In his brilliant little poem, "The Right Kind of People," Edwin Markham beautifully portrays the power of expectations. A traveler approaches a prophet sitting at a city gate and asks what kind of people live there. The wise man asks:
Quote
"Well, friend, what sort of people whence you came?"
"What sort?" The packman scowled; "why, knaves and fools."
"You'll find the people here the same,"
The wise man said.
Another stranger in the dusk drew near,
And pausing, cried "What sort of people here
In your bright city where yon towers arise?"
"Well, friend, what sort of people whence you came?"
"What sort?" the pilgrim smiled,
"Good, true and wise."
"You'll find the people here the same,"
The wise man said. *
Expectations often morph into self-fulfilling prophesies. Expect people to do well, and they will. Expect failure, and you will find it.
The migration to a business model for healthcare delivery continues to remove autonomy from healthcare providers. More and more, remote business people with no medical background are orchestrating the details of patient care. The new paradigm assumes that nurses, left to our own devices, will not make the best choices. More managing is required, and the escalating myriad of checkpoints will guide us to delivering better care. Unfortunately, detached micro-managers often worsen the very problems they're trying to solve. Unwittingly, they force three pitfalls: the destruction of teamwork, misplaced priorities, and an arena of failure.
Pitfall #1: The Destruction of Teamwork
The first pitfall of remote micromanagement is the inherent destruction of teamwork. We are each primarily responsible for our own assigned patients. But, as a team, we are all secondarily responsible for all the patients in our department. We can only adapt quickly to the rapidly evolving levels of acuity when we support each other. We frequently have to let things slide in our own area for the good of the unit, and the lives that may be on the line.
Remote micro-managers increasingly rely on spot check audits which inherently force a myopic focus on our assigned patients instead of the department as a whole. For example, I discharge an 89-yr-old female who decides she needs to stop at the bathroom on the way out. The discharge drags out nearly fifteen minutes. By the time we get her loaded into her son's car, I' m already bumping a required med effect for a patient who had IV Zofran nearly twenty minutes ago. I have a PO Norco order waiting for another patient, and hourly rounding due on a third. I also see that a new arrival is headed to the room I just emptied, but the patient appears to be in no acute distress. The guy waiting for the Norco 5, took a Norco 10 of his own 2 hours ago at home. He's got chronic back pain, and he's waiting for a CT result. My patient with the rounding timer ticking should be discharged soon. I know my patients are stable, but I have several timed checkpoints due.
Amber, the nurse in the four rooms next to me, has a potentially critical three-month-old with a temp of 103.4 and no obvious source other than being fussy and crying a lot. Amber hasn't been able to get an IV and asks if I can help her. In old-school, do what's best for the department nursing, the choice is simple: I should help Amber because her patient (who later proves to have bacterial meningitis) is clearly the most critical. If all goes well, we will have a good IV secured and labs drawn in about ten minutes. A difficult start could drag out twenty to thirty minutes, causing me to be late on several of my own timers.
In the evolving bean-counter environment, the person filling in the blanks on the audit form will have no clue what was happening in the rest of the department. Audit scores are a straight out pass or fail. The reviewer will not be checking other parts of the current patient's record to find out why the med was late, the rounding was more than an hour, etc., let alone checking records from the rest of the department to see what I was doing instead of the missed tasks. The only way to know I help Amber will be to pull all the charts of all the patients to see what else I was doing. That's not going to happen. If I start Amber's IV for her, the baby will live, but the auditor will only document my primary failures. Management's increased focus on my individual performance forces me to think more about keeping my own record squeaky clean and letting my coworkers fend for themselves, and visa versa. By nature, we want to be supportive, for the sake of the patients, but the pressure toward isolationism in mounting by the month. The trend is most unfortunate.
Pitfall #2: Misplaced Priorities
The second pitfall is that myopic focal points in chart reviews create misplaced priorities. We have a mandate to treat all long-bone fractures for pain within thirty minutes. It sounds great in theory. Success is tied to reimbursement, so management wants 100 % compliance. The irony is that every complaint of extremity injury -- no matter how old the injury -- is now announced overhead has a "possible long-bone fracture," alerting the LIP and the RN that the clock is already ticking. We don't even announce possible MIs or CVAs over the intercom. We know they matter, but the possible long-bone fracture gets the heads up overhead.
