Critical Incident in Healthcare - Essay Example

Critical Incident in Health Care Critical incidents do not have to be uniformly negative or about accidents, death or severe injury: “Critical incidents are snapshots of something that happens to a patient, their family or nurse. It may be something positive, or it could be a situation where someone has suffered in some way” (Alphonso, 2007). A critical incident that happened to me that was positive was when I felt very sick and went to a small clinic in order to be helped. Normally, waiting rooms at such clinics are very long, arduous affairs. But as I shivered, sneezed and felt in a great deal of pain, worried about a potential bacterial infection, one of the nurses offered me a bowl of soup to warm me up. Other patients in the room were clearly there for other less sensitive issues, but she couldn't change the order of their treatment, because that would be unprofessional. Instead, while she was waiting and processing orders, she handled my needs to improve my comfort. This helped alleviate a painful experience, and when it came time to be examined and informed that I had only contracted a nasty flu, I was no longer scared, lonely or miserable. Kolcaba notes that nurses were not always viewed strictly as providers of care with a minor comfort support position, essentially less-trained doctors (2003, pgs. 19-21). Rather, in the 19th and early 20th centuries, comfort provision was a key part of nurse care. Part of this may have been the domestication of nurse's roles and the association of nursing with femininity, but there was also a recognition of a holistic need for provision of comfort and care as well as treatment: “[T]here was nothing concerning the comfort of a patient that was small enough to ignore” (Kolcaba, 2003, pg. 21). Nursing wasn't just concerned with mechanically providing food, cleaning, and other specific services, but with general well-being. In an era where cures were few and far between, providing comfort became the nurse's unique role. But since then, the improvement both of cures and of pain medication has made it so that nurses view their comfort role purely physically and mechanically. In the 19th and 20th centuries, nurses did not discuss treatment with patients because this was the role of the physician. While the change away from this norm is undoubtedly both more socially appropriate and just and more medically sensible, one good consequence of this norm was that nurses were de facto mental health care providers, giving patients emotional as well as physical comfort. That soup that day and this critical incident analysis teaches me that the provision of comfort and attending to the needs of patients are vital. Hospitals are scary to many people: They feel deeply averred by sterile environments, other sick people, and an area where people often come to die. Provision of comfort is necessary to avoid deterring people from seeking medical care entirely. Resource management is vital to health care (Woloshynowych et al, 2005). Critical incident reports help guide those analyses. But most critical incident reports, while not looking solely at “death” and using a wide variety of indices and approaches, tend to focus purely on negative outcomes such as accidents. While critical incident reports should tend to take this approach, there is little point in focusing exclusively and perpetually on what was done wrong, what mistakes were made and what miscalculations were engaged in. Analysing success stories and proper provision in some vein, with the same techniques, is essential to resource management: One has to know where to put resources, not just where not to. Resource management in health care improves the provision and efficiency of health care through the following means: 1. Directly improving the efficiency and effectiveness of resources allocated to patients and therefore directly improving patient health (Mercado) 2. Prioritising of spending in terms of distribution between “populations, disease areas and interventions” (Dash, 2010). “Each intervention within a pathway can be quantified in terms of its expected impact on health and delivery cost. The resulting 'cost curve' identifies which interventions deliver maximal health gain per amount spent, and which add lower value. 3. Improve long-term care by using mechanisms such as patient registries, performance monitoring and lowering costs to patient and hospital (Dash, 2010) 4. Optimise care settings and places. My critical incident occurred in a small clinic since it was closer and more convenient. It turns out that hospital overhead is not always justified (Dash, 2010) 5. Scientifically determine optimal prevention strategies and then promote them (Dash, 2010) 6. Provide guidance and standards of care to promote greater uniformity without preventing innovation and individuality: This avoids 10% of inpatients who experience an adverse event, many of whom were caused by errors due to miscommunication or improper adherence to standards (Dash, 2010) 7. Optimise operations, reducing the number of support personnel to “reduce duplication, increase throughput and capture scale benefits” and make sure that expensive utilities like MRIs and CTs are always being used efficiently (Dash, 2010) 8. Reduce back office spending by 10-15% (Dash, 2010) 9. Mobilise patients, letting them leave earlier, monitor their own conditions and thus reducing overhead and increasing effective patient turnover (Dash, 2010) 10. Enforcing accountability (Berger, 2004) 11. Monitoring goals in a timely and relevant manner, giving immediate feedback to relevant practitioners (Berger, 2004) 12. Report results using a balanced scorecard composed of all relevant needs and taken from all relevant stakeholders (Berger, 2004) 13. Flexible budgeting for the unique difficulties of health care provision (Berger, 2004) 14. Giving concrete goals for overhead management (Berger, 2004) 15. Percentile goals, benchmarking, and monitoring and improvement of labor productivity and reductions in resource consumption (Berger, 2004) 16. Labor ratio goals These are all laudable goals and mechanisms, and should be achieved with scientific accuracy and professional acumen. But my fear reviewing them is