Today, nurses in the hospital where I primarily work are presenting signed Valentine’s to each patient. The patient bedside is where it all comes together – the quality and safety of clinical care provided, cost of care, patient satisfaction, and employee and physician engagement. “Love”, says Peter Pronovost, “is the secret sauce of healthcare quality”. Clinicians in the microenvironment around the patient, i.e., physicians, nurses, patient care technicians, trainees, allied health personnel like respiratory therapists, physical therapists, occupational therapists, dieticians and chaplains, often overcome several challenges to integrate multiple best practices as well as multiple hospital initiatives to improve quality, into the routine clinical care they provide. Patients respond to the challenges that clinicians face at the bedside in a variety of ways. The majority of patients want to help, but unclear on how to effectively participate in care.
Health systems are complex and adaptive in nature. The interactions happen through dynamic networks, and the individual clinical units (wards, intensive care units, clinics, procedure areas, etc.) are somewhat independent from each other while being connected and influencing each other. Behaviors of individual clinicians and the clinician groups in the patient microenvironment are constantly ‘mutating’ and self-organizing in response to local events (e.g., patient safety event such as medication error or wrong site procedure, disruptive behavior by a patient or clinician) as well as initiatives and mandates from a higher level (e.g., system-wide campaign to require identifying a patient using two identifiers, system-wide initiative to reduce healthcare-associated infections, getting the health system ready for a regulatory survey, national mandatory reporting of sepsis care processes, ebola outbreaks in West Africa and concern for infection among returning travelers).
What needs to happen in order to ensure quality, safety, and value at the patient bedside? First, it requires effective translation of events occurring at all levels of the health care system (Ferlie and Shortell, 2001; individual level, care team level, organization level, and the political and economic environment) into care practices that must be used in routine clinical care. The care practices need to be aligned with the six components of quality, i.e., safety, timeliness, efficiency, equity, effectiveness and patient-centeredness. For the last component, I would argue that relationship-centeredness might have several advantages over patient-centeredness, given how many physicians and nurses are experiencing ‘burn-out’. Second, it requires integration of these care practices into seamless workflows to ‘make it happen’ for the patient. Third, it requires physical spaces and information systems to be conducive for optimal patient care. Fourth, it requires that clinicians bring their ‘A’ game to the patient bedside every day. Knowledge, skills, expertise and experience, combined with compassion and integrity. Fifth, it requires that clinicians interact with each other effectively. The need for strengthening and leveraging positive peer pressure in the patient microenvironment has never been greater. External mandates and punitive measures only go so far, and they are not sustainable. All this requires respectful communication and leadership at all levels. I strongly believe that leadership is the key driver for making all this happen. Excellent leaders listen to the voice of the patient as well as the voice of the clinician.
There are numerous unknowns in this journey to converge quality, safety and value at the bedside for better patient care outcomes. We will explore them in future posts. My intent for writing on this topic is not to serve a meal, but to offer an appetizer. ‘Thought tapa’, if you will. Happy Valentine’s Day!