Left to our own devices, ER staff are drawn to life-threatening situations first, and less urgent needs are forced to wait. Micromanagement's focus list often creates a misplaced sense of urgency, nudging energy to areas that are medically less urgent. For example, a 68-year-old CHF patient has no timer ticking, but I know he's losing ground. It doesn't even show in his numbers yet, but I can see a subtle increase in respiratory effort. But there is a possible forearm fracture who has IV morphine ordered with no IV and eight minutes to the failure line in my room next door. The auditors may miss that we let the CHF guy slide closer to a code. The CHF guy's life is on the line, but the 30-minute Morphine timer is a line in the sand. Serious mistakes are possible if nurses myopically focus on chasing expiring timers instead of prioritizing the most critical patients. I write from an ER perspective, but similar scenarios of skewed priorities are evident in many other areas.
Pitfall #3: Escalating Checkpoint Failures
Micromanagement is creating an arena of escalating failure. Each new required checkpoint and documentation competes for limited time and resources. A good nurse pulled me aside a few weeks ago. "You better watch yourself on the new vital sign recheck within 30 minutes of discharge. I was called in and told a note was going into my file that I had been counseled for discharging a patient from minor care who had been in the department for 45 minutes. He was a healthy teenager with a little cut on his finger and normal vitals." We used to work with a 2-hour baseline for rechecks in the ER, and left it to the discretion of the staff to re-check more often as needed. (Ironically, the baseline is still Q 8-hour vitals for medical/surgical inpatients.) Apparently, management can't trust staff to make the right choices, so, even an 18-year-old with textbook vitals 31 minutes ago must be rechecked before he can go home.
The sheer volume of mandates and timers crashing into each other is creating an arena of failure. Several times a day, I now need to I ask myself, "where do I fail next?" Will it be the "immediate" timer to send a lactic acid level specimen on ice, the 5-minute timer to triage the new arrival, or the 10-minute timer to do her EKG -- if she gets out of the bathroom in time to make either of them? Or will it be the 20-minute timer for the med effect, the Q 15-minute timer for vitals on the blood transfusion, the 30-minute timer to call report to the floor, the 1 hour rounding timer, or the Q 2-hour timer to recheck the normal vitals on the patient chatting on his cell waiting for CT results? Two patients are asking for blankets. In my head, the cold patients beat the already-took-Norco-at-home-guy on his phone, but he has a timer; they don't. Hopefully, I can interrupt his call. I'm sure he'll help me out when I tell him I have 3 minutes until I fail - again. The timers are not targets or suggestions. They are pass or fail on an audit. With so many clashing timers, we are predisposed to fail on a regular basis.
A few weeks ago, I was on hold while trying to call report to PCU. If we are on hold for more than 5 minutes, we are supposed to hang-up and call the unit's charge nurse and ask him/her to take report, but I hadn't hit that timer yet. While I was waiting, a new nurse who frequently struggles to keep up asked, "Have you done your med effect for the IV Zofran in room six? I'm auditing your chart, and I don't want to mark it not done if you did it and haven't charted it yet."
I pulled up the chart and confirmed it had been twenty-six minutes since I gave the Zofran. I replied, "No, I haven't done it yet. It's okay to mark it "not done" on your audit form. I'll chart it when I get to it. But, I just have to ask, do you really have time to be doing this right now?"
"No, I'm behind on my own patients, but the charge nurse said I have to do these."
Is this what we have come to? Now, this nurse, who is already behind, is forced to use her time for clerical, non-patient care administrative tasks while her patients wait? And the charge nurse who asked her to do it? Also diverting more of her own time from direct staff supervision and patient interaction to generating audit information to pass on to upper-level management.
Will all the auditing lead to constructive changes? I hope so, but I'm not overly optimistic. In some cases, micromanaging may help get an unfocused nurse off her cell phone and to the beside a few extra times during a shift. Anecdotally, I believe the pitfalls may well outweigh the benefits. There are always real problems to fix, but a few little snapshots jumbled up and viewed out of order are not the same as watching the movie. Our environment is extremely fluid, with rapidly changing priorities vying for limited resources. Staff nurses need enough autonomy to nimbly focus our collective energy to do what is best for our patients. Unfortunately, the distrusting management systems that are undermining our autonomy are also breaking down teamwork, misplacing priorities and causing failure.
I ran this idea by a mid-level manager, questioning the value of massive chart audit increases. She looked at me like I was from another planet and asked, "How else are we going to solve the problem?"
Maybe start by asking yourselves what sort of people you have hired. Knaves and fools? Or good, true and wise?
* "The Right Kind of People," by Edwin Markham, in The Best Loved Poems of the American People, p. 66, Doubleday and Company, 1936.
