Lack of "customer service" as beneficial factor for chronic disease process? - page 2

I observed the following clinical scenario several times over the last few months and wonder if it is just episodic events or something more. There is a type of patients who openly abuse acute... Read More

  1. by   KatieMI
    Quote from Ruby Vee
    The "Customer Service" paradigm does seem to negatively impact patients' health. Whether it's the patient wanting gourmet food and hot and cold running opiates or the family screaming about drinks for the whole clan, blankets for everyone and oh, yeah can you find out how to get the Super Bowl on this crappy TV? -- customer service seems to be bad for health. As long as folks can run to the hospital and get whatever they want, there seems to be no incentive to take care of themselves. And nurses actually give them things that are contraindicated for their condition, just to keep them happy. It's nuts!
    Funny you mentioned Superbowl. I was driven close to screaming yesterday by endless calls begging me for "something quick acting for anxiety" (read:Ativan IV) for every person on census who was not on sedation in ICU, first because hospital TV system is flabby and the connection was spotty, second because whatever team was apparently so close but still lost it.
  2. by   blondy2061h
    Quote from KatieMI
    Funny you mentioned Superbowl. I was driven close to screaming yesterday by endless calls begging me for "something quick acting for anxiety" (read:Ativan IV) for every person on census who was not on sedation in ICU, first because hospital TV system is flabby and the connection was spotty, second because whatever team was apparently so close but still lost it.
    I'm surprised people in Michigan are Patriots fans.
  3. by   KatieMI
    Quote from Susie2310
    I don't agree with this idea at all. It's too bad that some nurses and physicians are disgruntled. Health care IS a service business. Nurses, by virtue of our scope of practice, and code of ethics, are PATIENT advocates. I don't see any questions on the HCAHPS survey that are unreasonable, unless we want to go back to the bad old days (I have been an RN for over 20 years) when patients (and family members) had a much lesser voice in how they are treated by health care professionals and the health care system. When my family member received an HCHAPS survey they were happy to provide feedback on the survey, and also to the hospital administrator who called them and asked them about the quality of the care they had received (the facility was having problems with the quality of patient care). We were thrilled on a separate occasion when an administrator called into my family member's room to ask them about the quality of care they were receiving; administration was listening to patients experiences and taking actions to improve patients experiences, and we saw concrete evidence of this.

    In addition, let's not forget that the patients and family members, along with their insurance companies (usually) are paying the bill, and that health care professionals jobs are dependent on patients seeking health care at the facilities they work at.

    Are some people objecting to the expansion of Medicaid in some states? The fact that poorer people in some states can more easily receive health care now? This demographic, which has found it difficult to access health care for years have medical problems that have gone untreated/undertreated for prolonged periods. KatieMI, you frequently post about the unreasonableness of patients and family members; perhaps you should consider another career where you don't deal with the public. The ACA has been a boon for patients and family members in my opinion. The authoritarian model of healthcare is obsolete, and should be.

    My personal experience, and that of my family, with the facilities we receive health care in, is that patients and family members are accorded more respect since the ACA; it is certainly not a panacea however. As the John Hopkins study suggested, medical errors are the third leading cause of death in the US. Patients and their family members can and do play a big part in helping to prevent medical errors if/when they are listened to, and the ACA has assisted them in being listened to.

    My opinion on the attitude of the nursing staff when my family member/s are hospitalized is this: Since the ACA I find some nurses more polite and pleasant, and more ready to listen to patients/family members concerns. This is by no means universal; some nurses are very rude; fail to introduce themselves when they enter the patient's room to provide care for the first time, provide care with their name badges turned backwards, and ignore patient concerns brought by patients/family members. I would never leave a family member alone in the hospital, as quite simply, too many medical/nursing mistakes happen and too many patient problems are not recognized or are ignored.
    I am pretty sure that neither you, nor any of your family members come to hospital to show a whole list of orders written on paper with melodramatic demand that "that's what I WANT to be done for me right away" (the list in question had, among other things, dilaudid 2 mg Q2h IVP scheduled, Ativan 1 mg IVP Q3h scheduled, scheduled penergan IV, 2 pills of Norco 10 Q4h PRN and some other good stuff enough to kill a mammoth, together with regular diet for A1C >12 and Cr. 2+ and being wheeled around the unit in wheelchair when he felt like it. After the guy happily signed out AMA, I kept it as a souvenir).

