Going the Extra Inch in Iowa: Service Excellence

So I went to a service excellence event sponsored by our employer called “The Iowa Experience: Excellence Every Time.” There was a lot of Disneyspeak in it, which I didn’t mind so much. The main idea is to remember to keep patients and families at the center by doing the little things, what gets called “going the extra inch” as compared to going the extra mile, meaning the little things can actually mean a great deal to people.

OK, there was this breakout group mid-morning; I usually hate them because I’m pretty shy about getting up and talking in front of a group of people. But this feature I didn’t mind so much either. The reason was that I got to finally put faces to names of those I work with on the telephone nearly every day when I’m co-attending psychiatrist working triage to our Medical-Psychiatry Unit (MPU). Triage means helping physicians from inside and outside our hospital find the safest place to hospitalize someone in our facility. Often the safest place is the MPU. The MPU has 15 beds and it’s for treating patients with complex, comorbid psychiatric and medical problems who more often than not are caught in the snarl of a sometimes unhealthy health care system that can confront patients and health care professionals with unexpected barriers to accessing care as well as other psychosocial challenges to healing and moving on.

And the beds are often full.

The people I met in our group are two of the telephone operators in our Admissions and Transfer Center (ATC) within the Telecommunications division of our large academic medical center. They have a critically important job that entails fielding about a gazillion calls from physicians both inside our hospital, many times the emergency room, and outside in community hospitals all across Iowa. When we introduced ourselves, we were all shocked. We talk to each other on the phone nearly every day for more years than I care to admit but had never met in person. I say nearly every day because when I co-staff the MPU, I work with a physician who is a faculty member from the department of internal medicine. We share the triage call from 8:00 AM to 8:00 AM every other day, sometimes for a month or more at a stretch. When my colleagues who are dually-boarded in both internal medicine and psychiatry staff the MPU, they triage every day. That means taking call every day or every other day, much of it spent on the phone with the operators.

I knew the operators by their voices. I also knew them by their deft management of extremely difficult conversations with overworked, harassed, and sleep-deprived physicians who often desperately need an MPU bed for their patients. Anyway, in the group, I was taken aback when they laughingly but disparagingly referred to themselves as the “bed nazis”. This reminded me of the old “soup nazi” routines on Seinfeld. The soup nazi was the soup kitchen guy who had maniacally obsessive, rigid routines for customers to adhere to if they wanted a bowl of soup. The soup nazi often denied them access, snarling “No soup for you!” over the most picayune infractions of his rules.

I imagine that’s how some doctors feel about our admission criteria to our MPU as well as to other beds in our hospital from general internal medicine wards to critical care units. One of the more frustrating situations involves the nearly constant “full house” status of our wards. Another is the unmet criteria problem: either the patient doesn’t have an acute psychiatric problem requiring psychiatric hospitalization or doesn’t have an acute medical problem severe enough to require medical admission. The operators are the first line of defense and will frequently give physicians the bad news first. But they also have an instinct, a sensitive ear for the exhausted doctors who have called everywhere searching for a place they can send a patient to get the medical and psychiatric attention she needs.

That’s when the operator calls me, invariably in the middle of the night. It usually takes me a while to stumble downstairs to take the call. They’re always very understanding. After all, it’s been a while since I was a resident and it takes me longer to get ungroggy. Then he or she prepares me for the upcoming difficult conversation I’m about to have at 2:00 AM with a disgruntled doctor. Their briefing more often than not carries the subtle suggestion that I probably should not simply say “No, there’s no room at the inn”. This is not a simple skill for the operator, because many physicians even nowadays are still not happy to hear advice about how to talk to their colleagues.

I have learned to take the hint. So I spend a good deal of time on the phone, offering clinically sound advice, (or at least as clinically sound as I can make it at 2:00 AM) about what might work best to keep the patient stable until I get a bed open, or I might even bend the rules about accepting a patient for transfer despite the lack of certain “criteria”, given the complexity of a given situation.

If anyone’s a bed nazi around here, it’s me-not the ATC operators. But over the years, those faceless voices on the telephone and I have worked out a kinder, gentler way of ensuring that patients don’t fall through the cracks more often than we can help it. That reminds me of something else I learned at the Service Excellence program, which is to respect the culture behind the saying, “While this (the barrier to admission to the MPU) is not my fault–it’s my problem”. I guess I would substitute the word “challenge” for “problem”, but let that pass.

So I feel a lot closer to the ATC operators now, which actually enhanced my experience of the Service Excellence, Disneyesque, way of saying that building relationships with patients and families doesn’t necessarily entail that I make miracles happen.

All I really have to do is consistently go the extra inch, because often enough it’s the small things that count.

Update: The University of Iowa Hospitals and Clinics began implementing a new admission triage system in 2013 that may unburden more doctors from long stints on call. Now that’s going the extra inch.

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