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How Patient-centered Surgery Boosts Hospitals' Bottom Line

 |  By ebakhtiari@healthleadersmedia.com  
   September 09, 2010

Patient-centered surgery 

Surgical services are a leading source of revenue for many hospitals. The OR increasingly acts as a financial engine for the organization, and more complex surgeries and greater volume typically add up to a better bottom line.

But from the patient’s perspective, surgery is scary and unknown. Whereas hospitals and physicians increasingly depend on surgical volume, patients want to be cut open as infrequently as possible—ideally, never. However, these disparate views on surgical services converge in the growing movement to make healthcare more patient-centered. As one of the most frightening and expensive stages in the care continuum, surgery has the most to gain from a more patient-centric approach. And although there are many idealistic reasons for emphasizing the patient’s needs, doing so is also perhaps one of the best ways to achieve the volume and efficiencies needed for financial success.

“A patient that has a nice experience is going to come back again. They might be one of my best marketers or referrers out there,” says Holly Lorenz, vice president of patient care services and CNO at University of Pittsburgh Medical Center (UPMC) Presbyterian, a 765-staffed-bed trauma center.

So what is the difference between a surgical process that is patient-centered and one that isn’t? The Institute of Medicine defines patient-centered care as establishing a partnership between providers and patients and giving patients the support they need to make decisions and participate in their care.

That’s easier said than done, though. No hospital is as patient-centered as it can be, says Lorenz. There are many reasons patient-centered care remains a struggle: The engaged, highly informed patient of the future is still a rarity; healthcare consumerism has stalled because the system lacks the transparency that makes markets work; and the reimbursement system discourages care coordination and integration.

Despite these obstacles, many providers are making strides in involving patients and families in the surgical care cycle. Those that are successful often enjoy better outcomes, lower costs, and higher overall patient satisfaction. “It’s so much more appropriate and easier to provide a good patient experience than to do service recovery on a bad experience,” says Lorenz.

Link the care continuum

Making surgery more patient-centered begins well before surgery. Each point of the care continuum should involve the patient in his or her healthcare decision-making. Often, the most important step is determining whether surgery is the best treatment approach, says Frank G. Opelka, MD, FACS, vice chancellor for clinical affairs at the Louisiana State University (LSU) Health Sciences Center, which coordinates care for the seven-hospital LSU Health System.

“Sometimes the best surgical care is making the decision when not to operate. Thinking about it in that sense, we’re no longer focused on surgery; we’re focused on the patient,” Opelka says. In a truly patient-centered system, the patient would have a clear view of the entire pathway—from diagnosis to surgery to recovery.

UPMC Presbyterian has developed what it calls “patient flight plans” to map out the surgical process, much like airline flight plans give pilots an idea of what to expect from takeoff to landing. “They know here’s what to expect, here’s how long you’ll be in the hospital, here’s the physical therapy you might need,” says Lorenz.  

The flight plan also gives providers a better idea of whether a patient is on track to be discharged on time. The hospital color-codes patient doorways red, yellow, or green to indicate throughout the process whether patients are on track for a timely discharge. The preplanning and scripting has enabled patients to leave the hospital sooner, cutting two days off the average length of stay, says Lorenz. 

The flight plans depend on members of a diverse team—outpatient physicians, surgeons, nurses, and office staff—all being on the same page. That type of coordination can be tricky from a leadership perspective, but Lorenz says there was virtually no resistance to the program because providers were aware of the benefits. “If the surgeons realize that their patients will always get a bed in the ortho unit because there is always a bed available, that’s a win from their standpoint,” she says. 

 

Involve families 

Care is not really patient-centered if it doesn’t involve the patient’s family, says Anthony M. DiGioia, MD, an orthopedic surgeon at Magee-Womens Hospital of UPMC, a 278-bed teaching hospital in Pittsburgh. DiGioia pioneered a patient- and family-centered care methodology through a total joint replacement program.

Family members often shape the care experience more than patients, who aren’t always active participants after undergoing sedation or when recovering from surgery. “If you don’t include [family], not only are you not tapping into a tremendous resource, but you also may lose an opportunity to show that you’re providing exceptional care,” says DiGioia.