    I am talking about that kind of patients, not just concerned relatives and people who have normal, reasonable expectations and questions. And I am speaking not about rude nurses and uncaring providers - I am speaking about ones who do not follow a patient's every whim about medically and socially inappropriate interventions because, well, hospital is a service industry but yet it is not Disneyland.
  4. by   Susie2310
    Quote from KatieMI
    I am pretty sure that neither you, nor any of your family members come to hospital to show a whole list of orders written on paper with melodramatic demand that "that's what I WANT to be done for me right away" (the list in question had, among other things, dilaudid 2 mg Q2h IVP scheduled, Ativan 1 mg IVP Q3h scheduled, scheduled penergan IV, 2 pills of Norco 10 Q4h PRN and some other good stuff enough to kill a mammoth, together with regular diet for A1C >12 and Cr. 2+ and being wheeled around the unit in wheelchair when he felt like it. After the guy happily signed out AMA, I kept it as a souvenir).

    I am talking about that kind of patients, not just concerned relatives and people who have normal, reasonable expectations and questions. And I am speaking not about rude nurses and uncaring providers - I am speaking about ones who do not follow a patient's every whim about medically and socially inappropriate interventions because, well, hospital is a service industry but yet it is not Disneyland.
    The ACA made it possible for millions of people who were previously uninsured or underinsured to receive medical care through private or public insurance. With more people receiving health care it stands to reason that there will be more episodes of what health care providers consider unreasonable or poor behavior on the part of patients. Some of this behavior is due to ignorance about how the health care system works. Some of it is due to a lack of education and other factors such as lack of family support and adequate financial resources. A largely poorer population are now able to access primary health care when previously they were often unable to. Some people haven't been able to receive primary care for years.

    Also there are simply more patients! I see it in my area. The medical facilities are full of patients; it is virtually impossible to park in the parking lots. Under the best of circumstances, even when one only has a minor health problem and has ample or adequate financial resources and a good support network, being a patient can be an exceedingly trying experience. I agree that presenting with a list of orders isn't the best thing to do, but maybe a patient who does that genuinely believes this is the only way they will be heard (and some of us who are nurses will agree that even when one is a nurse, being a patient or advocating for family members can be a difficult, frustrating experience).

    I think that health care providers already have all the necessary tools to deal with patients whose behavior is unreasonable to the point of being disruptive, threatening staff, violence, etc. Patients soon find themselves receiving the attention of security personnel, or the police, or they are warned they will be dismissed from a medical practice or actually dismissed. I think we have to make allowances for variances in patient behavior that doesn't constitute disruptive, threatening, or violent behavior.
    Last edit by Susie2310 on Feb 6
  5. by   Accolay
    One does not step into a McDonald's restaurant and request filet mignon only to become angry, demand said filet mignon and refuse to leave after McDonald's staff calmly explains that they do not nor have ever had filet mignon on the menu. The customer is not always right and will be removed. 'Cause it's crazy!
    What to do when my child wants a filet mignon at McDonald's? | Buffalo Grove - Yelp

    Humor aside, I asked myself questions about this when I used to work on Med-Surg. I have felt that we make it too comfortable for certain patients to abuse the system and if possible we would try to come up with a plan of care exactly like what happened to your difficult patient: start following policy and only give them what is required. The problem usually takes care of itself. If there is a mental health component, we attempt to come up with a behavioral contract with the patient so staff aren't abused.

    I also wonder why we need to do this dance since it's such a time waster. They refuse to participate with anything we recommend, what modern medicine tells us is the right course of action, so I don't see why we have to continue the relationship. We've offered, but they have refused care. They should try our therapy, or go home, or find an alternative therapy that suits them somewhere else. Free market, baby. But if we have and offer X while they refuse or want Y, then sorry, we can't help you right now. Come back if you're ready to participate with what we can offer.

