Final Reflections

Ten weeks ago I began my journey into the world of health administration under the tutelage of the professors at the University of Washington, MHA program. I arrived at the MHA program with an undergraduate degree in business management and four years of experience working for a nonprofit organization that provides support services to the mentally ill population of Josephine County, Oregon. I knew virtually nil in regards to medical clinical care. The MHA program required that I explore the topic further and I have since begun to understand that clinical care encompasses a variety of issues, processes, ideas, procedures, beliefs, theories and practices. One topic that I found particularly interesting was that of the role of the “provider” in the provider-patient relationship. Exploration of this relationship taught me how to ask questions. The answers of which will provide me with the information that I need to be an effective administrator.

One of the first clinical care topics that I was invited to explore in the MHA program was that of disease, illness and sickness. The question was simple, what is/is not a disease? I thought it interesting that during a discussion, my class and I tried to avoid attaching unattractive labels like “disease” to things that we considered “normal”. Prior to this exercise, I didn’t realize that negative connotations are almost always attached to words like sickness, illness and disease. Nor did I realize that as a result, many patients experience feelings of powerlessness, depression or loneliness. As an administrator, whose job it is to support my providers, the question becomes whether or not the role of the provider includes provision of services outside of the assessment of symptoms, diagnosis of illnesses and treatment planning for said illnesses.

Two more exercises in my clinical care class required that I watch a video. One video explored whether or not medicine is a calling or a business. Certainly, the video leaned toward medicine as a “calling” but, does that mean that in order to be a good provider one must forego the business end of medical care? The second video was about a woman who pours blessed water on people and prays in order to heal them. I was asked to evaluate whether or not hiring this woman was a good idea. At first, I thought the idea ridiculous. I then explored cultural relativism and realized that the term “provider” can mean different things to different people at different times.

Further investigation into the role of the provider in the patient-provider relationship was an exploration of error disclosure. This topic brought up some important issues. Should a physician reveal error? If so, how much information should be shared? How should the information be shared? Is the physician responsible for sharing errors with the patient? I also explored how the culture of medical school influences physician behavior. I discovered the importance of a good role model for young physicians to develop the bedside manner they need to work with patients. My question, after watching that video was how I might change the culture of medical school to, as Kurt O’Brien would say, “Humanize” patients for doctors.

The end result of my investigation thus far is that I now understand some of the aspects of the role of the provider in the provider-patient relationship, I also have a few opinions and ideas regarding the subject. More important, I am learning to ask the questions that I need to ask as an administrator to get the information I need to do my job.

More Technology: Physician or Technician?

The assignment:
Discuss your thoughts, feelings and insights as to a future health care system that is heavily technology-focused. In essence, what will it mean for leadership? Focus on the topics we have been working through this quarter - topics such as disease/illness/sickness, relationships, business or calling, and the like.

After last week's assignment on technology, I had the privilege of reading my classmates' comments. Many of my peers seemed to welcome the "wonders" that technology had to offer the medical profession. Some however, expressed concern regarding costs, legalities, and the lack of relationship inherent in technology based medicine. This week, I read some articles that my professor posted on our class website that provided me with more insight on the subject.

After all of my exploration in regards to medical technology, I have come to realize that my role as a healthcare leader in regards to technology will be one of scrutiny and balance. Literature suggests that it is often both financially advantageous and less time consuming to order a "test" than to actually sit with a patient, ask questions and draw on experience to make a diagnosis. My concern here is the assumption that machines are infallible--making the role of the physician one more of consequence than anything else. To be certain, the professional landscape of medicine is changing and an effective leader will have to change with it.

My family had a family practitioner that took care of all 6 of us. I knew my doctor's name, he knew my entire family. I got a lollipop when I went to see him. I realize that not all individuals share my nostaligic view of medicine and that some people may not want that same intimate relationship that I once enjoyed with my family doctor. I am careful not to impose my preferences on an entire healthcare system.

Literature suggests that most Americans want to "throw everything we got" at their disease or condition. However, a prudent leader must be able to discern the risk/benefits of a procedure and communitcate the same to the hospital staff and/or patient. Whether medicine is a business or a calling makes no difference to me. Beacause regardless of where you are on that continuum, the fact that we in the medical profession must hold our patients' best interests as our top priority remains unchanged. (Regardless of what motivates you).

