Let me begin with the story of the woodcutter… The young woodcutter was working extremely hard when I came upon him in the woods.
“How are you doing?” I asked
“Not so well,” he answered. “I’ve only cut down 3 trees and its almost 2 o’clock. I’ve got to cut down 10 by 5 o’clock.”
It was obvious from the sound of his saw that it was dull.
“Let me see your saw - look, it’s dull. Why don’t you let me sharpen it for you? It will only take a half hour.”
“Don’t have that much time,” he said. “Got to cut down 10 trees by 5 o’clock.
Could this be you?
Healthcare has its problems and we are all feeling the heat. We’ve got a lot of trees to cut. Our costs continue to rise while reimbursement stagnates or falls. Patient access and desire for information has never been greater. Direct to consumer advertising is on the increase. Our expertise and quality is being questioned. Differentiating yourself is a critical challenge as competition continues to intensify with patients shopping for the right surgeon and hospital. Profitability and patient satisfaction are difficult to sustain. Our delivery system is inefficient. While professionalism of physicians, nurses and ancillary staff is one of our great strengths, it is also one of our greatest weaknesses. Too often we work autonomously and devise independent plans of care for patients. While on the surface this may seem acceptable it has created a delivery system of complexity, confusion, inconsistency, costliness, and even errors. I call this “The 4 C’s Delivery System.”
Many of us have confronted these problems like the young woodcutter. Without the tools and pressed for time we work harder and longer. Unhappy with the results of this effort we risk burning out.
There is another choice.
Work Smarter
Its time to sharpen the saw. We must understand the wants and needs of patients and provide them in a better, more efficient and less costly way. This is no time to be just a surgeon or hospital. We are called to be the leaders of change. The paradigm has shifted. We need to provide value and we need to be effective. Value is more than quality care; it is the sum of measurable quality and superior service divided by cost. Effectiveness is the sum of measurable quality plus superior service divided by our time. I know from personal experience that through the use of focused, specialized clinical programs, quality care and superior service can be achieved at lower cost.
It Has Been Done
Despite the barriers, change can occur, as exemplified by Anne Arundel Medical Center (AAMC), a 250-bed hospital in Annapolis, MD. In 1995, eight surgeons at AAMC performed slightly over 200 total joint replacements (TJR). TJR was not profitable, inpatient care was inconsistent, patient satisfaction was merely “acceptable” and patients were migrating to hospitals in Baltimore and Washington, DC.
We realized that the model of health care delivery had to shift from a linear model to a circular one. Patients could not be shuttled from physician to hospital to anesthesia to physical therapy to rehabilitation to home care, etc without a consistent plan of care among all caregivers. To initiate change, a leadership team (myself, a nurse, and an administrator) was established. Other professionals were brought into the process: orthopedic surgeons, pharmacy, anesthesia, finance and public relations. The goal was to establish a “Center of Superior Performance”.
We set out with a lofty goal: to have patients rave about their experience at Anne Arundel. We felt that the resulting word of mouth would generate new volume. New volume would create a need for greater efficiency, which, if properly implemented, would improve profitability. In order to achieve a simultaneous improvement in satisfaction, volume, and profitability, we would need full commitment from all affected parties, and we would need to measure our results and modify our approach as needed.
We felt it was possible to improve satisfaction, volume, and profitability simultaneously. But we surprised even ourselves.
Our results have been spectacular. Patient satisfaction is exceptional. 80% of patients return home without home health. Hospital costs and length of stay are the lowest in the region. TJR is the most profitable service line in our hospital. The volume is now over 1000 cases per year, with growth rates of 21%, per year. AAMC is now one of the top three providers of TJR surgery in the state of Maryland.
Before you start sharpening your saw, you need to be ready to change the way you relate to your community, your surgeons, your hospital, your staff, and your patients.
Work Together
You must create a shared vision and a new delivery system in partnership together: surgeons, the hospital, nurses and patients. Instead of turning surgeons into competitors, hospitals need to create a service in which they will take immense pride. You must develop a comprehensive, standardized delivery system that eliminates wasted motion, duplicated effort and internal conflict. This new delivery system I call “The 4 S’s”-
- Simplify processes
- Standardize patient interaction and care paths
- Savings will result from improving value AND efficiency
- Satisfaction of patients and staff will improve dramatically
The patient experience needs to be outstanding. Unmatched patient satisfaction will generate powerful word of mouth marketing. Tapping into the experiences of our customers (the patients and our families) is essential to provide us with the fuel for ongoing improvement. Marketing your services in a professional way is important. Surgeon leadership is critical to the success.
