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Question #1: Fundamental attribution error is when an individual attributes a behavior to one’s character rather than the circumstances or situation surrounding the behavior. An example of this is a student who my daughter had met while in college (Elsa). Elsa was drinking a LOT of alcohol, most nights. It would have been easy to label her as having a drinking problem, or even an alcoholic, but was later revealed this student’s parents were going through a divorce at a very vulnerable time of her life.
Question #2: One decision that parents occasionally must choose when their infant is admitted to the NICU is if they will consent to a lumbar puncture during a sepsis evaluation, especially if the infant’s blood culture is positive. The standard of care for neonatal care is to evaluate and rule out meningitis when concerned for sepsis, bacteremia, or another serious infection in a newborn infant as infants cannot localize symptoms of meningitis.
The option is to either consent to an LP or complete 21-days of IV antibiotics in the NICU with placement of a PICC line. The thought of an LP in a newborn is so scary in the first weeks of life. However, by sitting down with parents utilizing illustrations which outline the steps of the procedure, this helps parents to see the needle is placed below the termination of the spinal cord (and therefore doesn’t risk paralysis). We also use EMLA as a topical anesthetic to decrease discomfort associated with needle insertion and knowing this reassures parents. By answering their questions and taking the time in a relaxed fashion, most parents agree to the procedure instead of an extremely long course of antibiotics.
Barry,
I love that you have meetings with the intention of building the team. Helping each employee feel as though they are central to the mission and goals of the team provides for employee satisfaction. Each employee then recognizes the contributions their attitude and efforts do to improve the quality of care you provide for the patients. I believe the team members can sometimes feel that only what the doctors or nurses do at the clinic really matters, but by building the team this allows everyone to feel their importance.
Hi Juby,
What a wonderful way to help new students integrate into an unfamiliar environment by meeting with all new students and making time and intentional contacts with them to help them adjust and feel welcome. I also praise them for reaching out to new students to provide updates and information in case it is missed. Bestowing accolades to recognize the efforts of students is a great way to reinforce positive behavior and improve attitudes of learners too!
Our hospital tries to keep their physicians satisfied, whether through compensation, allowing physicians to create their own work schedule, etc. – this correlates to the 1997 study by Estrada et. al. that showed satisfied physicians in a hospital setting were better able to make faster, more accurate conclusions therefore increasing decision effectiveness.
Our hospital system also goes to great lengths to promote employee satisfaction (happiness). As noted in the article, much literature has focused on employee satisfaction leading to increased creativity, productivity, and decreased turnover, which in turn, saves the system considerable money.
Question #1: I think the best way that the medical school where I work part time instills a sense of identity in me and all its employees is to provide a job title for each person and a job description to define expectations and goals. However, each employee is also encouraged to identify new initiatives and develop their position to a greater degree. Supervisors provide encouragement and if possible, funding, for these new initiatives. Yearly performance evaluations not only identify strengths and areas for improvement in each employee, but these sessions also provide support and brainstorming to help employees reach their self-defined goals.
Question #2: The NICU is very different than an office setting, but I love the idea of the ChenMed card described in Chapter 4. When implemented, this would work very different for the NICU babies. Instead of displaying the patient information on the RFID card, in the NICU the family information, including parent names, other children, hometown, and employment would be displayed allowing easy access to the information that helps shape care of and discharge planning for the infants. I also favor the idea of displaying any personal information the parents would like the medical team to know, such as history of post-partum depression, immigrated from Ghana 8 years ago, etc. Although this information can be found in the parents’ medical record (not the infant’s which we have ready access to), I feel this would provide additional information for the NICU medical team when caring for babies.
Abanda –
I did not know that the ten richest men in the world doubled their income during the pandemic. I like to think that they invested a portion of this money and other assets back into their country or region but I don’t know that they did. This does not surprise me and I know that many, many people who already were suffering financially developed even more problems during the pandemic whether it be losing their jobs due to their own illness, a dependent family member illness, lack of infrastructure in place to support them, or even loss of their job due to a direct result of the pandemic.
Hi Barry,
I am still so inspired by the clinic you have created and the success it has realized. You have provided healthcare and more for a population. I wonder how many of us would have persevered in such an endeavor if we knew we would not be paid for a few years. Probably not many of us.
And you are correct, there was no telemedicine for NICU during the pandemic. Although we didn’t have many babies ill with COVId (even if their mother was), it was still a risk. The risk didn’t rise to that of visiting COVID positive pstients in their homes as you did or caring for patients as they are triaged in the ED.
I choose the practice of Selective Hiring. I think back to when we recruited and interviewed several neonatology fellows to potentially join our practice upon their graduation. We met with each applicant initially via phone and then at least one (and sometimes two) personal visits, with the second visit typically including spouse and family visiting our community as well. This autonomy provided us by the hospital system allowed us to know each applicant and find the one with the best fit for our practice. We also utilized peer and professional references and contacted each reference to ensure we didn’t uncover red flags or work/personality characteristics that would jeopardize the cohesiveness and collegiality of our large neonatology group.
In the NICU we are always working to improve communication with families. Our NICU is in South Dakota, a very rural state, and it is not unusual to have babies transported in from several hours away. Thus, their families can’t visit frequently. We instituted a plan to improve communication with daily updates written on large sticky notes hung in the patient room and the neonatologists call families most days to keep them informed of the clinical status of their infants. Bedside nurses also provide frequent updates and a new online viewing system allows families to watch their babies in real time. As a result, our family satisfaction scores have improved.
