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The Importance of Following
He who has no faith in others shall find no faith in them.—Lao Tzu
We hear a lot about leading. There are best-selling books on the topic, courses in leading, articles on leading, and admonishments to lead. But is there an art to following? Many of us work on our leadership skills. We spend time trying to better understand those around us and their motivations and interests. We attempt to identify their strengths and engage them in projects that match their skills. We learn to give feedback in constructive ways so that others can improve. We try to understand the other’s perspective.
But when it’s our turn to follow, are we as diligent?
Regardless of our role at the hospital, within our group or in our medical community, we need to follow as well as lead. We may be a leader of our group, but a follower with the rest of the medical staff. We may lead some aspects of patient care, but follow on other aspects. How does our performance as a follower affect the group’s outcomes? Does it matter?
Some would say that there are four fundamental responsibilities of a follower.
Responsibility #1: Don’t act like a victim
As a project or program gets underway don’t be defensive or whine. Attempt to understand the rationale behind the project. Most leaders don’t wake up and invent things to keep people busy. They have a goal that usually addresses underperformance in some area. Operating room turnaround time may not seem important to you—discover why it matters to someone else. When a plan is presented, approach it with an open mind and suggest ways to improve the plan or its implementation. Even if the advantages of change are not apparent to you, give them a try before you make up your mind; you might discover that the new way is an improvement. Be straightforward with your concerns, but once the decision is made, play with the team.
We all knew families of brothers who seemed to fight among themselves. But if an outsider picked on one of them, the group banded together to defend each other. Make sure your team knows that they can count on you. Withdrawing from participation is certain to sabotage a project. Once your behaviors establish your reputation as a person who acts like a victim, you can be sure to be excluded from future projects or participation.
Worse than withdrawing is commiserating with others about your bad situation and demoralizing the group you are in. If you believe that the activity is unfair or dishonest, get outside opinions from other colleagues. Someone who is in another group or another field can be very helpful. In other disciplines (business, agriculture, manufacturing, and law), what you are being asked to do may be accepted as part of change. Solicit several opinions (and not just your family members). And when all is said and done, give it a try. Nothing is forever and every great journey starts with a single step—you might be in for a pleasant surprise.
Responsibility #2: Engage Yourself
Almost no one gets it right from the start. If you have ideas on improvement, not only speak up—take responsibility. Work with the project leader to supervise some part of it or assist in creating a monitoring tool or feedback loop. Every project has a number of tasks that need to be completed; volunteer to take responsibility for some part.
Engage others in finding ways to improve the process. Hospital-based processes are extremely complex and involve many stakeholders, entities, and professions. A number of pieces usually need attention. As the project progresses, be creative. Solve problems with open discussion and make improvements along the way. Focus on the end goal and suggest, implement, and monitor adjustments. Any sizable project will take time. Hospitalists and other physicians are used to seeing action and immediate reaction: Lasix relieves heart failure; nebulizers relieve shortness of breath. However, projects that really change organizations are long and arduous. They are multimonth and many times multiyear. This is quite a learning curve for many practitioners.
Responsibility #3: Do What you say
We certainly expect this of our leaders; we should expect it of ourselves as followers. It is difficult to lead a project when others on the team are late on deadlines or fail to show up. Volunteer to do only what you can. If you are overextended and don’t complete your part, the project can be crippled. Budget your time and energy to successfully meet expectations. If you get stuck on an assignment, ask for help. Delaying until the project is greatly behind can result in loss of your credibility and the whole project coming to a halt. Identify what you don’t know and identify ways to get the information you need. Many facilities and groups have a number of resources to assist you. They have members with experience expertise and other references available. SHM provides resources and online help at your fingertips.
Responsibility #4: stay the course
As mentioned above, the timelines on many projects take weeks and months. Don’t be discouraged if your progress is not as smooth as expected. Remember, you are remaking healthcare. Focus on your strategic priorities: Are they aligned with your patient care values? If you are off track, reanalyze. Look for the ways that the process is failing and revise the process. Maybe the wrong person is assigned to a task that is not to their strength. Review what you were trying to achieve. Maybe there is another path to get there. Follow directions and processes and support the design.
