Imagine Accountability

Created by AI

I believe there are questions that, if addressed at the end of every person’s assessment - every hospital visit - every triage, would hold everyone in the “chain of care” accountable for better outcomes.

I’d like to share a recent experience because it gives me an opportunity to express a vision for accountability.

A very good friend of mine wanted to make a day trip to visit her sister. I offered to go along to make the drive to and from Nova Scotia a little easier. When I reflected on the day’s events in my head, it got me thinking about how things could have been dealt with differently.

Although this is Nova Scotia, I am very confident the process would mirror the New Brunswick experience. I have spoken time and time again that I believe our system, and the professionals within it, need to work differently. This case highlights some of that for me.

Let’s imagine “Sandra” (name altered to protect privacy). An 86-year-old, 97 pounds, frail, older adult. She was sent home from a two-week hospital stay. Her family - who live away - advised medical staff of their concerns about this discharge, knowing a high level of care (24 hours) was recommended. The hospital staff said Sandra was ready to be medically discharged, she wanted to go home, and it was her decision. They discharged her.

Sandra was sent home supported by home care (limited to 8 hours per day in 2-4hour shifts) and VON arriving twice a day to administer medications.

Three days later, (the day of our visit), an oxygen technician made a call to the family and said, “I cannot leave the oxygen equipment. It is not safe. Sandra does not understand what to do for daily operation, care and safety. She needs to go back to the hospital.” After some discussion, the family did what they were advised to do?

An ambulance was called to transfer Sandra. The coming process was forewarned by the paramedics. They would transport Sandra to the ER. Because her vitals were stable, they would leave her in the waiting room until she was seen by the ER staff and could be admitted.

After a bit of time, and a request from her out-of-town visiting family member, the Triage Nurse checked Sandra’s oxygen level as she sat in a wheelchair, wrapped in a blanket. She was sent back to the waiting room.  Sixteen and a half hours later, Sandra was still sitting in the ER waiting room, in a wheelchair, wrapped in a blanket. A half hour after that, she was taken into the inner workings of the ER and got into a bed. In only three days after her discharge, she was admitted back to hospital.

I think about the decisions that were made along Sandra’s situation, and I can’t help but wonder if there couldn’t be a decision-making process that puts the care and needs of Sandra first.

Here are questions that I believe, if put atop the attending professional’s signature in the line of her care had to answer before signing off, could change the comfort and outcomes for every client/patient.

1)     Does this action make the client/patient situation immediately better? YES / NO

2)     IF NO, does this action have the potential to make their situation worse? YES /NO

3)     IF YES, what are the alternatives or potential alternatives?

Imagine if these questions were asked atop the physician’s discharge signature? If the physician had to honestly answer the first question with a “no”, what accountability would the coming actions necessitate?

Imagine if these questions were asked above the signature of the oxygen technician on the conclusion of the action that was being recommended?

Imagine if these questions were asked above the signature of the sign-off of the paramedics as they left her in the ER waiting room?

Imagine if these questions were atop the signature of the ER Triage Nurse?

None of these individuals had to think ahead, beyond what their world looked like. Decision made, process followed. The patient would be uncomfortable for as long as it took. No one looked a little way ahead to see what the impact would be, and more importantly, could the impacts be mitigated?

Would these questions provide pause to seek a better alternative? It should. And maybe, as the system begins to work differently, every professional associated with the chain of care will realize that it’s not about them. It’s about client/patient centered care that’s possible, even in a considered broken system. It could get better one client/patient at a time.

Let’s go back to the discharge. If the doctor answered “NO” to the first question and answered “YES” to the second, then the third question needs to be addressed. Let’s explore what could potentially happen.

1) Could she stay in hospital until further plans can be made?

2) Could there be an attempt to train her on the oxygen before she is discharged to see if she can manage it? If they knew this answer ahead of time, it would have helped make the definitive decision that she could not go home.

3) If she was sent home, could she be provided with temporary 24-hour care? Could Extra Mural (or VON in Nova Scotia) be “on call” if needed?

Discharge planning is at the heart of this. And it is a methodical process that should always have the client/patient’s best interest at heart.

Let’s examine the oxygen technician’s determination that “she needs to go back to the hospital”. It was obvious to me that everyone knew the process would be to go back to the ER to get admitted. Let’s look at the questions. If they answered “No” to the first question and “YES” to the second question, then the third question needs to provoke some foresight to see what that action really means for Sandra and what mitigation could be put in place.

1) Could VON (or Extra Mural in NB) do an in-home assessment to pre-admit to hospital and the client/patientt be kept at home until a bed is available?

2) Could any local family help with supervision, along with home support, to maintain 24-hour care until a bed is ready?

3) Could there be a “window-of-time” given to the family to get their loved one to the hospital once a bed is available?

Think of the upstream decisions that would have given relief to an already backed-up ER. And more importantly, think of Sandra’s comfort.

What will it take to promote innovation and creativity? More importantly, what will it take to put the patient first at EVERY decision point. We run our systems for the “system”. We think about avoiding exceptions because it will upset the process already established. But what if this “working differently” could actually begin to improve client/patient outcomes….one “Sandra” at a time. A collaborative system where RHAs, third-party providers and government departments speak to each other AND how collaboratively sharing resources could make this possible.

If we do not decide to work differently, outcomes will not change.

I am all ears for the nay-sayers. BUT, I would rather talk about how we make this happen.