First, we learned from the pandemic that most work and meetings can take place anywhere, with a strong internet connection. This has allowed millions of people to work from home and many find this to be far more satisfying than leaving the house each day. I suspect more work can actually be accomplished without office distractions too.
Second, I believe the pandemic only exacerbated the social divides inherent in and amongst minorities in the US but brought visibility to health inequities. Whereas, many Caucasian people could take their computer and work from home and insulate themselves from the risks of virus exposure, while being paid, many minorities were employed in blue collar positions where they could not work from home. A meat packing plant in our community rewarded employees monetarily if they did not miss a day of work during the pandemic. This resulted in workers who were symptomatic with viral symptoms from COVID presenting for work and exposing others. This resulted in a profound COVID outbreak that reached national headlines.
Abanda,
I was shocked to read of the reward system for physicians in Yaounde. How awful that physicians are actually rewarded by ordering more and more tests. This is harmful to the patients and I am sure overwhelms the laboratory. Who wouldn’t try and order as many (likely unnecessary) tests as possible for monetary benefit? This is in direct opposition to practicing evidenced-based care for patients.
Hi Abanda,
Thank you for describing the health care system in Cameroon. I find it shocking that so many aspects of health care are billed to the patient in a fee-for-service type system. This has got to put a burden on patients and their ability to access quality health care. You mention that even the basic necessities of labor are billed to the laboring mother. Does this result in more women seeking unattended home births where the costs aren’t so prohibitive?
An example from my professional experience of a reward system conflicting with expected outcomes is the health care system in which I am employed. It is a large mid-west US health care system. They have named themselves Sanford USD (University of South Dakota) health Center. The hospital system boasts educating the future generation of physicians and health care providers. They advertise themselves as dedicated to education and teaching, calling themselves a teaching hospital in the media and in print. They have a large research center named Sanford Research and invest in laboratory science and the training of graduate students.
However, this year when financial cuts were made throughout the enterprise, continuing medical education leaders were dismissed. Medical student research, which is critical with residency application in the 2020’s, was halted and no longer funded. Physicians are not paid for their efforts for teaching, lecturing, mentoring, or educating the numerous resident physicians-in-training in the hospital system yet this expectation of building the residency programs and dedicating time and effort to them is inherent from the enterprise leaders.
The hospital rewards RVUs and billing by the healthcare providers. Many of the physicians at Sanford Health are faculty at the University of South Dakota Sanford School of Medicine. There is no medical school practice plan in place like many medical schools across the US. Physicians are expected to give of their time and talent to education but are rewarded by the hospital system for their billing practices.
The hospital system could align this better by funding medical student research and providing funding for programs which enhance the development of faculty and their educational achievement in attempts to accommodate a better training atmosphere for our trainees.#1. The last time I was overwhelmed with options was over the New Year’s holiday a few weeks ago when I was on my Kindle trying to determine what novel I would download to read on the trip to my parent’s home. Because there are thousands, if not millions, of novels I could download, I narrowed the choices by searching the Kindle store specifically for fiction books that were mystery, which are my favorite easy-reading genres for free-time reading.
Next, I limited the choices to those with authors I have previously read and enjoyed. This way I knew I wouldn’t be risking my enjoyable free time with a novel I might not end up liking. Then, I narrowed the list even further by looking at books that have been recently released. Then I read the introduction to several different books and finally settled on one that was a sequel that followed a book I had previously read. This ensured that I was familiar with the main characters and the writing and would be entertained during my short vacation from work and other obligations.
#2. A fee-for-service payment system is one where a fee is paid to medical providers for a service or procedure they have performed. This rewards providers with the volume of services and does not value the quality or the patient outcomes of the care. As noted in the book, there may even be incentive to not collaborate with other healthcare providers and coordinate care of the patient, particularly the complex patients.
One initiative to transform payment models is the concept of bundle payments for particular disease processes (such as those requiring inpatient care) or surgical procedures (total hip or knee replacement). Hospitals and providers are reimbursed a set amount of money for a specific healthcare service and if the hospital course is complicated by a hospital-acquired infection or medical error on the part of the medical team, the hospital (and provider) isn’t paid any more money required to cover the costs of the nosocomial infection or error. This, in essence, costs the hospital thousands and thousands of dollars. The bundled payments increase quality and decrease costs.
Barry,
I completely agree with your assessment of the homeless and maintaining employment. I have many people say “Why don’t those homeless people just get a job and then they would have money for food and a home.” It is so much more complex than that, as you mention. So often those who are homeless can’t get a job because of so many logistical factors that impede this. They often don’t have appropriate apparel, a means of cleaning themselves daily, transportation to the job site, health, etc. Thanks for highlighting this in your post.Hi Barry,
I am so impressed with your fortitude and perseverance!! How awesome that you were able to take your vision and not only implement it – you succeeded beyond the imagination with a clinic that serves the less fortunate and persists to this day. This is nothing short of amazing.I have to agree with you on your comments regarding the Big System. I may be wrong, but it seems as though they make statements about supporting physicians and doing what is “right” in the name of health care, but it always goes back to cost, cost, cost. Only when there is a “sure thing” that will save money, does it seem to be enforced. My health care system has physicians in key leadership roles but far more business people driving the organization and the decision-making. Recently, our system had a mass exodus of surgeons when their compensation plan was abruptly changed. I don’t know the specifics of it, but many of these surgeons left the system for lower pay at a competing institution. They left based on principle.
Your comments about assessing an organization’s readiness for change is so important and probably the key princiciple in successfully convincing a hospital system to transform. Thanks for your insight and inspiration.