Lack of "customer service" as beneficial factor for chronic disease process? - page 3

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   TriciaJ
    Quote from Susie2310
    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.
    Maybe you never got herded to a Service Excellence scripting session, but many of us did and they predate ACA by quite a few years. KatieMI never said anything about ACA in her OP, so I'm not sure how that factors in.

    The whole customer service mentality (at least how it is enforced in many hospitals) is about making the patient happy at any cost. Even the cost of his own health. That is the point of this thread. When setting reasonable expectations and boundaries are seen as transgressions and cause the health care providers to face disciplinary action.

    Katie is only proposing a study to try to measure the effect of "customer service" on overall health. No one here is advocating for treating the patient with less than dignity and respect. I think the question is a worthwhile one to explore. Florence Nightingale said "First, do no harm." The question being raised is: in our zeal to be "nice" are we inadvertently doing harm?

    Some nurses have started to suspect we are doing harm. This is based on their professional experience, not prejudice.
  2. by   Katillac
    Quote from Susie2310
    . . . 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.
    Susie, I think I understand better now why you are reading into this that people are advocating to under-treat or refuse care to people who are vocal advocates for themselves and loved ones. I'm so sorry this happened to your family member. What a scary time.

    Rest assured nobody here is saying people who disagree with their health care providers or want more or different care than is being offered should be ignored, discharged, or not admitted. But that's not even remotely the same as wondering if health care providers stopped supporting self-destructive behaviors (which ultimately affects the bottom line by increasing readmissions) would it decrease the frequency of those behaviors resulting in better outcomes.

    Just wondering, Susie, did you read the linked articles? You may get a better sense of why this is an important issue to consider.
  3. by   Accolay
    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.
    Truth is that we all have our biases. Everyone has certain patients they never want to take care of and certain units they wouldn't ever like to work.

    Perhaps I didn't make my position clear enough. I will restate thusly:

    We readmit a small group of patients that tend to refuse the best of medical science and care we recommend and are able to provide in our hospital and who also choose to not participate in their plan of care within the 30 day readmission window for reimbursement and penalties. It does not matter if we have established an all encompassing discharge plan complete with follow up appointments, housing, transportation and or home health care public nurse and assigned social work to follow his case- this small population, for whatever reason continues to return and continues to use a larger portion of health care dollars.

    It is akin to the frequent known alcoholics we receive in the emergency department to be safe and sleep it of or who are having acute alcohol withdrawn who may require intubation and large doses of valium. We have attempted to commit some using the court process where they are restricted to a hospital room, sometimes for weeks, while we wait for the court system to complete the commitment process only to have some of these alcoholics return to drinking because they didn't want to stop in the first place = wasted time and money. (I don't think we do this any more).

    I've had one special patient we were attempting to treat for chemotherapy this process continued over the greater portion of a year with multiple multiple admission. Every instance this guy would move into his room with his SO staying with him. Instead of completing his chemo on our unit, we had to stop the therapy because we were unable to keep him from attempting to take his IV pole and associated chemotherapy drugs out to smoke and then couldn't keep him in the hospital due to his dependence on meth. We bent over backwards to try to accommodate this guy. He died a few months later.

    I have several examples of the population we are discussing only from a few years on a med-surg unit.
  4. by   Accolay
    Quote from Susie2310
    Why are some health care providers so concerned with this apparently new phenomenon of patient "noncompliance?" People have mentioned readmission rates and reimbursement.
    Yes. Healthcare dollars are a dwindling pile that is supposed to benefit everyone, not just the small population we are referring to. We lose money when this population is readmitted and it does affect the bottom line. This will be worse in the future- check out the problems with closing rural hospitals.

    Quote from Susie2310
    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?
    No. That's not what we're talking about here. Your example patient should be readmitted. Just like with the small population we are referring is sick, they are readmitted too because otherwise it's a real slippery slope. We don't leave people to die.

    Don't change the subject. Sometimes the pendulum swings to far in either direction.
    Last edit by Accolay on Feb 6
  5. by   Irish_Mist
    The customer service paradigm is destroying healthcare as we know it because it enables and encourages bad behavior. Instead of focusing on healing and providing evidenced based care, administrators are more concerned about whether or not someone got all the dialudid they wanted in a question disguised as "was your pain adequately managed". Long gone are the days where patients were given realistic expectations about pain in acute situations (surgery, illnesses) but instead expect a drug to fix every ******* ailment with an IVP of phenergan.
    Last edit by traumaRUs on Feb 9
  6. by   RobbiRN
    Interesting article, Katie. I read through the discussion and browsed the two studies you linked.

    Local management focuses on the satisfaction surveys like they are the golden key to fine-tuning our process to perfection. We were applauded when we hit the upper 90's, but last month we plunged to the 60's. We had multiple of admissions backed into the ER for most of the month with new arrivals treated in the hallway, but of course the focus was on where nursing failed. I pointed out that our most of our staff have been here 5-20 years, that we are the same people, doing the same things that got us the 96 the month before. Management was sure we had failed.

