27 September 2008

Instant feedback

Have you heard about the latest plan to give patients a PDA so that if they are not satisfied they can press a few buttons to record their problem in real time. The idea seems superficially very attractive. In the area of the hospital over which he has most control Dr Grumble sees that all the patients are given a questionnaire about their treatment. It doesn't actually help Dr Grumble that much. He knows what is wrong. It's getting it put right that is the problem. Data can help with that. If doctors complain the room is too hot or too noisy, managers take no notice. If you collect lots of data from patients and then tell them, there is a chance that something may be done.

The problem with all of this is the time it takes. The other day Dr Grumble asked his staff if his patients were happy. The answer: "We don't know."

"But what about the questionnaires?"

"We don't have time to look at them."

Dr Grumble knows though that his patients are happy with his service. Yesterday a private patient told him how good it was. Unknown to the private patient the NHS patients get identical care - except their breakfast does not come delivered by a smart flunky with paper doilies. Whether the breakfast is any better or not Dr Grumble has no idea but the NHS patients have occasionally made compliments about the breakfast so it can't be that bad.

One of the Grumble children has recently been an inpatient in an NHS hospital. He is a medical student so he has a little knowledge about how things should be. He was spontaneously complimentary about the nursing. Dr Grumble is quite critical about the nursing in his hospital. It's his job to be critical. So what hospital was the Grumble offspring in? Dr Grumble's very own. And what do you think the food was like? For the first time Dr Grumble can tell you. Dr Grumble sat his boy up to help him eat but immediately he became rather pale and sweaty. There were technical reasons for this which are irrelevant but it gave Dr Grumble a chance to taste the soup. It was not bad. By then the Grumble boy had recovered and the rest of the courses including a delicious pudding quickly disappeared apart from some potatoes and veg which Dr Grumble tasted. They were excellent. How they survived the system which brings the food to the wards Dr Grumble has no idea but they did.

Since then Dr Grumble has told this story to some of his patients and their relatives. Some of the relatives have also tasted the food just as Dr Grumble did. They are agreed. The food at the Grumble hospital is excellent. The average cost for inpatient food is less than £3 per patient per day. The catering staff deserve some praise. They work miracles. It's a shame Dr Grumble cannot name them.

Just as when Dr Grumble does his ward rounds, he has become distracted and gone off into a little anecdote when the purpose of this post was to address the concept of instant feedback. But the anecdote does show that workers at the coal face have constant instant feedback. Doubtless those that prepare the food taste it just as Dr Grumble has. You don't really need PDAs to know how good a job you are doing. Unless you sit in an office. Dr Grumble wonders how many times the Chief Executive has eaten food intended for the patients. Perhaps he has. Perhaps he should eat it every day.

Some time ago in the early days of the internet Dr Grumble was warned semi-formally that the hospital was scrutinising his use of the web. Everything he did was logged somewhere. That's a worry if you are a blogger. But the reality is that there is so much data being collected that it is difficult to really know what people are up to. There are ways of dealing with this but these days the miracle of computing means we all suffer from data overload.

The same is true of data related to patient care. While the Grumble staff are currently too busy to deal with all the data they collect on patient satisfaction, Dr Grumble gets weekly reports on certain areas of his clinical performance - in other words how well he performs against a certain standard. Graphs are provided showing in some detail the yawning gap between what he is doing and what he should be doing. This is just in one very tiny area of Dr Grumble's practice. Of course it something of particular concern to managers. It's just about possible to deal with but if they monitored everything Dr Grumble did to the same extent it would be wholly unmanageable. Nobody would have the time. Needless to say it's to do with a target.

So while this instant feedback from patients seems at first sight to be a good idea you need to remember that doctors and nurses are always getting instant feedback from their patients. It might have some purpose for managers who spend most of their looking at data on their computers or sitting through torpid meetings but for those of us bustling about the shop floor it is unlikely to tell us much that we do not already know. And even when Dr Grumble tells the pwoeres-that-be that something is very wrong it takes a long time for anybody to do anything about it. Sometimes even when you give them the data they just don't want to know. They have a poor sense of right and wrong. What is clinically important and what is clinically not so important escapes them. But they do know what a target is.

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