The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Could I have FINALLY conquered customer satisfaction? [HAVE I FOUND THE MOJO?] NOT!

For the past five months I have been working at a rural emergency department (ED) where I worked anywhere between fourteen to twenty-one consecutive twelve-hour shifts before going home for seven to fourteen days then back, rinse and repeat. Tonight is the last of those nights. Although a doable job, a lifestyle, that of being away from home, I rather not have to take part in. Yes, I realize that is bitching because if I catered to exaggerated unrealistic emotional expectation, entitlements and so-called VIP I would be home, rather than traveling, and even working for an organization I enjoyed working for, rather than working where no one else wants to work.
 
However, this blog is not for bitching. This blog is to point out how silly customer satisfaction is in healthcare and the senseless collateral damage it leaves behind. The blog also serves as a sounding board as it is not fair to share the stories with those we love most.
 
As a reminder from a previous blog, when I first came to work here part of the hospital’s orientation included a visit with the hospital’s patient advocate. An orientation I found interesting for a number of reasons but the most ironic was that The Customer is NEVER Right had gone on sale a week before that orientation. And as I pointed out in the previously mentioned blog, once in the ED I noticed the customer satisfaction propaganda signage was everywhere and patients were encouraged to complain, and references to comment on good experiences seemed to be an after thought.
 
Surprisingly, after the first 240 hours of working here and something I blogged about, I had not heard from the administration that anyone had complained despite patients either expressed their discontent to me or stormed out of the exam room whenever their exaggerated unrealistic emotional expectations were not met. Having said that, I am very well aware that although a patient may express discontent that does not assure a complaint to hospital administrators, however, five months without hearing from an administrator was unusual.
 
Believe me, I rather not hear about complaints but after seeing more than 2,500 patients (25-30 patients per shift x20 shifts per month x 5 months) and not hearing about a single complaint I am curious to how or why that happened. I am not boasting or wishing for complaints, just curious, as I have already blogged about a number of discontent patients from whom I never heard from. However, there were others that I did not include in the blog and those follow:
 
A family plan of four, three children and a father, all with different complaints varying in duration and none of them seen by their primary care provider (PCP). The youngest had a single skin lesion for over a week and the parent was concerned the lesion was impetigo. The oldest child, who was eating chips during the history and physical exam, had a headache that moment and that had been constant for more than a month yet was not given anything for the headache. The father had back pain since the day before I saw them and he had not taken anything either. The middle child, and the only one who appeared ill but not toxic, had a fever, body aches, runny nose, headache and tiredness for three days and not given anything for her fever, body aches or headache either.
 
Their diagnoses: (1) A tiny healing skin abrasion with a scab without infection, not impetigo, and prescribed wound care. (2) Attention seeking behavior pre-teen, although not what I said to the parent, was diagnosed with a headache and prescribed Tylenol. (3) Back pain, prescribed rest, heat and ibuprofen, after the father declined a muscle relaxant due to drowsiness and he was the only provider for the children. (4) Influenza, volume depletion and 102.8 fever was prescribed fluids and Tylenol all of which the patient was given in the ED. The family plan was then discharged home and the father told by me, “In the future treat the children for their symptoms, especially the one that is sick [pointing to the only sick patient] and follow up in the pediatric clinic.”
 
Advice that could not go without saying, but Nope! Instead, somehow, I had unknowingly opened up either an old wound or a can of worms. The father replying, “I work during the day and I cannot bring them to the doctors during the day.” Not that it mattered but in the same hospital and just down the hall from the ED was an adult, pediatric and dental outpatient clinics that saw patients between 8am and 8pm Monday through Friday and a general clinic was open on Sundays 12noon to 4pm that saw all ages. “So I am going to bring them whenever I can,” the father added. “No Sir, the ED is not for your convenience,” I said.
 
