One of the frequently overlooked issues in the quality and safety movement is the importance of the fundamentals of care. We have a tendency to look at high profile issues like ventilator associated pneumonia or medication reconciliation (both of which are important) while forgetting that basics of patient care must be in place first. If we don’t see the connection of basic care processes to the high profile issues, we are effectively treating symptoms rather than root causes. As insiders, we forget how much workaround we do to get the basics done. Patients as outsiders are able to see what for us has become invisible as the following story reflects:
I enter Mr. Smith’s room for a post-operative pain evaluation. My introduction and query into his level of pain are met with a cold, silent stare. I ask him again how his epidural and PCA are working for him. Initial silence, followed by a reluctant response: “I’m very angry, not at you but at the hospital for the way I am being treated here.” I sit down on the window ledge and ask him to share what’s going on. He informs me that up until last night he thought the hospital was the “best thing since sliced bread” but that after this morning that’s no longer the case. He has no complaints about the nurses and physicians providing the care and what he shares is his frustration and anger about the lack of attentiveness that has resulted from staff being stretched way beyond their capabilities. He notes that his nurse is taking care of so many patients, many sicker than he, that she has no time to clean him up, to change the sheets, to assist him with walking. He notes how earlier in the morning his IV pump was reading “low battery.” Since he hadn’t gotten any responses to his nurse call button before, he asked his sicker neighbor to push his button. (“The poor guy,” he says, “he’s been waiting to get an MRI for two days”). The nurse showed up just as the pump started to alarm due to power failure. Fortunately the pump needed to be simply plugged in so that the batteries could recharge, and as the nurse started to leave the room, the patient noted that all of the infusions were blinking “reset.” “I don’t think I missed out on getting anything, but what if I hadn’t noticed or been able to call the nurse back and tell her?” His nurse walks into the room carrying a chair as the patient and I chat. “Look at that,” he says, “nurses should not be spending their time moving furniture!” She smiles and as she hurries off to do something else says, “I do it willingly.” “Willingly or not,” says the patient, “she shouldn’t be doing it.”
This reminds the patient of another earlier experience. He recounts how he was sitting in a chair and that his oxygenation was too low on room air. His nasal cannula tubing would not reach the wall oxygen source from the chair and the nurse went off to find extension tubing. She was gone for 20 minutes, looking for the tubing. She finally came back, and having been unable to find the extension proceeded instead to rearrange the furniture so that he could sit closer to the wall with the regular tubing. She then started to change the bed sheets without turning the oxygen on, again having to be reminded by the patient. He’s incredulous. “She’s probably one of the best nurses here, and she’s great, but she just has too many things to do at once to keep priorities straight.” Finally he says, “I have to do something about this, I don’t know what, but I might have just found something new to do with my life.”
Food for thought: Notice how the experience encompasses multiple basic care processes in the areas of:
1. Quality of Care
2. Patient Safety
3. Patient Satisfaction
4. Staff Satisfaction
The only way these connections become visible is with a system-based approach to problem solving.
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