estimate a delivery time. If there is a change in delivery time – maybe the patient should even be notified…..

BBQ and Nurse Call

I have noticed that several of my blog posts involve food…diets…etc It’s a true statement that one of my vices is really good food – not pretentiously good food – just plain good food. My pallet is not well refined, but I know when something tastes good and when I am served well.



One of my favorite restaurants is Jack Stack BBQ. Disclaimer: I live in Kansas City and talking BBQ is similar to talking about religion. There are alliances to BBQ that span generations of families. So, to be fair let me list the other greats in the Kansas City: 1)Gates – where “HI MAY I HELP YOU” is shouted at you when you walk in the door, 2) Arthur Bryants - where sweat is integral to experiencing the meal, and 3) Oklahoma Joes - only loses points because of the name.


According to the Kansas City BBQ Society (http://www.kcbs.us/ ), Carolyn Wells Ph. B, tells me it is measured on Appearance, Taste, and Tenderness. To achieve success in competition you must have quality in 5 areas: cooking unit, meat, seasoning, fuel, and most elusive, expertise of the chef.


For those of us with the untrained tongue, the challenge with BBQ is all data to assess are qualitative judgment’s – meaning, based on how I feel at that very moment I have made a judgment call on its goodness. Don’t get me wrong - when you taste a crispy chopped burnt end sandwich with just the right amount of salt, spicy sauce, and for me Cole Slaw on top, you will know what heaven will be like and I challenge anyone to say it’s not good.


So, what does BBQ have to do with Nurse Call? I look at Question #4 “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” Answers: Never, Sometimes, Usually, Always, and I never pressed the call button. I think would I ever answer "Always"?

One of the most concerning aspects of healthcare is measuring qualitative – questions based on “feelings” without creating a reasonable expectation for delivery. For example, asking “Did Jack Stack taste good?” to a random selection of people. (I have heard you East Coast folks think you know BBQ.) My perception of good BBQ is different than a person who prefers Memphis “Dry” BBQ , a North Carolina Vinegar based BBQ, and Texas hunk of meat they call BBQ.


In the next few blog posts I plan to break down question #4 and dig through how we can really expect to build continuous improvement and value from a “feelings” based survey question. How hospitals can use data that is existing in their facility to create quantitative Inidications of Care or what we call IndiCares™.


Just to get you started:


“During your hospital stay” this is a variable length of time. A metric based on an inconsistent variable is not easily understood and does not lend itself to being fixed. The time frame “your hospital stay” could be 1 day, 2 days, 1 week, or in a rare situation 1 month. The variable also could be a “frequent flier” as my favorite Children’s hospital calls their recurrent patients vs a one time in five years visitor. Their time may be short and consistent or random and long. 

We have evaluated data from over 30,000 patient days and the interesting thing about the data it is until you break it down by specific consistent measures there are very few patterns.  You have to stop looking at the data as Spaghetti and create a waffle structure.


A parting thought - If the data is barcoded according to which patient submitted it – why not just look at their nurse call statistics after their stay in comparison to their responses? If you are a hospital and don't know how to do that - call me or email me - I will tell you how to get to your data. 

Be the Change

I know you were all expecting a blog post about Patient Communications – I will post it soon. Many of you have seen the tweets about Joella’s blog. For those of you who haven’t she was a beautiful little two year old girl who was suddenly diagnosed with Leukemia, and passed away on Sunday. I read the inspiring blog posted by her family, and prayed for them. The “Doer” in me kept saying what more can I do to help? I was talking to my tree hugging hippie little brother about her and he said “Bo, why don’t you join the Bone Marrow registry?” The brilliant scientist that I am – I replied “Grant, I am all ready an organ donor on my driver’s license” After he quit laughing he said “Dude, Bone Marrow is like a renewable resource in your body.” Since he used to work for the Red Cross – I thought he could be correct. So, two weeks ago – I started my research. Like every good geek I started with Wikipedia – which is never wrong – and it confirmed Grant’s statement. Then I found www.marrow.org if you haven’t been to this site I encourage a visit. I registered on the website – they sent me a 4 pack of swabs – I swabbed my mouth at my Kitchen table – then sent it back in their postage provided envelope. Let me assure you – I don’t like needles, blood, or IV bags – I am a soccer mom with 4 very active little boys and in my spare time I run two companies. Time is not in grand supply, and I am not a big fan of pain. However, if one life is saved – it’s all worth it.


Be the Change is a movement that transcends financial ability, race/ethnicity, and even religion. Though I do believe in my faith it’s a directive not a recommendation.

I was inspired recently by the move of KC Sporting – our local soccer team. Soccer, unlike many sports, has few borders and internationally reaches into all socioeconomic levels. KC Sporting recently named their new stadium LIVESTRONG field, the first time in history a professional sports team has taken a not for profit as their field namesake and not the sponsorship of a major company. For those of you who don’t know – two of the team’s owners are men who started Cerner. If prideful ambition had been their desire, they could’ve paid homage to their achievement and we could’ve had Cerner Field. Instead they chose to be leaders of change and part of a larger social awareness movement.

So, how do you plan to live your life in a way that demonstrates the change to society you want to see. You can tell a bucket of water to overflow – you can point your finger and speak beautiful words to the bucket and it will never overflow. You can actively pour water into the bucket and watch the results occur. Teaching, Preaching, and Telling will not inspire movement – Acting, Living, and Being create movement.

Being the Change does not require you to give masses of money, it does not require you to give hours of time, but it does require you to stop and make a conscious decision to make an impact on the lives of others.

Sometimes all it takes is a cheek swab…..
http://www.marrow.org/ click the link get the swab

A Confession....

A confession – focusing has never been my strong point. Some call it ADD others call it visionary, but mostly it’s just when I figure the puzzle out I am done. Since HIMMS my mind has been focused on ACOs, PCMH, and other items and different ways we can apply technology to those models to revolutionize healthcare. As I presented this long term vision to my team and watched the color drain out of their faces as my hands flew through the air – I realized in all fairness – the future is not today.

Today we have a set of technologies that must be leveraged to migrate today’s abilities with tomorrows vision. A more powerful vision then creating something new is to create a path that shows how to get from old to new. Reinventing the wheel in the healthcare environment is not necessarily the most effective or safe process.


So, the next few blog posts will be about today’s technology but with a twist.  In the spirit of collaboration - I hope to drive a conversation (whether on my blog or in your hospital) about what the technology today can do above and beyond it's basic "job". 

The first blog post series will be about Nurse Call - it can tell us immeasurably more about the patient then previously determined. Nurse Call - if applied correctly - can be an effective tool in mitigating risk associated with HACs.  Nurse Call is a workflow enabling tool....And locked inside that box is data that will change the way you manage capacity and the patient stay. 

Stay Tuned....here we go – hope you enjoy……

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.