These are some ideas about the responsibilities of a follower. Keep in mind that others need you to follow just as you need them to lead. Performing as a good follower has some outcomes that help you. You can learn important successes with the right leader. The group’s goals can be accomplished more readily. If you can follow others and assist them in being successful with their goals, you can expect them to follow you in return. Have some faith in your leader; work at being a good follower and then you’ll be leading, too!
I would like to recognize the Petrous Group (www.petrous.net) for sharing their material for this column. TH
Dr. Gorman is the president of SHM.
He who has no faith in others shall find no faith in them.—Lao Tzu
We hear a lot about leading. There are best-selling books on the topic, courses in leading, articles on leading, and admonishments to lead. But is there an art to following? Many of us work on our leadership skills. We spend time trying to better understand those around us and their motivations and interests. We attempt to identify their strengths and engage them in projects that match their skills. We learn to give feedback in constructive ways so that others can improve. We try to understand the other’s perspective.
But when it’s our turn to follow, are we as diligent?
Regardless of our role at the hospital, within our group or in our medical community, we need to follow as well as lead. We may be a leader of our group, but a follower with the rest of the medical staff. We may lead some aspects of patient care, but follow on other aspects. How does our performance as a follower affect the group’s outcomes? Does it matter?
Some would say that there are four fundamental responsibilities of a follower.
Responsibility #1: Don’t act like a victim
As a project or program gets underway don’t be defensive or whine. Attempt to understand the rationale behind the project. Most leaders don’t wake up and invent things to keep people busy. They have a goal that usually addresses underperformance in some area. Operating room turnaround time may not seem important to you—discover why it matters to someone else. When a plan is presented, approach it with an open mind and suggest ways to improve the plan or its implementation. Even if the advantages of change are not apparent to you, give them a try before you make up your mind; you might discover that the new way is an improvement. Be straightforward with your concerns, but once the decision is made, play with the team.
We all knew families of brothers who seemed to fight among themselves. But if an outsider picked on one of them, the group banded together to defend each other. Make sure your team knows that they can count on you. Withdrawing from participation is certain to sabotage a project. Once your behaviors establish your reputation as a person who acts like a victim, you can be sure to be excluded from future projects or participation.
Worse than withdrawing is commiserating with others about your bad situation and demoralizing the group you are in. If you believe that the activity is unfair or dishonest, get outside opinions from other colleagues. Someone who is in another group or another field can be very helpful. In other disciplines (business, agriculture, manufacturing, and law), what you are being asked to do may be accepted as part of change. Solicit several opinions (and not just your family members). And when all is said and done, give it a try. Nothing is forever and every great journey starts with a single step—you might be in for a pleasant surprise.
Responsibility #2: Engage Yourself
Almost no one gets it right from the start. If you have ideas on improvement, not only speak up—take responsibility. Work with the project leader to supervise some part of it or assist in creating a monitoring tool or feedback loop. Every project has a number of tasks that need to be completed; volunteer to take responsibility for some part.
Engage others in finding ways to improve the process. Hospital-based processes are extremely complex and involve many stakeholders, entities, and professions. A number of pieces usually need attention. As the project progresses, be creative. Solve problems with open discussion and make improvements along the way. Focus on the end goal and suggest, implement, and monitor adjustments. Any sizable project will take time. Hospitalists and other physicians are used to seeing action and immediate reaction: Lasix relieves heart failure; nebulizers relieve shortness of breath. However, projects that really change organizations are long and arduous. They are multimonth and many times multiyear. This is quite a learning curve for many practitioners.
Responsibility #3: Do What you say
We certainly expect this of our leaders; we should expect it of ourselves as followers. It is difficult to lead a project when others on the team are late on deadlines or fail to show up. Volunteer to do only what you can. If you are overextended and don’t complete your part, the project can be crippled. Budget your time and energy to successfully meet expectations. If you get stuck on an assignment, ask for help. Delaying until the project is greatly behind can result in loss of your credibility and the whole project coming to a halt. Identify what you don’t know and identify ways to get the information you need. Many facilities and groups have a number of resources to assist you. They have members with experience expertise and other references available. SHM provides resources and online help at your fingertips.
