Do You Have Oxygen?

Today, I will like to share two stories with you. Please read on:

Courtesy: Wikipedia

1.

On Wednesday June 24^th, I was called out of a church service by a well respected High Court Judge. He wanted me to help take a look at a little girl. Diane (not her real name) was a sweet looking two-year old. What struck me when I first saw her was how frail she was. She clearly had growth retardation and was about half her expected weight. She was in severe respiratory distress, cyanosed and febrile. Her parents said she had being admitted about 5 different times since birth for ‘pneumonia’. I didn’t have a stethoscope to listen to her heart. But, I immediately thought of a congenital heart disease.

I placed a call to a very good friend who is a Pediatric Resident and sent Diane to him for evaluation and management. After examination at the hospital where he works, he confirmed my fears. She had a Congenital Heart Disease. He promptly proceeded to admit her into the ward prior to investigations and further review. But alas, the oxygen cylinder in the ward was empty! And there was no oxygen in the entire hospital. Since her condition required oxygen as part of the immediate management, Diane was referred to another hospital. She died as soon as she got to the entrance of the emergency pediatric unit of the second hospital!

2.

About two years ago, a very close relative suffered a CVA and was admitted into the medical ward of a hospital. He was comatose for about a week and in that period, he needed oxygen to remain alive. The hospital didn’t have enough to go round all the patients. I wanted to keep him alive long enough so all his children could come visit him before his imminent death. As a result, I had to ‘borrow’ oxygen from several private hospitals in town to supplement what the hospital could spare for him.

The stories above are not fictional. They are real stories that involved real people who needed something as basic as oxygen. I am sure similar scenarios play out daily in hospitals and clinics all over the developing world. I have seen so-called emergency ambulances used to convey critically ill patients that lacked oxygen canisters/cylinders! Sadly, what Physicians in developed countries take for granted is now a luxury in many developing countries like mine. There is an urgent need to restructure and revamp the healthcare system in developing countries. We must put in place an organized system to prevent the absence or shortage of vital materials and equipment.

Oxygen alone certainly cannot treat all illnesses and diseases. Diane probably would have died even if she had received oxygen. My close relative also died despite my best efforts to provide oxygen. But that is beside the point.

The simple question is: Do you have oxygen and other basic live-saving equipment in your hospital?

It could mean the difference between life and death. If you currently lack oxygen and other basic life-saving equipment in your hospital, the time to get it is NOW! You would be saving lives.

Cheers!

BUILDING RELATIONSHIPS: A Customer Service Skill

In previous posts, I defined who your customer really is and explained the most basic need of customers. As a follow up, it is important you know that there are certain skills required by management and employees that will enable you render excellent customer service.

Much like a surgeon needs the right skills and tools to perform a successful surgery, every hospital employee will need to acquire the necessary skills to satisfy the customer. One of such skills is the ability to build relationships; with co-workers and patients.

Courtesy: Lucas

I had stated in another previous post that one of the elements of  medical services is ‘inseparability’. That means you cannot render service without coming into personal contact with the patient (at least in most cases). As a result, medical employees need to learn, acquire, or develop the skills necessary for building relationships.

Building relationships means getting to know your patients as people; seeing them as real people and not just as medical cases. The better you get to know them, the better you can help them. Developing relationships builds patients trust in you. Here are a few tips:

1.     Be Nice and Friendly

The first step to building relationships is to be nice to patients and their relatives. This begins with knowing the names of your patients. Patients have names and it is always nice if you call them by their names instead of referring to them as “madam” or “the man with the red cap”. In addition, learn to correctly pronounce their names. Their name is the sweetest sound to them when correctly pronounced. Knowing their name gives them a feeling of importance and makes them know that you genuinely care enough to know them.  

2.     Smile Always

It is also important that you always have a smile on your face when dealing with patients. A friendly smile is often reassuring and relaxing to patients. When they are relaxed, it becomes easier to get information from them.

3.     Listen

The next key to building relationships is listening. Listening is a skill on its own. Please resist the temptation to dismiss the patient before they even get to the kernel of their complaint. I know how difficult it is to listen to a patient blabbing away when you have a busy clinic. But you should do all in your power to steer the patient towards the important facts while maintaining a listening ear. Things to do while listening are making eye contact when patients are speaking, nodding to encourage them to speak more, asking questions to clarify certain points and repeating certain aspects of their conversation. (I hope to write extensively on how to be a good listener in a future post).