However, what I wanted to say was, “No Sir, YOU are only here because YOU have back pain since last night as the others were ‘sick’ before YOU. Yet, not only did YOU not seek care for them YOU did not give them anything for their pain or fever before YOU thought YOU needed to have your back checked on.” Instead, rather than continue the truthful and much needed conversation I remained silent filling out the four individual discharge instruction forms. Unfortunately, because silence is uncomfortable for some, especially when they are wrong, the father asked me, “Do you know anything about my people?” I looked at him and said, “No,” and returned to writing their discharge instructions because as I wrote in the book, “My experience has been that persons who are fast to pull the race card are comfortable making those accusations without concern for its meaning and much less the consequences of such actions.” Having that experience I knew what was coming next.
 
Without me asking, the father began his dissertation “about his people”. However, I ignored him as I was neither interested nor paying attention, because it was neither the place nor time for him to be teaching me about his people. And much less, it had nothing to do with the fact that he had not treated any of his children for their fever or pains and he was using the ED only for his convenience. Once I finished writing I went over the discharge instructions with the father, talking over him, while he was still actively schooling me “about his people” to which he yielded, as if he considered what I had to say was more important than his dissertation. Then, when I finished I asked, “Do you have any questions?” “No,” the father said but added, “I will come here whenever I want and I am going to complain that you did not do anything for ME.” “That’s fine,” my stock reply to exaggerated unrealistic emotional expectations, entitlements and so-called VIP.
 
However, what I wanted to tell the father was, “Sir, I did more for YOU and your three children, especially the sick one, than YOU did for them or yourself.” As I had given them all medicine for them to feel better, especially the child that was sick. Never hear that that father complained.
 
That same night the ED was packed, a night of many, where I saw twenty-six patients in the first seven hours of my twelve-hour shift. This is a rural ED where it was common for me to see twenty to thirty of the sixty to sixty-five patients seen in twenty-four hours. I mention that night being busy because while walking through the ED waiting area a patient I heard earlier telling others about how much dental pain she had, yet, “No one here will do anything about it,” says to me as I walked by her, “Andale.” Which I found interesting, because in the five months I have been working here I had not seen a single Spanish speaking person. However, andale is Spanish for “walk” and slang for “hurry” of which I was doing both, considering the number of patients I saw nightly.
 
However, I did not say anything to her after the above mentioned father tried to school me “about his people”. Because to me, your people, is truly insignificant when you are seeking medical attention, unless you are digging in your pocket to pull out the race card. Just as it was insignificant that the dental pain patient would know anything about my people to use a word from my people’s language to tell me to hurry.
 
Among the 2,500+ patients I had seen during the past five months there would be one patient I would recall, although sadly, not because of anything good and not even because of the patient. Instead, because of the drama surrounding the patient. The patient was a seventeen-year-old I was seeing in the ED but not because she was ill but because she had missed school the day before I saw her and her father wanted her to get a school absence note and I said, “Ah, no.”
 
To which the father went berserk, after I declined his note request, to the point of him getting in my face, something that never goes well. When I asked the father to move back he did but only to put his finger in my face, very close, but not close enough to touch me. Not sure why. At that point, the seventeen-year-old patient literally jumping in the argument from off the exam table yelling at her father, “Quit being stupid.” However, the father would not move his finger from my face so in turn I put my finger in his face and calmly said to him, “Can you see how disrespectful that is?” The father shouting back, “Get your finger out of my face.” And although furious I calmly said to the father, “Sir, you are being childish. The reason I put my finger in your face is so that you can see how disrespectful that is."
 
Making a very intense moment, of where I was so close to taking the father down, into a short story the father stormed out of the exam room. The incident occurred on another very busy night when the waiting area was packed and after a short moment to calm down, although still boiling in rage, I called the next patient into the exam room, and then the next patient, and the next, and the next. After seeing ten consecutive patients without stepping out of the exam room until there were no more waiting patients, at least at that moment, I stepped out of the room into the ED waiting area to give the nurse next door the stack of completed chart.
 
As I stepped out into the ED waiting area there were five to six persons in the waiting area. Then, as I stepped towards the nurse’s room next door I heard my name called from the furthest wall in the waiting room, “Torres! Hey, Torres!” It sounded like someone recognized me and that person was trying to get my attention so I looked to see if it was someone I knew. NOT!
 
