Thursday, September 6, 2007

Pissing Off the Management: a novella

Here I go again.

Okay, so my hospital has this new computer system that sucks, right? I know sucky software when I see it. It makes my jaw clench every single time I can't get something for a patient or hear about some Actionable Occurrence because of this POS software. I often think about things like which database protocol they'd probably need to get the Pyxis (or the med-dispensing system) to talk to the system that tells me which meds the patient should receive. Yes. Those systems are different at MyHospital. Can you say Recipie for er...Actionable Occurrences?

Yeah.

Do not get me started.

I'm not alone in this, of course. All the nurses around me are screeching at various volumes about the same thing. Patients are getting the shaft. Not only are there a lot of mistakes, their nurses are spending so much time charting or hunting down and correcting mistakes, that bedside time is seriously suffering.

Some elements in the hospital have handled us in a patronizing fashion: "it's a learning curve". Pat, pat, oh, honey, you'll just learn to love it. Your brain is just slower than my fine MBA mind.

So I tried to use my NPC way back in July to see how it's going on the units. I was kinda shot down, saying that the topic belongs in other committees. Practice Council is not the place to discuss how SuckySoftware is interfering with my practice. (Actually, what I was told, "We're not here to ride the SuckySoftware hobby horse." I don't know why that statement makes me giggle.)

Fine.

Time goes by and the sentinal event doesn't happen, but many bad things do. Some of the nurses decide to get rowdy and start going to meetings to which they were not originally invited. I love this. You'd think I was a Bolshevik at heart instead of a libertarian. They're mad, and they want changes to the software that make it workable for our patients and for us. They're right to want this.

The news from these rabble-rousing nurses (C, A and R) is that they're not getting far in these meetings. Frankly, it sounds like much of what they're getting is the runaround. Many/most other RNs at the table haven't touched a patient in years. Or they Direct an 8 bed unit at another hospital. We have 37 beds. We have some very sick patients, but one of our sister hospitals that goes live with SuckySoftware in a few weeks has a LOT of very sick patients. C tells me they can't get a geek at the table to talk through the problems.

I decide to show some support. I have a legitimate avenue wherein I can yank the CNO's ear through Practic Council, so why not?" So I send an email. A big one. To tell my fellow reps what's goin on in ICU, to get the word out. Communication in power. Numbers are power. Nothing pisses a nurse off more than seeing his or her patients get the short end. Stirring the pot keeps the eyes of everybody who can make decisions on the problem, our problem, our patients' problems.

The email went to NPC reps, to the CNO, to our Magnet Champion, to Quality Control (all of them sit at the NPC table). I copied C, A, R, and M (the rabble rousers), G (my partner in crime on NPC...she's the quieter partner :D ), my boss and Director.

You woulda thought it was WWF Smackdown Email.

I didn't think it was all that bad. Of course, I've been wrong before.

Some patient safety issues:
In the ICU, it is critical that we have access to the full patient "story", which can take hours of searching to obtain in SuckySoftware...does not give a complete story, and certainly not in the timeframe we require that story. We do not feel we know our patients, and as a result we don't feel like we are giving adequate care, much less the care we want to give. We think this system flaw is fertile ground for lawsuits.
One of the most simple examples of this is that meds given in cath lab aren't carried over. Patient comes in with chest pain to the ER, and nowhere will it show that this patient received aspirin, nitro and dilaudid. Not only are we concerned for the patient, we are concerned for our licenses. I believe that this is within our Core Measures initiative, yes? The one that ties real dollars to this hospital?

We also have a problem with a $SpecificDollarAmount system that requires that we use handwritten pieces of paper to obtain certain medications. We had a patient last week develop sudden rapid atrial fibrillation and stay in this dysrythmia for NINETY MINUTES because we had to wait for pharmacy for the physician-ordered IV Digoxin. The process is to hand-write a piece of paper, tube it to pharmacy in order to obtain the med. We do NOT fault pharmacy for what is a serious flaw in SuckySoftware.

