Fast Food Nation: When Customer Service Competes with Patient Safety

by jparadisi

Drive-Thru Health Care by jparadisi

Calculating chemotherapy doses by surface area (m2) or kilograms was a smooth transition for me, a former pediatric intensive care nurse. In pediatrics, every medication, even acetaminophen, is dosed by weight. Tailoring chemotherapy doses to a patient’s weight was already a familiar concept; likewise dose reduction or withholding treatment altogether based on the patient’s lab values and assessment.

It’s a rare patient, however, who understands that her chemotherapy is prepared to order, not mixed ahead of time and awaiting her arrival, as if it’s fast-food made for the masses, preserved under a warming lamp.

This doesn’t matter as much if the patient receives his or her care in the hospital, but sometimes it creates unrealistic expectations in ambulatory oncology clinics. Somewhere along the line, good customer service has become confused with fast service, resulting in more and more patients with unrealistic expectations for their appointments.

It was one of those shifts when appointments backed up. Several factors contributed: Harsh weather conditions meant some patients arrived either late or too early for their appointments. The rapidly approaching holidays caused schedule changes for some patients. Of course, there were the normal, garden-variety delays: lab values requiring attention and patient veins that refused to accommodate IV catheters, etc.

Throughout the shift patients asked, “What’s the holdup?” Each time I thanked them for their patience, and validated the importance of their time. All shift long I explained, “One of the difficulties is that administering chemotherapy is not like making fast-food. Each treatment is made to order, measured against your lab values and tolerance. Our most important service is guarding your safety.” The explanation was received well, refocusing expectations on patient safety. Patients expressed appreciation for their nurses, oncologists, and pharmacists watching out for them.

The shift reminded me of a statement made by my husband, “Health care is neither inexpensive nor convenient,” and another one I heard a celebrity say on TV, “There’s never enough time to do things right the first time, but there always seems to be time to fix the mistakes later.”

Delivering prompt care is part of customer service, and as nurses, we should endeavor to keep appointments on schedule. However, our most important responsibility is patient safety.

How do you help patients keep their expectations regarding their care realistic?

TMI? How Transparent Should Nurses Be With Patients?

by jparadisi

cartoon by jparadisi

While on vacation, my husband and I waited patiently in a restaurant for our food.  In contrast with our leisurely pace, the wait staff swarmed almost cartoony in the effort to serve the endless crowd of customers. Clearly, they were short staffed, but not a single server complained.

Since we work in healthcare, my husband and I were sympathetic. Our server earned every bit of his tip.

Likewise, most nurses feel badly when patients wait too long for their care. Delays occur for many reasons: orders that haven’t arrived, lab results that aren’t back, unexpected admissions, critical changes in a patient, short staffing, unavailability of a medication, clerical errors, the list goes on. Because nurses are at the bedside we take on the brunt of the problem, whether or not the patient complains.

Hospitals competing for healthcare dollars compound a nurse’s frustration by intertwining messages of customer service with expectations for patient safety. In the worst cases, under duress, nurses and patients also confuse the two.

Most patients admitted for treatments are already aware of the potential risks: medication errors, hospital-acquired infections, or enduring the wrong procedure.They come to us for treatment because their options are otherwise limited. So, where is the line between giving patients honest answers about their treatment delays, and disclosing that you are short-staffed on the day of this patient’s very first chemotherapy infusion? Do you tell a patient that their treatment is delayed because there’s a mistake on the orders? If so, how do you do so without intensifying their anxiety?

Putting this conundrum into another context, I’m imagining how I’d feel if a flight attendant announced that our flight is delayed because “The captain heard a funny noise during the landing gear check,” instead of simply saying, “Please remain patient. We’ll take off shortly.” Would you want to know, and perhaps exit the plane? Or would you rather not know, trusting the plane wouldn’t take-off if there is an unresolved problem? How much transparency is too much?

Do you feel patients need to know everything happening behind the scenes about their care? If so, how do you engage in this disclosure? Does consideration for colleagues come into play? For example, has a colleague ever blamed you for a delay or mistake in front of a patient?

The Fragrance of Caring

Cupcakes! photo: jparadisi

Hospitals are not known for their fragrance, and recent shifts in particular have lacked delicate bouquet. It comes with the territory, and if I wanted a perfumed environment, I should have chosen a profession that doesn’t include the collection and measurement of body fluids. People with sensitive stomachs should think twice before becoming nurses. Whining about poop and vomit belongs in the “Well What Were You Thinking It Would be Like?” file.

If you require regular and predictable hours for happiness, nursing is not the career for you either. Shifts are unexpectedly extended because of late admissions, acute changes in patient conditions (read EMERGENCIES!!!), short staffing, etc.  In the past weeks, I have left work late for these reasons. Poop, vomit, EMERGENCY! I’m not complaining. This is what I am educated to do. I am proud to be a nurse with the necessary skills to lead patients through their dark moments.

Recently, I came home from a particularly long, smelly shift to find a UPS slip stuck to my door, informing me that a package required my signature IN-PERSON for delivery. The package was my birthday gift from David. I worked the following few days, so I called the UPS customer service number and arranged package pick-up. There was enough time left to pick up the package that evening. Since the gift was from David, he wanted to go get it, even though he’d also worked a longer than expected shift that day. We changed out of our smelly work clothes, and hopped into the car to get the package.