that they are focused on mathematical notions of efficiency and uniformity of standards that might prevent adapting care to individual patients and to the particular needs of communities. The above critical incident report indicates profoundly the importance of comfort provision. The problem is that comfort provision is much harder to quantify. Does one quantify satisfaction and avoidance of pain with surveys? With nurse reports? And patients who are being treated right may not notice the particular intervention. The soup I was given was so startling precisely because it was a clinic and such services were not normally provided. But if I had been at a hospital, I might not have noticed if a nurse had brought me an extra soup or a hot blanket that was not strictly part of my rotation. What patients, doctors and administrators don't and can't notice can't be included in analyses. I propose, then, that comfort analysis be part of any resource management proposals. Berger (2004) provides for patient satisfaction surveys in his proposals for resource management. I would further add that the surveys taken of nursing staff should include sections asking what nurses do to provide comfort, to what degree they believe patients notice, what importance they put on that behavior and other indicators of their actual provision and importance placed on comfort services. Teamwork is also obviously deeply relevant to health care performance. A hospital in particular and the health care system in general is a partnership between an immense number of stakeholders and service providers. Patients need to be attended to by support staff, their information taken down and processed; that information needs to be made available to nurses, who in turn need to be able to work with doctors and physicians; primary care physicians need to be able to trust and work with specialists; administrators need cooperation with doctors and nurses who in turn need administrators to be responsive to and serve their needs; etc. It is unsurprising, then, that there is a large literature on the benefits of teamwork in health care provision. Leggat's study found that the current model of health care provision is deeply unsatisfactory in terms of accounting for the different interpretations of needs and the highly team-centered provision of health care. “Although not part of the research question the data suggested that the competencies for effective teamwork are perceived to be different for management and clinical teams, and there are differences in the perceptions of effective teamwork competencies between male and female health service managers. This study adds to the growing evidence that the focus on individual skill development and individual accountability and achievement that results from existing models of health professional training, and which is continually reinforced by human resource management practices within healthcare systems, is not consistent with the competencies required for effective teamwork” (2007). Studies by Leggat (2007), Oandasan through the CHSRF (2006), Clements et al (2007), and analysis by Lighter determine that teamwork improves the provision of health care through the following means: 1. Improve quality of patient care 2. Enhance patient safety 3. Reduce workload and burnout 4. Reducing miscommunications and thereby reducing unnecessary, redundant or dangerous interventions 5. Creating an environment of camaraderie and cooperation that directly leads to patient comfort and satisfaction 6. Reducing waiting time for patients by improving coordination As we've seen, health care management provides support through four means: Operations management, providing managerial tools and employing them, providing valuable effective management, and conflict management. The basic principles of operations management are to reduce overhead, reduce costs to the patient and to others footing the bill, preserve the fidelity of financial control and insure that financial statements are accurate, enforcing accountability and creating and monitoring goals, and making sure that support and administrative staff are as small as possible so that the maximum money can go towards direct care provision (Berger, 2004; Dash, 2010; Mercado). Techniques of operations management include percentile goals, surveys, flexible budgeting, enforcing low overhead costs (below 40% being a good goal), and using labor ratio and “cost curve” analysis to make sure that labor and interventions are maximally efficient and to guide practitioners to the least expensive tool that accomplishes the job the best (Bertger, 2004; Dash, 2010). There is a risk of unwarranted stinginess with operations management, which is directly relevant to comfort provision, but that is only a risk of style and not inherent to the concept. Cost management is good. A hospital has limited funds and resources. Every resource allocated to one patient must in essence be taken away from another. Justifying severity of condition, necessity and efficiency of treatment, and so forth may seem cold, calculating and mathematical, but it is ultimately designed to make sure that patients get the least onerous, least extensive treatment. Effective operations management reduces the cost to the patient, the time patients spend in hospital, the cost to the government, and the wages and benefits for doctors and nurses. Everyone wins when the system is more efficient. As long as comfort provision, quality of care and patient satisfaction is made the number one priority, operations management is a powerful tool. Similarly, effective human resources and general management can be a valuable tool (Dash, 2010; Mercado). Palfrey et al point out that proper management has been a part of medical care provision for the entire 20th century (2004). Effective management can improve patient care by 1. Using “best value” analysis and performance management to optimize the success and efficacy of practitioners (Palfrey et al, 2004) 2. Promoting strategic decisions about the scope of the organisations' activities (e.g. if a hospital might need to shrink to a clinic in order to provide more efficient care), the organisation's environment (e.g. if practitioners repeatedly express and demonstrate weak