I see letters like this from patients intermittently, not as articulately put and informed by clinical savvy as in this instance, but with physician, nursing, ancillary services, environment, and patient service problems. It would be handled in our hospital by our customer service people, with the clinical quality issues delegated to the medical director, and, certainly in this instance, to nursing leadership. I would approach these patient issues by trying to separate problem type by responsible disciplines, along the lines that were used in the narrative.

The physician issues relate to infection control standards, specifically hand washing, the process for obtaining informed consent, and the approach to the patient at the bedside, an aspect of professionalism. All but the hand washing observations mention the surgery and anesthesia house staff. We know from multiple lines of evidence that providers of all types do not wash their hands adequately and do not respond well to interventions aimed at improving compliance. For several years, hospitals have been required to make alcohol-based hand washing gel available in clinical units, so hands can be cleaned without water. We have put thousands of dispensers throughout our medical center. I believe that there is some, but not conclusive, evidence that the dispensers improve compliance with hand washing. Nevertheless, it is unlikely that alcohol-based hand cleaning accounts for the circumstantial observations about lack of soap-and-water hand washing. I would check with Infection Control about recent initiatives to improve hand washing compliance, look at availability of soap and alcohol-based dispensers on the units, and do in-services with services or units where compliance was poor. Certainly, if there were units or services with outlier nosocomial infection rates, I would concentrate on them.

The patient and spouse observations mandate a review of house staff training on understanding informed consent and professionalism through the chair and program director. Professionalism, broadly defined, is 1 of the 6 competencies defined by the ACGME for all training programs. The approach to patients at the bedside or in the clinic is something best taught in person by experienced clinicians, usually on teaching rounds. The chief medical officer and I do these rounds with house staff every year at our hospital and focus on the approach to patients-showing respect, listening, and answering questions. Examining patients with the whole team is part of that, but the biggest piece is how to establish a connection, not demonstrating the enlarged spleen. Medicine residents do a series of attending-observed history and physicals during their training; the professional approach to patients is also part of the medical school curriculum.

At my hospital, there is a formal policy that goes through the rationale and process for informed consent. Residents can obtain informed consent for an attending physician, but the attending is ultimately responsible. The patient narrative, as described, completely subverts informed consent. I would want the program director to counsel this resident and use a teaching conference to go over obtaining consent with the entire house staff.

The patient and his spouse identify multiple nursing practice problems-medication administration errors, discontinuation of treatment/monitors, and also professionalism issues. Improving nursing practice is the major focus for our chief nursing officer. Electronic medications administration with bar codes on patients to ensure proper identification gets to the missed and incorrectly timed doses, and shows promise for creating true accountability for medications administration. Again here, in the short run, I would concentrate on the specific unit where problems were identified and make sure that all shifts were involved. How can we improve medications administration in the paper world? What is the supervision like at night?

Many of the complaints are about the physical facility. I recently visited another local hospital and was surprised at the poor condition of the patient rooms: dirty walls and windows; peeling paint; poorly lit, 4-bedded rooms, The quality of the physical environment including food is a major determinant of patient satisfaction. What I witnessed as a visitor at another institution was unacceptable; it needs significant corrective action from the facility management, using patient satisfaction survey results as a follow-up. At our hospital, we recently recruited additional "Service Associates," who clean the rooms, turn over the beds, get supplies etc, in response to patient feedback about the facility.

So much of what the patient and his spouse describe relates to poor customer service. We and others have undertaken Service Excellence initiatives to improve our service, centered on the patient. Our senior leadership drives home the importance of excellent customer service here, and despite the culture change it represents, is an absolute requirement for patients and all healthcare providers as we move ahead. Hospitals started out as almshouses and can still treat people as if they have no choices. That the outcome of care in this case was good but a poor experience for the patient and his spouse is no longer good enough. That is about culture; leadership focus, including incentives; and resources.