Bring a Solution

Bring a solution.

As far back as I can remember I've told anyone working for me that I don't like surprises, so if there's trouble on the horizon tell me, we'll work through it together, and I'll have his or her back. But if my first clue that something might be amiss comes only when the excrement hits the fan, then my underlings are on their own while I join the lynch mob out to get them. And, when they do come to me with a problem, they also are to bring a solution.

These count as among with wisest dictums I've ever issued, serving to keep communication open even if some people have had to be scared into it, and keeping the focus on forward movement towards goals. Needing to bring solutions along with problems keeps people from being stuck at the level of the difficulty, forcing them to think about what would make things better. It decreases whining and blame-fixing, and effectively thwarts any tendency to try to delegate "up." But most importantly, it brings action ideas from those most closely associated with the problem, as well as closest to resources to solve it, along with insight into potential impediments to the process. The proffered solutions don't need to be perfect, or even very good. They just have to be the best jumping-off point the person identifying the problem can offer. And we go together from there. I will tell you that people generally solve their own problems, and often all I need to do is help clarify, provide resources, and/or keep obstacles out of their paths. It's always made my job easier and our results phenomenal, credit primarily to others than myself.

In this space I tell stories about problems, oddities, and ironies in healthcare, giving "outsiders" an "inside" look and bringing to light situations that otherwise might go unnoticed. From time to time when I've told of a challenging clinical scenario or a broken system someone will ask how such circumstances are to be fixed. And once again I find myself saying, "Those closest to the problem must bring a solution." We can help them do this, and then work together for positive change, but they can lead us to the starting line and then help us stay on course.

Over the next few weeks I'll suggest some jumping-off points that together can help to address the headaches and heartaches of health and healthcare in new ways. Here's the first one:

Help People Become Helpers

Fred Rogers used to tell of being frightened by things in the news as a child and his mother counseling him to "Look for the helpers" in those situations, because there always would be people working to help. We would do well to realize that there also are many people who want to help, who are willing to help, but who don't know how or don't realize their assistance would be valuable.

"Luke" was a seriously ill heart failure patient who also had diabetes, vascular disease, and a host of other problems. One of my favorite patients, he lived in an apartment in a Cabrini-Green high-rise during some of the worst times in "the projects." It was an ongoing struggle to keep him hydrated without overloading his body with more fluid than his heart could handle, to find the best cocktail of medications to help him without potentially deadly side effects, and to teach him and his family to manage his daily care with their few resources and dangerous living circumstances. Some days I would find him sitting on the side of his bed bloated with fluid, hooked up to oxygen, and struggling to breathe; other days he would be smiling and telling me that he had been able to walk to the bathroom and sit in the living room to be with visitors for awhile the day before.

But the time came when I couldn't manage his plethora of problems by myself with the physician only on the other end of the phone line, and all involved knew Luke needed to see his doctor, undergo some tests, and have his treatment plan adjusted. I made the appointment, arranged for the hospital van to meet Luke in front of his building, and hoped he would be having a good day when the time came.

But then Luke gave me a dose of reality.

"I can't go," he said.

"Why not? You must!" I replied, detailing all the reasons he already knew.

"Dem boys. I can't go out there with dem boys. I'm too weak. I can't take care o' myself. I can't even walk."

Luke looked at me with sheer terror in his eyes, and managing both his emotions and shortness of breath explained in winded bursts that the gangbangers hanging out in and in front of his building never would let him pass, and that indeed they would prey on a helpless old man, robbing him at the very least and perhaps harming, even killing him. Luke was a prisoner in his apartment.

I always had a police escort when I saw Luke, and more than once my escort pointed out cause for concern as we approached the building and instructed me to be attentive and prepared to leave suddenly and quickly. The "rules" were that once inside a home I was in charge of the clinical encounter, but going to and from the apartment or any time a danger arose inside the officer was in charge and I did as he told me. On the basis of the warnings I had received from my escorts along with my own observations, I had no doubt Luke was right about the danger awaiting him. The day before his appointment the most Luke would do was agree to scope out the situation the next morning and decide then if he dared venture downstairs to meet the hospital van.

There had to be a better option, I thought, so I called the police lieutenant who provided my escorts and explained the problem. Did he know anyone in the 18th District, where Cabrini-Green was located, I wondered, who might arrange to have a squad car nearby and visible around the time the van was to arrive for Luke? I still can hear his voice telling me, "I have a very good friend over there!" and that a call would be made. I think I fell asleep that night with my fingers crossed.

The next day dawned, bringing with it mounds of newly fallen snow. Clearing snow in Cabrini-Green wasn't high on anyone's priority list, so Luke would be facing one more hurdle. The likelihood of his making it to the medical center seemed to shrink with each passing hour.

The following day I headed back to Luke's home, ready to hear that he had missed the appointment, and trying to think of what more we could do at home with no direct physician evaluation or input and no further test results. Climbing the stairs to Luke's apartment was particularly onerous that day, probably because of the added weight of my own very heavy heart.

But once there and inside I found a calm, bright-eyed, smiling Luke! "Did you go to the doctor yesterday?" I asked.

"Yes, I did, and here are my papers from him," Luke responded, adding, And I couldn't believe what happened!" He went on to explain.