Responsibility #4: stay the course
As mentioned above, the timelines on many projects take weeks and months. Don’t be discouraged if your progress is not as smooth as expected. Remember, you are remaking healthcare. Focus on your strategic priorities: Are they aligned with your patient care values? If you are off track, reanalyze. Look for the ways that the process is failing and revise the process. Maybe the wrong person is assigned to a task that is not to their strength. Review what you were trying to achieve. Maybe there is another path to get there. Follow directions and processes and support the design.
These are some ideas about the responsibilities of a follower. Keep in mind that others need you to follow just as you need them to lead. Performing as a good follower has some outcomes that help you. You can learn important successes with the right leader. The group’s goals can be accomplished more readily. If you can follow others and assist them in being successful with their goals, you can expect them to follow you in return. Have some faith in your leader; work at being a good follower and then you’ll be leading, too!
I would like to recognize the Petrous Group (www.petrous.net) for sharing their material for this column. TH
Dr. Gorman is the president of SHM.
He who has no faith in others shall find no faith in them.—Lao Tzu
We hear a lot about leading. There are best-selling books on the topic, courses in leading, articles on leading, and admonishments to lead. But is there an art to following? Many of us work on our leadership skills. We spend time trying to better understand those around us and their motivations and interests. We attempt to identify their strengths and engage them in projects that match their skills. We learn to give feedback in constructive ways so that others can improve. We try to understand the other’s perspective.
But when it’s our turn to follow, are we as diligent?
Regardless of our role at the hospital, within our group or in our medical community, we need to follow as well as lead. We may be a leader of our group, but a follower with the rest of the medical staff. We may lead some aspects of patient care, but follow on other aspects. How does our performance as a follower affect the group’s outcomes? Does it matter?
Some would say that there are four fundamental responsibilities of a follower.
Responsibility #1: Don’t act like a victim
As a project or program gets underway don’t be defensive or whine. Attempt to understand the rationale behind the project. Most leaders don’t wake up and invent things to keep people busy. They have a goal that usually addresses underperformance in some area. Operating room turnaround time may not seem important to you—discover why it matters to someone else. When a plan is presented, approach it with an open mind and suggest ways to improve the plan or its implementation. Even if the advantages of change are not apparent to you, give them a try before you make up your mind; you might discover that the new way is an improvement. Be straightforward with your concerns, but once the decision is made, play with the team.
We all knew families of brothers who seemed to fight among themselves. But if an outsider picked on one of them, the group banded together to defend each other. Make sure your team knows that they can count on you. Withdrawing from participation is certain to sabotage a project. Once your behaviors establish your reputation as a person who acts like a victim, you can be sure to be excluded from future projects or participation.
Worse than withdrawing is commiserating with others about your bad situation and demoralizing the group you are in. If you believe that the activity is unfair or dishonest, get outside opinions from other colleagues. Someone who is in another group or another field can be very helpful. In other disciplines (business, agriculture, manufacturing, and law), what you are being asked to do may be accepted as part of change. Solicit several opinions (and not just your family members). And when all is said and done, give it a try. Nothing is forever and every great journey starts with a single step—you might be in for a pleasant surprise.
Responsibility #2: Engage Yourself
Almost no one gets it right from the start. If you have ideas on improvement, not only speak up—take responsibility. Work with the project leader to supervise some part of it or assist in creating a monitoring tool or feedback loop. Every project has a number of tasks that need to be completed; volunteer to take responsibility for some part.
Engage others in finding ways to improve the process. Hospital-based processes are extremely complex and involve many stakeholders, entities, and professions. A number of pieces usually need attention. As the project progresses, be creative. Solve problems with open discussion and make improvements along the way. Focus on the end goal and suggest, implement, and monitor adjustments. Any sizable project will take time. Hospitalists and other physicians are used to seeing action and immediate reaction: Lasix relieves heart failure; nebulizers relieve shortness of breath. However, projects that really change organizations are long and arduous. They are multimonth and many times multiyear. This is quite a learning curve for many practitioners.
