RAP Lesson Learned #1: The Power of a Conversation

Rhonda Barcus, Program Specialist

The Rural Hospital Performance Improvement (RHPI) Project is a federally-funded initiative that supports performance and quality improvement projects in eligible rural hospitals in the eight-state region of the Mississippi Delta. One of the ways hospitals are supported is through onsite, consultant led projects designed to impact operational, clinical, or financial issues. About 2 ½ years ago, we created a process called RAP, Recommendation Adoption Progress, as the vehicle to gather information from the participating hospital administrators concerning the extent to which they were able to implement consultant recommendations, outcomes, and the impact on the hospital and community.

Hired to create and implement this process, my background is actually in behavioral health and organizational development. Pure data collection and analysis is not my passion! But, I do know how to gather information and one of my closely held beliefs is that looking at data in the form of numbers alone will only tell a piece of the story. We began discussing what the RAP process would include and I knew that sending an impersonal questionnaire to be returned to me was not the way I wanted to go. Most people are “surveyed out”!

So RAP became a conversation with the hospital administrator. Yes, it involves the discussion of data and outcomes and “what has this project meant to the bottom line” but more importantly, it has become an opportunity to dive deeper. My first lesson learned was that just having a conversation can become a powerful motivator for the hospital. In the midst of impersonal communication, actually TALKING about the process, keeps the hospital focused. It also is an opportunity to coach and educate about the importance of the non-measureable ways the project impacts the hospital. If we only discussed measurable outcomes, we would miss the value of project impact such as “staff is more engaged” or “managers are taking responsibility for their budget” or “staff are now bringing ideas for quality improvement to their leadership.” While not necessarily measurable, these are the indicators of culture change. What we know is that without a change in the hospital culture or “the way we are”, there would not be sustainability, regardless of the excellence of the project.

And so, my first lesson learned with RAP is that we intuitively named it well. While an outdated term from the 60’s, it’s still a powerful way to receive and share information and build trusting relationships along the way. It’s just the power of a conversation.

Next time, RAP Lesson Learned #2: The Power of Meeting People Where They Are.

When to do a medical procedure when the patient is on aspirin- the answer is..that depends on their risk profile and mine.

        I was asked to do a procedure on a patient taking aspirin.  Aspirin helps prevent heart attacks and stroke but it also promotes bleeding - not good when a doctor is going to use a sharp object like a scalpel or needle on you.  Although the data is not clear, my hospital has a policy to wait 5 days off aspirin if the reason for the procedure is not life threatening.   but this can result in delayed care and patient inconvenience.  Guidelines leave room for clinical judgement.

This is a relatively simplistic example of a broader care issue.  There is no free lunch in healthcare.  Almost everything providers do to patients have the potential to harm.  This may be radiation exposure up through serious complications or death from a simple biopsy or surgery.  How patient's view risk varies.  It seems ironic that we spend more time asking people about their investment risk strategy, than their ideas about health risk. Ideally, providers would know their patients, and something about their willingness to accept risk relative to care options.  

A provider's risk profile is also unknown.  Some seem to be afraid of their own shadow, practicing as if there is a lawyer in the room.  Others are less risk averse, willing to forgo even recommended tests if they feel there is limited value.  In one practice I know of there was a 10 fold difference in mammography call backs comparing senior, more experienced and assured, radiologists and their junior partners.  The art of medicine more than occasionally equates to provider preference.  American healthcare is far from evidence based.  Treatment decisions are strongly influenced by the risk tolerance of provide, what they are willing to miss both for the patient's benefit and (medical-legally) their own.

Ideally there would be time for patients and providers to know each other better.  However, until there is a change in the financial pressures and fragmented care, perhaps healthcare can borrow from the finance industry.  A shared assessment of risk tolerance for both patients and providers might allow a better care match.  Although modern healthcare is often viewed contentiously, care decisions should represent a social contract between a patient and their provider, a willingness to try and move forward in partnership.  There is no guarantees of good health, but at least decisions should align with personal choice.