Patients are receiving extra doses of medication that should have been discontinued.


And I go on.

Cos I have a tendency to do that.

I got a call from my boss at 8a.m. Her boss, Director, called the meeting for 2pm the next day, which is a great time of day for the night shift. C is called to this meeting, too.

I have some nurses read this email because I'm feeling badly at first, and Director is calling it "negative" and saying it has "gross misperceptions". Maybe I overstepped. My words have been known to be sharp before. The other nurses tell me that they think the email is 'truthful'. Is it negative? They tell me it's negative only in the sense that I'm describing the problem, which is by definition, negative. I reread the email many times.

What I come to is that there's nothing I said that I do not mean. What I come to is that I make no demands, that I'm communicating information I believe to be true to other nurses who may be in similar situations. What I come to is that the people who I respect most, the ones who are here, and who have my back...agree with me. A few nurses thank me "for sticking up for us". This matters to me. That they support what I've said erases any residual am-I-out-of-line feelings because of an irate director.

I show up for the meeting.

I'm bolstered by one more thing: I see a nurse who'd left MyHosptial weeks ago. I don't know him well, but we get along amiably, and I stop to chat. I tell him my tale of woe, and he laughs. He says he's been called into "the office" several times so far this year for some of his actions, actions that either advocated for nurses or for patients but were inconvenient for management. I laugh. As I turn to go to my meeting, he smiles with crinkled eyes and says, "It's never wrong to get hauled into the office because you were advocating for patient care." I was so grateful for that. Put the swing back in my step.

They started in on me before C arrived. Director said that though I don't know her, she wants me to know she's blunt. I nod. Then she tells me what her kneejerk reaction was to my email, which has expletives and included "who the hell is this person?". I nodded. She took several minutes to get through her list of problems with my email (to each, I nod), how she wishes to correct the gross misrepresentation (to which I continue to look at her, listening), how she wishes to offer her support to train me and any other nurse in the finer points of SuckySoftware (to which I continue to look at her, listening), and how she wishes to address the unit-based NPC (I nod). This woman was mad at me. Really, really, mad at me.

I have been in tougher boardrooms than this. I grow calmer by the minute as the rant continues.

At one point, Director muttered to CNO, "That email's gone everywhere by now! Probably all the way to CEO-Of-Hospital-System." CNO quietly said, "Oh, yeah."

I didn't grin but I really wanted to. So that's it. The thought actually hadn't occurred to me that it go any further than hospital-wide buzz on the units, and into some departments. I'm just a stepdown nurse.

The email offended the people who brought SuckySoftware to MyHospital, because they took my criticisms of the systemic problems personally. I knew that. There might have been some sensitivity to me going to the NPC which could have been construed (inaccurately) as "going over someone's head". But there it was: they think it's gone to the system CEO, and likelier still it's in the inbox of CEO. And gee, that probably looks really bad.

These are not bad people, understand me. I believe that they are good people. They want good care for the patients, too. They just want this done quietly. Their interest is keeping things running smoothly, having good patient care with good profits (that is not a criticsm; I'm a libertarian and a proud capitalist). Nothing about a large software implementation in smooth. They don't know how to do this is all. You're not supposed to have lowly stepdown nurses with a pittance of 20 months experience howling about how the multi-million dollar computer system is preventing her from taking care of her patients adequately, much less opening her up to litigation risk.

Thing is? A bedside nurse typically doesn't give a shit about how it looks to people in suits if s/he can't provide good care for her/his patient. Period. None of us chose this job to make money for hospitals.

C and R arrived later in the meeting, having gotten stuck in another SuckySoftware meeting. They didn't want me to be alone, and I appreciated this. R was unceremoniously tossed out at the door by Director. R had taken patients in a 12 hour shift the night before and couldn't have gotten more than 3 hours of sleep. She did this support the efforts, to support me. She gave me a long look, but bowed out graciously. Certainly with more class than Director's got.