Instead, the person calling me was the son of the father who had left upset earlier and the son says to me, among other things, “Why were you being disrespectful to my father and sister?” The young man, in his early twenties, wearing a white tank top by the way, steps towards me throwing his arms at his side, a common gesture on the block that meant, “You want a fight?” Still in rage, I stepped towards him, something I could tell the young man did not expect as he abruptly stopped in his tracks and he stepped backwards and then, literally, exited stage left hurrying outdoors to the parking lot.
 
As the young man rushed outside he hollered, “You better watch your back.” The ten charts still in my hand, I followed him outside after getting the attention of a police officer standing inside the registration room. As the young man stepped out through the exit door I questioned him, loud enough for the police officer to hear, “Was that a threat?” And the young man replied, “Yea! So you better watch your back,” yet still hurrying outside as if he knew I was behind him.
 
As the police officer and I walked outside I shared with the police officer what had happened. Incidentally, the police officer was wearing a heavy bomber coat because it was that cold outside, yet the twenty-year-old was wearing a white tank t-shirt, just thought that was comical and why I pointed it out. Outside the police officer and I found the young man driving away and the police officer chased after him in his patrol car and I went back inside to turn in the charts I had in my hand.
 
Moments later, the hospital security arrived in the ED waiting area as they had seen the hostile exchange on their closed-circuit monitors. After I shared with them what had happened I was asked to complete a statement, which I did and turned in before leaving that morning. Keep in mind, that threat was in a community where I stuck out like a sore thumb, where being Mexican was an oddity, and where most the head injuries I saw in the ED were due to senseless attacks with baseball bats. Because of that, I became very attentive to my surroundings when I left the ED every morning after the incident.
 
Unfortunately, it was not the first time I had been threatened and likely it would not be the last time either. However, adding to the silly drama, I was told by the registration staff after the seventeen-year-old patient returned to the ED that night, and seen by someone else, that the family had stated that I was to watch myself as the patient was the goddaughter of blah blah blah. My take on the third threat was that the young warrior they sent to take care of the boogie man was not sufficient, so now I would also have to watch out for the patient’s godfather as well. Great! Because, although the patient's father and I were the same age he did not want to take on the boogie man himself.
 
In the book, I cited a research study that pointed out how much more disturbing threats from patients or family members were to healthcare workers than actual acts of physical harm. By the way, the cited study should be one read by all in healthcare, workers and administrators alike but especially healthcare administrators. With that in mind, while I do not allow threats to define me, I was curious to where the administration was? Nowhere! They made no comment! None! How is it the administration had not heard of the incident after I submitted a statement to the hospital security, the police spoke with the young man and the registration staff warned me to watch out for the patient’s godfather, someone the registration staff described as a notorious bully in their community?
 
All of that drama because I would not write a school absence note for a patient I had not seen. Although, after seeing the patient it was likely I would not have written an absence note either, as the patient did not have an illness that required absence from school, or work for that matter. Having said that, would I still have been threatened had I actually seen the patient and declined to provide a school absence note then? Unknown, but likely they would have asked to be seen by another healthcare provider, a common strategy of those with hidden agendas or exaggerated unrealistic emotional expectations and entitlements.
 
Keep in mind, no one thought the seventeen-year-old needed medical attention before it was time for her to return to school, not even when she was so sick that she missed school. Another marvel I mention in the book, if you decide to skip school, or work, that is between you and your school, or employer, and no business of healthcare. Regardless, after so much drama, where were the comments from the administration or the patient’s complaints? No where.
 
Then there were the handful of patients who declined to be seen by me due to their expectations were not catered to on a previous visit when I had seen them in the ED, so they asked to be seen by another healthcare provider. A common accommodation, I must add and always for a number of reasons, none of which are justifiable. Where did those complaints go? Oh! Wait! They didn’t complain. Why would they? After all, someone else did not only cater to their accommodations but the patients were given the pathetic special attention they craved of bending over backwards for them!
 
