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Are Patients First or Care Givers First? It Depends…
Are Patients First or Care Givers First? It Depends…

For the past decade at least, most health care organizations have had a Patients First initiative.  While it seems intuitively obvious that the customer of the health care organization should come first, this initiative, when pursued without a deep understanding of the care process, can result in unintended negative consequences that lead to burnout for physicians and nurses.

The most serious consequence is a negative reaction from care givers (the doctors, nurses, technicians, and assistants) who are already stressed out, feeling over-scheduled, overburdened, and underappreciated.  The thought of being asked to do more, particularly by an administrator who is perceived as not understanding the realities of patient care, can leave the care givers feeling as though no one cares about them.  This is a recipe for burnout.

And if this is the way a Patients First program is implemented, the care givers are right.

Are Patients First, or Second?

One result of this concern is a movement labeled, Patients Come Second in order to ensure that care givers’ needs are being properly addressed up front.  I have deep concerns about this as a tag line.

In my five years as CEO at Sutter Gould Medical Foundation, I started most meetings by asking, “Who is the most important person at Gould?”  It was gratifying to hear almost everyone respond that the patient is the most important.  After all, without patients, we would have no reason to come to work, no opportunity to fulfill our professional or personal goals, and no revenue coming in to pay our salaries.  Clearly the patients are the most important.

Then I would ask, “What is the most important thing that we do?”  Everyone would agree that taking care of our patients was most important.  I would then explain that the most important thing that happens in our work is the healing interaction that takes place between a care giver and a patient.  And care givers included anyone who directly interacted with a patient, whether on the phone, at a check in desk, in the exam/hospital/procedure room, or anywhere else that interactions take place.  Every interaction gave a care giver the opportunity to reduce pain and suffering, relieve anxiety, provide solace, and/or educate and promote better health. In other words, an opportunity to put Patients First.

While I have had tens of thousands of healing interactions with patients over the decades of my career as a family physician, when I was CEO I no longer directly cared for patients.  My role had changed. It was my job to support the care givers to ensure that they had everything they needed to provide the best possible healing interactions, with every patient every time.

So while the patient is the most important person, the care givers need the most support from management.  This is a crucial distinction.  The “Who comes first?” question has to be answered differently depending on the role of the person answering the question.

For care givers, the patient must come first, for the reasons I’ve provided above.  Patients are reason for our work.  Care givers care for patients.

For administrators, the care giver must come first.  Patients are still the reason for our work, but as administrators we don’t take care of the patients directly ourselves.  We provide care indirectly, through our front line care givers.  Our job is to take care of our caregivers, with as much commitment, concern, and compassion as our care givers have for their patients.  It is our responsibility.

People often ask me if I miss taking care of patients.  I do.  And I have found that I experience a lot of what I miss by truly caring for my front line providers, and for everyone who supports them and reports up to me.

The Quadruple Aim

There is a movement developing that is adding to the Triple Aim (great care, great service, and equity) a goal of a great workplace experience, and coming to be known as the “Triple Aim + 1” or the “Quadruple Aim.”  Whatever we end up calling it, it is right on. Care givers strive to holistically address patients’ physical, psychological, and social needs to promote overall wellness.  Administrators should do the same for care givers. This is key to preventing physician burnout.

Lean management done right creates an organizational culture that supports care givers. 

That’s what “Respect for People” is all about.

So let’s ask the key question again.  “Who comes first?”  For care givers, it’s their patients.  For administrators, it’s their front line care givers.

More to come on all this in future blogs, as the movement to promote care giver well-being is growing.  I’ll introduce you to some of the key players.

Who comes first where you work?  Is your Patients First initiative resonating with physicians and nurses, or is it antagonizing them?

I welcome you to share a comment with your thoughts.

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