Beaumont’s response to the letter was immediate and impressive. Two hours after posting the blog I received an e-mail from the director of corporate communications saying Michalski had directed the administrator overseeing the home service division to contact my mother and conduct a thorough investigation. I soon got an e-mail from Michalski, who said he would be calling mom and would get to the bottom of the problem.
The administrator talked to my mother and the home health services staff, checked phone logs, called the local supplier in my community and pieced together what had occurred. She then made calls to mom and I to explain what happened. She found multiple breakdowns in processes and didn’t make any excuses. She bemoaned that we were told Medicare would need to be contacted to get a list of authorized dealers in my community, because filling the empty oxygen canister “cost $15, for Heaven’s sake!” and that could have been resolved in the first phone call to Beaumont.
She found the tubing my mom had on the machine was much longer than the recommended 4 feet but there was no notice on the machine of a maximum length. The manager with authority to quickly fix the problem had been in meetings and had not been pulled out as I twice had requested because the people answering our phone calls or looking at work lists did not recognize the urgency of the problem, even though they were told three times mom was not receiving enough oxygen to drive home. The problem was quickly resolved once the manager was out of the meetings and notified.
As a result of the investigation, Beaumont is building decision trees for front-line personnel who answer patient phone calls so they will have guidance on handling various issues and clearly understand urgent issues get immediate attention. Further, under a new policy, anyone can pull anyone else out of a meeting or other activity to quickly handle a problem. Beaumont also will implement a “secret caller” program to observe staff performance first-hand.
“Communications breakdowns happen from time to time and it’s something health systems struggle with,” the administrator told me. “We’re not there yet, no one is.” Michalski, she added, came to Beaumont two years ago preaching the gospel of care coordination and this incident was a reminder that while good progress has been made the work must go on.
And that’s all I wanted to hear--that Beaumont gets it. The organization may not ready for the era of accountable and tightly coordinated care, but they understand where they are heading and the urgency to get there.
Mom heard a similar message from CEO Michalski when he called her, and when his lovely--and really big--vase of flowers arrived at the house with the note, “Thank you for sharing your experience.”
Mom emphasizes that her experiences with caregivers at Beaumont have always been positive and it was this one experience with management that caused a problem. “I do believe that Beaumont will do what it can to make all levels of management aware that when they’re dealing with a patient’s health, that has to come first.”