teamwork skills thanks to an individualist culture in medical school) and resource implications 3. Promoting integrative decisions that integrate health care providers better vertically (up the chain to national health organisations and down the chain to individual clinics and primary care physicians) and horizontally (between two hospitals or clinics) Managing conflict is part and parcel of teamwork. Ramsay (2001) explains, “Managing conflict in the workplace is a time-consuming but necessary task for the physician leader. Conflicts may exist between physicians, between physicians and staff, and between the staff or the health care team and the patient or patient's family. The conflicts may range from disagreements to major controversies that may lead to litigation or violence. Conflicts have an adverse effect on productivity, morale, and patient care. They may result in high employee turnover and certainly limit staff contributions and impede efficiency”. Threats Ramsay identifies that lead to conflict and mechanisms for dealing with them include 1. Disruptive physicians: Since most physicians are type A and highly directed and ambitious personalities, and since medical schools do not often provide good training in teamwork and moderating type A behavior, conflict management needs to manage among type A physicians who may not be able to coordinate and between type A physicians and type B staff members 2. Preventative measures: Conflict is best nipped in the bud rather than managed after it starts, and so the best way to avoid this is to provide training and support in terms of professional, conflict-aversive, teamwork-inducing behavior and to continue to promote that philosophy so conflicts never start or are short-circuited by proactive apologies 3. Poor emotional intelligence: Emotional intelligence is another skill not often taught in medical school that hospitals may need to teach 4. Avoiding violence in the workforce: Over one million US workers are assaulted yearly and the UK is not substantially different, and increasing stress may cause physicians to become violent; using non-aggressive posture, talking, positioning (e.g. no cornering of the person, physically or metaphorically) and so on can manage these issues One of Leggat's (2007) primary critiques of currently inadequate health care provision was the lack of focus on proper communication skills and team coordination. Communication skills in medical care is literally a matter of life and death (Oandasan, 2006). Communication to patients must not only be skillful, assuaging them and not delivering undue stress, but must also be honest, unequivocally clear, given to them in a manner they understand (e.g. as little medicalese as possible) and satisfy legal and ethical requirements of informed consent. Communication from patients must be understood precisely for diagnostic and treatment purposes. These two factors are part of the comprehensive, holistic approach to comfort provision. Similarly, communication amongst providers must be clear. At each step along the treatment arc, providers must provide information clearly, comprehensively and succinctly, telling the next person involved in the treatment of the patient what is wrong, what current tests have discovered, what current and past treatments are and have been employed, etc. Ultimately, comfort provision for one patient requires a whole hospital. That day, the nurse demonstrated a commitment in her institution to making patients comfortable and preparing them for arduous treatment. Effective health management can advance that goal as well as a bowl of soup. References Alphonso, CD. “Reflection on a Critical Incident”, Available at: http://www.contemporarynurse.com/archives/vol/24/issue/1/article/2218/reflection-on-a- critical- incident American Health Lawyers Association. Conflict Management Toolkit. Available at: www.healthlawyers.org/Resources/ADR/Documents/ADRToolkit.pdf Bass, PF the III, Talente, GM, Wood, JA. Conflict Management in Health Care. Available at: www.sgim.org/userfiles/file/AMHandouts/AM06/handouts/WC08.pdf Berger, SH. 2004, “10 ways to improve healthcare cost management: if your hospital hasn't been achieving cost savings, maybe you need to make—or renew—a commitment to cost management”, Healthcare Financial Management, August, Available at: http://www.hcillc.com/about_us/books_and_articles/ 10_ways_imprv_hc_cost_mgmt.html Branch, WT Jr. 2005, “Use of Critical Incident Reports in Medical Education”, Journal of General Internal Medicine, April 27. Clements, D, Dault, M and Priest, A. 2007, “Effective Teamwork in Healthcare: Research and Reality”, Healthcare Papers, 7(Sp): 26-34. Dash, P. 2010, “The eight ways to save cash and improve care”, Health Service Journal, November 8. Dieleman, M, Gerretsen, B, van der Wirt, GJ. 2009, “Human resource management interventions to improve health workers' performance in low and middle income countries: a realist review”, Health Research Policy and Systems, April 17, vol. 7 no. 7. Kolcaba, K. 2003, Comfort theory and practice: a vision for holistic health care and research, Springer Publishing Company. Leggat, SA. 2007, “Effective healthcare teams require effective team members: defining teamwork competencies”, BMC Health Services Research, February, 7:17. Lighter, DE. 2009, Advanced performance improvement in health care: principles and methods, Jones and Bartlett Learning. Medical Training Institute International. “Managing Conflict in Health Care”. Available at: http://www.mediationworks.com/mti/certconf/healthcare.htm Oandansan I et al. 2006, Teamwork in Healthcare: Promoting Effective Teamwork in Healthcare in Canada, Canadian Health Services Research Foundation. Palfrey, C, Thomas, P, and Philips, C. 2004, Effective Health Care Management: An Evaluative Approach, Wiley-Blackwell. Ramsay, MAE. 2001, “Conflict in the health care workplace”, Proceedings (Baylor University Medical Center), April, 14(2): 138-139. Rawls, R. 1998, “The hurt that never heals: Conflict management in health care”, Georgia Nursing, Aug/Sep. Woloshynowych M, Rogers S, Taylor-Adams S, Vincent C. 2005, “The investigation and analysis of critical incidents and adverse events in healthcare”, Health Journal Association, May. Read More