Medical technology

Looking at the advancement of technology over the last two centuries is a sobering experience and to be honest, I haven’t given much thought as to what these advancements mean to a me as an MHA student. Will healthcare be a place where I can find job satisfaction?

In order to answer this question, I must first consider how the rapid advancement of technology will change the healthcare environment and then consider the ramifications of these changes. I will try to consider the organization, financing and delivery of healthcare while making my analysis.

I looked up the term, “medical technology” on Wikipedia and here is what I found:

“Medical technology refers to the diagnostic or therapeutic application of science and technology to improve the management of health conditions. Technologies may encompass any means of identifying the nature of conditions to allow intervention with devices, pharmacological, biological or other methods to increase life span and/or improve the quality of life.” According to this website, “the three largest companies active in this sector are Siemens A.G., GE and Philips.”

The website also lists roughly 20 (and opportunities to click and explore) examples of some of the technologies in use today.

From this view, it looks as if technology has greater effects on the delivery of care than perhaps any other arm of the industry. Of course, this is not the only area of the system that will be affected but probably the one that requires the most scrutiny—especially in light of the political climate of today where many are looking to the “healthcare home” model to improve quality and manage costs.

Certainly, the vision of being ushered into a room to have some machine perform some diagnostic test or therapeutic intervention seems rather cold when compared to the Norman Rockwell on your grandmother’s kitchen wall. I have read countless articles and research papers wherein large numbers of individuals feel somehow cheated by the “drive-by” service they get from providers. Will the introduction of these technologies exacerbate the “lack of personal attention” that is already a problem? Or, will technologies free up physician’s time which can in turn be spent with patients?

Another sure-bet as far as technology and healthcare goes is the design, development, and implementation of EMR systems. Today at the Washington Health Legislative Conference I was reintroduced to the idea of a 3rd party medical records storage provider. This provider operates a bit like igoogle. Insurance companies will contract with these third parties (who will contract with one another) and patients will store all of their lab test results, X-rays, medical histories and so forth on some server maintained by the third party. Each person will have an access code and will give the code to whomever they see fit, including providers. Some organizations will go other directions with this. Some will buy, some will hire and build, and some will hire for design and build themselves. At any rate, eventually all companies will have to implement some type of EMR system if they want to stay competitive. I wonder just how much cost savings are really involved here.

Some medical technology (if not most) helps sick people to live longer. In a world where insurance is supposed to spread risk but each player vies for the healthiest enrollee’s, I wonder if the distribution of these advancements will be fair and equitable. Lots of policy stuff here…What about overuse or underuse of technology? If cost containment is already so HUGE, what will the influx of new, expensive technologies mean in terms of costs?

Taken from the CNW Group website at http://www.newswire.ca/en/releases/archive/August2008/21/c5740.html

CT exams per 1,000 people performed 2007
Canada (103)
United States (207)
Belgium (138)
Sweden (89)
Spain (57)
England (54)
Denmark (34)

Rate of MRI exams per 1,000 2007
Canada (31)
England (25)
Spain (21)
Denmark (17)
U.S. (89)
Belgium (43)
Sweden (39)

Well, it doesn't seem as if Americans are adverse to technology, looking at this data! However, a CT scan or an MRI is a far cry from sitting in a doctor's office with a machine to take your pulse and temperature, check your heart rate or measure your height. Which I believe is where we are headed.

Medical technology will no doubt affect the world of healthcare across the entire system. Questions of quality, policy, workforce training & recruitment, equity, availability, social perceptions, and many more are on the horizon. All of which I feel confident that I would like to explore further, thereby increasing my interest in the industry. Moreover, I believe that medical technology has much to offer the healthcare industry in the way of increasing quality of care and improving business processes. I believe that I can find job satisfaction as a leader in healthcare and I also believe that healthcare will gain with the advancement of technologies.

Interview with a nurse

Today, I interviewed nurse "M" in order to complete an assignment I have been given by one of my professors from the MHA program at the University of Washington. Most of my experience has been with mental health administration and federal financing of state and local programs. So it is, with minimal clincial care experience, that I set out to find out how I might gain a better understanding of what exactly nurses do and look at ways that I, as a future administrator, might contribute to a better work enviornment for nurses and enhance the quality of care for patients. Below is a synopsis of the interview


Explore with your informant some aspect of nursing and health care that you find compelling

Knowing very little about nursing, I started with the basics and asked
My interviewee, “What do you feel are the different aspects of nursing?”