    Our hospital has a clinic and personnel who attempt to manage care for such special cases since they use a huge amount of resources and they usually end up readmitting within that golden window to screw up our reimbursement rates. They have flags on their chart only get admitted for certain criteria, only see a certain provider etc. and make sure that if they are restricted to a certain hospital, they go there instead. I only assume other "last resort" hospitals such as mine are finding ways to do the same.
  6. by   Susie2310
    Quote from Accolay
    One does not step into a McDonald's restaurant and request filet mignon only to become angry, demand said filet mignon and refuse to leave after McDonald's staff calmly explains that they do not nor have ever had filet mignon on the menu. The customer is not always right and will be removed. 'Cause it's crazy!
    What to do when my child wants a filet mignon at McDonald's? | Buffalo Grove - Yelp

    Humor aside, I asked myself questions about this when I used to work on Med-Surg. I have felt that we make it too comfortable for certain patients to abuse the system and if possible we would try to come up with a plan of care exactly like what happened to your difficult patient: start following policy and only give them what is required. The problem usually takes care of itself. If there is a mental health component, we attempt to come up with a behavioral contract with the patient so staff aren't abused.

    I also wonder why we need to do this dance since it's such a time waster. They refuse to participate with anything we recommend, what modern medicine tells us is the right course of action, so I don't see why we have to continue the relationship. We've offered, but they have refused care. They should try our therapy, or go home, or find an alternative therapy that suits them somewhere else. Free market, baby. But if we have and offer X while they refuse or want Y, then sorry, we can't help you right now. Come back if you're ready to participate with what we can offer.

    Our hospital has a clinic and personnel who attempt to manage care for such special cases since they use a huge amount of resources and they usually end up readmitting within that golden window to screw up our reimbursement rates. They have flags on their chart only get admitted for certain criteria, only see a certain provider etc. and make sure that if they are restricted to a certain hospital, they go there instead. I only assume other "last resort" hospitals such as mine are finding ways to do the same.
    Without more information about those "special cases" that "usually end up readmitting within that golden window to screw up our readmission rates" your scenario sounds a lot like prejudice.
    Last edit by Susie2310 on Feb 6
  7. by   Here.I.Stand
    Susie, I don't think anyone here disputes the need to be conscientious on our jobs, or the need to treat everyone with dignity. The problem which I see being argued is that the hotel mentality is detrimental to everyone.

    Sometimes it is truly okay to say, "I am not able to give a dozen individual telephone updates every shift. So I can focus on your loved one, you should decide on one contact person -- I will update them, and they will need to communicate that to the family," or "One of my goals is to get you functioning at your full potential. For this to happen, I can't do FOR you what you are able to do for yourself," or "if your family needs refreshments, the cafeteria is down the elevator on 1st floor," or "Unfortunately I am not able to fetch a Snickers from the downstairs vending machine.

    Those are quick examples of advice that is appropriate -- but go against the customer is always right, RN is their personal concierge mentality.

    Personally I don't cater to unreasonable demands, but I do provide *clinically appropriate* "customer service." I do because I'm not a jerk.
  8. by   Susie2310
    Quote from Here.I.Stand
    Susie, I don't think anyone here disputes the need to be conscientious on our jobs, or the need to treat everyone with dignity. The problem which I see being argued is that the hotel mentality is detrimental to everyone.

    Sometimes it is truly okay to say, "I am not able to give a dozen individual telephone updates every shift. So I can focus on your loved one, you should decide on one contact person -- I will update them, and they will need to communicate that to the family," or "One of my goals is to get you functioning at your full potential. For this to happen, I can't do FOR you what you are able to do for yourself," or "if your family needs refreshments, the cafeteria is down the elevator on 1st floor," or "Unfortunately I am not able to fetch a Snickers from the downstairs vending machine.

    Those are quick examples of advice that is appropriate -- but go against the customer is always right, RN is their personal concierge mentality.

