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If there is one phrase in the description of a new intervention, initiative or ‘tool’ that makes my heart sink, it is ‘can be completed in only X minutes’. Do the people who come up with this stuff ever stop to picture how it will work in practice?
When a patient is admitted to hospital, they have to be registered on the system, clerked, and have medication prescribed. Then they need a VTE risk assessment, a falls risk assessment, a nutritional score, a moving and handling plan, a mini mental state test, a Waterlow score and, of course, a feedback questionnaire. That’s only the ones common to most hospitals: I haven’t started on the local initiatives, audits and extras yet.
And yes, each one takes just a couple of minutes to complete. Each one, in itself, is a small task to complete. And nearly all of them have a sound justification for why they’re a good idea. Only, by the time they’ve all been filled in the best part of an hour is gone, and the queue of people waiting to be seen is lengthening all the time.
Every minute we spend filling in a form is a minute we don’t spend on something else. Sometimes, the form genuinely needs doing – few would quarrel with the need for an accurately completed death certificate or discharge prescription. But if it isn’t more useful than whatever we’d be doing with the time instead, it should be ditched. It’s precious little use to an elderly patient to have her malnutrition risk assessment tool beautifully filled in, if as a result the nurse hasn’t had time to help her eat.
‘Quality improvement’ is a fine aspiration, but it’s so much easier to bring in a new initiative, to design a new form, than to prune or streamline the mass we already have. The cumulative impact of all these apparently good ideas is seldom considered. Sure, if we had unlimited resources it might improve quality to screen every patient for risk of delirium, or constipation, or vulnerability to financial abuse, but in a system already working near its limits opportunity cost has got to be considered.
Even the tiniest extras add up. Record an expected discharge date? Another half-minute. Document absence of safeguarding concerns? Another straw on the camel’s overburdened back. It’s not good enough for forms to be quick to complete, if there are dozens of them. If you’re a GP, 10 one-minute-long interventions mean you have no appointment left at all. Your patient will leave the room with every box ticked but, but the fundamental aim of helping them sort out their medical problem will have been smothered in a blizzard of well-meaning paperwork.
By the Secret Doctor. Read the blog and follow @TheSecretDr on Twitter and on Facebook
I think for a good majority of NHS managers achieving targets (usually meaningless ones) and avoiding complaints is their principal concern. Looking after staff wellbeing and supporting evidence-based care, comparatively, is generally rather neglected.
Very well said! Ultimately, I believe that most of the things these admin tasks aim to achieve would be achieved in a much more meaningful way if they were embedded in our clinical approach, when and if they are necessary, just as you said. And not only talking about doctors, but all healthcare professional. E.g. assessment of delirium goes beyond the 4ATs. Ultimately, if we don't address the many reasons (not just an infection) and provide the right stimuli (or lack of) in the ward, it is all futile! We have all seen elderly patient on antiplatelets or anticoagulants who are at falls risk and very frail. A risk assessment then becomes a clinical necessity and, again, goes beyond a VTE checklist, but rather requires much more clinical accumen and knowledge of the evidence base that these tick boxes will ever provide. These are a lot harder to achieve and need real education.
Also, the sad part of all this is that, for the purposes of the "service", a good doctor is exactly the one who obeys all those tick boxes and does not forget their 24hr VTE assessment, or that has set a early 24-48 hrs EDD for their patient... Focusing on patients is considered a luxury, and by demanding to make them the centre of our work-routine seems - and most importantly, intellectual focus - makes us seem we are spoiled and "lazy" for the "true work".
I was in an ICU ward round recently were the consultant stopped everybody and said "How do you expect me and my team to concentrate with all this chatter and admin requests. We will come back later and deal with them". It was a moment of true relief and joy, focusing on the medicine was, for a brief amount of time, the most important thing...