Like the patient who had menstrual pain for the past four days, and the same pain for the past four months since diagnosed with some condition her PCP was aware of and who I should have called for directions on how to manage, according to the patient.
 
“No ma’am, I am not going to call your physician. My question was not how to manage your pain. My question was, why have you not taken ibuprofen or naproxen for the pain you have had for four days now?” I replied to the patient when she suggested I call her PCP at 10pm Saturday night. The patient snapping back, “Because my doctor told me to get a ‘pain shot’ when the pain is severe.” “But ma’am, you said the pain has been the same every month with your menstrual cycle and you have had the same pain for four days without having to take anything for it. I am not going to give you a shot when you can take ibuprofen or naproxen for the pain.”
 
“But my doctor told me to get a ‘pain shot’ when I get the pain,” the patient repeated in a louder tone as if I had not heard her the first time. The “pain shot” was Toradol an injectable anti-inflammatory, similar to ibuprofen or naproxen except an injection, in this case, likely a placebo. “Ma’am, there is no reason why you cannot take ibuprofen or naproxen for your pain,” I said.
 
Then the family chimed in, “What if she [the patient] has a single kidney?” Not that I shared but I wanted to, “The drug insert clearly states that Toradol is contraindicated in patients with advanced renal impairment or at risk of renal failure and it is not for chronic or minor pain. That is not something I made up, the drug insert says that, so I have no idea why your physician would tell you to get a shot of Toradol if you have chronic or minor pain and even worse a single kidney. Of course, unless your physician was hoping you give them a high customer satisfaction rating, because only that would explain he or she suggesting Toradol against the contraindications.” Instead what I told the patient was, “Even more reason not to use Toradol. That is not a good choice if you have a single kidney.”
 
After that scrubbed down and politically corrected reply I looked at the patient’s electronic health record and I could not find anywhere that the patient had a single kidney, and when I pointed that out to the patient the family member stated, “I didn’t say she has a single kidney. I said, What if she has a single kidney?” WHAT!?! Was I on candid camera? Flabbergasted I said to the patient, “Ma’am I am going to give you ibuprofen for your pain.” The patient snapped back, “I want to see someone else.” “Sure,” I replied, “You can wait in the waiting area and they will call when they can.”
 
Truly, whatever unknown condition the patient had was irrelevant to her pain. However, some believe any medical condition they may have, rare or not, makes them a medical marvel and why they cannot accept being told, “No.” By the way, the seventeen-year-old who needed the school absence note had a history of Henoch-Schonlein purpura. Once, as an infant, and why her father thought she was a medical marvel needing to be excused from school anytime the patient had abdominal pain. Yet they did not seek medical attention when she had the abdominal pain, and when it would have been most crucial, but did seek medical attention when it was time to go back to school.
 
AS FOR THE MENTRAUL CYCLE PAIN, NOT THAT IT MATTERS, BUT DID I MENTION THE PATIENT WAS TALKING AND LAUGHING IN THE WAITING AREA AS I CALLED HER INTO THE EXAM ROOM. Never heard that that patient complained either. Oh yea! Why would she? She got her Toradol after waiting to be seen by another healthcare provider.
 
Then there was the patient with an ear infection who could not understand why I would not prescribe her “something stronger than motrin” for her ear pain. Not that it mattered but her ear looked fine. Instead, what she had was an exudative pharyngitis for which she was seen two days before and was prescribed antibiotics along with narcotics and she was out of them by day two. And although she did have an acute illness, she did not appear ill or in acute distress, and much less in need of a narcotic.
 
“Ma’am, even if you had an ear infection I would not prescribe narcotics. I see children and infants all the time with ear or throat infections and I never prescribe them narcotics. Why would I prescribe an adult narcotics for the same illness,” I said.
 
“They gave them [narcotics] to me the other day."
 