4.     Pay Compliments

We all want to hear how nice we are, how lovely our dress is and how smart we work. It is the same with patients. Learn to give honest and sincere compliments like “You are doing a good job with your diet plan” or “thanks for coming promptly for your appointment”. Don’t criticize, condemn or complain about them.

5.     Small Talk

During downtime, indulge in small talk with patients, their relatives and friends. Let them see your ‘human’ side, your ‘informal’ side. Avoid being serious and business-like all the time. When you talk, talk in the terms of the other person’s interest. Let it be clear that you genuinely care.

6.     Bedside Manner

Finally, adopt a congenial bedside manner. This means being pleasant and responsive to the needs of your patients.

In conclusion, building relationships with patients will ultimately affect your profit margin, positively.

 See you soon….

What do Patients Need?

Many physicians have asked this question countless times in exasperation. What do patients need?! It seems when you’re nice to patients, they take you for granted and call you at odd hours for the most trivial of issues. Conversely, when you are not so nice, they call you a snob.

What do patients really need? Can you ever please them? Do they need treatment in the form of drugs, counseling, surgery, physiotherapy, or a combination of all these? Or is there something deeper that they need?

I usually tell physicians that the most basic need of any customer/patient is EMPATHETIC HELP! You certainly cannot cater to their every want but you will do well to offer them emphatic help.

Image Courtesy: www.fotosearch.com

Usually, patients cannot do much for themselves. When they come to the hospital, they often feel like crap and cannot make themselves better. This helplessness may be physical, mental or emotional. My little daughter’s dictionary says to help is ‘to make it easier for someone to do something, by doing part of their work or by giving them advice or an object they need’.

Empathy means the ability to identify with and understand somebody else’s feelings or difficulties.

Empathetic help therefore means the ability to do something, give something or give advice from a point of understanding to a patient. For example, when a patient comes in vomiting all over the couch, empathetic help means providing relief and cleaning up without being rude or impolite. It also means a woman who is in labor is not screamed at or slapped on the laps. Rather counseling and some form of acceptable pain relief is offered. In addition, empathetic help means putting yourself in the patient’s shoes and giving the treatment and attention you would expect to receive if you were a patient.

The components of empathetic help are:

—  Friendliness:

The act of being nice to patients and being receptive to their queries

—  Understanding:

This is having the right attitude towards patients based on your ability to interpret or infer their feelings.

—  Fairness:

This means providing a balanced and impartial service to patients regardless of their gender, color, creed, ethnicity, religion or political leaning.

—  Confidentiality:

This means not divulging the patient’s medical history or condition to unauthorized persons.

—  Information:

This involves providing facts and data about the patient’s condition in terms they can understand so that they can make informed choices.

—  Control:

This is allowing patients or their guardians to make informed decisions at each point in their treatment process.

—  Options & Alternatives:

This implies providing equally beneficial treatment choices to patients as well as directing patients to another service provider when you cannot manage their specific health issues.

Beyond the aesthetics and facilities of your hospital, empathetic help is a culture that your hospital must imbibe. To remain competitive, you should learn it and train your staff to give it.

So, when next you get exasperated by your patients and wonder what they actually need, read through this article. That way you can keep on providing quality healthcare with a smile.

Cheers!

Who Are Your Customers?

There are two basic questions I always ask in my Customer Care Training Workshops. The first is “who are your customers”? I get various responses like; “my customers are my patients”, or “customers are those who buy services from us”. Then I ask the next question, “who is a consumer”? At this stage, a lot of people get stumped and ask “aren’t they the same”? Well, not really.

Your customer is someone who purchases a product (a service or a good) from you. The customer may not necessarily purchase the product for personal use or satisfaction.  A customer is also a person with whom you have dealings. A consumer on the other hand, is a person who actually uses your product and derives personal satisfaction from it.

In this context, a customer could be a Medical Insurance Company or a Health Management Organization (HMO) that purchases health insurance for a group of employees. The employees are the consumers. A customer could also be a parent who pays the dentist to do scaling and polishing for his daughter. In this case, the daughter is the consumer and the parent is the customer. A person who presents in the ER and pays for his treatment is both a customer and a consumer.