Family involvement begins with the initial office visit. Family members are included in the education process and have the option of viewing x-rays and other health information with the patient, says DiGioia. Before surgery, patients take part in an education session that prepares them for their care experience, including the rehabilitation exercises. Family members—or close friends, in some cases—are encouraged to attend as “coaches.” This helps improves compliance after the surgery, he says.

DiGioia also solicits feedback from family members after surgery. “Families are really concerned about the transitions of care—meaning going from outpatient to inpatient, but particularly coming home. They’ll be the care providers when the patient comes home. Everything we do by including the family and starting the education process weeks ahead of time sets the stage to reduce anxiety,” he says.

Family-centered initiatives must be sensitive to patients’ individual circumstances. Some patients may not have close family available; others may not want family participation. But it’s important to offer family education as an option because it helps not only with recovery, but also with the quality of the care experience.

Listen to patients 

The best way to find out how to make surgery more patient-centered is to ask the patients. What do they find most frustrating in the current care process? What do they like about it? Ask them, and they’ll tell you.

Surveys are one of the most common tools for collecting and quantifying patient feedback, but many hospitals aren’t getting quality information because the go-to survey for patient feedback, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, wasn’t really designed for surgery, says Opelka. That could change soon, however. The American College of Surgeons has been working with the Agency for Healthcare Research and Quality to tailor a new CAHPS survey specific to surgical services. New questions will dig into issues unique to OR procedures and give surgeons a better idea of what patients think after their surgery.

Keep in mind, too, that soliciting feedback can involve much more than surveys. DiGioia encourages care teams rolling out new patient-centered initiatives to shadow patients and families throughout their care, then redesign the care experience completely from the patient’s perspective. “When you force everyone to look through the patient’s eyes and the family’s eyes, you begin to knock down those silos, which are extremely important to get rid of if you’re going to deliver exceptional care,” he says.

Improve OR efficiency

Although a lot of the changes to make surgery more patient-centered happen before and after the actual surgery, the quality and speed of the operation is one of the most important elements of patient satisfaction. 

OR teams have been working for years to improve the efficiency and safety of hospital ORs, and many of the best improvements have come from other industries, says Opelka. The surgical checklist, similar to what pilots use before takeoff, is perhaps the most well-known example. But many surgical teams have also adopted simulation team training from the airline industry to prepare for emergency situations.

After-action reports adopted from other industries and other methods of analyzing performance are also helping OR teams learn from every operation to improve the overall process and, most importantly, the performance.

To discover ways to improve OR work flow, DiGioia and his team mounted several video cameras in the OR to record a series of hip and knee operations. This enabled surgeons and nurses to perform their normal routines while timing each stage of the operation and identifying areas for improvement.

For example, simple steps such as introducing the anesthesiologist in the room could take anywhere from two to nine minutes. The care team learned that they could standardize some of those steps and cut down overall turnaround time.

“OR efficiency is not only good for the hospital and the OR team, but the patient as well,” says DiGioia. “But remember, it’s good to look at OR efficiency, but the patient’s care experience involves a lot more than just the surgery.”

Surgical CAHPS 

The new surgical Consumer Assessment of Healthcare Providers and Systems (CAHPS) has questions not found on the original CAHPS survey, including the following:

  • During your office visits before your surgery, did this surgeon tell you there was more than one way to treat your condition?
  • After you arrived at the hospital or surgical facility, did this surgeon visit you before your surgery?
  • Before you left the hospital or surgical facility, did this surgeon discuss the outcome of your surgery with you?
  • After you arrived at the hospital or surgical facility, did this anesthesiologist visit you before your surgery?
  • During your office visits before your surgery, did this surgeon or a health provider use pictures, drawings, models, or videos to help explain things to you?
  • Did this surgeon make sure you were physically comfortable or had enough pain relief after you left the facility where you had your surgery?

Elyas Bakhtiari is a freelance editor for HealthLeaders Media.

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