Vice President for Finance and Business Operations Krasnoff Quality Management Institute, USA
Senior Vice President and Chief, Clinical Quality Education and Research Krasnoff Quality Management Institute, USA USA
New advances in promoting patient safety, such as requiring physicians to comply with evidence-based medicine, pay-for-performance initiatives supported by the government and transparency for consumer information have been interpreted by some clinicians as an infringement on their autonomy. Healthcare organisations need to develop processes to bridge the physicians’ need for independence and the government’s and public’s pressure to deliver improved care. One of the most successful ways to build this bridge is through involving physicians in creating and implementing a valid and reliable methodology for communication about and accountability for evidence-based care. Clinical pathways, which are algorithms for care based on evidence that detail specific interventions and expected outcomes along a timeline, is such a method and successfully help to resolve the conflict and promote trust between the healthcare organisation and the clinical staff.
Ensuring continuum of care
To improve the delivery of care for patients who required total hip replacement, a partnership was established among a quality management methodologist, a nurse who understands clinical operations and an orthopaedic surgeon. The goal was to enable the surgeon to operate on as many patients as possible while maintaining excellent clinical excellent results. Because this increasingly popular surgery is performed to improve quality of life and pain-free mobility, treatment must be more comprehensive than the surgical procedure itself and must include the entire continuum of care, from the pre-surgical physician office visit to effective postoperative rehabilitation. Technological advances have provided procedures and materials that can result in excellent outcomes for patients. In addition, these surgeries are among the most lucrative for hospitals. Therefore, healthcare organisations that strive to deliver excellent and efficient care, protecting patient safety while managing resources and costs benefit from improving the management of joint replacement surgeries.
Developing a clinical pathway
To maximise efficiency and standardise the effective transfer of information among the care-giving team, the collaborative initiative focussed on mapping the process of care from the physician’s office to the operating room to recovery and rehabilitation (Figure 1). The ‘mapping’ was done in a multidisciplinary group of healthcare providers involved in the care.
A clinical pathway was developed that would permit the entire team to be on the ‘same page’. Expectations were established for daily therapeutic interventions and appropriate outcomes. The orthopaedic surgeon, with a background in engineering, demanded that each member of his team follow the detailed algorithm of care with the goal of standardising the process of care. It should be noted that many physicians avoid using clinical pathways because they perceive them as a nursing tool rather than a detailed method to coordinate and monitor the delivery of care. This surgeon recognised the benefit of following the pathway.
The goal of the innovative programme was to focus attention on appropriate patient management. Appropriate management includes processes that reduce length of stay, unplanned returns to the operating room, unplanned return to the hospital, surgical wound infection rates, avoidance of blood clots and results in high patient satisfaction and level of functioning. The team—from surgeon through physiatrist—is educated and trained in the same way. The patient and family attend multidisciplinary educational sessions where they learn what to expect as regards mobility and pain management and meet with the team. Operating rooms and surgical trays are set up the same way. Pre- and postoperative care is managed in the same way. All patients are placed under a dedicated surgical unit.
Patient-friendly clinical pathways were developed, which inform patients regarding what to expect from the surgery and recovery in lay language (Figure 2). Using these pathways to educate patients about the details of their episode of hospitalisation and post-surgical care, helped them to become active participants in their own healthcare. The pathways also help to reduce patient anxiety by effectively communicating information about pain management, the importance of nutrition and mobility and expectations for recovery.
By standardising every aspect of the delivery of care, outcomes are predictable. Moreover, any variation from expected outcomes is immediately documented on the pathway and therefore quickly recognised and addressed. Noting variation in real time helps the staff focus on patient needs and real-time evaluation becomes integral to the care process. Physicians and nurses have an explicit focus for communicating about the patient’s progress and treatment.
Delivering efficient healthcare
The team is trained to work together. Every member of the team gets to know each patient. Each member of the team assesses the patient before surgery; every member of the team is involved in postoperative care. Anaesthesia manages postoperative pain; physical therapy begins the first day after surgery, the physiatrist manages postoperative rehabilitation exercise and a case manager sets up discharge planning. Importantly, each member knows not only his or her own responsibility but understands the responsibility of the other team members as well (Figure 3).
Compliance with the key interventions of the care pathway for total hip replacement surgery, for instance, is 100 per cent. Therefore, each patient who has undergone a physical therapy evaluation, is moved from the bed to a chair in a specified time frame, has appropriate pain management, receives anticoagulants and antibiotics prior to surgery, and discontinues antibiotics 24 hours after the end of surgery as the pathway specifies. These standardised interventions lead to predictable outcomes. For example, 100 per cent of patients tolerate getting out of bed to a chair and express an understanding of their pain management. Of course, not every outcome can be predicted, but most patients (over 90 per cent) have laboratory values within a therapeutic range and almost all patients (97 per cent) have incisions without redness, swelling or drainage. The ongoing monitoring by the surgeon reinforces appropriate behaviour of the team.
The standardisation and predictability of the delivery of care has an impact on the organisational efficiency and financial integrity of the hospital. Operating rooms are booked and used productively. Materials, staff and supplies are efficiently allocated. Throughput, from the operating room to the post-surgical care to discharge is seamless and predictable. Patients are housed at the appropriate level of care. Because the patient’s initial history and examination is so thorough, those patients who are at risk for complications are targeted early and carefully monitored by the surgeon and appropriate medical consultants. High-risk patients are moved to the ICU postoperatively if necessary, and encouraged to move to a lower level of care as soon as medically allowed. The successful programme has drawn patients to the hospital and the programme has been replicated in other hospitals.
Results of the programme
Results of the programme have been successful. The volume of surgeries has increased, with a ten-fold increase over an eight-year period. During the same period, complications have been reduced. The rate of infection has decreased to almost zero. The rate of blood clots has also decreased. Patient perception of their physical and mental well-being (using SF-36 v2) is assessed at the preoperative visit, six weeks postoperatively and one year postoperatively. (Results are not available yet.)
The pathway improved communication. The patient became a partner, which helped in their recovery; expectations were established and efficiency became an explicit part of the process. Medical responsibility for the ‘total continuum of care’ in combination with evidence-based methodology leads to positive results.
Yosef Dlugacz is an internationally recognised expert in the field of quality management in healthcare. His research focuses on developing models for improved patient safety and clinical outcomes. Dlugacz has educated clinicians and administrators throughout the United States and internationally, with academic appointments at New York University Medical Center, New York Medical College, Hofstra University, Baruch College, CUNY and Beijing University.
Carolyn Sweetapple is responsible for the day-to-day business and financial operations of the institute as well as the development and success of the institute’s consulting. Sweetapple was the Administrative Director of Special Projects at Southside Hospital, of the NS-LIJHS. She is licensed as a certified public accountant and registered professional nurse in New York State. Ms Sweetapple is certified as a Six Sigma Master Black Belt and is currently completing a Master’s of Business Administration in Quality Management.