Having a hip or knee replaced is becoming common today but it is still a painful procedure, so you would think that, once home, a patient would want to steer clear of the scene of the crime, as it were. But patients at the Spine and Joint Surgery Center at Flagstaff Medical Center (FMC), a member of Northern Arizona Healthcare, are happy to come back two or three months later for a reunion with their caregivers and, especially, their fellow patients.
That's because a big part of the program is the camaraderie and relationship building that patients do with other patients and family members, according to program coordinator Sherry Mace. "They do group physical therapy (PT) together twice a day, they have group education pre- and post-op, and they have a catered luncheon with families and staff twice a week."
This collegial approach is one of the reasons for the center's high patient satisfaction levels - likewise, the high physician satisfaction levels. Structured with the patient experience in mind, the program was also specifically tailored to meet the needs of the two orthopedic groups in town.
Giving the Surgeons a Voice
It was, in fact, the orthopedic surgeons who approached the hospital in the first place, says Steve Spravzoff, vice president, supply chain and process improvement. The message was "things are pretty good here but they could be much better. Let's think out of the box." 6 months later, in November 2006, the 11-bed surgery center opened for joint surgery; spine was added in December 2007.
From the get-go, says Spravzoff, "we really focused on giving the surgeons a voice. We allocated some money to pay one of them to serve as a medical director for a year to get all the pieces in place. More importantly, we invested in Sherry's position."
Mace oversees the continuum of care for the patient, which at FMC extends from the time the decision is made to operate until about a year post-op. "We follow the patient all the way through the process, giving them consistent information from the doctors and the hospital," she says. "And my office is up by the physician's lounge, so I'm right there every day to listen to the surgeons' concerns and get things done for them expeditiously."
They were pretty deep into the architectural planning for the unit when FMC's current president, Bill Bradel, came on board and immediately held discussions with Mace and the surgeons. Bradel's leadership was a major factor in the program's success, explains Spravzoff.
"Right off the bat, the decision was made to change the plans and invest more capital into the layout. For example, there wasn't sufficient space for the group therapy model we wanted to use; we needed a very large room for all the group activities."
Standardization a Key
The Spine and JointSurgery Center operates on protocols - patient education protocols, OR protocols, post-op care protocols - that were based on best practices gathered by staff and approved by the surgeons. It's a highly orchestrated affair, says Mace, "down to the hour sometimes.
"On day 1 the patients do this, on Day 2, they do that. At 5 am we get them up, at 9 am they attend the first therapy session, etc.. A consistent message is delivered to the patient and family throughout the experience, starting with standard patient education materials that the surgeons provide."
Scheduling of surgeries and on-time starts were a focus from the first day. In order to get the patients through in groups, joint surgeries were blocked together - initially five days a week, now with all the efficiencies that have been introduced, typically three.
Standardization also occurs in the OR, starting with specialized surgical teams and, increasingly, specialized supplies. For example, Mace says, "we saw nurses opening 50 different things in the OR, so we worked with our supplier to put together packs of supplies for total hip and knee replacements, getting surgeon buy-in on every item.
"This was actually easier than I thought it would be, and the reason is that we had put together a program the surgeons were very happy with. Once it was up and running, and the surgeons began to see the benefit of standardization and the improvement in patient satisfaction, they were more willing to go along with us on other efficiencies and on streamlining processes. The program itself generated the goodwill."
Reinvesting, Breaking Down Silos
One of the things the surgeons saw was the willingness of the hospital to back up its commitment with cash. For one thing, FMC bought additional capital equipment to speed turnover between cases. For another, senior management approved a $53,000 variance to the budget for the purchase of sterile containers (called caskets) to make sterilization of the surgical instruments safer and quicker. (See sidebar.)
In addition, Spravzoff says, they invested in additional training for the surgical nurses, to prepare them for certification by the National Association of Orthopedic Nurses. "This was something the surgeons had requested, so we brought a trainer onsite to upgrade staff skills."
Another factor in the success of the program, says Mace, was bringing together a multidisciplinary team that crosses all departments that come into contact with the patients, including administration, dietary, pharmacy, nursing, physical therapy, and anesthesiology.
"It wasn't easy at first, getting everyone to think about the entire continuum rather than just 'the patient in the lab' and 'the patient in the OR.' Bill Bradel really helped us break down the silo mentality, so that every department was willing to give a little in terms of their standard operating procedure. In the end, we all share the same vision of taking patients through the process and empowering both patients and families to be active participants in their care. We meet every two weeks to continue problem solving and in between we communicate via e-mail, so there's a lot less time spent on crisis management."
Team members have blossomed, says Mace. Where previously they felt stifled and unable to make improvements, now they see that they can effect real change.
The Proof Is in the Pudding
The surgeons also get together to talk about process improvements and set new goals, more often at first, every six months today. And every six months the hospital asks them to rate their satisfaction with seven items:
- Order sets and patient care protocols
- OR scheduling and availability
- Unit/patient rooms
- Patient care staff
- Levels of communication and collaboration with the orthopedic service line coordination and FMC administration
- Reporting of outcome measures
- Public awareness of the spine/joint program
"We also ask for some qualitative data," says Mace; "what we could improve, what concerns they have."
As might be expected, the scores went up considerably after the first half year of the center's operation - from an average 2.72 to 4.35 on a 5-point Likert scale -- and they have stayed up. The number of items rating a 5 increased from a baseline of five to 20.
The cost of supplies went down an average of $2,000 a case, room turnover in OR went down -- from 39 minutes in May 2007 to 27.8 minutes in March 2008 - and a minimum of 80% of surgeries start on time.
A recent meta-analysis of 22 studies of knee and hip joint replacements found that clinical pathways can, in addition to reducing costs, shorten hospital stays (by a mean of -2.61 days) and lead to significantly fewer post-op complications. So it should come as no surprise that both complication and readmission rates at FMC went down, so that patients go home earlier - almost a day earlier than before the program was launched --and safer.
And, of course, patient satisfaction scores are consistently high. But if you really want to get a sense of patients' feelings about the Spine and Joint Center, come on down to the group therapy room for the next reunion…
For more information on Flagstaff Medical Center's Total Joint Program, please contact Sherry Mace at firstname.lastname@example.org.
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Publication Date: Tuesday, September 22, 2009