"I know preoperatively who's not going to be able to go home right away. An octogenarian that lives in a six-floor walk-up in Manhattan . . . is not going home, she's going to rehab. We try to identify those people early on in preop. It makes the process smoother, rather than on postop day three or four trying to get in touch with a social worker," says Padgett.
Service Line Success Key No. 2: Cut length of stay
Hospital for Special Surgery instituted clinical pathways in the 1990s primarily to reduce patient length of stay. At that time, the average patient would spend a week or more in the hospital after a major joint operation, but by 2008, the average length of stay was roughly four days. That hasn't all been from process improvements and variability reduction, however. Clinical improvements and advancements in the understanding of pain management have shortened the recovery time for a joint replacement, as well.
"The world is changing. Part of it is doctors' understanding of what the body can physiologically tolerate. In many respects, certainly in orthopedics, enhanced mobility is safer for patients. It's better to be up and moving," says Padgett. That means that medicating pain can actually have an adverse effect if it leaves a patient immobile and bed-ridden. The anesthesia department's pain management approach can make a big difference in a patient's ultimate recovery time.
The other area that has cut down on length of stay for many joint patients has been the complexity of the procedures. Like most other service lines, joint replacement has been bitten by the minimally invasive bug.
In fact, the industry isn't far off—maybe a few years, maybe a few months—from outpatient joint replacement becoming a feasible option for a growing segment of healthy patients. Hospitals that can pull it off will see even faster throughput, and greater potential volume, as patients get in and out in a day or so.
Service Line Success Key No. 3: Target physician customers
While a more efficient joint replacement process tends to leave patients more satisfied, it has the dual benefit of keeping physicians happy with the program. Hospital CEOs rated orthopedic surgeons as the physicians most difficult to manage—with nearly half saying they were either slightly or very difficult—according to the HealthLeaders Media Industry Survey 2009.
Particularly when the physicians are in private practice, physician relations is an important component of a joint replacement service line, and the doctors are often thought of as a second set of customers, says Greg Partamian, chief operating officer for Crittenton Hospital Medical Center, a 250-staffed-bed acute care facility in Rochester, MI.
"We try to create an environment that is customer-friendly to our physicians," he says.
At times, the needs of the two sets of customers overlap. Developing pathways often leaves patients happy because it lowers surgery-to-recovery time, but it also helps meet one of orthopedic surgeons' primary needs: surgical volume.
But volume alone doesn't ease all tensions between administrators and physicians. Communication is also important.
Partamian meets with the chief of orthopedics once a month, and the entire department meets quarterly to air grievances and discuss cross-departmental concerns. The point is to convey a single message—that physicians are valued and supported at the hospital.
That message can be sent with actions as well as words. A few years ago, the chief of perioperative services at Crittenton established dedicated operating rooms for orthopedics where staff is specifically trained to meet the unique needs of an orthopedic surgeon.
That level of attention, and the dedicated resources to make orthopedic surgeons' jobs easier, went a long way toward winning over surgeons.