What Counts?


Editor's note: The author of the following article is using a pseudonym to protect the identity of the facility where he is employed. He is an MT (ASCP) with many years of laboratory experience.)

Laboratory personnel are well acquainted with on-site visits of state national accrediting agencies. The stamp of approval gained by their visits gives a degree of assurance that a given laboratory is meeting a designated standard. The role of these agencies appears to be an integral part of the health care system.

Yet most hospital employees are aware that such visits and subsequent affirmations have an aura of artificiality - that what they observe and approve is not always typical in the work-a-day world of the hospital.

THIS INCONGRUITY is more or less to be expected because on-site visits are usually announced months in advance, and the standards evaluated are public knowledge. Med techs can and should be able to put on their "best face" when the announced evaluators descend upon their workplace.

Several questions emerge from this scenario. How well do the conditions existing during an on-site visit represent the actual practices that a consumer/patient encounters during his/her stay in the hospital? How important is accreditation to the typical patient when measured against the treatment the patient personally receives? To what extent should hospitals regard the opinions of their patients as a basis for framing policy and practices? Should patients' opinions be considered a type of consumer accrediting agency? If consumer/patient opinion is to be held in high regard, how should this information be gathered and implemented in improving health care services?

THE ADMINISTRATORS of the state and JCAHO-approved community hospital where I am a long-time employee in an AABB-approved blood bank recently used a rather novel method to answer some of these questions. In an effort to initiate a guest relations improvement program, the services of a well-qualified public relation consultant were secured. The fact that his past clients include Walt Disney World, Walmart, and McDonald's gave our administrators some confidence in his ability to render helpful data.

And helpful data it was! With only the administration, board of directors, and a single cooperating physician informed of his actual mission, the consultant, whom we'll call Mr. X, came to our emergency room on a Saturday afternoon with doctor's orders to be admitted for severe gastrointestinal pain.

The sequence of events he encountered over the next day and a half not only was revealing, but could almost qualify as a "comedy of errors". Unfortunately, the reality of some of these experiences are too common in many hospitals to be regarded as comical.

HERE ARE the highlights of our mystery patient's experiences as shared in a day long seminar for hospital administrators, departmental supervisors, and other key personnel on the day following his dismissal from the hospital.

  • After receiving a thorough physical exam at the cooperating physician's office, Mr. X came to the emergency room Saturday afternoon for admission. He gave his address as "out of state", indicated he was a "private pay" patient, and offered his credit card as a guarantee for payment.. He also expressed his desire for a private room. Because of the scarcity of private rooms, his requests were not too warmly received and only after receiving a call from his physician was his request granted.

  • Just before being transported to his room-but after being admitted- he asked about leaving his car in the emergency room parking lot. Curtly informed that he was not allowed, he went out to move his car and had to walk some distance in order to return to the emergency room.

  • When the phlebotomist came to his room to obtain a blood sample, Mr. X informed her that he was a very difficult stick. After two unsuccessful attempts the phlebotomist decided to take the sample via a finger stick. Meanwhile, the respiratory therapist and EKG technician came in and, in the midst of all this, the phlebotomist misplaced the blood sample. THE TWO technicians and Mr. X joined her in searching for it on the floor but to no avail. They finally decided that the blood must have been discarded in the "sharps" box. When the use of forceps and other methods failed to retrieve them, they decided to empty the dirty needles into the sink, whereupon the unlabeled blood was discovered. "How do you know its mine?", Mr. X asked. "It has to be," replied the phlebotomist. The needles were returned to the box, but no one made any immediate effort to clean the sink. The phlebotomist had intended to return as indicated by the gloves, 4X4's, and alcohol swabs she left behind. AFTER WAITING for some time, Mr. X decided to clean up the "war zone", as he phrased it. But even after all this, the sample had hemolyzed, requiring one more stick that evening. Fortunately, the next morning's blood collection was without incident.

  • A routine urine collected about 3 p.m. was finally reported around 10 p.m. that evening.

  • In compliance with his NPO orders, an attendant moved Mr. X's water away from his bed. Unfortunately, the attendant on the next shift returned the water to his bedside. In the morning Mr. X received a breakfast tray and only after some discussion among his nurses was it removed.

  • The transportation attendant who took him for his CAT scan, although courteous and friendly, did not take time to secure an IV pole. 

  • Consequently, Mr. X's blood began to return in the IV line. An observant pharmacist agreed to hold up the IV bag until our mystery patient reached his destination. UPON ENTERING the elevator, Mr. X was pushed straight to the back of the elevator and remained facing in that direction while others on the elevator conversed without ever acknowledging his presence.

  • During the scan itself, things continued to deteriorate. The technician and the physician discussed a play that they had seen the night before, with only minimal recognition that the patient was in the room. He later said he felt more like an intruder than a patient.

  • Early Monday morning the cooperating physician signed his dismissal orders. At 9 a.m. Mr. X inquired about leaving and got the classic, "We're working on it." After a second inquiry about 10 a.m., a ward clerk took it upon herself to walk through the "excuses" and got Mr. X dismissed around 11.

  • Mr. X left the hospital without paying a dime, without leaving a forwarding address, and without signing any dismissal papers. Courtesy dismissals for hospital employees are sometimes granted, but Mr. X should not have qualified for such privileges.

  • Transported out of the hospital by a "kind and sweet little old lady," Mr. X said her frailty made him more afraid of her falling during the exodus than he was for himself. When she learned that no one was there to meet him, she offered to watch his belongings while he went to get his car.

SO MUCH FOR the bad news. Mr. X was professional enough to use the incidents as a beginning point for initiating improvements. In a day-long seminar, he shared with administration, department heads, and other key personnel how such information could be utilized to make significant advances in guest relations in health care institutions. He strongly emphasized that his purpose as an incognito investigator was not to identify personnel or departments that needed to be reprimanded, but to identify underlying philosophies, practices, or traditions that contribute to poor guest relations.

High on his list was the concept that all employees, patients, and visitors were to be regarded as real guests of the hospital and treated with genuine respect. Such was the policy he had promoted at Disney World, Walmart, and McDonald's (Who would dare deny their success in dealing with the public?)

MR. X'S NORMAL prescription for improving public relations in health care delivery begins with his incognito visit, followed by his "revelation" seminar. He then provides a menu for success that may include several years of hospital activities to build and develop the "guest" concept. Follow-up seminars and/or training sessions are made available for institutions who desire such assistance.

This concept of incognito evaluation cannot and should not replace professional accreditation. If the motivation for such evaluation is to identify patterns of employee behavior that foster public relation problems and to develop remedies, then this novel approach seems to have real merit.

As the result of our mystery guest's brief stay, our lab and our hospital definitely will see improvements.