There are a whole lot of nurses on that unit that respect R, and know that she has their backs, too. They'll hear that the Director tossed R out at the door.

Director graciously allowed C to come to the table. The hammer was turned from me to C. Director accused her of spreading misinformation, and C volleyed. Director demanded to know "what else she was telling people" and ranted that the subcommitte "had agreed to take a positive approach", implication being that C is "negative". It was all a load of shit: a combination of that old Florence Nightingale nursey guilt shit (and I don't know why that still works on so many of us), coupled with ad hominem attacks and diversional logical fallacies.

It pissed me off. C was on the defensive, and C had done nothing wrong. C was busting her ass trying to do something good for our unit, and I'd had enough of it. Director started hammering at C for my email having direct quotes from the subcommittee meeting. I cut Director off. I leaned forward and put my finger down on my email, (a gesture that was meant to be aggressive), "These words are MINE. That email was written by me, and signed by me, and sent from my email address. I am quoting no one. These are my thoughts, my words." Oh, I was HOT.

Incidentally, Director could not point to a single thing in the email that was incorrect. Not a single "gross misperception." I asked. Several times.

The purpose of the meeting was the email, right? The funny thing about the whole clusterfuck is that the send button had been pushed. Nothing could have been done about it. The meeting could not have had any useful or practical outcome.

I think Director found the meeting most unsatisfactory. She got to unload on me and C, but we hadn't done a single thing wrong. She and the CNO just don't like what we're saying. I'm not sure what CNO hoped to get out of the meeting, if anything.

Fortunately for C and I, MyHospital is also trying to get Magnet status. So the rampant Bolshevism about bedside nurse advocacy (which I happen to believe in, down to my marrow) may have made those smiles excruciating to perform, but they didn't have much choice but to go with it. Truth be told, these women were once bedside nurses, too. Under the fear of the corporate types above them, they want the best care for patients, too. They know we're right. God's on our side, oooh! aah!

If they were trying to persuade me to "be more positive" about SuckySoftware, they just made it worse. If they wanted an apology, they got: "I'm sorry you took this as a slap to you, but this email isn't about you or CNO or anyone else. This is how many of the staff nurses in ICU/SDU are feeling right now, and I'm communicating that to my practice council as one of ICU's representatives to council." If they wanted me to shrivel, they just got me mad.

You threw a nurse I respect, who came to support me, out of your office.

You verbally railroaded another nurse I respect when she is putting up with your abuse in order to do the right thing.

You were snide and snotty to me. It wasn't even witty snide.

You are more concerned about how SystemCEO perceives what's happening at this hospital than you are about my patient last night, who CRIED IN PAIN FOR TWO HOURS BECAUSE THE FUCKING SYSTEM DOESN'T WORK.

The system is so difficult to use that an MD misinterpreted an I&O tally on a patient, discontinued her chest tubes, and that patient was back in the hospital three days later for a pleural and pericardial effusion. Fifteen hundred cc's were drained from her lung, and 300 cc's from her pericardial sack.

WHY AREN'T YOU FIXING THE SYSTEM FOR MY PATIENT AND HER HUSBAND INSTEAD OF DRAGGING ME AND MY COLLEAGUES INTO MEETINGS IN ORDER TO SLAP US INTO SHUTTING UP?

And you think I was a bee in your bonnet before?

just. wait.

10 comments:

writingweb said...

Oh yes, let's blame the users and then blame the people who recognize that the problem really isn't with the users. It's absolutely mind-boggling that the "right" solution is to walk a piece of paper to another part of the hospital to get a prescription. Seriously? Maybe you're not ready to totally reengineer your processes for the 21st Century. OK, fine. How about the 19th? Pick up a fucking telephone. We could even go to 1980: fax, anyone? Geez.

