Wednesday, September 12, 2012

Apparently the Customer Service Professionals have decided that nurses no longer know how to ask patients how they’re doing.  You know these people.  They’re the folks having lunch with the Vice President of Patient Care (who was, back in the day, the Head Nurse, and before that the Matron), the ones who do the mandatory Patient Satisfaction Inservice on your day off replete with squishy foam stars as party favors and day-old bagels in the back and a mandatory fifteen minute showing of the video of guys throwing fish in Seattle.  They’re the ones who always start their talk by going around the room and having everyone introduce themselves, the ones who pint to you and ask you to give an example of great customer service (“Leaving me alone so I can sleep in the back row” may be the correct answer, but not the right one), and who always remind you that they know what’s it’s like because they’re a nurse, too.

(Incidentally, when I went to Seattle, there were forty people standing around the fish stand waiting to watch a fish being thrown but nobody actually buying fish.  I did see one guy buy a live lobster, but that didn’t get thrown.  Probably something about hearing the lobster shriek as it flies through the air, claws open, antenna waving frantically, all ten legs spread out in terror.  The fish-tossing industry is nothing if not ethical.)

The origin for all these highly paid and mostly useless consultants is the advent of something called the Hospital Care Assurance Program (HCAP), where patient satisfaction scores become a factor in Medicare reimbursement.  It is another element in the general trend to regard health care in terms of subjective patient opinions rather than outcomes, despite recent studies showing that the “most satisfied” patients have higher morbidities and incur extra costs on the health care system.  The advent of these scores have given consultants yet another vehicle to sell their services to unsuspecting hospitals.  (If any of you highly paid and mostly useless consultants are out there and want to have a serious discussion about how HCAP scores are essentially flawed measurements, and how efforts to improve HCAP scores are often directed at lower level employees rather than established administrative systems, I’d be delighted to have that conversation.  For now, it’s my blog and I’ll say what I wanna.)

As I’ve said, these Men in Black and Women in Pastels have determined that one of the keys to customer service is that nurses need to see patients more often and ask them more focused questions about their needs.  The fact that nurses are overworked, overstressed, dealing with sicker patients with greater demands in an increasingly more complex clinical and administrative environment is apparently not the problem.  So the Customer Service Professionals have put together an “Hourly Rounding Log.”  It’s kind of like the sheet you see posted on the door of the restroom at Target, where someone named Randy initials that he has meticulously inspected the facility each hour and it has met his standards for cleanliness, the fact that Randy also has dog barf on his pants  from his last job at PetSmart notwithstanding. 

The Hourly Rounding Log is headed by a script that features the sequence of questions one is supposed to ask of the patient during your assessment.  It also implies that you should be asking these questions every sixty minutes, even in the wee hours of the morning, because there is nothing that gives patients the warm fuzzy feeling of care like being woken from a deep sleep every sixty minutes to ask if you’re okay.

The script is not a Tennessee Williams production.  (If it was, you’d expect one of the lines to be “Bedpan!  Bedpan!  BEDPAN!”).  Here are the five scripted sayings:

Is there anything you need?

I have time now to take you to the bathroom.

Is there anything else you need?

Let me be sure your call light is within reach.

Please call if you need anything, otherwise someone will be back in an hour to check on you.

Professionally, I was insulted by this on behalf of the many highly trained and experienced nurses I’ve worked with over the years.  Caring cannot be taught or scripted any more than clinical instinct can be, time is not a function of clocks and charts but of acuity and need,  and the “script” is yet another example of how health care systems try…and fail…to reduce healthcare to factory piecework.  Personally, I was offended by the fact that apparently the Hourly Rounding Log does not apply to me.  I am a doctor, after all…a nice Jewish Doctah, at that…and I passed Physician Egotistical Behavior 101 with honors. 

So I went and asked one of my nursing colleagues why no one was rounding on me.  I was told that since I’ve made it clear what I really need is a winning lottery ticket, a bathtub in my home big enough to drown a pig, and one-way bus fare to the Frustrated Writer’s School, there was no way I could be helped.  I was told they could take me to the bathroom if I wished, but I would have to know they would gossip about what they saw.  (One of every male ER doctor’s fear is that they will get in a horrible accident, need a urinary catheter, and expose their assets to those who really do understand that saying how long it is in centimeters rather than inches is just a dodge.)  And I was told that while they would  be back to check on me in an hour if I hadn’t moved any patients, and they would do so with the expectation of doing CPR.  Because if I’m not moving the meat, the only excuse is to be dead.  Preferably with a Do Not Resuscitate Order in my hand so I don’t take up a bed.


  1. Randy should just shut up and let me sell my boat. Its a state law I swear to god.

  2. We have had scores that have gone up and down and are totally inconsistent month by month. I am an RN with 20 years of experience in Obstetrics. I am having difficulty dealing with this added stress. I am close to 58 and all this added rounding sets up expectations that I cannot keep. I do the best I can do but people are absurd on their expectations. One person downgraded us because we did not have a toll free number for her relatives to call from Atlanta. We are not in metro Atlanta!!! Our small rural hospital is 2 million dollars in debt for calendar year 2013! Not only do I feel like a slave to the hospital expectations but I no longer feel like a professional nurse! The people that are always setting in the cafeteria when I rush down to get my lunch are always thinking of new questions and things we have to check. So its not the basic 4 position, pain, plan of care for the day, and the potty. Its "what's the most important thing I can do for you today?" and more things like garbage, straighten the room when most folks can't even hit the garbage can. Meanwhile, I might be a labor and delivery nurse and the next 30 minutes a nursery nurse. There are 4 of us for whatever is there and whatever walks in the door. Also, they keep changing the computer system so that you just get use to doing something one way and it ends up some other way. As in all the patients are now going to virtual beds and we have to place them in the correct room. If my computer locks up what would have been simple 10 years ago now requires a 20min call to the help desk. While my nurse manager is wanting me to go take care of another baby that was just born. Frustrated YESS!!!!

  3. As an ER nurse, that was really funny!