Her response:

§ Patient advocacy
§ Cultural diversity
§ Nurse-Doc relationships
§ Bedside manner
§ Team natured work
§ Provide care
· Assess the patient
· Diagnose the problem
· Make a plan of care
· Implement the plan of care
· Continually evaluate the plan


Do this with your HA hat on. What do hospital administrators need to know about nurses and nursing such that we could create a better environment of care.

o Administrators need to know what nurses do!

I asked, “What do nurses do?”

Her response:

§ Implement care
§ Monitor medications
§ Read test reports
§ Collaborate with Dr
§ Must have licensing in order
§ “run like a chicken with your head cut off”

I asked, “How might administrators help you to do those things?

Her response:

Nurses need:
Supplies & equipment where and when they need them
Competitive pay
A big one: ongoing education!
Up to date equipment
Competent coworkers

Nurse “M” works in an ER. She has 3 years experience. She shared that nursing is getting more and more complex with the number of different procedures & new equipment to learn. Keeping up to date and having “specialty” nurses to maintain a well balanced team is big for this nurse.
§

Try to get your informants to reflect on the core nature of what nursing was, is - and could be.

According to “M”, nursing started out as palliative. Nursing was "just caring for the sick." But, medicine has evolved to curative and nurses now actually play a major role in the implementation of curative care. In fact, members of the nursing profession actually help facilitate the healing process.

Summary

One of the themes throughout my conversation with nurse “M” was that nursing encompasses a huge array of services and procedures. Today’s nurse must know more and do more if they are to be effective in the curative process. Different conditions, diseases, and ailments require different techniques and clinical know-how. Nurse “M” felt that the best advice for administrators was to appreciate the nature of the nursing profession and all that it takes. In addition, hospitals need to provide on-going training for their nursing staff in order to meet the demands of the profession.

Nurse “M” shared that she felt underappreciated by doctors at times. Sometimes the orders a doctor gives are too excessive (even if they are necessary) for her to possibly accomplish while caring for other patients. She said she felt angry & frustrated when she was given 15 hours of work to do in 8 hours time.

I asked if nurse “M” felt that patients sometimes didn’t get the care they needed. Nurse “M” became quiet and with a sad sigh, said, “Yes, It’s hard to be a patient advocate when you are stretched so thin that you cannot provide all of the care a patient needs.”

Medical Error Disclosure: Best Practice?

Hello readers!

I am an MHA student at the University of Washington. Currently, my classmates and I are studying medical error and how to best address the issue. There is a great amount of literature that points to medical error as a problem in the U.S. healthcare industry. Certainly, we can all agree, both in and out of the professional world, that "errors" do happen. The question is, how do we best deal with the problem? There are two sides to this issue. First and foremost, how do we prevent medical errors from happening and second, what do we do when our efforts at prevention have failed us?

Many experts agree that healthcare is a team effort and that medical errors are often the result of some failure in the system. (one of my professors at UW thrives in the systemic environment!) A UW mini medical school video http://www.uwtv.org/programs/displayevent.aspx?rID=4086&fID=841 identifies 8 main causes for medical error. Clearly, the problems identified here all happen in different parts of the system. This means that failure happens at different stages in the chain of care. Therefore, a series of errors in the care delivery chain generally has to happen prior to what we call "a medical error".

One of the tools I use to assess the risk of systemic errors in an organization, and therefore prevent them from happening, is the DEPOSE Organizational Analysis Model by C. Perrow. You can find the article in "Decision Making, Conflict & Technology," in Complex Organizations: A Critical Essay, 3rd ed., New York, NY, McGraw-Hill, Inc. Perrow guides us through the true nature of systemic breakdown by revealing how multiple small errors (that on their own are harmless) in a linear delivery system can lead to significant problems. Perrow also draws distinctions between centralized and decentralized decision making and how the locus of decision making affects the intended outcome of the system.

