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By Bruce Brown, MD, Director of Hospital Medicine, NMMC-West Point
Keystone asked me to become the Medical Director of Hospital Medicine at NMHS-West Point in January of 2018. I had been working there as a hospitalist for about two years by then. It was not a happy place. The program cultural norm was set by the two physicians with the greatest number of days on schedule, and I was working part time to fill days between them. They projected a defensive attitude which had the effect of limiting admissions and was unwelcoming to the advanced practice nurses asking to admit from their offices. Our relationship with the Emergency Department physicians was strained by condescension. The admissions were screened aggressively, and a lot of time was spent finding reasons to either send patients home or transfer them to higher levels of care.
I understood the attitude of the hospitalists because I had taken it on myself. Even though admissions were limited, it was still an unhappy place because of all the needless conflict. One day I calculated the maximum workload if we took every possible admission. I realized that with the limited number of available beds in this small hospital, the census could not outgrow our staffing. That was the day I decided that we needed a “Culture of Yes”. As director, I told the doctors to just relax and say ‘Yes’ to admits. No need to work so hard to say no and find a complicated justification; just bring them in.
Barry Keel, our hospital administrator was supportive from the beginning. He told me that our first priority was to provide good service to the referring physicians and their providers. He was willing to accept all patients to observation status, if necessary, in order to bring in the less severe cases which could not justify inpatient admission.
Unfortunately, when I wasn’t at the hospital, the hospital medicine physicians lapsed back into prior attitudes. I decided that I needed a motto that would define the attitude I wanted to see, and present it in a permanent way that would declare itself to be the only acceptable future. When I was not present myself, the motto would be there to guide. I chose to commission a challenge coin for our program that would carry the names of the administrator, the chief nursing officer, the regional medical director and myself on its edges. Square in the middle of the coin was our new motto: “Start with Yes!” Barry told me to show everyone where we were headed, and allow them to decide if they wanted to be a part or not.
I handed coins to the doctors and told them to begin every conversation with “Yes, I can take that patient.” If at some point the patient is too complex, then that can be transferred, but in no case were they to hesitate on the low complexity side. I handed the coins to the referring doctors and told them to call me day or night if they didn’t get the answer on the coin. Within a day, the conflict was removed. All the names on the coin stood together in support of our goal. Those doctors who couldn’t relax left on their own, and were replaced by those who knew the rule from their first orientation. The bickering which had robbed us all of happiness took a vacation, and we began to celebrate the rising tide of census. Our hospital reputation began to change in the community, and the hospital gained market share as we began to admit appropriate patients that came from surrounding facilities who had refused to bring them in.
The following year, I brought out a new coin and replaced the regional director with our emergency department director. Dr. James Caffrey and I coordinated a memo of understanding which codified the ‘Start with Yes’ into a stepwise protocol that even included behavioral health patients and surgical illnesses. Together, we began handing out these coins among any staff we could find going above and beyond for our patients and creating a smooth transition from the ED into the hospital. Nobody really knows what it takes to get a coin, but there are smiles all around when it happens!
We’d love to hear from you! To learn more about our “Culture of Yes,” contact us here.