“I asked the nurse for a psychology consult for Gloria Teller on the third floor,” the dietician told me. “She’s not eating well, and when I went to talk to her, all she could do was cry.”
“Thanks,” I replied. “I’ll keep an eye out for it.” I jotted the name down in my book so I could follow up. Consults had a way of going missing.
Sure enough, after a week had passed and no consult appeared in my mailbox, I began to track it down. Putting on my Sherlock Holmes cap and taking out my pipe, I considered the possibilities: the nurse could have forgotten to write the consult, the order could have been written but no corresponding consultation form was generated, or the consult form could have been misplaced on the way to the mailboxes.
I wonder how many other consults go missing?
I wonder if a clinic appointment gets cancelled, how often it’s rescheduled?
I wonder if a family member tells the aide that her father does better on Medication B than on Medication A, if that information ever gets to the attending physician?
I wonder if I leave a note for the doctor on the floor where he has only one resident, will he see it in a timely fashion or at all?
I wonder if we’ve run out of MD order forms, how many orders go unwritten?
I wonder who’s in charge of the FLOW of communication, because it seems to me that while we’ve got department heads, we don’t have an INTERDepartment head, and we could use one.
Back to my consult: I started with the most likely scenario and asked the nurse, who replied, “Oh my gosh, I completely forgot!” She pulled out some papers, scribbled furiously while telling me about the emergencies she’d been fielding the day the dietician spoke to her, and thrust the yellow consult form into my hand. “Ms. Teller really needs you. She’s a mess.”
Dr. El, it’s really nice that you write down potential consults and track down the people in charge. I wonder if there’s also a possibility that sometimes consults were sent to a different professional because the staff believed that what the resident needed was psychiatric or medical, not psychological care.
I’ve worked at places where they have a serivce coordinator on each unit and an overall service coordinator. Others have tried to “punish” staff who forgot to file a consultation form. I wonder if there could be “incentives” to motivate them instead.
C,
I think a good incentive for people to do their job is that they actually get to keep their job!
What worries me, Sue, is that the communication issue often isn’t recognized as an issue, and therefore isn’t considered part of the job description.
Sue, I agree with you that staying employed is important to many. If that is the only thing management focuses on (as an “incentive”) I do wonder if staff will be operating in a culture of fear. There are too many things you can get written up for these days.
I don’t want to make excuses for others but at a lot of facilities, they are constantly short of staff; have insufficient resources, and a confusing system of communication. People need to play by the rules but the rules also need to be feasible and clear.
Dr. El,
It goes without saying how important good communication is. The larger the facility the more chances for miscommunication. Systems and procedures are important, but are only as good as the people following them.
Thanks for your contribution to the conversation, Sue. Good communication is essential, but we’re often in our own silos (departments), so that while we may foster good communication within our department, it can be more challenging to foster interdepartmental communication. I agree that systems are only as good as the people following them, but if systems and communication are seen and emphasized as a value of an organization, and training is put in place, the people are more likely to follow the system.
Ya know, communication is so complex, subliminally in a nursing home environment . “Too much information”” is frowned upon…. “don’t ask, don’t tell”, “I’m better off keeping my mouth shut”, “Its best to stay under the radar”,, “don’t kill the messenger” , “If you bring that to their attention, you’ll be labeled a troublemaker”….” If it isn’t written down it didn’t happen” Don’t interrupt or ambush someone in the hallway with pertinent info because you are afraid you’ll forget the next time you see them”…”.Don’t write that down in a email, they may hold it against you”, “I didn’t find out in time, I finally sat down at my desk at 3:00 to hear and see voice mail and email….the list goes on and on. There seems to be an unspoken rule to just “bob and weave” while navigating through all these communication systems. I often wonder if communication is thwarted and compromised because some staff take advantage of a “demented” Residents concern ,complaint or behavior. Sometimes, “issues du jour” that are trending take over and drown out common sense.
When I started out in a nursing home, YES, there was alot of complaining about the” overhead page”. Yes, it is noise pollution and disruptive. But, I gotta tell you, communication just seemed to flow better. When it comes to communication in general, sometimes I think we are spinning so forward to move backwards!!!! hahaha
Genie, in most organizations, not just nursing homes, there seems to be a reluctance on the part of the management/administration to hear the suggestions for improvement on the part of the workers. Sensing the reluctance, disinterest, lack of follow-through, or even opposition, the workers learn not to say anything in order to protect their jobs. Certainly line staff workers don’t have the same sense of the overall picture that the management/administration does, but on the other hand, management/administration doesn’t have the knowledge of how things are working “on the ground” and can benefit greatly from getting that information. Regarding the overhead paging, there are many other communication options these days that allow staff members to reach each other without disrupting the entire nursing home, and I agree, it’s essential that workers are able to contact each other quickly and easily.