Yeah, you used a few key words there, "lawsuit" among them. Did the people who reacted so strongly participate in decisions that led to the software working the way it does? And of course it's never a good thing when something comes to the CEO's attention (in some people's perspective, anyway--I think it makes things pretty interesting).

The wonderful thing about technology is that it's ubiquitous. Everyone has access to it. It can do wonders to solve complicated problems. The really sometimes horrible thing about technology is that people let the complexity of coming up with good technology trump everything else, including and especially user needs. It's easier to just say "no, it can't do that;" (it could if they wanted to/had to go to the trouble). It's hard to understand user stories and deal with the infinitely more complex wetware. Technologists and consultants and business executives are willing to sacrifice the complexity of the real-world problem on the altar of easy technology solutions, dismissing the needs of the people involved and ignoring the consequences of failing to put the real-world needs foremost on the list of criteria against which decisions are evaluated.

This has to change.

User advocacy (a.k.a. human factors, human-computer interface, usability, accessibility, etc.) isn't ubiquitous yet. The people who recognize its importance must not let up in their advocacy and in demonstrating the real value of implementing good solutions that address real needs the right way.

The other problem, of course, is that you know what the fuck you're talking about AND a feminist-libertarian with Bolshevik tendencies.

Fight the good fight, my sister. These battles don't have the same consequences in my world, but we're fighting them, and slowly making progress.

Lisa said...

Keep up the good work! they don't want nurses to speak up than why have things like NPC? Stick to the facts and the problems and they will eventually have to listen and hopefully your SuckySoftware can be changed!

and I hope your director realizes she really must be professional! Sounds like a fight in high school.

JustCallMeJo said...

You rock, WW. Miss you.

Lisa: well met, and thanks.
/jo

shrimplate said...

It's good to see people fighting the good fight. Well done. Very well done!

Jodie Elrod said...

I am the managing editor of a medical journal called EP Lab Digest, which publishes articles in cardiac electrophysiology (EP). I recently came across your blog and very much enjoyed it -- you are a good writer. I found your blog because of the title -- "Sinus Arrhythmia" -- just to confirm, do you work specifically in cardiology or in another medical specialty? Let me know if you'd be interested in writing for us sometime -- we are always looking for more articles that give a better perspective into cardiac nursing. I can be reached at "jelrod@hmpcommunications.com".

Thank you!

Best regards,
Jodie Elrod, Managing Editor, EP Lab Digest

ali said...

hi just found your blog and sat hear and read as far back as june, i loved every post (especially the cancer woose, lol) i'm a nurse on a medical floor and i tend to not get involved in the process because i'll say the same stuff you do and get myself in trouble, i'm a big mouth nurse....no one asks what i think because i'll tell them! that and i've got a two yr old and a newborn i'm required to feed and cloth, need my job....
i loved this post and i will be back!

ali said...

ahem---*here* not hear-i blame the no sleep and the 3 week old

Griffin3 said...

You GO!!!

No one has ever changed the world, has ever changed *anything* by smiling and saying "yes, ma'am, sir" ...

RehabNurse said...

Jo:

I'd love to know what Sucky Software you're using, because, as an RN with computer experience, I intend to use what I know from the floor to infiltrate the IT group and change it from inside.

Will it happen soon? Gotta wait until I am eligible to apply for the latest crop of jobs, but I know my system has a lot of wonks without experience, so I'm figuring to start the revolt from the inside.

It's time to use my powers for the good of the floor folks! And if that doesn't work, I'll always go with Plan B...

RehabNurse said...

Jo:

I'd love to know what Sucky Software you're using, because, as an RN with computer experience, I intend to use what I know from the floor to infiltrate the IT group and change it from inside.

Will it happen soon? Gotta wait until I am eligible to apply for the latest crop of jobs, but I know my system has a lot of wonks without experience, so I'm figuring to start the revolt from the inside.

It's time to use my powers for the good of the floor folks! And if that doesn't work, I'll always go with Plan B...