THROUGH PRACTICAL INITIATIVES Introduction Goal One: Build a team of health care professionals who understand their contribution to effective care giving Goal Two: Empower all clinical-based staff to help improve care through practical actions Patient Outcomes This is a way of measuring the how well a patient responded to the treatment provided It is usually compared to averages compiled by organizations Meeting or exceeding those averages is considered a way of gauging proper care Why improve patient outcomes? Why improve patient outcomes? Governments, health departments or insurance companies may Measure your abilities on outcomes achieved Base their reimbursements on outcomes Decide on accreditation for facilities But more importantly, improving patient outcomes means improving people’s lives Health Disparities Are differences in the quality of health and health care Usually noticed among groups of people: Minorities, Rural populations Non-citizens Health Disparities Reducing health disparities means finding out who in a patient population is receiving substandard care And why they are receiving substandard care Health Disparities Substandard care may be caused by: Communication Problems Discrimination Lack of insurance coverage Poor transportation Shortage of care givers Health literacy (patients have problems understanding health information) Team Building A health care team includes: Doctors Nurses Schedulers Billers Receptionists Security guards Anyone who works in the clinical facility Team Building Each member of the team can affect patient care through their actions, So they must understand how they can maximize positive contributions to patient care When all of the team members are attuned to the mission of improving care, Positive health outcomes will follow Empowering Staff Staff can be oriented about how their work affects patient care, Through clarity of their job description to understanding the mission of the organization to practical skill building Empowering Staff Staff members can understand how their contributions matter when it comes to providing excellent care Successful Teams Understand that everyone has a role to play in helping patients get quality care Know that quality care improves the lives of those people they serve Successful Teams Understand that unnecessary visits are reduced because care is more effective Know that the experience better for everyone involved Recognize quality care is what we would expect for ourselves, so providing it to others is the Golden Rule What are common challenges Medication non-adherence Lost to follow-up Patients with low health literacy What are common challenges Patients saying “yes” when they mean “no” Difficult patients, e.g. Common challenges, cont. Difficult patients: Substance users: alcohol, drugs Angry patients Drug seeking patients Violent patients Mentally challenged Adolescents Et cetera Forging Solutions Solving these and other problems is not a one person job: Everyone in a health care setting contributes to the solution; From the receptionist, To the schedulers, To the accountants, To the nurses, To the doctors… Forging Solutions At its heart, health care is based on service It is also a professional environment where: Everyone understands their role within a team Knows what they contribute to the team, Forging Solutions And how it can affect care giving, For the better, And for the worse… (African sickness mask) Forging Solutions Each person can affect patient outcomes: The unfriendly intake person can drive up lost to follow-ups, The unhappy scheduler can discourage patients, The resentful clinician can too Forging Solutions Patients need to feel comfortable at each step of their visit, encountering professionals committed to their care: Forging Solutions Employees will not intuitively know their specific responsibility to help patients understand their path through care, Forging Solutions They must learn the importance And responsibilities of their role, And how much it is valued by the management and those they serve Forging Solutions The Hippocratic Oath can apply to all in the health care setting: Hippocratic Oath …Our responsibility includes not only the presenting illness, but also how the illness affects the person's family and economic stability. Forging Solutions: Professionalism Staff orientation upon hire and annually thereafter can ensure that people understand their professional responsibilities Forging Solutions: Professionalism Understanding the organization’s mission and how a staff member’s work contributes to the mission helps diffuse frustration among patients and staff alike Forging Solutions: Professionalism To understand how one’s work contributes to the overall attainment of the organization’s mission Forging Solutions: Professionalism Ground’s a person in the importance of their work Clarifies a person’s