    Personally I don't cater to unreasonable demands, but I do provide *clinically appropriate* "customer service." I do because I'm not a jerk.
    I have to disagree with this notion of "the hotel mentality." I don't really see patients as being more or less unreasonable in general today. As I mentioned, with the ACA there are now more patients, which puts more strain on facilities and on patients/family. Of course nurses should utilize appropriate boundaries and set reasonable limits with patients. However, the OP is talking about more than that, and is proposing more than just utilizing appropriate boundaries and setting reasonable limitations.
  9. by   mmc51264
    My two cents. We get a lot of patients from outside hosp. and it amazes me that the only pain regimen is IV dilaudid. They get to us and we have a protocol of non-opioid, PO, meds, then PO oxy/dilaudid and then, if pain is not controlled, small doses of IV breakthrough. They all are like,"where's the liquid stuff?"

    We keep people on narcotics until they don't need them anymore. Some get angry and amazingly they are good enough to go home. We had one pt that was d/c from one hosp and 3 hours later back to ours (same system-diff hosp) looking for more pain medication. With the new rules about prescribing pain medication, he thought he was going to get the whole shebang again. the admitting team wouldn't give him more so he treated the rest of us like crap and called patient relations.
    I will say that most of the repeat patients I see are sickle cell, which they cannot help, and diabetes issues. Oh, and the one that drives me crazy-the people that will not quit smoking. I have learned that this is the number one issue that causes the most amount of damage on a large scale. COPD/CHF pts that won't quit, non-healing/union of fracture or joint replacements. flaps, blood clots. have a person that has a genetic condition that predisposes them to blood clots to the point of needing a fasciotomy all the way up an arm to try and save. Person will NOT quit smoking. Arm is being amputated this week.
    This is a poor, uneducated person with no insurance (but finds $$ for cigarettes) and you educate, educate, educate to no avail. then it is our fault that the arm is lost. smh
  10. by   Katillac
    Quote from Susie2310
    Without more information about those "special cases" that "usually end up readmitting within that golden window to screw up our readmission rates" your scenario sounds a lot like prejudice.
    Prejudice against whom? People who refuse to engage in health promoting behaviors? I get it, you think the ACA has resulted in many people who were formerly denied care who arrive at our hospitals naive to the system. But these aren't the people the patients and families the OP is talking about.
  11. by   Buckeye.nurse
    The studies I found used cohort designs which make access to medical documentation necessary.

    The Cost of Satisfaction | JAMA Internal Medicine | The JAMA Network

    Patient satisfaction linked to higher health-care expenses and mortality (link embedded)

    I can make a literature review as an article when the flu epidemics will subside.[/QUOTE]

    You referenced the exact same article that I was going to KatieMI!! I have been in healthcare in one aspect or another since 1995 (as a 14 year old candy striper). Over the years, I have seen many changes...and the patient experience aspect is one of them. One of my previous employers even went so far as to change the rugs in the visitor elevators so that they said "Have an EXCELLENT day", thinking this would subconsciously change survey result answers.

    Here's the thing...I agree with much of what Susie2310 said. There *are* healthcare providers who do a sub-par job, there *are* medical/nursing mistakes that happen, and there *are* patients who desire better care. The question is, though, is a higher patient satisfaction rating correlated with evidence based care and better outcomes? The Cost of Satisfaction | JAMA Internal Medicine | The JAMA Network seems to suggest that it isn't necessarily a link.

    Here's an example from a surgeon that I respected and worked with for 7 years. Two patients, identical in every respect, are admitted for hernia repair surgery. Patient A is admitted to the penthouse suite. He is given a PCA pump, has his pillow plumped regularly, is allowed to rest in bed, and can eat whatever he wants. Breakthrough pain is dealt with promptly, and breakthrough nausea is treated. Vital signs are checked every 8 hours so that he can rest at night.

    Patient B is cared for on a typical post-op unit. He is expected to be up in a chair the night of surgery, and to ambulate in the hallway the next day. He is given an incentive spirometer, instructed on its use, and expected to use it hourly while awake. He is started on a clear liquid diet, and advanced as tolerated. He most likely will have a PCA pump the first night, but be weaned from it if tolerated the next day. His vitals are monitored Q 4 hours.

