Co-ordination of individual patient care in hospital
My mum is in hospital so I’ve witnessed the NHS at close quarters recently. I thought it worth recording some thoughts from the perspective of my interest in patient and public engagement and in co-ordination both within and between organisations.
Her care has been mixed, from the poor (e.g. two MRI scans missed unnecessarily, about which a complaint was submitted) to the excellent (compassionate and high quality). I’ll focus here on one incident which raises a few issues.
In brief: speech and language therapists prescribed thickening her drinks to make it easier to swallow. What went wrong:
- The thickening powder wasn’t available the next day. When I went in, she was very thirsty and evidently hadn’t drunk for some time. I was told there was a delay because they couldn’t get the powder. When a healthcare assistant (HCA) finally came, she took the powder out of a drawer.
- Later, my mum was offered a hot drink, but the person didn’t realise it should be thickened. There was a poster behind the bed which was supposed to make this clear.
- The next day a junior (and I think quite inexperienced) junior doctor came round and said she was dehydrated. He said she could have a hot drink and (incorrectly) didn’t think it needed thickening. He also prescribed a drip for fluids.
- That evening she wasn’t on a drip. When I raised it, a nurse denied that she needed to be, but shortly after said she now was and put one in place.
- The first day she was on thickened drinks, a HCA said I shouldn’t thicken them myself. The next evening a nurse was happy for me to do it.
I clearly don’t know everything going on behind the scenes, so can’t comment definitively, but it seems likely there are opportunities for better co-ordination which needn’t require more resources. The sort of areas that would need to be examined would include:
- Stock ordering, storage and access so things such as thickener could be quickly available – I presume this is a fairly routinely required product
- Methods for informing a variety of staff, skilled and unskilled, of the patient’s requirements. The poster behind the bed is an important part of that process but clearly wasn’t working effectively. There could be other procedures, such as a sticker on the water jug.
- Training, education and communications to ensure systems and processes are followed (such as noting the poster requirements)
- Planned and ad hoc communications, such as in multi-disciplinary team meetings and informal updating of staff
- Staff utilisation including greater consistency in staff looking after a patient so they are more aware of their needs. I assume this would have been done if possible, and perhaps staff shortages or use of bank or agency staff was to blame.
Those are all aspects of routine management, but there are two other important things which are frequently missed.
The first is the involvement of patients, their families and carers. The promise in the (legally supported) NHS Constitution that “The patient will be at the heart of everything the NHS does” is not always clearly fulfilled. But beyond that, greater involvement of family and carers could be helpful to the hospital. I was an additional node in the network of ad hoc information sharing, letting doctors and non-clinical staff know that she needed her drinks thickening and reminding a nurse to put her on a drip. However this could have gone further. I could have administered the thickener from the beginning, possibly avoiding her becoming so dehydrated. I could conceivably even have gone along to pick it up from the stores in the first place.
This is not to suggest that there are easy answers here. Not all family members would be happy or capable of taking on such roles. There are risks and issues of liability. The point, though, is that there is an untapped resource which could perhaps be made better use of and this is worth exploring further.
The second point is about how the hospital deals with such problems. Improvements could be made, but feedback would have to be welcomed and sought, and mechanisms in place to do something with it. Staff should be constantly on the look out for feedback and ways of making things better. Suggestions for immediate changes could be quickly evaluated and implemented, such as by the staff themselves or mentioning it to a more senior colleague who could authorise just getting on and doing it. Where the answer was unclear, there should be a way of flagging it up as an issue and adding it to a list of items to be worked through in priority order through a systematic improvement approach.
However, to make that work, you need a culture that values improvement and that takes comments, even when expressed as criticism, as an opportunity. That should be supported by an overarching vision (perhaps of moving from ‘Requires Improvement’ to ‘Excellent’), leading by example and good communications.
None of that is new. We’ve known those things for years. So why isn’t it being done? Have the daily pressures and lack of resources just driven out such thinking? Maybe, but why weren’t those things put in place in the good times, to support maximum efficiency in these dreadful times?