Observations from a Front Seat at a Healthcare Organization

Nothing like a serious illness to a love one that requires daily visits to a hospital to provide a front seat view of the current state of our healthcare system.  My 85-year old mother was going through CRT (combined chemotherapy and radiation treatment) for cancer.

At the cancer treatment center, Monday was “infusion day.”  Infusion wait times of four or more hours were the norm.  Department associates explained that, “Mondays are very busy.” Scheduling practices such as starting all new patients on Mondays is a contributor to the un-level demand.  My mother’s treatment plan, one that many patients also followed, involved accessing her port and giving her a weekly ‘bottle’ each Monday which was removed each Friday.  This too contributed to the un-level demand.  The fact is that demand on the Infusion Department is very predictable (everyone is scheduled).  Clearly, no one has learned about the concept of ‘matching capacity with demand,’ or ‘leveling’. But let’s forget the possible causes.  Recognition of a problem is the first step of any problem solving effort.  “Mondays are very busy,” is not the problem.  The fact that seriously debilitated patients must wait for hours to receive treatment in highly uncomfortable conditions is the problem, and there is no recognition of this.  A quick glance of the waiting room should be sufficient evidence, but instead it is viewed as ‘normal for Mondays.’  By the way, the 15-minute infusion procedure and the 15-minute radiation treatment totaled 30 minutes of value add time over an average of 7-1/2 hours or 6.7%.

Anyone who has been through something similar understands the relationships that form not just with the caregivers, but between patients.  It is heartening to see the humanity that is demonstrated among patients.  No social status, everyone is equal.  Fellow patients lending a helping hand, words of encouragement and the like were on daily display.  At one point an associate in the Infusion Department approached my mother and said, “You have to give up your wheelchair, we need it in the back.” At that point my mother was no longer ambulatory.  As I tried to explain this, my mother, now roused from sleep, attempted to stand to accommodate the request.  I quickly turned to help her into a chair.  By this time several patients were literally yelling at the associate to “Leave her alone,” “That’s a disgrace,” and similar comments.  Embarrassed or feeling threatened, the associate retreated only to return later and tell us that they didn’t need the chair after all.   My mother looked up and said, “I’m already out of it, take it.”  As one patient asked, “Would she do that to her own mother?” A good question indeed.

Availability of wheelchairs was a daily struggle.  I asked about it, and the response was, “We have them, it’s just the night shift guy doesn’t collect them for the morning like he is suppose to.”  Either this was an example of the prevailing ‘blame and shame’ culture in healthcare, or a fact that indicates a systemic cause, which can and should be addressed.  I don’t believe that the concept of special versus systemic cause is well-understood in healthcare.

Radiation treatments were received Mondays through Fridays.  Wait times were a little over one hour most days, a welcomed respite.   However, by my estimate one of two treatment machines were unavailable nearly 30% of the days.  On those days, wait times would obviously increase, to about two hours.  Machine downtime would carry over through weekends on occasion, which I found interesting.   Therapists, nurses, and attendants were apologetic on these occasions.  Obviously, ‘predictive and preventive maintenance’ concepts have yet to find their way to healthcare.

My mother took a serious turn for the worse during the third week of treatment.  She was no longer able to swallow food, was only able to consume a small amount of water, and was suffering from persistent diarrhea.  After three days I took her to an Emergency Room at a ‘sister’ hospital of the cancer center.  After a 4 1/2 hour wait, she finally was given an exam room.  While we waited, I closely monitored her.  Her lips and mouth were dried out, tearing stopped so her eyes were visibly without moisture.  She did not have an evacuation the entire time we were there, this after three days of the opposite.  She was dehydrating.

The first doctor that saw her in the ER exam room, a resident, led off with the statement, “Before I look at your lab results, I want to hear from you.”  This brought a smile to my face.  Based on my mother’s responses, he ordered an IV.  After an x-ray and a CAT scan, we were all assembled in the exam room.  Joining us for the first time was ‘the boss,’ the attending physician.  He stated that my mother had gastritis that would be treated by medication, a common condition with patients receiving chemotherapy.  I asked about the dehydration.  He said, “I have the lab tests, she is not dehydrated.”  I suggested that he exam her.  Purposely looking away from my mother and towards me he said, “I have the numbers, she is not dehydrated,” and cancelled the IV.  Within 36 hours of that discussion my mother ‘crashed’ from dehydration.  We were back in the cancer center, and fortunately, they were able to immediately respond.  Clearly the ER physician has not heard of the practice of ‘listen to your patient.’ We returned to the same ER the following week.  My mother had fallen and broken a rib.  The same attending physician was there, “I remember you from last week.  How is the gastritis?”  I informed him that the medication was indeed working.  I also explained that my mother had crashed within 36 hours of leaving his ER the week before.  He stared at me for 20 seconds or so, and said, “So what seems to be the problem this week?”  He would not even acknowledge what I said.  Perhaps when I am not in his presence he will take the time to reflect.  Otherwise no learning, and no improvement will result, and that would be the more important mistake made.

Despite these experiences, healthcare professionals like RN Katie and ER Dr. Brian give me hope.  Katie ‘rose to the level of her license,’ provided exemplary care and always with empathy.  Besides being fully capable in all tasks required, she listened to her patient, asked others for input to cross check decisions she was about to make, and went above and beyond in her caregiving.  Such ‘humble inquiry’ was a breath of fresh air in an environment that sees little of this practice.

ER Dr. Brian was the doctor who first saw my mother in the ER and ordered an IV, the same IV that his boss had cancelled.  Brian practiced ‘go-see, ask questions, and show respect’ with his patient.  He truly listened to the patient and the family member, an act of respect in and of itself.  His colleague needs to do the same, and if he had done so, a serious situation could have been avoided.

As for my mother, she was taken off chemotherapy after less than three weeks.  Her appetite and ability to eat returned after two weeks of doing so.  She completed her radiation treatments.  She is now in an 8-week post-treatment period before surgery.  My sincere hope is that my next report will be filled with more positive observations of our healthcare system.

To learn about what you can do to create more positive observations for your patients and their families, go to createvalue.org to reach the website of the ThedaCare Center for Healthcare Value.  Here you will find downloadable white papers, videos, products, as well as custom and public education to equip healthcare leaders to transform the industry.

Submitted by Drew Locher, Center Faculty