understanding of how they contribute to improving people’s lives Forging Solutions: Professionalism Job descriptions can be a tool to clarify staff members’ role in care-giving They reduce ambiguity by clarifying expectations Forging Solutions: Professionalism Annual performance reviews based on job descriptions can provide valuable guidance about successes and opportunities for improvement Forging Solutions: Professionalism Performance reviews Can actually reassure employees If done with the intent of helping someone find solutions to challenges they face And providing skill building methods to help And praising the successes they have demonstrated since the last review Forging Solutions: Professionalism In short, every employee needs to understand that each patien--regardless of who they are--deserves respect and professional care At the core, we must remember… Forging Solutions The Golden Rule: "Do unto others as you would have them do unto you." Forging Solutions The Golden Rule is the cornerstone of human rights. Essentially, regardless of: Their circumstances Their station in life Their appearance The choices they have made The time of day, the day of the week… Forging Solutions Each patient deserves equal and just treatment. As caregivers, our role is Not to judge people, Not to impose our resentments on patients, Not let our political views color our care Forging Solutions It is to set aside any ill will we may have before we encounter a patient And treating all patients with the consideration and respect that your faith and/or professional code expects of you Forging Solutions Active incorporation of the Golden Rule into our professional lives can: Reduce culturally-based differences Reduce health disparities Resolve underlying issues chronically and adversely affecting health outcomes Approximately how many different cultures are there in the Asia/Pacific region? 1. Nine 2. 23 3. Unknown What does culture include: 1. Language 2. Traditions 3. Behavior 4. Beliefs 5. All of the above 6. None of the above What is your culture? 1. I’m a health professional 2. I’m a Christian 12% 12% 12% 12% 12% 12% 12% 12% 3. I’m masculine 4. I’m feminine 5. I’m heterosexual 6. I’m gay 7. I’m wealthy 8. I’m educated ... e y .. y ed ... e lin lth ga p. in tia xu at in cu th ea I’ m ris se uc m al as w ro Ch ed fe he m I’ m te I’ m a I’ m I’ m a he I’ m I’ m I’ m Cultural Competency is the ability to: 25% 25% 25% 25% 1. Interact effectively with people of different cultures 2. Appreciate differences and adapt for effectiveness 3. Implement system-wide practices to optimize care 4. All of the Above . . . .. t.. c. . f .. o. ys di ffe Ab ts te e he en c ia ct t ra m e of te pr e pl l In Ap Al Im Which of the following ways can improve your cultural fluency? 20% 20% 20% 20% 20% 1. Ask and really listen 2. Minimize your assumptions 3. Empathize with your clients 4. All of the above 5. None of the above .. . .. . ... .. .. b. o. ith lly ur ab ea a yo w re th he ze ize d t of i an th im of ne pa k in l Al As No Em M Which of the following is True: I am a Deaf/Mute 33% 33% 33% 1. Don’t worry, I can’t hear a thing 2. Ignore me because I can’t speak 3. I want to be treated with respect and dignity ... ... . t.. ca ,I be ry be or o e tt tw m an re n’ Iw o Do Ign A family member is an effective interpreter for patients seeking medical care 33% 33% 33% 1. True 2. False 3. Other se er ue l h Tr Fa Ot Which of the following is NOT true of a culturally competent organization: 25% 25% 25% 25% 1. Provides professional interpreters 2. Information is in the languages of its patients 3. Staff reflects the cultural mix of its of its clients. 4. Staff does not need to be reminded to treat all patients with respect. .. .. .. . e.. ts . is. ot. rof c on sn fle sp ti oe e ma ff r id e ff d or Sta v Sta Pro Inf Case One Ramone • 45 Filipino male who works on a fishing boat. • Married to a local woman with 3 young children • He is very religious. • Has sex with other men but does not consider himself homosexual. • Very upset with positive HIV test and accuses you of malpractice How would you address his concerns? Case Two Rich 35-year old local male seeing you off and on for 5-years. HIV+ and doesn’t work. He is an alcoholic, angry, and wants pain medications immediately Non-adherent to HAART because of the diarrhea and nausea How should the receptionist be taught to deal with this patient? How can the physician help this patient? Forging Solutions While this is all well and good, the question ultimately becomes how do we handle situations that challenge our attempts to live by the Golden Rule? Reducing Lost to Follow-up What can we do? Standardize information gathering Document, Document, Document… Confirm contact information at every visit. Ask patients for the best way to reach them Ask if patient expects to move within the next six