Traffic was horrendous. It was raining, and getting dark. I told David it wasn’t important; we could pick up the package the next day, but he was on a mission. When we finally arrived, it was twenty minutes past the office’s closing time. Surprisingly, the light was on, and the door unlocked. A smiling woman stood at the counter, holding my package. “Are you Paradisi?” she asked. “Yes, I am. Are you waiting for me?” “Yes,” the woman said. “I didn’t want you to drive all this way and find us closed, not in the traffic and weather.”  She extended her shift to take care of me, as I had done during my shift to take care of someone else. It is the essence of excellent customer service: the fragrance of caring, and the gift of time.

The Woman from Human Resources is Right About This

An Unexpected Discovery photo: JParadisi 2009

     A friend of mine told me about his experience a few weeks ago at a dental appointment. He arrived on time for a scheduled cleaning with his hygienist. After waiting five minutes, the hygienist came to the door of the waiting room. My friend stood up to follow her, but the hygienist called the name of a woman sitting across the room instead. My friend sat back down. Puzzled, he assumed the hygienist would return for him shortly.  My friend works in health care. The doctor’s office he works for sometimes runs late, and patients wait. He figured it was Karma.  After staring mindlessly at the pages of a six month old tabloid magazine, he checked his cellphone for messages and noticed  half an hour had passed. He requested a day off from work for this weekday appointment. Anticipating it to last an hour he scheduled other appointments and mundane errands after the routine dental cleaning. He wasn’t going to finish his errands that day.     

     Finally, a dental technician called his name. Once he was in the exam chair, the technician told him the appointment changed. He was rescheduled for an exam with the dentist instead of the hygienist. The technician readied to take a full mouth of x-rays.  My friend asked about the cleaning  he  scheduled the appointment for, and the tech told him not to worry about it.  He told the tech that  he only had time for a teeth cleaning, and this was his priority for the appointment. Could he reschedule the exam with the dentist for a later date? Annoyance reverberated throughout the dental office like an earthquake measuring 8.8 on the Richter scale. Eventually his teeth were cleaned. The appointment lasted two hours. My friend left puzzled by the entire scenario. Weeks before this appointment, the office called him twice with reminders that he needed to call within 24 hours to avoid an office charge if he wasn’t there.  Why was his appointment changed without his permission, my friend asked?  Why wasn’t he at least informed a change was necessary with one of those phone calls?     

     There are lessons to extrapolate from my friend’s story into my nursing practice.  Occasionally my patients wait beyond their scheduled appointment times too.  Events occur or sometimes patients are late, causing unexpected delays. More intriguing is the chasm between the expectations of my friend and his dentist, leading to an unhappy encounter for each. I imagine that the dentist and my friend both felt disrespected.     

     How many times do patients say, “I didn’t realize this was going to take so long”? Immediately, we have different expectations for the appointment. I don’t remember any patient expecting a different treatment than the one I expected to administer though.     

     The story reminds me of how important communication is when managing expectations for both the patient and the care provider.  Unexpected changes without explanation during a medical (or dental) appointment are rarely appreciated.  The Human Resources woman is right about this:  managing expectations is an important factor in customer service and satisfaction.

Who’s a Jethro? Thoughts on an Aging Nurse Population

Study Detail/artist: JParadisi (2009)

     My patient was watching The Beverly Hillbillies on TV while I set up the supplies needed to start her IV. I stopped what I was doing when she said, “What is this show? Is it a movie? What’s the name of this show?”  

     “How young are you?”, I asked, gesturing towards the TV.  “That’s The Beverly Hillbillies. You know how people say, What a Jethro? Well, that’s Jethro. He’s always coming up with good ideas that don’t actually work.”  

     I’m not all that old myself. The Beverly Hillbillies was already in syndicated reruns when I was in elementary school. However, I meet the over 40 criteria which the Age Discrimination and Employment Act uses to identify “older” employees.  

      I read an article on Medscape,  Retaining an Aging Nurse Workforce: Perception of Human Resources Practices, written by Mary Val Palumbo, Barbara McIntosh, Betty Rambur, and Shelly Naud. The paper explains that a majority of employed nurses are over 45, and Human Resources departments worldwide are looking for ways to increase retention of nurses into their 60’s.  

     According to studies, nurses want three things from the organizations they work for:  

  • Recognition and Respect
  • Having a Voice
  • Receiving Feedback

     Really? That’s what nurses in studies say they want? Really?  

      Listening to my colleagues discuss what they want, increased healthcare benefits, increased reimbursement for educational conferences, pay increases for career related achievements such as advanced degrees and certifications, are examples of what nurses want. I think this falls under Recognition.   

     Nurses universally complain about missing scheduled breaks because of too heavy patient assignments, and uninterrupted lunch breaks are considered a luxury by most of us.  Some department managers even post important notices such as changes in policy on the staff bathroom walls, to read during our “bathroom breaks”. Fortunately, the walls of the staff bathroom where I work are free of required reading. This probably falls under the Respect category.  

     Coincidentally, I attended a Human Resources customer service presentation. A Power Point slide projected a scripted phrase to ask the patient (customer): Is there is anything else I can do for you? I have the time.”  The HR representative emphasized that studies show the phrase “I have the time” is a crucial part of the customer service interaction, and we were urged to say it.  I raised my hand: “I’m playing devil’s advocate here: if the phrase is of such importance, then shouldn’t staff be provided with the necessary resources ( i.e. time = staffing)  to say it truthfully?”  

  • Recognition and Respect
  • Having a Voice
  • Receiving Feedback

will never be achieved unless nurses of all ages find the voice to clearly define what these terms mean to us.