Etiquette Based Medicine Article 15 - 17 XI the Patient Comes First 19 XII Organizing Committee 20

1 TABLE OFC ONTENTS

SN TITLE PAGE I Introduction 3 II Definition of Etiquette 4 III Functions of Etiquette 5 IV Etiquette in Islam 6 V Etiquette in Medicine 7 VI Etiquette at KFMC 8 Etiquette- Based Medicine Project at VII 9 - 11 KFMC VIII Patient Satisfaction Survey Form 12 - 13 IX Quote 14 X Etiquette Based Medicine Article 15 - 17 XI The Patient Comes First 19 XII Organizing Committee 20

2 Introduction:

The medical profession receives not a little ridicule for observing rules of etiquette, but their observance is a protection against not only embarrassment and confusion, but misapprehensions and dissensions, injurious alike to physicians and patients.

Medical ethics and Etiquette, Austin Flint Sr., 1883

3 Definition of Etiquette

Etiquette is derived from the Greek Word for graceful,, elegant or manifesting good form or bearing

4 Functions ofE tiquette

When it provides for predictability in social relations, such as meeting strangers.

In its codification of behavior during events such as ward rounds

When it determines the tacit rules governing professional interaction

5 Etiquette in Islam

Prophet Mohammed (PBUH) was a living example of the finest and the most beautiful manners.

He stressed politeness and consideration as an expression of the Muslim faith, which means to treat other human beings as they like to be treated and as one likes to be treated oneself.

6 Etiquette in Medicine

There is a long tradition in medicine to discuss physician conduct as a moral virtue necessary for the proper care of patients

Historic Greek literature stresses that The Chinese medical doctrine of Nei Jing was politeness, courtesy, manners, appearance, and formed from the cultural philosophies of respectfulness are vital attributes of a Confucius and Tao. These philosophers stressed physician. gentleness, frugality, and humility.

. Hippocratic texts asserted the importance of appearance and humility for physicians. The great Muslim physicians of the 10th . Galen wrote about the century A.D. followed a similar tradition. Abad characteristics of a good physician Al-Tib philosophized on the behavior of and gave advice on how patients physicians, citing Hippocrates, Galen, and should select their physician. Aristotle.

7 Etiquette at KFMC

Recent patient surveys requires us to focus on measures to improve the etiquette of our healthcare staff.

Our inspiration to implement an etiquette based approach to patient care comes from an article published in New England Journal of Medicine in May 2008 (Etiquette Based Medicine, Michael Kahn, M.D., Volume 358, Number 19)

The article stresses that medical education and post graduate training should place more emphasis on this aspect of doctor-patient relationship.

The Author suggests developing a checklist of physician etiquette for the clinical encounter to improve patient satisfaction.

Such a checklist has the advantages of being clear, efficient to teach and evaluate, and easy for trainees to practice.

8 Etiquette Based MedicineProj ect at KFMC

We are initiating a quality improvement project about etiquette- based approach to patient care at KFMC.

Our Slogan Is“ I C A RE “

I - Introduce yourself to your patient

C - Communicate effectively and frequently so your patient knows you care

A - Address the needs of the patient in a prompt and caring manner

R - Respect, show dignity and compassion to your patient.

E - Explain your role on the team

9 Etiquette- BasedMedicine Project atKFMC

 Do a polite introduction or  If you know the patient , offer a sincere welcome and greeting I  Address the patient by their name and make eye contact

 An important aspect of effectively communication is good manners and proper etiquette.  Talking is the easy part; listening and making sure that your patients and colleagues are understanding is the difficult part. C  Remember what is said is only a part of communication, the non-verbal expressions are a critical part of communication.  Look at the person, show real interest and interact in an effective way.

 Care for the patients most immediate needs like pain relief, bathroom use, etc. in a prompt manner. A  Apologize to the patient if there is a delay and explain why?

 Obtaining patient’s respect and trust are pre- requisite to obtaining a meaningful history and convincing the patient to follow a therapeutic plan.  Building rapport is a complex process of sharing an understanding with R the patient, bonding and feeling empathy. It is difficult t accomplish and easy to lose. It can be achieved with charming manners or lost with a slovenly appearance or an unfeeling remark.

