End of Life Decisions

I think that nothing is more challenging for families, physicians and nurses alike as end of life decisions. I left out patients from that list, as I have found through the years that patients have the easiest time talking about death compared to the rest of us. The rise of hospice care in the United States, while purported to represent "Death with Dignity," which I think is appropriate and true, is also about helping physicians and families deal with death. The difficulties and confusion comes from trying to determine a patients' wishes as they relate to end of life. Is there a next of kin, a health care proxy, an advance directive, a signed Do Not Resuscitate/Do Not Intubate order? All of these questions, whether they are asked and answered, affect our ability to provide the appropriate care to the patient, and allow our physicians, nurses and families to feel comfortable in providing that care. I know it is cliche, but make sure you talk about it with your loved ones: what would you like me to do in this situation? Speak with your primary physician about it so that it is in your file. Let the hospital know; don't assume they do. We have the questions built into all of our admitting processes so make sure you use it each time you or a loved is admitted.

The Importance of Primary Care

I was directed to this quote from the book, "How Doctors Think," by Dr. Jerome Groopman, which I found interesting in its description of our perception of subspecialization and primary care. I thought I would put it on my blog to see if anyone has some thoughts on it.

A common error in thinking about primary care is to see it as entry-level medicine...and, because of this, rudimentary medicine...This is a false notion. One should not confuse highly technical, even complicated, medical knowledge--special practical knowledge about an unusual disease, treatment, condition, or technology--with the complex, many-sided worldly-wise knowledge we expect of the best physicians.

The narrowest subspecialist, the reasoning goes, should also be able to provide this [broad] range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor.

What it Means To Be Accredited

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, for short) is one of the main bodies that essentially license hospitals to operate and care for the community. A group of JCAHO reviewers, made up of nurses, physicians, engineers, visit every hospital in this country, without notice on a regular basis. Usually the time frame is every 3 years, though this interval varies based on the reviewers' findings. When JCAHO "comes to town," it takes the work of the entire hospital to make transparent the quality and safety of our operation. The reviewers spend 3-4 days looking at everything from our cafeteria to our power plant, from our Emergency Department to our operating rooms, and from our nurses to our physicians. They look in credentialing and licensing to make sure everything is uptodate. You can imagine how much work this process entails on everyone's part. That being said, I find it a helpful process in that we should always be testing ourselves and our processes to make sure that we are the providing the best care. If we fall short, it is our responsibility not only to identify the shortcoming, but to look at the cause and create a solution. After their 4 day visit, the reviewers from JCAHO renewed our Accreditation. I often say that health care is not about getting a pat on the back or an "A" for effort, because we are talking about lives, however, it is nice to get the positive review of an objective observer.

Physician/Nurse Rounds

Amidst the however-many-feet of snow today, the Anna Jaques Hospital team kept the hospital going strong for the community. I walked with Delia O'Connor, our CEO, around the hospital to visit each unit today. I was amazed by the nurses and physicians and staff who slept at the hospital last night or stayed in town in order to make sure they were available today to provide care. I am glad that I was able to make "rounds" today, as it really helped to emphasize how dedicated these folks are. The "Physician/Nurse Rounds" will help to emphasize to our patients and families the coordination of their care. When the physician comes to see the patient, he or she will notify the nurse and they will interview/examine the patient together. This ensures that plans of care will be communicated and consistent. If the nurse caring for the patient is busy with another of their patients, the charge nurse will perform this activity. The most common issue that I have seen at hospitals across the country is the effectiveness of communication, whether between physicians, nurses or patients and their families. Our caregivers are doing what they were trained to do, but in the hectic environment of the hospital, it occasionally is not communicated as effectively as any of us would like. These "rounds" should enhance our ability to achieve that goal. We had an interesting week, last week, with our triennial review by the Joint Commision on Hospital Accreditation. Certainly, we passed with flying colors. Tomorrow, I will describe some of what was involved.

Patient Centered Approach

A "Patient Centered Approach" to medicine is also known as a Team Based Approach. I prefer the latter since the former implies that the patient has not always been the focus of many well intentioned caregives. A Team Based Approach utilizes caregivers from many different discliplines, physicians and non-physicians, in order to coordinate the approach to a given patient. Institutions like the Mayo Clinic and the Cleveland Clinic have very good outcomes utilizing this approach, however many smaller institutions, including our own, have similar outcomes. What is different is the way in which patients perceive or experience their care. The Clinics, in their model, have hired all of the physician on the team, use the same information systems, and seem to have an easier time communicating between the caregivers and the patients. This is possible at institutions that do not employ their caregivers, but the myriad scheduling systems, billing systems, electronic health records and even simply locations create the need for an extra solution to get to the same place. At Anna Jaques, we are constantly looking for better ways to communicate with patients, physicians and family. We are going to implement soon the Physician/Nurse Rounding structure which I will describe in tomorrows blog.

It's Nice to Meet You!

My name is Jason Krupp. I am an internal medicine physician and the new Chief Medical Officer of Anna Jaques Hospital.

I asked to do this “blog” in order to try to communicate on a regular, if informal, basis, how I am working with everyone here at Anna Jaques to improve the hospital daily.

In this age of transparency, hospitals provide a great deal of information on things they are doing well and things that need improvement. However, there is so much that goes on behind the scenes every minute in a hospital, I thought this snapshot would be of interest.

I get asked an awful lot what a “Chief Medical Officer” does. I believe my job is to utilize my experience as a physician to assist Administration in ensuring that our hospital provides the safest and highest quality environment and processes that allows physicians, nurses and other practitioners to provide their best care to all of our patients and their families.

Maybe this is not an elegant description, but I think it is inclusive. I’m not sure if my kids comprehend it either. As an example of the breadth of my role, today I have met with a physician about numbers of shifts, I am going now to Chair our Compliance Committee, and I have been working on a program that will allow us to provide even more coordinated care with our community physicians.

I look forward to blogging with you, and appreciate your feedback.