At a recent International Forum on Quality and Safety in Healthcare, Maureen Bisognano, president and chief executive officer of the Institute for Healthcare Improvement, shared the following story in her keynote presentation. A young man working in the Saab aircraft engine factory in Linköping, Sweden acquired nephritis and required dialysis. He went to the local hospital where the nurse hooked him up to the dialysis machine. The man watched as she manipulated the various tubes and settings. Being mechanically inclined, he asked the nurse to teach him how to run the equipment. The nurse proceeded to teach him how to operate it, and on each subsequent visit, the man hooked himself up and performed his own dialysis. Pretty soon, the other patients noticed and started asking if they could learn as well. Today, most of the patients at this center run their own dialysis, freeing up the nurses to attend more broadly to patients' medical and social needs.
Bisognano, a former intensive care nurse and hospital CEO, went on to say that she asked the man if he worried about the safety of allowing medically untrained patients to perform such highly technical procedures. His answer surprised her: "The quality is better when I do the dialysis myself." The man told Bisognano that he learned how to adjust everything on the dialysis machine exactly the same way every time, as well as how to calibrate certain settings that, based on his symptoms, would minimize post-procedure fatigue. He also noted that by performing the procedure on his own, he reduced the risk of infection by lowering indirect physical contact with the other patients.
My first reaction was to this story was: what a great example of patient empowerment! Clearly, as Bisognano pointed out, this individual had a personal investment in a quality outcome. If this had taken place in an American hospital, the nurse would probably brush off the request or perhaps explain why only someone with advanced medical training could operate such a complicated medical device. But I also realized that it's a story about professional roles in patient care.
Healthcare involves many different professionals: physicians, nurses, administrators, laboratory technologists, clinical laboratory scientists, information technologists, and others. The roles of these professionals are protected by both tradition and regulations. But if we look at these roles with fresh eyes, some interesting questions come to mind. For example, what should determine who performs a particular role within a healthcare setting? Education and training are obviously important criteria, but so are availability and proximity to the patient, process efficiency, and other factors.
Non-traditional Professional Roles
To illustrate how breaking out of traditional professional roles can improve patient care, consider two examples.
A number of years ago, the state of Alaska recognized a major problem with dental health in rural communities. Many Alaskans who live far from cities have no access to dentists and as a result have suffered serious quality of life, nutritional, and medical consequences. The Alaska Department of Health observed that other countries around the world use dental hygienists to perform fillings and other basic dental procedures. They recruited hygienists willing to work in underserved communities and sent them to New Zealand for training.
Not surprisingly, the Alaska Dental Association (ADA) saw this as a threat and filed suit under the state's medical practice law. The case ended up at the Alaska Supreme Court, where the justices upheld the hygienist training program and excoriated the ADA for indifference to the needs of rural Alaskans. Since its inception, the program has grown to provide basic dental care to 35,000 people who would otherwise have gone without it.
Historically, the professional role of pharmacists in hospitals centered around tight control of drug dispensing. My father, who passed away recently, spent most of his professional career directing the pharmacy at Intermountain Healthcare's flagship hospital. In the late 1970s, he observed that the biggest quality issue related to drug dispensing was the amount of time required to courier medications from the central pharmacy in the basement up to the nursing units. To shorten this time, he arranged for patient medications to be stored in locked carts on the nursing floors. Pharmacists kept the carts stocked, and nurses retrieved the meds as needed.
The new system forced the pharmacists to give up a bit of control to the nurses; however, it led to improved care because patients did not have to wait for their meds. This approach soon spread to other hospitals and paved the way for the automated dispensing systems seen in most hospitals today.
Take Home Message
So what can we learn from these examples? Don't get me wrong. I am not suggesting that just anyone can perform complex healthcare functions. Quality and process standardization require clear definition of job roles, but roles should be defined based on what makes the most sense for a particular organization and setting.
For example, it may be appropriate for nurses to perform venipuncture within an intensive care unit, but for phlebotomists to perform this function within a general medical unit. Similarly, having nurses perform point-of-care testing is better in some hospital settings, but inferior to core lab testing in other settings.
In the laboratory, reconsidering the roles of staff also presents opportunities for improving patient care. In some laboratories, medical technologists may be responsible for interpreting a particular lab test like protein electrophoresis. Other laboratories may assign this task to a pathologist or other doctoral-level laboratorian. Depending on the task and the context, laboratories may designate particular tasks to phlebotomists, technicians, technologists, doctoral-level staff, or staff without a formal laboratory certification.
Patient safety and regulatory compliance will continue as the primary drivers of professional roles within healthcare; therefore, shifting responsibilities from one group to another requires careful analysis. But when executed thoughtfully, such changes have the potential to lead to greater job satisfaction and increase collaboration across traditional medical professions.