    After 25 years of ER nursing, I firmly believe your premise that treating to patient satisfaction can be detrimental. I shouldn't have to qualify this, but, I am not advocating sub-par, discriminatory or unprofessional treatment. Kind, compassionate, excellent healthcare does not guarantee that a patient will be satisfied. ("I'm on six antidepressants and I'm still not happy.") I hope you do the research.
  7. by   ThePsychWhisperer
    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.

    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.
    I'm really not sure why you continue to reference the ACA; KatieMI never referenced the ACA, and honestly, I believe it to be irrelevant here. KatieMI was simply wondering about a correlation between not giving a patient everything s/he wants, and the patient finally wanting to participate in his/her own care because "it will keep me out of the hospital that no longer gives me my IV Dilaudid, Phenergan, and Benadryl, or fluffs my pillows." I'm rather interested in this correlation myself.
    As far as "patient satisfaction" goes, I don't believe this is a benchmark that should be influencing insurance reimbursements; there are some patients that you will never be able to make happy, no matter what you do. There are also articles that have been referenced here regarding the negative relationship between "happy patients" and positive outcomes; they're worth a read.
    As far as my customer satisfaction views, I'm all about keeping my patient happy... to a point. No, I will not give you Dilaudid IV if your BP is 70/40; No, I do not have the time to give you an update every 10 minutes; No, I cannot give you a cup of regular coffee if your HR is 130; No, my first priority is not to grab you a turkey sandwich and a Coke if you can't breathe; No, I do not have time to fluff your pillow; Yes, you need to get out of the bed and be up and walking around if you are able. Remember, there is a big difference between being rude and being firm in order to promote positive outcomes.
    And no, we do not always have the necessary resources to deal with violent, threatening patients. If I have a belligerent patient up in my face, threatening to "be waiting for me in the parking lot" (which this has happened), you can bet that yes, they will be getting a visit from in-house security or a uniformed officer that may be handy.
  8. by   missmollie
    We live in a society that is all about convenience, but the hospital is the one place that mentality should not be tolerated. I've had patients who refuse to get up, only to end up in a nursing home when it was entirely preventable. I am glad to see this push away from narcotics, because that will start the change that needs to happen.

    Should you happen to design a study, I volunteer as tribute to be the nurse that gives the needed care and not the customer service care!
  9. by   TriciaJ
    I've said this countless times: you should not work harder on someone's behalf than they are willing to work for themselves.
  10. by   SpankedInPittsburgh
    Tricia, I totally agree. I tell my patients all the time that "nobody will or should care more about you than you". Educational and customer service can not overcome denial and entitlement.
  11. by   LoveMyRNlife
    You always make me laugh, thank-you!!
  12. by   LoveMyRNlife
    Quote from Davey Do
    You always make me laugh, thank-you Davey Do!
  13. by   LoveMyRNlife
    I have read through the thread and I agree with KatieMI. I feel as though Susie2310 feels there is bias towards the lower economic population. I just want to point out a few things.
    1) It costs nothing to say please,thank-you, excuse me, or you are welcome.
    2) It costs nothing to quit smoking
    3) If you come from home alone, do not ask me to do your ADLs or pull your blanket up if you are capable
    4) the zero pain scale is ridiculous. We have people getting their foot amputated d/t there uncontrolled DM and are expecting NO pain. Unrealistic unless we want to completely snow them. I had a patient with an A1C of 12.1, a smoker, and his wife expected us to give him every pain medication possible on the hour or less for a diabetic wound. This was an A & O x4 man that had a stage 3 wound on his coccyx because he couldn't turn himself d/t being plowed and she refused to let us do it. Meanwhile she blamed us and the previous hospital for his demise. On top of that she ripped the wound vac off and refused to let the nurse put a dressing on it. The police were almost called because she kept disappearing after the discharge papers were given.
    5) I understand people that do not have money for some of the meds prescribed, but again, stopping smoking costs nothing. We even offer many free wellness programs to assist anyone that wants to stop. So why should the hospital have to pay for someone that destroys themselves?
    5) When I grew up people were responsible for their own actions. You mention that patients have the right to self-destruct or die by being non-compliant, which I agree with, but I believe the issue people have with that is when it costs someone else money.

    I personally listen to all my patients about their conditions and requests and I will advocate for them. We as nurses ( on Med-surg) have broad knowledge but patients with chronic issues can usually help me give them better care because they know what works best for them. I also give patients information in writing if the MD changes their treatment and explain the rationale. Many appreciate that because they are stressed during a hospital stay and they do not remember everything they are told.

    I could be wrong but I believe the majority of posters in this thread are referring to those patients that are basically killing themselves and expect us to help. I also want to say that none of this is said with anger towards you or what you commented on. It comes from my personal experience as a nurse. I didn't feel anyone was attacking you either, sometimes so much is lost in text.

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