Phronesis and the Medical Director

The psychophysics of transition to long term care

More than a decade after the publication of To Err Is Human, cognitive error remains a mystery to physicians. Competent and conscientious physicians rarely recall making a single cognitive error, yet this must be central to the explanation for inappropriate physician nonadherence to evidence-based guidelines. Published information regarding cognitive error in the medical literature is scarce and widely scattered. We do know that cognitive error is induced by complexity, duress, and uncertainty, conditions that regularly confront long term care physicians when they assume care of a new patient at the skilled nursing facility. Negative attitudes and low expectations of care are common among new patients and families. This is compounded when care is assumed by an unfamiliar physician. The initial disquiet and negative misconceptions of patients and families regularly make the transition one of the most error-prone events in medical practice. On the brighter side, the transition provides an excellent opportunity to study cognitive error. Cognitive errors at transition typically begin with a decision to avoid mention of necessary changes to flawed treatment plans already in effect. This is done as a temporary measure to avoid further stressing the patient and family. But what appears to be an ideal compromise is a risky option and should be avoided. Evading the issue introduces long-term risk to the patient. In addition, although it is seldom acknowledged, evading change often has a negative impact on local standards of care. Five cognitive principles are presented as root causes of cognitive error. Six contextual factors are identified that are endemic to nursing home practice, making the physician even more error prone. Because mistrust is central to dysfunctional decision making at the transition, strategies are presented to expedite gaining trust. This article makes the case for adding training in the cognitive psychology of medical decision making to core requirements for certification in medical direction.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 2)

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the problems and identify their diverse causes. This fourth and final article in the series (divided between last month's issue and this one) recommends strategies to make sense of improvement and reform efforts. This month's concluding segment covers additional proposed approaches. Despite the challenges of the current environment, all of the proposed strategies could potentially be applied with little or no delay. Despite having brought vast increases in knowledge, the research effort may be losing its traction as a formidable force for meaningful change. It is necessary to rethink the questions being asked and the scope of answers being sought. A shift to overcoming implementation challenges is needed. In addition, it is essential to address issues of jurisdiction (the apparent "ownership" of assessment and decision making over patient problems or body parts) and reductionism (the excessive management of these issues and problems without proper context) that result in fragmented and problematic care. Issues of knowledge and skill also need to be addressed, with greater emphasis on key generic and technical competencies of staff and practitioners, in addition to factual knowledge. There is a need to rethink the approach to measuring performance and trying to improve quality of care and services. There are significant limits to trying to use quality measures to improve outcomes and performance. Ultimately, vast improvement is needed in applying care principles and practices, independent of regulatory sources. Reimbursement needs to be revamped so that it helps promote care that is consistent with human biology and other key concepts. Finally, improving long-term care will require a coordinated societal effort. All social institutions and health care settings need to address their own shortcomings and contribute constructively in order to improve and reform nursing homes and health care generally. It is not helpful to scapegoat nursing homes for what are far more universal problems of care, practice, and performance.

Aging male

There are several special issues that confront the physician when dealing with the older male. Physicians need to pay attention to these issues and recognize their importance to their patients. This article briefly reviews these unique challenges.

The basis for improving and reforming long-term care. Part 3: essential elements for quality care

There is a pervasive effort to reform nursing homes and improve the care they provide. Many people are trying to educate and inform nursing homes and their staff, practitioners, and management about what to do and not do, and how to do it. But only some of that advice is sound. After more than 3 decades of such efforts, and despite evidence of improvement in many facets of care, there are still many issues. Despite improvements, the overall public, political, and health professional perception of nursing homes is often still negative. To date, no tactic or approach has succeeded nationwide in consistently facilitating good performance or correcting poor performance. Only some of the current efforts to try to improve nursing home quality and to measure it are on target. Many of the measures used to assess the quality of performance have limited value in guiding overall quality improvement. Before we can reform nursing homes, we must understand what needs to be reformed. This series of articles has focused on what is needed for safe, effective, efficient, and person-centered care. Ultimately, all efforts to improve nursing home care quality must be matched against the critical elements needed to provide desirable care. Based on the discussions in the previous 2 articles, this third article in this 4-part series considers 5 key elements of care processes and practices that can help attain multiple desirable quality objectives.