“I know they did. However, if I had seen you on day one, I would not have prescribed you any narcotics. Like I said, I never prescribe narcotics to children with ear or throat infections and I am sure neither do my colleagues. So why would I prescribe them to adults and much less two days later."
 
“I want to see someone else who is going to give me ‘something stronger’ for this pain."
 
“Have a seat in the waiting area and they will call you as soon as they can,” I said and moved on to the next patient. Never heard she complained either but likely she got “something stronger” for her ear pain. So why complain?
 
However, what administrators may not realize, or care to realize, is that once they grant patients special privileges, like accommodating the ever so common “I [patient] want to see someone else!”, with idiotologies, like bending over backwards policies, they create a new product that others are not privileged to. As a consequence, on return visits those same patients will demand, “I [patient] do not want to be seen by him [NP J. Torres],” and their chart given to someone else. Howspecial?
 
Likely that crowd, the ordained with special privileges crowd, was the forever-dissatisfied five percent I mentioned in the book. However, that five percent would have been 125 patients of the 2,500+ I saw in those five months but I do not recall the number of ordained patients being that high. However to avoid argument, as the number has no merit, lets say it was 125 patients who received the administration’s mandated and elitist accommodation treatment of bending over backwards. Which, from this point forward I am going to call what it really is, bending over, as it is notadministrators who are the ones bending over backwards but instead healthcare workers who are just bending over in order to keep their jobs.
 
Unfortunately, on a third visit, yes the third time I would see some patients in five months in the same ED, and why I did not believe the number of dissatisfied patients was that high and not to mention again, at a hospital that had an adult, pediatric and dental clinic just down the hall. Nonetheless, on the third visit when it was much busier, those same ordained patients could not be seen expediently as the previous visit, when their chart was given to someone else, and on their third visit they had to wait there turn. Of course, waiting did not go well with those patients as now they were elitist, who knew how to manipulate the system by making demands knowing the administration would yield; just to avoid a patient complaint.
 
However, some of those patients themselves yielding to the idea of having to wait to be seen by another healthcare provider, and although disheartened, were willing to be seen by me again on a fourth or fifth visit. Yes, their fourth or fifth visit in five months, not to mention the times they came to the ED when I was not there. Nonetheless, where are those complaints for 125 patients? None.
 
Another patient I thought would have complained was upset because I do not use the pain scale, another idiotic medical breakthrough that I mention in the book. The patient saying to me, “Did you not see the paper I filled out? My pain is eight.” “No ma’am, I do not look at the chart. I prefer to ask patients why they are here,” I said to her. However, later I noticed the patient had written that her pain was eight on the registration form, a form intended for patient demographics collection and not for medical purposes. However, although the registration form did request “reason for visit today” no where did it ask patients to rate their pain, yet, that was where the patient had written, “severe back pain at 8”.
 
“What kind of doctor are you that you do not use the pain scale?” the patient asked. “First of all, not that it matters regarding the pain scale, I am not a doctor. I am a nurse practitioner. Second, we do not all practice the same. Those are guidelines and I have chosen not to use the pain scale. That’s all,” I said to the patient.
 
Unknown to the patient I have also given up on asking most patients for pertinent negatives during the review of system. Why? Because way too many say yes to all the above without even knowing what the symptom is, like, when I ask a female with an upper respiratory infection if she had priapism and she said, "Yes," without asking what it was. In lieu of the review of symptoms, I have come to learn that if the patient has a symptom they will express it during the history of present illness/injury and if they don’t mention it, likely they do not have the symptom. So why plant a seed for them to say, “Oh yea, I have that too.”
 
The same with discharge instructions, what I have learned from patients in the ED is that they are there for a lesser symptom so why tell them to come back if it gets worse. If they came in when it was least, then you know they will come back when it is worse, you can bet on it without having to tell them. Because, what I have noticed is that when I ask a patient why they returned to the ED commonly they state, “Because they told me to come back if it got worse” although it was no different than it was according to the notes in the chart. Nonetheless, after all that, where was the administration with complaints that I do not ask patients to rate their pain? None.
 