The previous day not only were there big drifts of snow between Luke and any place the van could access, but also the elevators in his building were out of service, as often was the case. But at the appointed hour for Luke to be downstairs there was a knock on his door, and "dem boys" were there, looking for him. No doubt initially terrified to see his visitors, Luke soon discovered they were on a mission of mercy. "Dem boys" carried Luke, in his wheelchair, down those flights of stairs, out of the building, through the snow, and into the van. And when the van brought Luke home "dem boys" carried him back to his apartment, through still more snow, up the stairs, wheelchair and all. Luke had no idea how they knew about his appointment or his need for help.

I, too, never learned exactly how this came to pass, but don't believe the police requested that level of service. Most probably an officer stopped by for a chat, explained that an old man needed to go to the doctor, and pointed out that it would be best if he didn't encounter any trouble doing so. I would bet that, once learning of the need, "dem boys" took care of the rest themselves.

Over the years I encountered many locals of the ilk of "dem boys." From time to time my police escort needed to intervene to assure our safe passage, and now and then we had an occasional mild shouting match: "You DCFS? [child protective services, never a welcome visitor]" I'd be asked harshly. "You blind?" I'd reply, brandishing my stethoscope, or perhaps, "You new in da 'hood, you don't know Sue-the-nurse?"

But when I needed to call EMS to transport a seriously ill patient from Cabrini to the hospital I asked "dem boys" for help every time. To be clear, EMS was in and out of those buildings all the time and didn't need "help," but being shown the respect implicit in a request for assistance shifted the tenor of the interactions with "dem boys" 180 degrees, and smoothed the way for the EMS crew to follow. Shouting was a standard mode of communication in Cabrini, and no offense was taken at raised voices. So I'd emerge from a stairwell and shout at "dem boys" hanging outside, "Hey, a little help here!," ignoring any initial menacing posturing on their part. "I have an old lady on the 9th floor who's really sick and needs to get to the hospital. The ambulance is on the way. I need to go to somebody else, so I need you to be sure the ambulance crew gets up to her and gets her out quickly and safely. Can you do that, and get them an elevator?"

"Dem boys" came through every time.

Over time as I grew more comfortable and well known in Cabrini I made more visits without the police, and without having to ask had "local security" looking out for me each time.

For a host of reasons, "dem boys" hadn't had much success in school, weren't highly marketable, tended to be rough around the edges socially, and couldn't have made a living on the wages of any unskilled labor positions they might have managed to secure, so a life of finding belonging among their "homies" while dealing drugs, running whatever cons they could, and looking for "opportunities" on the streets became their best apparent option. But no matter how tough, how hardened, how angry they were, when asked for help and told how to help, they delivered.

So the first part of my answer to the question of how to fix problems of health and healthcare is to stop looking so very much to the leaders and experts and politicians for answers and instead shift the focus to helping those in the communities and populations we serve become helpers themselves. This does not mean withdrawing or lessening services or support, but rather marrying those with the strengths and possibilities inherent among our patients and in their communities. They are closest to the problems, closest to local resources (make no mistake about who controlled the elevators in Cabrini-Green!), and may be the most credible "experts" to those at highest risk. Where they are more marginal, as "dem boys" certainly were, the best rather than the worst is most likely to be released in them when they are respected as people who can make things happen in their communities instead of treated as somehow lesser for want of sophistication, formal credentials, and finesse.

Likewise, if similar respect were shown the nurses, physicians, and others engaged every day in clinical practice when problems in healthcare delivery need to be solved I have no doubt tremendous insight and resources would emerge. As I write this I also am preparing a course in business development for home healthcare geared to executives and other leaders in the field, and have realized along the way that every idea I ever had that grew into a successful business-building, revenue-generating program came from my experience in practice, not from my tenure in executive suites or ivy-covered towers. I also have taken a gander at curricula of MHA (Master of Healthcare Administration) programs across the country and have yet to find a single one with a clinical component. Courses in finance, strategy, policy, leadership, the politics of healthcare, systems and structures, healthcare law, etc. abound, but there are none that deal with clinical problem-solving, how physicians and other clinicians are trained to think, how various professionals are educated and what they can or must do, issues in the development and management of medical practices, patients' experience in healthcare, the development and use of clinical science, or anything else pertaining to the substance of the businesses MHA students aspire to manage. Yet often it is these executives who determine policies and programs for patient care. I am reminded of a time when I was brand new and very green in my first Director position and summoned to tour new surgical suites under construction. Although I never worked in the OR a day in my life, since I was the Director I was asked to determine where equipment should be mounted for the surgical team to use during operations. Lord have mercy!

Just as "dem boys" needed to know their help was needed and how to deliver it, so avenues need to be opened through which the expertise and insight of those closest to healthcare problems, i.e., patients, communities, and practicing clinicians, can flow. Executives and politicians can work the system to make things happen, but those closest to the problems best know what the essence of those things needs to be.

I chose a career in nursing many, many years ago because my youthful self wanted to help people. What I have learned over the decades that followed is how very pervasive that desire is, with different people having different gifts for helping in different ways. Instead of seeing only "patients" or "personnel" or "problems," we would do well to see potential helpers who, with our respectful collaboration, may in the face of challenges prove best suited to

Bring a Solution.