Memorial Sloan Kettering's new cancer surgery center incorporates five years of rethinking a patient's journey through various surgeries. It places an emphasis on reducing patient recovery time and anxiety and overall, creating better outcomes.
Sure, the Josie Robertson Surgery Center, a 16-story edifice on Manhattan's Upper East Side, is a gleaming new jewel at the world-famous private nonprofit Memorial Sloan Kettering Cancer Center. The 179,000-square-foot outpatient surgery center, funded by a $50 million gift from Josephine (Josie) Robertson and her husband Julian opened Jan. 5 and features all the latest technology, the newest thinking in industrial engineering on patient movement and flexible work spaces.
But its best innovation might be invisible.
That's because the clinicians treating cancer patients at the 471-bed hospital didn't just want a fancy new surgery center when they started planning it five years ago.
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Vincent Laudone, MD |
Instead, they took it as a rare opportunity to redesign and standardize care protocols for a variety of cancers such that patients would be able to go home sooner, says Vincent Laudone, MD, Chief of Surgery at the Josie Robertson Surgery Center.
He says in the five years of planning before the opening of the new center, clinicians did plenty of research on why some patients—a little more than half, were able to go home immediately following surgery, while others were staying at least one night.
Indeed, the majority of patients who spent at least one night in the hospital following surgery spent more than one night there. One of the main reasons, was that there was no standard postoperative care protocol based on type of surgery. Instead, post-op instructions were solely left up to the surgeons themselves in the form of their orders.
Standardizing Care
"We studied the variability," Laudone says. "Why is it some can go home the day after while some won't? We identified those things we could improve on, and this has been a refinement process, but the results speak for themselves. Now, for example, prostatectomy patients who were going home after one night five years ago can now be reliably discharged the same day 95% of the time."
In determining how best to standardize care, Laudone says clinicians focused on the following services: breast surgery, plastic surgery, limited urology surgeries, prostate and kidney surgeries, gynecologic oncology, lymph node removals, and head and neck surgery such as thyroid and cancers of the mouth.
Laudone says the process of refining and standardizing care protocols started by simply cataloguing standard orders for each physician to find the variability. That started a focused set of discussions and consensus building around specific procedures aimed at eliminating variation where possible.
"Some of what we did stemmed from a need to standardize the clinical pathways for patients," says Laudone. "Traditionally surgeons have dictated the care given to the patient after surgery and that's where a fair amount of variability can occur."
Physicians' orders include when the patient is to be ambulated, when the patient should be fed, and what should be given for pain management.
"All of those things, when looked at clinically, [include] certain measures which are much more amenable to getting the patient ready for discharge at a certain point in time," says Laudone.
Now surgeons at Memorial Sloan Kettering have a standard order set based on the particular surgical procedure that should be applied to all patients who receive that procedure.
Clinically Driven to Reduce LOS
But physicians' orders weren't the only tool to help cut down on length of stay. Further modifications in care protocols call for including the patient's caregiver as an active participant in the process. Caregivers receive educational information and are encouraged to stay with patients throughout their hospital stay. It helps immeasurably having them present to encourage the patient and for post-operative education and understanding, Laudone says.
"They are critical to helping the patient feel well-prepared to leave the hospital," says Laudone. "This starts well before the postoperative period."
Further standardization has been applied to anesthetic regimes with a focus on what surgeons can do interoperatively for to lessen postoperative pain.
"Suddenly the focus for the anesthesiologist is not just during the operation," Laudone says.
Where once managed care attempted to reduce length of stay as a blunt cost-cutting tool, Laudone says today's attempts to reduce hospital stays are clinically driven.
Evidence shows patients do better when they can recover at home when possible, he says, but as importantly, standardization in general allows for easier comparison of patient outcomes because more variables are eliminated or controlled.
Laudone says part of the information they're able to gather on outcomes is based on reams of data generated from patient and caregiver surveys following such standardized surgical and post-surgical processes.
"Being able to collect outcomes at a very granular level for everything we do is the way to transform cancer surgery worldwide," says Laudone.
"We have installed and are continuing to develop systems to allow us to do that. For example we're in the process of sending out daily symptom scores to patients after they finish surgery to assess exactly what happens to patients when they leave a facility. The assumption is if you don't hear from them, they're probably doing OK. But we don't know that to be true and there's wide variation on what OK means," he explains.
He says the cancer center's biostatistics department can analyze that data and allow surgeons to translate the findings into further refinements in clinical care.
"We intend to fully share in the public sphere what we learn from because that information just isn't out there right now."
Philip Betbeze is the senior leadership editor at HealthLeaders.