You must ensure you identify both the customer and the consumer in each case and provide the service that each needs. The consumer needs good health, while the customer expects value for money. Satisfying both is always a delicate balancing act. This is especially true with regard to Medical Insurance Companies and HMOs. Excellent service involves satisfying both the customer and the consumer.  However, the ultimate person is the consumer, who is the patient.

To satisfy the consumer, you need to understand the concept of the customer chain. But first, let us consider the various classes of customers encountered in a typical hospital:

• —  External Customers
• Internal Customers
• Corporate Customers
• Regulatory Customers

The external customers come from outside the hospital environment. They are the most important component in the customer chain. The external customer includes the patient, his/her relatives and friends. They require the services of the hospital. External customers can be both customers (purchase the service) and consumers (derive personal satisfaction from using the service).

The internal customers come from within the hospital environment. They include doctors, pharmacists, hospital administrators etc. They require the service of another service provider to perform their own duties. Internal customers are mainly consumers. They use/consume the services of others.

Corporate customers are also from the external environment. They differ from external customers because they do not consume hospital services. Rather, they provide service to the hospital. Examples are suppliers, pharmaceutical company sales reps, waste disposal companies etc. Without your corporate customers, you may not be able to meet the needs of your external customers.

Finally, the regulatory bodies monitor the activities of the hospital to ensure minimum standards of healthcare quality are met.

The Customer Chain

These different types of customers form a chain called the customer chain. The chain begins when the corporate customers supply drugs, consumables and other services to the hospital. The quality of service received from the corporate customers influences the quality of service the hospital will provide to its other classes of customers.

The customer chain continues when the external customer/consumer/patient requires treatment and presents at the hospital. The internal customers then ‘processes’ the patient through the hospital system.

For example, the front desk provides a service to the doctor by pulling out the relevant documents pertaining to the particular patient. The doctor also requires the service of the laboratory scientist to aid the diagnosis. He in turn provides service to the laboratory by requesting for the right investigation. The nurse is expected to carry out the instructions of the doctors.

The regulators ensure that all that takes place is acceptable and legal. The chain goes on to the last point of service the patient comes across before exiting the hospital.

If one person in this chain does a shoddy job, the customer leaves with an unsatisfactory service. A break in this chain leads to poor service. Shoddiness can result from misdiagnosis, wrong tests results, expired drugs, poorly filled prescriptions e.t.c.

Excellent customer service therefore begins from identifying your customers and consumers; ensuring each member of the medical team understands the customer chain and their position in it; and encouraging everyone to give their best at their respective work stations.

See you soon…..

Beyond Aesthetics: Campus Sheraton

I initially planned to title this post “Does Your Hospital Have Aesthetic Value?”. But after some careful thought I decided to title it “Beyond Aesthetics”. This is because I have discovered that a lot of hospitals are stepping up their look in terms of modern designs and buildings. This is especially so in the urban areas. Many though, in rural and semi-urban areas are still living in the past, providing services from dilapidated structures and unkempt premises.

I have always believed that a hospital building should be trendy (forgive me, I am still under 45), have wide corridors, neat and air-conditioned rooms, shiny floors, sparkling clean bathrooms, a pleasant fragrance, comfortable furniture, adequate lighting, spectacular landscape, an imposing signpost, functional ambulances, smartly dressed staff, state of the art facilities etc. This sounds like a five-star hotel. Well, I think the modern hospital should be a five star hotel and even more.

Back in school, we had a cafeteria complex that catered to the culinary needs of the entire campus. There were about 12 separate canteens called ‘Buka’ 1- ‘Buka’ 12. Sometime in my 4^th or 5^th year, Buka 1 was taken-over and became known as ‘Campus Sheraton’. The new management transformed the dingy lit canteen to a five-star hotspot. The furniture was changed to a more comfortable one; the exterior was re-designed, the interior was re-decorated and air-conditioned. But most importantly, the menu and service were drastically changed from what the other cafeterias were providing. The management employed waitresses who were smartly dressed, friendly and courteous. My wife and I still reminisce on those good old days as students when we went ‘tearing’ turkey wings, eating fried rice and drinking chilled coke at Campus Sheraton; all at the expense of our parents! The place sure wasn't cheap but the service and food was spectacular.

That is what ‘Beyond Aesthetics’ means; going beyond mere external beauty to provide profitable quality. While it is necessary to improve the outlook of our facilities, the focus should be more on provision of quality service at all times. The aim of every infrastructural project should be to enhance the experience of the patient and improve patient outcome. A beautiful building will attract patients but only consistent quality service will keep the patients.