 As we are a tertiary care facility, dealing with complex cases, requiring care from a multidisciplinary team. It is important for team members E to explain their involvement in the care of the patient.

10 Physicians should be caring and emphatic,

 Take the time to explain the findings of the medical evaluation.  Describe the disease process in layman terms  Do not rush when answering questions  Show sensitivity and compassion when relaying bad news  Display a realistic but positive attitude towards treatment plans.  Explain the test procedures and medication being recommended

11 To evaluate our quality improvement initiator there will be a patient satisfaction survey from October 2009 to March 2010.

12 13 Quote:

“Anyone to whom God has favored and given knowledge of how to heal the sick, yet he is so hard hearted as to not advise them and commiserate with them, than he is indeed far away from all good and far away from medicine” Hippocrates

14 Review Article

Etiquette-Based Medicine Michael W. Kahn, M.D.

Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that "he just stared at his computer screen," "she never smiles," or "I had no idea who I was talking to." During my own recent hospitalization, I found the Old World manners of my European-born surgeon — and my reaction to them — revealing in this regard. Whatever he might actually have been feeling, his behavior — dress, manners, body language, eye contact — was impeccable. I wasn't left thinking, "What compassion." Instead, I found myself thinking, "What a professional," and even (unexpectedly), "What a gentleman." The impression he made was remarkably calming, and it helped to confirm my suspicion that patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive.

I believe that medical education and postgraduate training should place more emphasis on this aspect of the doctor–patient relationship — what I would call "etiquette-based medicine." There have been many attempts to foster empathy, curiosity, and compassion in clinicians, but none that I know of to systematically teach good manners. The very notion of good manners may seem quaint or anachronistic, but it is at the heart of the mission of other service-related professions. The goals of a doctor differ in obviously important ways from those of a Nordstrom's employee, but why shouldn't the clinical encounter similarly emphasize the provision of customer satisfaction through explicit actions? A doctor who has trouble feeling compassion for oreven recognizing a patient's suffering can nevertheless behave in certain specified ways that will result in the patient's feeling well treated. How could we implement an etiquette-basedapproach to patient care?

The success achieved by Peter Pronovost and colleagues in solving a different kind of complex problem — reducing the likelihood of central-line infections in critical care patients1 — provides a thought- provoking suggestion. Instead of taking an elaborate, "sophisticated" approach — say, tackling infections by developing more advanced antibiotics or clarifying the genetic basis for drug resistance — Pronovost et al. introduced a checklist to enforce the use of hand washing, thorough draping of the patient, and other tasks that could be easily performed. The results of this simple intervention were swift and dramatically effective. I would propose a similar approach to tackling the problem of patient satisfaction: that we develop checklists of physician etiquette for the clinical encounter. Here, forinstance, is a possible checklist for the first meeting with a hospitalized patient:

15 1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in thehospital.

Such a checklist has the advantages of being clear, efficient to teach and evaluate, and easy for trainees to practice. It does not address the way the doctor feels, only how he or she behaves; it provides guidance for trainees whose bedside skills need the most improvement. The list can be modified to address a variety of clinical situations: explaining an ongoing workup, delivering bad news, preparing for discharge, and so forth.

Training for an etiquette-based approach to patient care would complement, rather than replace, efforts to train physicians to be more humane. Pedagogically, an argument could be made for etiquette-based medicine to take priority over compassion-basedmedicine. The finer points of patient care should be built on a base of good manners. Beginning pianists don't take courses in musicianship and artistic sensibility; they learn how to have proper posture at the piano and how to play scales and are expected to develop those higher-level skills through alifetime of study and practice. I may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering. I think I can, however, train them to shake a patient's hand, sit down during a conversation, and pay attention. Such behavior provides the necessary — if not always sufficient — foundation for the patient to have a satisfying experience.