    Which patient will be happier? Which patient will have a better outcome? Generally speaking, most patients DON'T KNOW what they need to do to stay healthy. In my specialty (hematology-oncology), we spend a hefty amount of time educating our patients and their families on how to protect themselves from harm. Patients will often accept education if it comes from a kind/understanding healthcare provider with whom they have developed a relationship...but not always. Sometimes tough love is in order.

    We've earned the Press Ganey Guardian of Excellence award multiple times, and we're happy that our patients are happy....but we're more concerned about their outcomes.
  12. by   Katillac
    Quote from Susie2310
    The ACA made it possible for millions of people who were previously uninsured or underinsured to receive medical care through private or public insurance. With more people receiving health care it stands to reason that there will be more episodes of what health care providers consider unreasonable or poor behavior on the part of patients. Some of this behavior is due to ignorance about how the health care system works. Some of it is due to a lack of education and other factors such as lack of family support and adequate financial resources. A largely poorer population are now able to access primary health care when previously they were often unable to. Some people haven't been able to receive primary care for years.
    Nope. People naive to the system don't know to request "that special cart with the cookies and coffee", don't know specific routes, dosages, and times for meds, and don't know to start yelling for the patient advocate when they get to the door of a semi-private room.

    Quote from Susie2310
    I agree that presenting with a list of orders isn't the best thing to do, but maybe a patient who does that genuinely believes this is the only way they will be heard.
    I think you misunderstand. The problem isn't the list as much as the expectations and the resources devoted to responding to the list long after determining the demands are against the patient's best medical and nursing interests.

    Quote from Susie2310
    I think we have to make allowances for variances in patient behavior that doesn't constitute disruptive, threatening, or violent behavior.
    Again, nobody has suggested allowances not be made. Nobody is suggesting it's not OK for people to ask for what they feel they need. The theory presented by the OP and supported by some research is that by supporting noncompliance with recommended treatment regimens, health care professionals are putting patients at greater risk in search of good patient satisfaction scores.

    The related issue is that facilities expect HCPs to deliver care resulting in great scores, but don't staff for it.
  13. by   Susie2310
    As far as knowing the med cart etc., what is wrong with setting appropriate limitations with patients?

    Patients have always had the right to make their own decisions about their care and to accept responsibility for their outcomes. They have the right to be given sufficient information about their medical problems to make informed decisions; to be informed of treatment options including no treatment and the consequences for both. Then decisions about their treatment are theirs. Patients have the right to make decisions about their care that health care providers disagree with or consider poor decisions.

    Why are some health care providers so concerned with this apparently new phenomenon of patient "noncompliance?" People have mentioned readmission rates and reimbursement. I remember when a family member with comorbidities presented with sepsis symptoms (fever, hot, flushed, diaphoretic, onset of severe weakness, tachycardia, tachypnea, lethargy, blood pressure going up, feeling very unwell) within the 30 day period after a previous hospitalization, and the ER physician tried their best to try to prepare to discharge them while they were still symptomatic before finally admitting my family member to a monitored unit for sepsis, where they spent three days fighting to survive. I won't even talk about the stress that ER physician caused for my family member and myself. My family member was entirely compliant with their treatment plan following the initial discharge, by the way. I understand the financial incentives not to provide care. Is it possible that this discussion is really about: "Our facility is losing money when we re-admit patients, and some of the patients we judge not to merit readmission; non-compliance with the treatment plan being just one reason?" If this is what is really underpinning this notion of "Lack of customer service as beneficial factor for chronic disease process" I think we should be honest and call it that if the primary concern is reimbursement rates. Let's stop dressing this up as regard for the patient's wellbeing if the concern for their outcomes is primarily financial.

    EMTALA laws require a medical screening exam (not triage assessment) by a medical professional (usually a physician) to rule out serious conditions that would constitute a risk to life and to one's health; to do anything less than treat patients in good faith would be illegal and unethical.

    Are some nurses suggesting that the laws should change to permit health care professionals to refuse care to patients on the basis of the progression and/or number of their chronic disease/s if the patient is considered to be a frequent user of health care services and this affects facility reimbursement? That this should be ok?
    Last edit by Susie2310 on Feb 6

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