There are several dimensions of quality which must be regularly assessed to determine how well you are doing on the quality scale. These are:

• ·        Timeliness
• ·        Completion
• ·        Courtesy
• ·        Accuracy
• ·        Mistakes

The time dimension of quality emphasizes promptness of service to patients. Patients should not be delayed unduly and adequate measures should be put in place to reduce patients waiting time to the barest minimum.

 Quality also means each task in the hospital process is properly completed. An incomplete or poorly performed task could affect the performance of the next task in the sequence.

Another quality dimension that must be regularly assessed is courtesy. Measures and standards of behavior should be set for hospital employees at employment, induction and at regular intervals during the period of their employment. It is unacceptable for hospital workers to be rude to patients whose basic need is emphatic help.

Accuracy is a dimension of quality that relates with hitting the mark in patient care. The incidences of misdiagnosis should be rare and far between.

Finally, mistakes should be avoided. Hospital managers should design measures to prevent mistakes e.g. use of checklists, adequate planning of duty rosters, putting name bands and marking surgical sites on patients going for surgery e.t.c.

These measures will improve quality and reduce litigation. In addition, ensuring quality service helps you move beyond aesthetics to actual profitability.

See you soon…..

Two Public Health Issues (plus one)

Two days ago, I was driving my daughters to school when they spotted a lady on a motorbike. She was smartly dressed in a white shirt on a beige colored skirt. Her shirt had epaulets on them signifying she was a ranked member of a uniformed organization. Ruby, the older of my two daughters asked “Daddy, which organization does this lady work for?” Tara replied “she is a special mobile police woman”.

I couldn't help laughing as I told them that she was a Sanitary Officer/Inspector. Nowadays, they are also referred to as Environmental Health Officers (EHOs). I went further to explain the functions of EHOs to include monitoring and inspection of restaurants, eateries and other establishments to ensure that they adhere to the prescribed standards of public hygiene. My daughters were surprised that such an organization existed because in their combined 17 years on earth, they had never seen anyone performing such functions.

The next question from Ruby was: “why don’t these people inspect our school canteen? It is always so filthy and has flies all over the place.” “I guess that is why children who eat there are always going to the toilet.” Tara contributed.

How true! We do have EHOs but they don’t really do much to earn their pay. When they do inspect and monitor public establishments, many of the EHOs end up collecting money from offenders without actually penalizing such offenders. This is a danger to our collective health because an epidemic can break out from such unhygienic facilities.

That incidence reminded me of another public health disaster noticed in our neighborhood about a year ago. We woke up one morning to find that a newly constructed house had a drainage pipe which was emptying waste water directly into the street! The water consisted of bath water and kitchen waste. Guess who owned the house: a (dis)honorable member of the State House of Assembly. The health hazard posed by this impudence was immeasurable. Several hundreds of school children and others walked across that puddle of water daily. Imagine if a child had fallen right into that watery bacterial mess. For those of us who drove past it daily, it was quite an eyesore. Several months and multiple visits later, the legislator finally constructed a proper drainage system to handle the waste water.

The above scenario plays out in so many cities across Africa and the developing world every day. Little wonder that we still have people dying from cholera and other diarrheal diseases.

After dropping Ruby and Tara in school, I decided to see my Auto Mechanic to fix a minor fault in my car. At the workshop, I saw a well dressed and apparently enlightened middle-aged man having a pedicure. I wasn't fascinated that he was having his toenails trimmed and cleaned in such a public place. Rather, I was shocked at the manicurist/pedicurist who was doing the job. The chap was barely literate and knew nothing about infection control nor the proper use of sharp objects. He had a rusty scissors that was razor sharp and a few other sharp things. (These traditional manicurists/pedicurists are ubiquitous in Northern Nigeria). I tried unsuccessfully to educate both the manicurist and the ‘manicuree’ on the dangers of using sharp unsterilized instruments. When I wasn't making any headway and it looked obvious that I was a busy body, I shut my trap, did my business and left the scene.

As I drove to the office that day, I realized that we still had a long way to go to ensure public health and safety. While the developed countries have progressed to producing cutting-edge medical technologies, the developing world is still struggling with basic public health issues like personal hygiene, clean school canteens and unregulated practitioners.

