Performance surveys: 90% is the new bad

So we had our monthly meeting this week. One of the things that comes up at each of them are various performance surveys. And the ironic thing is that no matter how good they are the bosses are never happy.

I know never is a generalization, but in this case it seems to be true. Shoreline contracts out a company to interview random patients to see what they thought of services provided, and the results showed for the caradiopulmonary department (or the RT Cave) were 95%.

"I know that sounds good," the RT boss said, "but that still means that 5% of the people are not happy with our services."

This is the kind of stuff we deal with at just about every meeting. Good is never good enough, as 95% is good. In essence, good is the new bad. To an idealist that might be a good thing. But to a realist like me it's simple insanity.

So at today's meeting I said, "You know what, Gary, that 5 percent are probably people who wouldn't be happy if you scratched their backs and picked their noses for them. We sit here and listen to you guys every month complain about really good performance reviews. Can we not find anything better to do?"

Of course then you get your political response, "It's always good to have a goal; to continue to strive for better."

"Yes, I know," I said, "and I think we all do that here. Everyone in this department gives 110 percent with every single patient. It's not just good, it's great to try to make things even better. I just think we can find better things to do with our time than deal with this stuff every month."

That was when my co-workers chimed in to back me up. Dale said, "Come on, Gary! Here we are doing stress tests, making people run on a treadmill until they're about to puke, and then we ask them, 'so what did you think of the stress test.' Well, some of them will simply say, 'it sucked.' Does that mean we provided a bad service. No! It means what we did wasn't any fun.

"We do ABGs," he continued. "We poke a patient where it ain't fun to be poked. And then we expect them to say, 'Excellent!' Come on! Let's get real here."

So the rest of the meeting played off this theme. Our intent was not to be negative or pessimistic, and I don't think we were. It was simply all of us RTs, who do all the work, who have to sit in these meetings every month, trying to make sense of why do we continue to do these performance surveys.

A similar session happened before and we were called complainers and whiners. I didn't say this yet I wanted to, so since this is my blog I'm going to write it here and pretend I said it to my boss: "There's an old saying: The truth hurts, and then it makes you better."

Fewer Vent paitents is ailing small town RT Caves

It used to be really busy here at Shoreline. In fact, even back two years ago I remember being so busy I didn't even have the time to read a chapter of whatever book I stuffed into my tote bag.

In the past year, however, I feel like I could literally sit here in the RT Cave and write an entire novel -- each night.

About a week ago we had a patient on the ventilator when I arrived. Don't laugh, but I had to actually search for the silence button. And then, that same night, I had to set up a vent. My brain was a little rusty, and I couldn't remember the formula for determining ideal body weight.

Other than that I was in RT Heaven that night; it felt great to be doing real RT work.

But that was one night. The next night we were back to our usual 10 patients, 9-10 of whom giving the treatment was equivalent to having them drink a glass of water for pneumonia.

I saw a recent trends report for Shoreline, and it went something like this: 99 vents set up in2000, 98 set up in 2001, 88 in 2002, 80 in 2003, 84 in 2004, 74 in 2005, 48 in 2006, 24 in 2007.

None the downward trend.

What's the reason for this? Total patient admissions have been consistent, so it's not because people are choosing a different hospital. BiPAP set-ups have been consistent, so it's not because the BiPAP is saving people from going on vents.

Another trend is length of stay on the ventilators, which has dramatically dropped from an average of 100 hours per patient all the way down to 21 hours per patient. This, I believe, can be attributed to a variety of factors, including quality staff, great doctors who are more receptive to protocols, and new microprosessor ventilators.

So, technology can be attributed to some of our decline, but what about the lack of ventilators overall trending down? I have theories here too.

Many of the most critical patients are being shipped to specialty hospitals, i.e. cardiac, neuro, trauma. While we used to take care of more cardiac patients, it doesn't make much sense to keep them here when they can be minutes away from a cardiac doctor.

Not that we still couldn't take care of these patients here. We could.