Once we tackle the question of "why" errors occur and the "how to" of prevention we are still faced with the question of what to do when our best efforts have failed us? According to Dr. Mengert and Dr. Gallagher, full disclosure is the best practice. Even this poses some questions. When I watched the simulation in the above mentioned video, I likened the experience to one of poor service in a restaurant. As a recipient of poor service, my first thought would be, I KNOW I won't be paying for that 100 units of insulin OR the trip to the intensive care. I thought of how angry I would be if I got a bill for those "services" and how likely it is that I would. OUCH!

I'm sure that we all assume that providers who make errors absorb the costs of the unnecessary "services rendered" during the course of those errors. But, is there anyone who is ultimately responsible for making absolutely certain that those who are the vicitims of error are not billed in additon to being on the receiving end of poor service? Adding insult to injury is something I know that I want to avoid at all costs!

In a restaraunt, the manager generally gives you your meal for free or some other kind of compenstion when the service is less than adequate. This is done to maintain your patronage. I think it strange that, after hearing numerous conversations around the topic of medical error, the only "compensation" that anyone seemed concerned with was a law suit. In a restaraunt a customer would most likely refuse to pay for poor service. However, there are several reasons why compensation, other than a law suit seem unfeasable. One of which is the fact that insurance pays most people's medical bills so a "free" stay in the hospital never even seems to come to most people's minds.

The fact that people rarely consider a free medical service as having any immediate value points right to one of the reasons healthcare costs have climbed so exponentially over the last few decades. Because of the reimbursement system we have in the U.S., people have historically been somewhat immune to rising costs. This seems to be the case in the wronged patient. The is made evident by the lack of people seeking "a reckoning" for poor service. But, there have got to be better ways of compensating individuals who have been the recipients of poor healthcare service than litigation!

I thought about what I might like in exchange for poor healthcare service. Would a free hospital stay do it for me? An appology? hhmm . . . After pondering the subject, I decided that I would want charity service be given to someone who needed it in the exact dollar amount that my insurance company would have paid for my care. Yes, a direct relationship between the dollar amount in errors and dollar amount in charity care would "right the wrong" in my eyes.

I am now pondering how an incentive plan for "error free" service might reduce the number of errors in a healthcare organization. Many manufacturing plants have the signs, "error free for X number of days." This practice we know is one aimed toward reducing workman's compensation claims. Might we employ the same strategy in a patient care setting? Something to ponder.

Thanks for reading and please post your thoughts or comments.

Understanding Clinical Care: What Every MHA Student Should Know

Understanding Clinical Care: What Every MHA Student Should Know
By: Monica Wickham



When given this assignment, I immediately thought of a particular incident during my employment at Options for Southern Oregon, a mental health provider in Grants Pass, Oregon. I was asked to sit on a hiring committee to help interview a candidate for a Mental Health Therapist I postion. During the interview, one of the members of the interview team posed the question, “What can you tell us about your clinical experience?” I had no idea what would come out of our candidate’s mouth other than what he might know about direct service.

The gentleman we interviewed talked about implementing treatment modalities, patient relationships, and how he implemented best practices into his work. I don’t recall the specifics of what the man said but I do remember becoming acutely aware of the fact that I knew very little about what the term “clinical care” really meant.

I set about asking some of my colleagues what they thought the term meant. I got as many answers to my question as the number of people I asked. After interviewing my coworkers, I came to believe the term to encompass a variety of meanings, all within the realm of direct patient services. What I don’t know is whether or not “clinical care” includes services rendered by anyone other than the clinical provider. Does it include lab services? Does it include the receptionist who takes the clients’ insurance information? Or, is the term strictly used to define the relationship between the client and the direct service provider?

The term “clinical care” remains unclear to me. However, I am certain that every MHA student should have the ability to discern the meaning of the term regardless of context. I am further convinced that an MHA student should have the ability to consider the impact of organizational decisions on deliverables (clinical services). Therefore, I will spend the next quarter in David Masuda’s class defining and clarifying the term “clinical care” so that I might gain the ability to fully participate in discussions where the term is used and make decisions based on what I learn.

I will reach my goals by listening to speakers, asking mentors, research, and surrounding myself with others who have similar interests. I will know that I have reached my goals by answering the question, “what is clinical care?” with confidence. I will also know that I have reached my goal by discernment. If, when I hear the term, I know what people are talking about and I can make a meaningful contribution to the discussion or conversation, I have reached my goal!