Minister gives clues to turning problems into patient relationship successes
Here are some best practices
Each hospice and each hospice employee will have moments when patient care fails to achieve all goals or when an unanticipated problem arises.
So the question is not how to prevent these events, but how to make the best of them, says Robert C. Miller, BA, Mdiv, a Lutheran minister and vice president of clinical development and ethics for VITAS Healthcare Corp. of Miami, FL.
"We know that certain patients have problems, like those in a lot of pain or who have shortness of breath or at risk of bleeding," Miller says. "Those are the ones who call us a lot, and so we should focus on those patients as much as we can to find a way for them to have confidence in their provider."
Hospice workers should read and adopt the philosophy imparted in the book Healing Words: The Power of Apology in Medicine, written by Michael Woods, MD, and Jason Star, and published by Doctors in Touch in April, 2004, Miller says.
"The book is written for doctors and focuses on the physician-patient relationship when something goes wrong," Miller says. "But if people have this difficult relationship with physicians sometimes, then there is something we can generalize out of that to help us in hospice."
Most of the time when a patient sues a doctor it hasn't been just one event that causes the lawsuit, it's typically a problematic relationship and series of events, Miller says.
"So if you have a patient who has a problematic relationship with a health care provider and not just with a hospice, then focus on that patient proactively," Miller says.
For physicians, three minutes can make the difference between being sued and not being sued, Miller notes.
"A study quoted in the book shows that physicians who spend just a few more minutes in an office visit with a patient end up getting sued less frequently, and it's literally three minutes difference," Miller says.
What hospice workers need to ask themselves is what they can do to help patients feel like they aren't going to abandon them and are truly present with them, Miller says.
The key is to know how to turn a service failure into an opportunity to improve a provider-patient relationship, Miller says.
"Whenever there's a service failure, you should do everything you can to involve the physicians who referred the patient," Miller says. "We might ask the medical director to be in contact with the attending physician for guidance."
Someone needs to proactively contact the doctor to let him or her know there has been a problem so the doctor doesn't hear about it from patients, Miller says.
"Our relationship with the attending physician is probably the most critical relationship in terms of their feeling comfortable in making referrals," Miller says.
Another way to handle service failures is to have a forensic quality assurance program, such as a forensic utilization review meeting in which the appropriate staff will look at a case to try to determine what went wrong, Miller suggests.
"They should look at the chart, look at what was there and whether there was something that should have been done differently in that situation," Miller says. "They can pick the chart apart and think about it on a broader scale, such as if it happened one time was there something that could be learned to prevent it from happening again?"
Woods' book focuses on apology because this is a powerful tool in working with patients and families, Miller says.
Despite what risk management specialists will say, health care providers should apologize when needed, he says.
"It's only one step in terms of what you need to do overall, but people need to know there's a human being on the other side of the phone," Miller says. "They need to know that we're really sorry that this happened, and we shouldn't be afraid to say so."
Some law firms even have a corporate apology program in which major corporations save themselves millions of dollars annually by apologizing in writing to the individuals who were harmed by their products.
Miller makes an analogy of the power of apology to a broken arm that has healed properly, calling it "stronger in broken places."
"It's a reference to the novel Farewell to Arms, in which Ernest Hemingway talks about how a bone that is broken is unlikely to break again in the same place because it's actually stronger than it was," Miller says. "The human spirit grows stronger in the places where it was broken."
When hospice workers have a relationship with a patient and family and the trust is broken, possibly because of a mistake or because the service failed to meet the patient's expectations, then that's when the bond is broken, Miller explains.
"So what we want to do is recover in a way that makes our relationship with them grow stronger, providing a catharsis," Miller says.
Miller has seen this phenomenon regarding apology at work in his own experience: "My wife just had surgery and had a hysterectomy," Miller explains. "She bled internally, and it was rough for about 24 hours."
The doctor came back to see her several times that day and was apologetic for what she was going through, Miller recalls.
"He was obviously very concerned and very calming and talked about what we would do and that really made all the difference for us," Miller says. "We didn't feel like we were alone in that experience."
Another tactic for dealing with service failures is to respond immediately and respond in person whenever possible, Miller says.
"One typical way of handling a complaint is to go out and investigate it and then call the family," Miller says. "Our practice is to not investigate it because that could take 24 hours, and meantime the family is wondering why no one is calling them."
Instead, a hospice should show the patient and family that someone will help them and care about what they're going through, Miller says.
"You have to foster the kind of environment where people feel comfortable volunteering their mistakes, saying, 'This situation didn't go as well as I would have wanted it to go, and you can help me handle this in the future better,'" Miller suggests.
At VITAS Healthcare, this type of environment is fostered at team meetings where each meeting includes a few minutes for education, Miller says.
Customer service also is a main focus during the educational segment of the meetings, he says.
"We're trying to help the manager encourage these kinds of conversations to happen," Miller says.
"One big stumbling area for hospice people is if we treat a complaint as though it's ineffective coping, saying, 'They are not coping well; they are anxious and grieving,'" Miller says. "When in fact there might be things that are really critical for this individual and we don't listen for that."
For instance, there might be a patient who complains because the home health aide is 15 minutes late two times in a row, Miller says.
Instead of attributing his complaint to his inability to cope with his illness, the hospice staff should take his complaint seriously and find a solution, he says.
At a workshop Miller held on this topic, one hospice employee provided an ideal solution to this problem: "She had a caregiver who was an engineer, and every time the home health aide was a couple of minutes late he'd be on the phone with her supervisor," Miller recalls.
So the supervisor asked the home health aide to call her when she was running late, and the supervisor would then call the caregiver and talk with him for the five minutes it took for the aide to arrive at his home, Miller says.
"She'd talk on the phone with him about the weather or whatever, waiting until the aide arrived, and then he'd say, 'I have to go because the home health aide is at the door,'" Miller says.
The idea is to create an environment in which people feel comfortable talking about mistakes, Miller says.
"It's finding that balance between making sure we foster the right kind of environment where people are comfortable talking about things and holding people accountable for what we expect from them," Miller says. "Our main goal is that when a mistake happens we do everything we can to make sure it doesn't happen again for that family and any family."
Need More Information?
- Robert C. Miller, BA, Mdiv, Vice President of Clinical Development and Ethics, VITAS Healthcare Corp., 100 S. Biscayne Blvd., Miami, FL 33131.
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