Tag Archives: systems improvement

Teaching better sign-out

I was watching this video about signouts (I know, I’m really fun at parties). But anyway I was struck by how little training we get on the communications skills aspect of medicine. At my institution we had maybe 2 talks on how to present a patient’s story formally on rounds, and a few of my residents coached me on it, and that was it – I more or less figured it out. (Not to mention that different attendings want different things from med students). Student notes have to be co-signed by a resident, so I did get some feedback on those, although I have to say, it was pretty inconsistent, in that some interns like to do things one way, and some another. But I didn’t get any formal instruction on how to sign out a patient to whoever is cross-covering, and that’s one of the key skills for patient safety.

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Another perspective on hospitals as hotels

In terms of appearance, at least. I definitely believe that the design elements mentioned in the article (natural light, nature) promote healing. The question is whether that translates into measurable outcomes, and if so, which ones.

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Filed under Medicine and Healthcare

More on grocery stores

Another thing that irks me about my local grocery chains is the customer service. Not that I quite expect radiance, a la Pret a Manger, but I do appreciate basic politeness, which I define as, i. a greeting/acknowledgement of my presence, and ii. lack of attitude that I am inconveniencing anyone by my presence. The last time I went to Stop&Shop in fact the only word spoken to me the entire encounter by the cashier was “Sign”, re my credit card slip. No greeting, no please, even. Not to mention the eye rolls I was awarded for bringing my reusuable bags. It seems like a management failure, some combination of not treating employees well resulting in disgruntledness or not hiring the right people or not setting expectations of behavior.

There are obviously exceptions, and one of them is Trader Joes. People there are consistently pretty helpful and pleasant, even when it’s hectic. So it was nice to see that they treat their employees well and make their money back in increased productivity.

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Should hospitals run more like hotels?

“She thinks that this is a hotel.” That phrase gets spoken a lot in hospitals, about a certain type of patient who seems disinclined to leave, even after their medical problems are resolved. It frequently but not always seems to be a woman, maybe middle-aged, with kids and lots of responsibilities at home or work, who is unable or unwilling to set limits on what they can reasonably do there, and is thus very reluctant to go home again. And so when you tell them they’re ready for discharge, they mentions some new ache or pain, which sometimes must be evaluated, prolonging her stay…and then the process repeats itself the next day. Even though it’s not (necessarily) on purpose, it’s still frustrating for the medical team, who see the culprit as taking time and resources away from those who are actually sick.

And so patients are stereotyped: people who bring their own pajamas or pillows are suspect, because it looks as if they’re settling in. Don’t let them get too comfortable, is the feeling, because then they won’t want to leave again. I think this is part of the reason there hasn’t been more of a movement to reorient hospital routines so that they’re centered around patients, instead of the needs of the hospital staff: on many services, it’s impossible to sleep after 5am, because of repeated interruptions for vital signs, phlebotomy, medication administration, and 1-4 visits from people on the medical team. Not to mention that no one seems to understand the global picture of what’s going on with the patient; you would think the doctors would, but one of the surprises of medical school for me was how much stuff happens that the medical team isn’t involved in (or is involved in only nominally): immunizations and fall risk by nursing, placement by case management and physical therapy, random visits by the chaplain or social worker because someone thinks it’s indicated. (It’s not that the nurse necessarily has a better handle on what’s going on, either – information gets lost when they change shifts, and also their focus is less on the medical issues.) Some units do a really good job of having interdisciplinary rounds where everyone communicates, but on most it’s pretty haphazard. And this general state of disorganization makes life uncomfortable for patients, which encourages them to want to “go home so I can get some rest”. I know that part of this is inertia/resistance to change and not active hostility to patients overstaying their welcome, but the general attitude in most hospitals I’ve been in is not one that prioritizes patient comfort.

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On grocery stores, or why there’s room for improvement

One of my pet peeves is American grocery stores. Mind you, I love the concept of a grocery store: the bounty of fruit heaped in shiny pyramids, the Lunchables, the prepared mirepoix, the half aisle of energy bars. It speaks to reinvention, of trying on new identities: for our eating habits, and thus our selves. We are what we eat–and when I’m in the football field sized Stop and Shop, I believe I can become anyone I want to be.

And yet. The execution is so flawed. There is SO MUCH that could be improved on, and no sign of innovation. It drives me batty.

Exhibit A: the cart pusher. All American grocery stores and Targets have a staff person(s) who collect the carts scattered throughout the parking lot and return them to the front of the store. THERE IS A BETTER WAY TO DO THIS. Where I grew up, in Canada, the carts stayed neatly collected at the cart return areas. Here’s why: when you wanted to get a cart, you had to deposit a dollar coin in a gizmo at the top to unlock it. Then, when you returned the cart in an orderly fashion, you got your dollar back. It was a security deposit of sorts: you could definitely still leave your cart in the weeds, but you’d be out the dollar. It assigned laziness a price, and the end result was the carts stayed collected a ready to use. Returning abandoned carts even provided a form of pocket money to teenagers and homeless individuals, so much so that it was featured in a TV beer commercial in my youth. And the store didn’t have to pay anyone to return the carts.

Exhibit B: the self checkout line. I don’t particularly mind checking my own groceries, although non-banana produce slows me down considerably. I don’t mind at all at CVS, where I tend to only buy a couple items, and the bags are right on the checkout kiosks. But all of the self-check kiosks I have encountered at mainstream grocery stores have a fatal flaw, which is that the bags are way down at the other end, so you have to take a few minutes after you pay to collect your purchases. Meanwhile, the person behind you, who is already annoyed by the time it took you to look up rainbow chard on the touch screen, has already started sending their items merrily down the conveyor belt, where they mix with your still to-be-bagged items. WHY? Self-bag grocery stores, which I have encountered both in Europe and in discount US stores, long ago figured out a solution: the end of the conveyor belt fans out into 3 discrete areas, with a movable divider, so that after you pay, your stuff ends up in one collection area, and the next person’s in a discrete space.

It’s not like these technologies don’t exist. Moreover, in my sadly limited exposure to the world I have already seen these two not minor but GLARING inefficiencies. Has no one in the entire Stop&Shop higher ups ventured outside their own store? I understand retraining consumers is hard, but surely these are minor fixes compared to teaching us to check our own groceries? And yet, they persist. The lesson I take from this is that changing the system is hard, and that sensible solutions get ignored because that’s just the way things get done. And I continue to silently fume about the lack of progress.

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