months. Reducing Lost to Follow-up, cont. Obtain/Confirm emergency contact information for the patient at each visit. Obtain employer information Reminder calls Smiles and friendliness go a long way Reducing Lost to Follow-up, cont. When suggesting follow-up appointments, you might ask: How will you get here? Will you have transportation? Would 4:30 be better for you? Reducing Lost to Follow-up, cont. Could you call us if you can’t come so we can schedule other patients? Make it clear that “No” is OK. “It’s okay if that time doesn’t work for you. Tell me what time is better.” Improving patient satisfaction Active listening to improve outcomes People often are not listening attentively to one another. They may be distracted, thinking about other things, or thinking about what they are going to say next Improving patient satisfaction You can help by: Tuning in, ignoring distractions Acknowledging key points, and confirm w/patient, Expressing yourself clearly and succinctly Enhanced Listening Active listening structures listening and responding to others. Enhanced Listening It focuses attention on the speaker. Suspending judgments is important in order to fully attend to the speaker. Enhanced Listening Modifying listening skills: Summarize the patient's chief concerns. Interrupt less. Enhanced Listening Modifying listening skills: Offer regular, brief summaries of what you are hearing from the patient. Reconcile conflicting views of the conversation. Enhanced Listening To improve understanding between patient and care-giver, you could ask: "What I hear from you is ….Did I get that right?“ This affirms the patient’s perspective, And reduces misunderstandings Enhanced Listening To illustrate empathy; ensure understanding of patient's emotional responses to condition and care: "You seem quite upset. Could you help me understand what you are going through right now?" Enhanced Listening To improve adherence: "What's your understanding of what I am recommending?“ “How does this treatment fit with your ideas about how to cure your illness?“ Enhanced Listening These questions can confirm your instructions and reveal challenges to treatment the plan Universal Skill: Clear Communication Don’t…... Use medical jargon Prescribe w/o explanation Provide too many recommendations Assume the patient understands Expect patients to recall your medical advice Universal Skill: Clear Communication Do…... Use simple explanations Be specific Prioritize, and focus on a few critical recommendations Universal Skill: Clear Communication Do…... Ask the patient to describe the treatment plan Give your patient written, simple instructions Universal Skill Building Don’t…... Assume knowledge/skill Teach too much at one time Assume one-session learning Assume skills will remain accurate over time Universal Skill Building Do... Observe behavior Prioritize, teach one skill at a time Repeat instructions Make skill assessment and instruction part of standard care Foundations for Success Don’t... Be judgmental Criticize and threaten Expect too much Ignore good behavior Foundations for Success Do… Accept less than perfect behavior Do problem solve Set realistic goals Praise even small positive behavior change Difficult Patients: Types Substance users: alcohol, drugs Angry patients Drug seeking patients Emotionally Needy Violent patient Mentally challenged Difficult Patients: Types, cont. Adolescents Demanding/Complaining Emotionally Needy Re-scheduler Seductive Non-paying Others? Difficult Patients May have difficulty understanding common social boundaries The patient/care-giver encounter is like any interpersonal relationship Boundaries must be established and maintained to encourage positive outcomes and maintain professional standards Difficult Patients: The How’s A “demanding patient” may be a person who challenges the customary professional or personal boundaries between the patient and the care- giver. Difficult Patients: The How’s They may challenge boundaries because: They don’t understand/recognize them Psychological impairments Neediness Et cetera Difficult Patients: The How’s It is the care-giver’s responsibility to maintain professional and personal boundaries. Difficult Patients: Boundaries Basic boundaries Adhering to the law. Maintaining standards. Keeping appropriate emotional distance. Precluding inappropriate physical contact. Difficult Patients: Boundaries Maintaining standards (rules). Rules are relative to a social setting. Rules promote efficiency because everyone abides by them. If rules are bent, then systems can be compromised (Change the rules if they are failing to meet needs) Difficult Patients Challenging boundaries can; Engender feelings of frustration, Ambiguity, Anger And create a feeling of being manipulated Difficult Patients: The Whys They may feel mistreated, cheated or ignored Have personality problems Be