Responsibility #3: Do What you say
We certainly expect this of our leaders; we should expect it of ourselves as followers. It is difficult to lead a project when others on the team are late on deadlines or fail to show up. Volunteer to do only what you can. If you are overextended and don’t complete your part, the project can be crippled. Budget your time and energy to successfully meet expectations. If you get stuck on an assignment, ask for help. Delaying until the project is greatly behind can result in loss of your credibility and the whole project coming to a halt. Identify what you don’t know and identify ways to get the information you need. Many facilities and groups have a number of resources to assist you. They have members with experience expertise and other references available. SHM provides resources and online help at your fingertips.
Responsibility #4: stay the course
As mentioned above, the timelines on many projects take weeks and months. Don’t be discouraged if your progress is not as smooth as expected. Remember, you are remaking healthcare. Focus on your strategic priorities: Are they aligned with your patient care values? If you are off track, reanalyze. Look for the ways that the process is failing and revise the process. Maybe the wrong person is assigned to a task that is not to their strength. Review what you were trying to achieve. Maybe there is another path to get there. Follow directions and processes and support the design.
These are some ideas about the responsibilities of a follower. Keep in mind that others need you to follow just as you need them to lead. Performing as a good follower has some outcomes that help you. You can learn important successes with the right leader. The group’s goals can be accomplished more readily. If you can follow others and assist them in being successful with their goals, you can expect them to follow you in return. Have some faith in your leader; work at being a good follower and then you’ll be leading, too!
I would like to recognize the Petrous Group (www.petrous.net) for sharing their material for this column. TH
Dr. Gorman is the president of SHM.
Please Stop the Racket!
Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.
Welcome to the hospital.
Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.
A Growing Problem
The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.
“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.
Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.
Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.
These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).
Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.
Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”
Sound Solutions:
Innovative Ways to Reduce Noise
Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:
- Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
- Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
- Put foam padding on the bottom of chart holders.
- Identify patients who don’t need nighttime care—and don’t disturb them.
- Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
- Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
- Lower the volume of telephone ringers and other equipment wherever possible.
- Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.
At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.
It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM
For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).
None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.
Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.
“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.
Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.
Worst Offenders
In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.
Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.
These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.
Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).
Squeaky Wheels
Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.
The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”
Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.
Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.
Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.
Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH
Norra MacReady is based in Southern California.
Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.
Welcome to the hospital.
Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.
A Growing Problem
The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.
“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.
Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.
Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.
These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).
Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.
Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”
Sound Solutions:
Innovative Ways to Reduce Noise
Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:
- Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
- Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
- Put foam padding on the bottom of chart holders.
- Identify patients who don’t need nighttime care—and don’t disturb them.
- Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
- Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
- Lower the volume of telephone ringers and other equipment wherever possible.
- Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.
At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.
It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM
For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).
None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.
Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.
“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.
Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.
Worst Offenders
In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.
Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.
These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.
Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).
Squeaky Wheels
Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.
The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”
Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.
Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.
Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.
Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH
Norra MacReady is based in Southern California.
Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.
Welcome to the hospital.
Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.
A Growing Problem
The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.
“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.
Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.
Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.
These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).
Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.
Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”
Sound Solutions:
Innovative Ways to Reduce Noise
Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:
- Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
- Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
- Put foam padding on the bottom of chart holders.
- Identify patients who don’t need nighttime care—and don’t disturb them.
- Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
- Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
- Lower the volume of telephone ringers and other equipment wherever possible.
- Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.
At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.
It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM
For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).
None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.
Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.
“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.
Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.
Worst Offenders
In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.
Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.
These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.
Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).
Squeaky Wheels
Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.
The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”
Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.
Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.
Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.
Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH
Norra MacReady is based in Southern California.
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Which code for Gartner’s duct cyst procedure?
But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).
The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.
Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).
The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.
Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).
The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.
Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Correct coding when the patient goes to ER
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
ICD code depends on why labor was induced
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.