Likewise, more and more patients are prevented from moving to the critical care floor due to early intervention and treatment. This goes along with improved education, quality of care and increased vigilance regarding patient's showing early signs of problems and nipping them in the bud.

So, now I sit here with seven or eight expensive state of the art ventilators collecting dust in the back closet. I'm prepared to take on an epidemic, and yet here I sit while my skills atrophy.

I've written before on these pages how we have been trying to get protocols, and how the RT leaders are against them more so because they are afraid they will result in less work for us. Well, what better time than the present for them to make their case.

I know from reading other blogs, and talking with other therapists, that we are not alone in this.

This is part of a developing trend for small town hospitals. In fact, it might be the wave of the future. We might never get back to the level of having 100 vents in a year again, even though we are more than equipped to handle it.

The reason I saw these statistics is because the admins are concerned about recruiting RTs here in the future. Are we going to be able to recruit RTs to a hospital when they know they'd just sit around waiting for an emergency to happen, as my main character does in "The RT Cave in the Year 2020."

If you're a young RT fresh out of RT school who wants to keep his skills up, a small town RT cave may not be for you anymore. But trust me when I say that wasn't true two years ago, and it definitely wasn't true when I started here.

Rumor has it the admins are aware of how a high quality area is being underutilized, and are seeking to bring something in to generate some business for us. That in itself is a scary idea, especially if this downward trend is an aberration.

The admins tried to make us RTs automatons

"The first topic of discussion," Gary, our department head, said to start the meeting, "is what you are going to have to say for now on when you go to do a breathing treatment."

I rolled my eyes. Looking around the room, I observed many eyes rolling.

"Now who's going to volunteer to work on this?"

"I will," Dale, one of my co-workers said, raising his hand.

Well, this ought to be interesting, I thought. Dale wasn't just the biggest complainer about useless breathing treatments, but the biggest joker about it.

At the next meeting, Gary asked Dale if he had a program prepared.

"I sure do," Dale said.

"Go ahead."

"You walk into a room," Dale said, "and you say, 'Hi, my name is Dale, I have your before breakfast peace pipe here. Are you short-of-breath?"

Everybody, including Gary laughed.

"What do we say after the treatment?" Gary asked.

Dale said, "Well, after the treatment you ask them if the treatment improved their work-of-breathing."

"Simple enough." Gary glanced at his clipboard. "But what should we say seriously

Without hesitation, Dale shot back, "I am being serious."

Needless to day, Dales presentation was changed by the next meeting. This is what Gary came up with after verifying the patient:

"Hi, my name is ________. What I am going to do is give you a breathing treatment (explain procedure). Do you have any questions? (answer questions and perform procedure) Thank you for letting me give you a breathing treatment. Is there anything I can get for you? I will see you again at approximately ________ for your next treatment. Thank you."

I watched as Dale's jaw dropped. "You want us to say that?"

"Yes," Gary said.

"What about asking the patient if he is short-of-breath?"

"You can ask that if you want, but you don't have to. Breathing treatments are given for more reasons than just for shortness-of-breath."

There was some grumbling in the room. I looked at Dale and he looked at me: we were both thinking the same thing, "How idiotic." Neither one of us said any more. We just wanted the meeting to be over.
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This happened about eight years ago, when I was still new at this game and still working mostly days in the pool.

Likewise, we were told we had to stick to this, and that the admins would be hiding behind curtains listening to make sure RTs and RN were sticking to their respective programs.

And, needless to say, I followed this line for a few weeks, only because I feared someone might be listening to me. Finally I decided the spiel wasn't working for me, and I went back to my old routine. I was a bit nervous about this, however.

"I feel like an automaton giving that speech," I told Dale one day, "The patients probably think we are a bunch of robots."

"I never do it."

"You don't."

"Hell no. It's not personalized."

"So, what do you say then," I asked.

"Hey, I have your before breakfast peacepipe here?"

I laughed.

They may have had good intentions with the automaton speech as parts of it are well intended, and it's probably still on the records, but it was dumb.

The admins must have realized their folly, for they have never brought it up again.