experiencing social/financial problems Lack trust, information or have communication difficulties Cultural differences Difficult Patients: The How’s Set limits Restate common goals Schedule regular visits… Difficult Patients: The How’s Keep visits short and focused Prioritize the patient’s needs Deal with the most pressing issue first Difficult Patients: The How’s Schedule follow-up w/understanding given to the patient that her/his concerns are valid; They will be addressed fully in future visits; But it is important to focus on one issue at a time to ensure thorough care Strategies : Complaining Patient Evaluate the physiologic basis for each symptom Conduct a thorough medical evaluation Refer for consultation with a mental health professional if needed Strategies : Complaining Patient Some patients who complain no matter how well they are doing; Need to be evaluated for a physiologic basis for each symptom; Strategies : Complaining Patient Care-givers need to understand a patient’s emotional patterns without labeling the symptoms as real or psychosomatic; Diagnosis of symptoms should be based on objective clinical and lab findings. Strategies : Complaining Patient If a care-giver exhausts tests and cannot find the cause, the patient should be assured that there were no serious findings. And consider referring the patient to another physician for a second opinion. Strategies : Complaining Patient In either case, it is imperative to document complaints in the medical chart. Documentation may preclude future misunderstandings Re-Scheduler/ Non-Compliant Patient Provide patient with written notification of the potential consequences of failing to follow medical advice Inform the patient, in writing, of the need for ongoing care Strategies: Re-Scheduler Care-givers are responsible for maintaining regular follow-up on patients who are prescribed medication on a regular basis since medical conditions change, progress, and get complicated over time. If changes are unidentified, Care-givers may miss something important. Strategies: Re-Scheduler Patient education is necessary to reinforce the value of regular follow-ups. Rules should exist so that all patients are seen at set intervals of time. Missed appointments should generate a letter or conversation explaining the need for regular patient care. Strategies: Re-Scheduler Repeated missed appointments may have an adverse outcome on the patient’s long term health. This information needs to be communicated to the patient, with documentation made in the patient’s medical record. Strategies: Angry Patient Politely isolate patient into private space Assure him/her that privacy will aide your complete attention Leave the door slightly ajar to facilitate your escape, if necessary; Strategies: Angry Patient Maintain your composure As the professional, your task is to control the situation through careful attention to your emotions Anger, fear, visible displeasure are unhelpful at this time, Strategies: Angry Patient Visible concern and empathy can help to de-escalate a situation If you feel unsafe, excuse yourself politely and seek assistance Otherwise… Strategies: Angry Patient Listen to the patient Don’t escalate the discussion by; Raising your voice; Vehemently contradicting the patient; Vigorously denying the patient; Strategies: Angry Patient Confirm what the patient is saying by succinctly restating the problem in a calm manner at natural break points in the conversation; e.g., “I understand you’re upset that we did not provide your test results as promised; that must have been very frustrating to not know your prognosis.” Strategies: Angry Patient If feasible, offer a solution or solutions to the patient within your capabilities; If accepted, re-state your understanding of the frustration the patient experienced; Strategies: Angry Patient Confirm your plan to resolve the matter, and Obtain a clear sign that the patient accepts and is satisfied with the solution. Strategies: Violent Patients Maintain a calm demeanor as a means of being a neutral factor in the exchange Suggest the conversation be moved outside Strategies: Violent Patients Never let the patient get between you and the door, If the door is closed, get it ajar in a non- threatening manner; Keep your back to the door at all times Strategies: Violent Patients When in doubt, politely excuse yourself, and get help; If there appears to be no means of de- escalating the situation, recommend an opportunity to collect more facts, and promise a follow-up phone call or meeting Concluding thoughts All of us in the health care field contribute to the well-being of our patients Concluding thoughts We each can make a positive difference in someone’s life through our actions Concluding thoughts By treating all patients with the consideration and respect that your faith and/or professional code expects of you Questions?