Another patient I expected to complain after he told me he was going to complain during our interaction. An interaction that went down hill the moment the patient entered the exam room and he asked me to open the window blinds and I declined. “I have my vehicle out there without a windshield and I would like to keep an eye on it,” the gentleman said to me after his vehicle had lost the windshield during a motor vehicle crash.
 
“No Sir. I am not going to open the blinds."
 
“I have $20,000 invested out there and I would like to keep my eye on it."
 
“No Sir. I am not going to open the blinds. I am here to provide medical care if you need it. If you want to keep an eye on your vehicle then you need to go outside to do that,” I said.
 
Incidentally, the gentleman was not initially the patient but instead he had brought his wife into the ED after the motor vehicle crash where he lost his windshield. Regardless, the gentleman and his wife drove to the ED in the same vehicle after the crash and the vehicle was parked outside without a windshield and why he wanted the blinds open. And although the gentleman had no medical complaints, during registration, someone suggested to him as he said, “That [he] get checked out for insurance purposes.”
 
“Okay. Whatbothers you?”
 
“Nothing. I do not have anything wrong with me.”
 
“Oh. Okay. What would you like me to see you for if you have no medical complaints?”
 
“I do not know. I was told to get checked out for insurance purposes.”
 
“Sir, I do medical care. I do not make insurance claims.”
 
“Can’t you just make a record that I have nothing wrong with me?”
 
“Sir, that makes no sense. I have no idea what that means.”
 
“What is that computer you have there for then if you don’t make claims?”
 
“Sir, that computer is for the electronic medical record. That is where I document in your medical record but that is not for insurance purposes.”
 
That unproductive back and forth exchange went on until the patient asked me, “Where are you from?”
 
“I am from NewYork.”
 
“That explains your attitude. Around here we are nicer to people and we care about one another,” he said.
 
Not that I shared with the gentleman, but his community, where they “are nicer to people…and care about one another” has by far been the most hostile community I have ever worked at. Not only towards people from outside the community, like those of us working locums, but between themselves as well. Again, of all the ED I have ever worked at, urban, rural, suburbs, big and small, I have never seen so much senseless intentional violence among family or kinship, as opposed to random and/or senseless violence among strangers.
 
Not to mention that was the same community who asked me, “Are Mexican?” As if that matters. The same community where I was threatened by three different men because I declined to write a school absence note. The same community where baseball bats are favored and used frequently to settle grievances. Clearly, the motor vehicle crash gentleman must have been fantasizing about a different community for his people, and I do not blame him for fantasizing, where people were nicer and cared about one another, because that was not that community.
 
So, Sir, spare me the story that your community has any sense of being nice or caring about one another. If that were so, why would you be so worried about your vehicle being raided or stolen from the hospital parking lot? Again, just a thought.
 
The reason I kept the blinds closed was because the window is right at the desk where I sit and after being threaten I did not want to give anyone a window of opportunity, pun intended, to carry out their threat. Because of that, no I was not going to open the window blinds and more so after the administration had made no effort to protect others or me, as the administration must have known that I had been threatened, through my reports to police and security. On top of that, I did not believe that was something I needed to share with anyone, to include a patient. Regardless, never heard the motor vehicle crash patient complained either.
 
Another patient/family who said she was going to complain was carrying around the omnipresent complaint form and making sure I saw it. A grandmother, who carried her ten-year-old grandson into the exam room, a ten-year-old boy who was as big as she was, yet, she carried him. Not because he was sick but because he was sleeping. I could not recall the grandmother but it was likely I had seen her as a patient as her speech was pressured as if a past experience had not gone in her favor and she was not going to let that happen again.
 
The interaction began with a lot of bloviating, from the grandmother, about how much she loved her grandson and how sick he was, yada yada yada, none of which had anything to do with what I had asked to that point, “What is the patient’s name?”
 
After the grandmother finally stated the patient’s name, I asked, “What brings him to the ED?” Again, more long-winded bloviating about how much she loved her grandson, yada yada yada, but without a mention as to what brought them to the ED. Finally, on the fourth attempt I asked, “Ma’am, why are you here?” and the grandmother continued to struggle, as if embarrassed to announce the reason for the visit and as if she and I had had that conversation before.
 