Dr. El,
So true about the disconnect between line staff and admin. Not too long ago I was at a QA meeting with representation from interdepartmental staff. The overall tone of the meeting was sort of a free flowing brain storm, where staff could speak freely and listen without feeling that something they said would hold them accountable to put into action or dismiss or trial and error their initiative.. Somehow that “tone” was frowned upon by admin. Unfortunate, really. The premise is so simple “how do we come together to make life better for our Residents”. Communication is always a big topic. Admin is always saying things like “how come I am finding about this issue now, and not in a timely fashion? ( could it be the fear/punitive piece???) In general, there does always seem to be a fear/punitive tone always present. Admin also operates from this fear culture when getting ready for survey. My God, 15,000 things could go wrong, be scrutinized and cited. Yes, upper management can be proactive and supportive in setting up and implementing better communication systems….BUT, above them, CMS, the State, I think, has ultimately created this monster, in terms of the content that we are communicating.
PS. I wish all staff were outfitted with those nifty headpiece intercoms that I’ve seen salespeople use in Sonoma at the Mall, to communicate with each other……heheehe. I can’t tell you how many times I am looking for someone on the floor or wherever, and I observe other staff doing the same…….ARRGH….really such a waste of time. And again Residents observe this rushing around , looking for people and scratch their heads…….sorry for the vent
Genie, I worked for a few years in managed care, reviewing and approving or disapproving inpatient and outpatient mental heath care. It was fascinating to see how therapists and facilities reacted to the review process. Some people were collaborative, but more were openly hostile before I’d said a thing. I presented on the topic at an American Psychological Association conference at the time: The Managed Care Case Review Procedure as a Clinical Intervention. Most of the tension between facilities and surveyors is a reality-based fear of reprisal, and some of it is projection based on past experiences with authority. A lot could be done at many levels of long-term care to create a more collaborative approach that benefits everyone involved.
Alot can be done and is being done I find it fascinating that CMS has exempted some of the cutting edge models such as the Greenhouse Model of skilled care from archaic scrutiny. CMS’s directive to surveyors in terms of interpretative guidelines relative to the new survey process is not to use traditional investigatory practices for these places. For example. some “neighborhood” concepts of care or Greenhouse facilities do not need to provide or produce the traditional Recreation calendar or archaic attendance records that function as “proof” positive documentation that Residents are experiencing quality of life relative to their leisure interests. These innovative models support an atmosphere of spontaneity and a more person centered approach to activities. Just because I do not work in these environments, I am trying to infuse these concepts into my more traditional nursing home setting. Surveyors need to support these initiatives as “works in progress” . I should not have to cower under this “gottcha mentality” during survey, making sure all my documentation is full proof. Surveyor Interviews with Residents, staff and family should suffice. The most useful and important documentation I could contribute would be a detailed “LIFE HISTORIES/STORIES” placed right in the front of each individuals chart for all to read/see/celebrate share and validate with the Resident . The chart is jammed pack with scientific jargon, numerical absolutes and present day behaviors that say NOTHING about WHO THIS PERSON IS. Sorry for the ramble and rant. I guess I’m just angry. We are very close to our survey window and everyone is in “Cover your A—– mode”. This just amplifies the whole notion that our hands are on the chart, not on the Resident!!!!!
AND……….I got so “off topic”
If you can, Genie, document quickly and move on. Your residents need you.
Thank you Dr. El! for reminding why I got into this field in the first place! You have no idea how perfect,. simple and clear your response is. I guess I just love the way, when I “leave a reply” on this blog, it says “REQUIRED FIELDS ARE MARKED” and then I look and I see no red asterisks anywhere!!! hahah
i work with elders in the community, in a collaborative case management model funded by state fmoney, for low income elders, to provide services to stay at home and age in place. Funding issues and need for soliciting donations due to shrinking govt funds and increasing needs have led the management to focus on looking good but not on doing consistent quality of care. “As long as the paperwork looks good and is done on time…..” is what management looks for ‘All sizzle no steak” is the underlying theme, which I guess is similar to surveys in a SNF. . Any suggestions for trying something new or having trainings to improve knowledge and skills (and morale, with no raises in four years) does mean that YOU will get to work extra to do it, or get labeled a troublemaker for ‘complaining’. I feel like the little boy in the story about the emperor’s new clothes! This is not just a SNF problem, it’s an issue for area agencies on aging, Medicaid waiver programs that pay for nursing home level of care in the community, etc. Even with Medicare money involved, the end points that are monitored are not ones that have relevance to client satisfaction. As an RN I am committed to being an advocate for my clients, but I have decided to pick my battles carefully. I know clients and families have the same frustrations in lack of communication and coordination of care with us and our subcontractors, and with us and the medical providers, etc. I try to remember that sometimes we do great work IN SPITE OF the bureaucracy, and that is what keeps me going! Thanks for the airtime, and thanks for your blog! I have suggested it to people at work, and to family members. Keep up what you are doing – someday I may be in that nursing home too!
Clairesmum, thanks for offering a wider perspective on the communication problem. It reminds me of the scenario when I tell a resident who reports that “they’re taking my clothes.” I say, “It’s not just you. I don’t know if this will make you feel better or worse, but clothes have disappeared in every nursing home I’ve ever worked in.” I don’t know if I feel better or worse, knowing that this communication problem is everywhere, but it certainly calls for examination and intervention.
Thanks for spreading the word about my blog. I appreciate it.
Major thanks for the article post. Really Great.