Furthermore, it's simpler to change behavior than attitudes. Although reading medically relevant literary classics and writing reflection pieces (as is now done in many medical schools) may make some students more mature and humane, I wonder whether these exercises are most helpful for those students who arrive at medical school already in possession of those qualities to some degree. For many students, I suspect that these exercises may have a more limited effect, if only because they are too brief to allow the student to comprehend, practice, and master the intended values. It isn't easy to modify a person's character or outlook in a classroom; besides, clinical training is more effective when it resembles apprenticeship rather than graduate school. Trainees are likely to learn more from watching colleaguesact with compassion than from hearing them discuss it.

Etiquette-based medicine would prioritize behavior over feeling. It would stress practice and mastery over character development. It would put professionalism and patient satisfaction at thecenter of the clinical encounter and bring back some of the elements of ritual that have always been an important

16 part of the healing professions. We should continue our efforts to develop compassionate physicians, but let's not overlook the possibly more immediate benefits of emphasizing good behavior.

No potential conflict of interest relevant to this article was reported.

Source Information

Dr. Kahn is a psychiatrist and an assistant professor of psychiatry at Harvard Medical School in Boston.

References

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-2732.[Erratum, N Engl J Med 2007;356:2660.]

17 Internal Medicine Nursing Department

“The Patient Comes First”

Nursing, as part of the multidisciplinary health care provider team, will utilize clinical skills, critical thinking and the implementation of the nursing process to provide professional holistic quality and safe patient care to patients admitted to the Internal Medicine Wards.

Our three C’s of Medical Nursing are Courtesy, Consideration and Concern.

Nurses commence utilization of the three C’s as soon as patients are admitted to the wards. The nurse assigned will welcome the patient & family to the ward, escort the patient to her/ his room and ensure that the patient is comfortable. Once the patient has settled into the bed, the room orientation will begin. This will include orientation to the bathroom facilities, the nurse call bell system, bed controls, telephone, television, pantry use, visiting hours, meal times, and watcher permission & guideline policy.

When the patient is settled in his/ her ward environment, the assigned nurse will begin the patient admission assessment and development of the nursing care plan.

The patient’s health status and risk indicators are assessed to identify patient problems, both current & potential. When all information has been collected, the nurse will document the findings which will form the basis for the nursing care plan.

Planning of care includes:

1. Problem identification 2. Goal identification 3. Formulation of nursing care interventions 4. Review & updating of the plan in relation to the patient’s response. 5. Preventative actions as per risk factors identified 6. Patient/ family discharge education 7. Discharge process/ outcomes Florence Nightingale 8. Home care equipment/ supplies.

Provision & implementation of care incorporates evidence based nursing practice taking into consideration the patient’s rights, cultural values, needs and responses. 18 Monitoring & evaluation of care is performed to assess the patient’s current health status. The nurse will monitor the patient on a daily basis to ensure that data are collected, documented and reviewed to identify current status, trends and changes. Findings are evaluated to determine the effectiveness of care provided. The plan is modified based on the evaluation and patient care needs.

Prior to discharge, the patient and family will receive information for their transition towards self care or home care. Patient and family education are a part of the ongoing care process. The multidisciplinary health care provider team will be available for information about resource availability, equipment, supplies, transportation, and rehabilitation.

In short nursing encompasses autonomous and collaborative care of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying patients.

Nurses should focus on courtesy, consideration and concern at each patient encounter .There will be a patient satisfaction survey to evaluate this quality improvement initiative from October 2009 to March 2010.

19 Organizing Committee

1. Dr. Khalid A. Qushmaq - Chairman, Internal Medicine 2. Dr. Shazia Mukaddam - Consultant Internist 3. Dr. Tariq Sulaiman - Resident, Internal Medicine 4. Ms. Linda Kennedy - Director of Nursing, Main Hospital 5. Ms. Helen Kirwan - Head Nurse, Female Medical Ward 6. Ms. Lungelwa Magqashela - Head Nurse, Male Medical Ward 7. Ms. Huda A. Al Husaini - Ward Clerk, Male Medical Ward 8. Ms. Maisaa A. Al Ghareeb - Ward Clerk, Female Medical Ward