Knowing I would have to do a physical exam I gave up on asking the grandmother for the reason they were in the ED. However, as I tried to do a physical exam on the 10-year-old that wanted to sleep at 11pm, I asked the grandmother to wake him up and she became upset that I would not just do the physical exam while the patient slept. She then became more upset when I asked the patient to get off the exam table and to stand, a distraction that always keeps children awake at that time of night, except once, and that child had had a closed head injury. Unfortunately, when I asked the patient to remain standing while I completed the physical exam, BOOM!!! The grandmother exploded, as if I had blown her cover, and all the drama and bloviating about her loving grandson was that he needed a medication refill and rather be seen at the pediatric clinic and pick up the medicine at the pharmacy, that was inconvenient and why she wanted to get the refill through the ED. “I want to see someone else,” she said and her wishes granted. However, although she waved the complaint form for me to see I never heard that she complained either. She must have gotten what she came for.
 
A phenomenon of this facility was that to be seen as a walk-in patient at the adult, pediatric or dental clinics meant having to get up early in the morning to get in line from where only the first fifteen patients were selected for that morning. Those not selected were then asked to return at noon to repeat the process of waiting again to only select the first fifteen to be seen that afternoon, without regard to how far they had gotten in the morning line, rather than picking all thirty then and dividing them up to be seen in the morning or afternoon. Because of that, it was common for patients to be seen at the ED where they did not have to wake up early to get in line and where they could come at their convenience, where they were sure to be seen within one to two hours of their arrival and not turned away as the clinics did after they reached their maximum number of fifteen walk-ins for that time of day, and lastly, although it seemed like an absurd reason it was logical for some, but some patients had learn that after the pharmacy closed at 10pm ED prescriptions were dispensed directly to patients rather than patients having to wait long at the pharmacy to pick up those medicines, to include over-the-counter medicines which were offered and readily available but only with a prescription and medication refills. Of course those patients who had figured out how to beat the system were few but the grandmother was one of them and likely the reason she was embarrassed to state her reason for coming in that late with a child that was not ill. As mentioned, I believe the grandmother and I had been through the above misuses of the ED before.
 
Another patient who said she was going to complain came in because her leg hurt after a fall the day before she sought medical attention in the ED. Because the injury was related to a fall, I asked the patient, “Are you hurt any where else? Did you hit your head? Did you hurt your neck? Did you pass out?” After a long pause and moment of silence the patient said, “I do not drink so I do not appreciate you asking me if I passed out.” What just happened!?! I thought. “No ma’am. I could care less if you drink or not. Why would I ask if were drinking yesterday for an ED visit today? I ask if you passed out because you had a fall and the concern is that could have a head injury if you had hit your head,” I said.
 
After an x-ray of her lower leg, which I only ordered at the patient’s requested as it was not clinical indicated, I provided her with a diagnosis of contusion of her shin and discharge instructions and the patient said to me, “Well, am I going to see someone else?” Without reason to be alarmed I said to the patient, “No. We are done." The patient then expressed she was upset because she could not believe her leg was not broken and she wanted another opinion. “Ma’am, I did not believe your leg was broken when I saw you initially. I only ordered the x-ray because you requested it. Otherwise I would not have ordered it. If you want another opinion you can follow up in the outpatient clinic. In the mean time follow the discharge instructions I provided you with,” I explained to her. Never heard that she complained either.
 
So, after so many shifts, after so many patients and not once hearing from an administrator for any reason, not even of concern after I was threatened, could I have finally, although unknowingly, gotten the customer service or better yet, the customer experience mojo. Not likely. So then what happened after five months and seeing more than 2,500 patients without a comment from the administration or the patient advocate, knowing some of those 2,500+ patients were not content because their exaggerated unrealistic emotional expectation were not met?
 
No se (Spanish for “I do not know).

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