In a public medical group that adopted Arbinger's work, the leadership team was conducting an investigation into a case in which a patient died after he had sought medical consultation more than a week ago. The patient was sent home to wait for the lab test result as his blood sample was taken at the end of the clinic's operating hours. If the lab test results are normal, no action is needed till the patient's next visit to the clinic. However, if the lab test results are abnormal which imply that immediate and urgent medical attention is needed for doctors to conduct medical intervention or investigations, the clinic then must follow certain standard operating procedures (SOP) for what is termed as "Critical Lab Results" SOP.
This process involved calling the patient and trying to reach him or his family to seek medical consultation as soon as possible. The SOP spells out specific steps and measures to take, for example, first by phone contact, if the patient was still not reachable after 3 attempts, the "critical lab test result" will be mailed to the address of the patient. Under the SOP, there is no requirement for the clinic management to take necessary step to check whether the patient receives the letter or he actually seeks medical consultation. All goals and targets set for various steps in the SOP focus on the clinic's roles and what they ought to do and not the outcome of what they do.
In the case concerned, the patient who had abnormal critical lab test result was sent home on a Saturday afternoon after his blood sample was taken when it was near the clinic's closing time. Unfortunately, when the abnormal result came out the next day which was a Sunday. When the clinic staff made three failed attempts to contact the patient on Monday, the next step was to mail the critical lab test results to the patient's residence. As there was a public holiday within that week and aggravated by delay in delivering the letter to mail room, the letter was only mailed out and reached the patient's residence a week after his last clinic consultation. The clinic subsequently received a call from the son of the patient, saying that their father had passed away a few days after his clinic consultation while waiting for the lab test results. The letter was received a day after the patient's funeral wake.
The leadership team convened its inquiry and wanted to prevent this from happening again. The question they had to confront was, "if we are truly seeing our patients as people, what should my responsibility and therefore the outcome be?" In the discussion, they realised that seeing patients as people required them to reframe their previous goals measuring specific steps they do like making phone calls, sending out mailers etc. to specific outcome they want as a result of what they do i.e. "Ensuring all "critical lab test" patients receive medical attention within a reasonable time frame (48 hours) from their time of clinic consultation"
The shift fundamentally re-oriented the way they would approach patients who had abnormal lab test results. Clinic management team therefore must assume their own responsibility (self accountability) to ensure whatever steps or measures they take for all critical lab result cases, their only goal is to ensure patients must receive medical attention within 48 hours from the time of last clinic consultation. After reframing the mind set to set outcome goal for all critical lab result cases, the management is able to track and monitor monthly how many critical lab result patients sought medical attention within 48 hours and how many did not and why
This process involved calling the patient and trying to reach him or his family to seek medical consultation as soon as possible. The SOP spells out specific steps and measures to take, for example, first by phone contact, if the patient was still not reachable after 3 attempts, the "critical lab test result" will be mailed to the address of the patient. Under the SOP, there is no requirement for the clinic management to take necessary step to check whether the patient receives the letter or he actually seeks medical consultation. All goals and targets set for various steps in the SOP focus on the clinic's roles and what they ought to do and not the outcome of what they do.
In the case concerned, the patient who had abnormal critical lab test result was sent home on a Saturday afternoon after his blood sample was taken when it was near the clinic's closing time. Unfortunately, when the abnormal result came out the next day which was a Sunday. When the clinic staff made three failed attempts to contact the patient on Monday, the next step was to mail the critical lab test results to the patient's residence. As there was a public holiday within that week and aggravated by delay in delivering the letter to mail room, the letter was only mailed out and reached the patient's residence a week after his last clinic consultation. The clinic subsequently received a call from the son of the patient, saying that their father had passed away a few days after his clinic consultation while waiting for the lab test results. The letter was received a day after the patient's funeral wake.
The leadership team convened its inquiry and wanted to prevent this from happening again. The question they had to confront was, "if we are truly seeing our patients as people, what should my responsibility and therefore the outcome be?" In the discussion, they realised that seeing patients as people required them to reframe their previous goals measuring specific steps they do like making phone calls, sending out mailers etc. to specific outcome they want as a result of what they do i.e. "Ensuring all "critical lab test" patients receive medical attention within a reasonable time frame (48 hours) from their time of clinic consultation"
The shift fundamentally re-oriented the way they would approach patients who had abnormal lab test results. Clinic management team therefore must assume their own responsibility (self accountability) to ensure whatever steps or measures they take for all critical lab result cases, their only goal is to ensure patients must receive medical attention within 48 hours from the time of last clinic consultation. After reframing the mind set to set outcome goal for all critical lab result cases, the management is able to track and monitor monthly how many critical lab result patients sought medical attention within 48 hours and how many did not and why