Though the future may appear bleak, healthcare professionals should not despair. We must continue to partner with both the government and the public. Our role remains to educate the public in our consulting rooms, at the market, in our homes, neighborhood and yes, even in the auto mechanic workshops. We must also hold the government accountable to ensure that relevant agencies inspect and monitor public facilities, enforce the laws, eliminate (?) corruption, punish offenders and reward exceptional compliers.

The journey to a safer public health seems far, but each determined step taken will lead us closer to our destination.

See you soon….

Using Checklist to Improve Hospital Services

I must really apologize that I did not write this post as I had earlier promised. I have been on the road and it has really being hectic. 

However, here is my take on using checklists in healthcare settings.

A checklist is a list of items or points for consideration and action. Like its name, a checklist may be a list of things to check before you do something. A common example of a checklist is the aviation pre-flight checklist used by pilots. Before taking off, there is a list of things that every pilot must do regardless of his/her level of experience. This is done all the time. The purpose is to ensure that the plane is functioning properly before take-off and to prevent any future air mishap.

There are different types of checklists used in medicine. These include:

• ·        Procedure Checklist e.g. Surgical Checklist

• ·        Diagnostic Checklist e.g. Algorithms

• ·        Equipment Checklist e.g. Medical Equipment Checklist

• ·        Iterative Checklist e.g. Protocol for Monitoring Post-Op Patients

It is sad to note that a lot of errors take place in the healthcare industry on a daily basis; wrong surgeries are performed, wrong medication given e.t.c. Majority of these errors arise from lapses in concentration, distractions, or fatigue. Some are quite preventable.

In a recent discussion with a female physician, she said something like “we are doing quite well without checklists. Checklists will just add to the current paperwork burden that we have”.

 Before you nod your head in agreement, please consider the following:

• ·         Firstly, human beings are not infallible. Distractions, fatigue and concentration lapses lead to variability in service delivery. Variability leads to mistakes and mistakes can lead to severe disability or death (What physicians like to call iatrogenic). With the use of checklists, the hospital system is strengthened, peer review and assessment enhanced and variability reduced.

• ·        Secondly, you cannot remember everything or commit everything to memory. I am sure you can recall several instances that you forgot a critical step or item in a procedure. Using a checklist will make sure you don’t forget a thing. You become almost infallible.

• ·        Thirdly, different people follow different steps to perform the same procedure. Some steps may be necessary and correct; others may be unnecessary and incorrect. This results in a waste of time, resources, efforts or skills. This also causes variability which is an enemy of quality service. A checklist will thus help to standardize procedures, reduce waste, eliminate variability and improve quality.

I will illustrate with the case study below:

Dr. Wright is in the OR performing an elective C-section on Mrs. Gabo, a 42 year old primigravida. He has already extracted a 4.5kg male neonate. In the process, there is a deep tear extending from the anterior part of the lower uterine segment towards the posterior surface of the urinary bladder. In an attempt to close the uterus beginning at this “angle of sorrow”, the suture snaps. The scrub nurse is so jittery that he drops the replacement on the floor. That happens to be the last Chromic 2 suture available in the hospital. The only other available chromic suture is a Chromic 2/0. Dr Wright struggles and fumbles to use this to repair the tear. Unfortunately, Mrs. Gabo continues bleeding and eventually dies from severe hemorrhage.

A simple procedure checklist used at the beginning of the surgery could have prevented this death. An equipment checklist used before the commencement of the surgery could also have revealed the inadequate quantity of relevant sutures.  

The World Health Organization (WHO) developed a simple surgical safety checklist some years ago. This can be adapted and modified to suit local conditions. You can see it here.

Before developing any kind of checklist for your hospital, it is important you determine first and foremost the purpose of the checklist. What is the checklist meant to do specifically? 

Next, decide on the type of checklist that is needed to fulfill the given objective i.e. a procedure checklist, equipment checklist e.t.c.

Another important step in developing checklists is to involve the group of people to use the checklist in a brainstorming session. This group should also include experts/specialists in the area of need. Several different ideas may be considered during development. A checklist that is acceptable to all concerned should be the product of this session.

Of course, you also need to set benchmarks to help you determine the effectiveness of the checklist. This will enable you review the checklist periodically to ensure it remains relevant to your practice.

Please note that a checklist is as important in a private hospital as it is in a public hospital.

They should be a necessary part of any hospital. 

Thanks for reading. See you soon….