Hospitals continued (was Lawsuits…)

My last post here painted a pretty rosy picture of hospital care, at least at some hospitals. And it’s true that there have been very significant improvements in many areas. But while I was there as a visitor (for many hours over several days) I also saw that the human factor is still a crapshoot.

Many of the nurses that we dealt with were excellent. In fact, I’d even say that most of them were very good at a minimum, but it seems that there are still a few in this profession that have a bad attitude toward his or her work and/or patients.

Of course, some nurses seem weighed down with paperwork (or computer work) and this is a matter of balance between patient care and possibly the kind of verification I wrote about last time. This might not be the fault of the nurse, but an unrealistic policy set by administrators. The result, however, is patient neglect. The obvious danger in this is that something serious could be happening and fail to get attention when needed. But patients don’t always know when something is serious so even when an issue is trivial they can experience severe anxiety when the nurse just won’t come.

But the worst thing I observed on this visit (and many other times) is the “Nurse Ratched” archetype.

Nurse Ratched knows what’s required and you don’t need to know – whether you’re a patient or a family member. She (sometimes he) speaks to her patients in an inappropriately loud voice and somewhat in the manner of a drill sargeant. She doesn’t ask, she tells. She manhandles her patients in order to accomplish her tasks efficiently, doing things like rolling her patients roughly from side to side of the bed like big sacks of potatoes so that she can change the sheets.

Nurse Ratched, however, is very experienced and doesn’t make big mistakes. She knows her job well. But she might up her patients’ dose of morphine just to make them go to sleep and stop complaining. Nurse Ratched is not easy to get rid of, especially in today’s situation where nurses are in somewhat short supply.

Because nurses are in demand, the employment situation for them is the opposite of that for almost everybody else. To generalize a little bit, I’ve noticed that when U.S. unemployment has been low, it seemed I was surrounded by incompetence – people not knowing how to do their jobs or just not caring. On the other hand, when unemployment is high, lots of good, able people are either without jobs or there are architects bagging groceries or something.

If given the choice, I would choose the former rather than the latter situation. I would put up with incompetence rather than high unemployment, which can be a self-reinforcing phenomenon as businesses fail that once supplied goods and services to employed people. I sure wish we could deal with both problems.

How about this? We pay people a decent wage that actually allows them to relax a little and not feel constantly under pressure. Then, we give people mandatory vacation time. With decent pay, he or she could plan for their time off and not go broke. When the employee is on the job, he or she might not resent the situation so much and just might take the job more seriously.

My bet is that each worker’s productivity would go up dramatically, as would job satisfaction. With their time off, workers would spend their money, and spread around the prosperity. Are government policies solely responsible for societal outcomes? Of course not. But policies can help to guide these situations in the right direction. That’s part of what governments are for.

Well, this is a decent idea for many kinds of jobs, but nurses are already paid pretty well. The fact is that nurse Ratched will probably never really go away no matter what we do.

-Tom Rossi

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Tom Rossi is a commentator on politics and social issues. He is a Ph.D. student in International Sustainable Development, concentrating in natural resource and economic policy. Tom greatly enjoys a hearty debate, especially over a hearty pint of Guinness.

Tom also posts on thrustblog.blogspot.com

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Lawsuits – the driving force for change.

I’m in the hospital right now – not as a patient (this time) but visiting a family member who is a patient. It’s a good hospital – better than most. It’s in my home town and I have been here many, many times for various reasons and I’ve witnessed everything except an actual operation in progress.

Because I’ve seen so much, I’ve been able to notice some significant changes to procedures over the years – changes for the better. For one thing, when blood or what they call “blood products” (plasma, etc.) are to be given to a patient, there are at least two people on the task. They scan the bar codes on the patient’s wrist band (another innovation from several years back) and the bar codes on the blood. They don’t just rely on technology, though. They read the full name and other identification information about the patient and the material aloud. They verify the blood type at least twice and maybe three times. All this to assure that the wrong thing doesn’t go into a patient.

Another interesting procedural innovation is in the way that the head doctor (attending physician) of a department conducts what are called “rounds”. This is where the doctor gathers and verifies information on the patient from all of a patients nurses, therapists, etc. All the information has already been entered on the computer system and the doctor has a linked laptop computer right in front of him. But everyone is required to verify each piece of relevant information from his or her own notes. Then, the doctor gives any visitors who are present at the time a breakdown in understandable language of the patient’s condition, prognosis, and several details.

Everywhere I look, as I walk around and watch the hospital at work, I see caution, verification, and various other methods of, essentially, mistake prevention. So why has this system evolved so well? Well, one important reason is malpractice lawsuits.

A hospital could save a significant amount of money by having only one person administer blood products, but even infrequent mistakes can cost MUCH more in lawsuits and legal fees. So, mistake-preventing procedures pay for themselves, perhaps many times over. The result (a positive externality) is that patients enjoy improved safety and improved medical care. So, lawsuits have driven these changes.

There are two alternatives to the present, lawsuit-based system when it comes to the relationship between individuals and corporations (including hospitals): much stronger government regulation to protect patients (and consumers of various types) or simply trusting market mechanisms. The former might be viable if strict regulations had sharp teeth – large fines and even criminal charges in some cases (more than now). To work, this would require enforcement on many levels – again, more enforcement than we have now. We would have to agree, as a society, that good treatment of individuals outweighs profit maximization.

On the other hand, letting corporations essentially choose how relationships with individuals work would mean that society had chosen to believe that profit maximization would drive these relationships to an “optimal” form. The idea is essentially that poor quality of services delivered will cause the business to suffer because the flow of customers will stop.

One problem with this is that the negative publicity that might come from news of an accidental and unnecessary fatality can be overcome by an active public relations (PR) campaign – TV commercials, magazine and newspaper ads, etc. All that need be done is to feature some trustworthy-looking person telling a story (fictional) about what a great hospital this one is. And so, the principle that the market will punish poor quality often fails.

Essentially, the market drives improvements incrementally and usually only within a short time horizon – within which changes in profits are quickly apparent. Without lawsuits or fines shifting the cost equation, many improvements to safety practices would either never happen, or would happen much more slowly.

Am I actually praising lawsuits? No, but lawsuits are yet another necessary evil in our world. It’s the most effective and efficient way we have to coerce painful, otherwise bottom-line worsening changes that are in the best interest of patients and consumers. Lawsuits are a way of shifting the balance back toward human well-being.

-Tom Rossi

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Tom Rossi is a commentator on politics and social issues. He is a Ph.D. student in International Sustainable Development, concentrating in natural resource and economic policy. Tom greatly enjoys a hearty debate, especially over a hearty pint of Guinness.

Tom also posts on thrustblog.blogspot.com

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