Educate Effectively
Our system for educating patients is ineffective. We rely too much on verbal physician/nurse to patient interaction. It is an inconsistent and ineffective way to educate. Retention of information is low, resulting in poor compliance and, ultimately, patient dissatisfaction. Patients want you to be on time, want to tell you their story and they want you to listen. They want to have a clear understanding of their diagnosis, all the available options, the expected outcomes, and your recommendations. They want to follow-up with you to discuss the results of the treatment. However they don’t need you to personally provide all this information verbally. The time-honored belief is that patient satisfaction equates with the time we spend with them. Patients do want to spend time with us. They want to know we care and that we are the authors of the information they are receiving. Once this is established, other methods of communication are preferable, such as videos, written patient treatment plan reviews, brochures, etc. These alternative educational tools can save you considerable time while improving consistency, comprehension, retention, and compliance.
Don’t Reinvent The Wheel
There may be the will but no defined way. Most physicians have only their skills and a pen. Like the woodcutter who tries to cut trees with a dull saw, we find ourselves busy, overwhelmed and without time to sharpen anything. You need tools to sharpen a saw. Without effective tools the task before us may seem too daunting. Where do we start? Will we succeed? Might we make things worse? These and other questions create doubt. With doubt comes procrastination and acceptance of the status quo. It is critical to have a successful template, to understand how it works, to see it in action and have an implementation plan. Effective tools for educating and designing new systems are available as well as training for ancillary personnel. Making the time to learn how to use these tools and develop your people is essential.
The help of someone who has “been there, done that” helps overcome the barriers so as to ensure success.
Lead
The lack of physician- hospital collaboration is another obstacle. While many surgeons sit on hospital committees, few are responsible for the important issues of measuring quality, reducing cost, improving efficiency, patient satisfaction and productivity. There is often the expectation from the surgeons that these are hospital problems and hospital administrators should solve them for us. They can’t do it alone. They can only solve them with our help.
What about professionalism? There is nothing wrong with professionalism unless it leads to individualism. This can be a huge obstacle when you are trying to develop a simplified, reproducible standardized approach to care. Individualism resists teamwork. We know that a professional team is always more successful than a group of professionals on a team. A physician, nurse and administrative champion is so valuable here. These champions can help other professionals understand that giving up some of their autonomy for the creation of a professional team is in their interest. The lack of a champion, especially a physician champion, who can nurture other physicians, can be a huge barrier to success.
Developing a Center of Superior Performance: Translating the Vision into Daily Execution
The AAMC joint center contained the following elements: a consistent message to patients, coordination between
surgeon offices and hospital, standardized care plans, an identifiable joint unit, dedicated staff, multidisciplinary
involvement, a high level of patient/ family involvement, outcomes measurements, continuous quality improvements, cost effectiveness, and a leadership team to provide guidance.
We identified a delivery system that had proved itself successful and had many of the critical elements, including professionally-produced educational materials for both the surgeon’s office and the hospital (videos, brochures and
marketing materials). We added expanded educational materials, including surgical guidebooks for knees and hips. All
of these materials improved quality and compliance, provided a consistent message, and saved time for the surgeons.
As part of the program, the hospital established a 4 bed total joint unit (now 20 beds), added a full time coordinator and dedicated staff to TJR. The surgeons developed and used a standardized care process that outlines the patient care plan on an hour-by-hour basis for the entire three-day hospitalization, including discharge. The surgery schedule was reconfigured so that patients had their surgery on Monday (additional days were added as the program grew). Busy surgeons were given two rooms to use simultaneously. To improve efficiency, the implant vendors were reduced from 8 to 2.
Patients were dressed early and out of bed spending most of the day in a recliner or participating in group activities, including lunch. Patients walked on post-op day 1 and climbed stairs on post-op day 2. A dedicated physical therapist coordinated group physical therapy. Family members were designated “coaches” and were trained to assist at the group sessions. This reduced the need for additional staff. Creating appropriate patient expectations are critical. Total joint patients are not “sick;” they need mending. By treating them as healthy, they look at themselves as healthy, and have expectations of faster recovery. What patients expect, they realize.
Clinical outcomes are measured yearly. Every patient is surveyed by telephone at 3 weeks and all patients are invited to a monthly luncheon to provide constructive criticism. In addition, two monthly physician-led conferences were
established: a clinical case conference to discuss difficult surgical problems, and a multidisciplinary administrative conference to discuss issues.
Don’t Get Complacent: Measure, Revise, and Measure Again
Improvement and expansion continues. As minimally invasive surgery becomes more prevalent, we are developing modifications to accommodate the shorter stay. Confidential “report cards” are being developed for individual surgeons that cover a broad range of clinical and financial measurements.
The successful program was reproduced by our spine surgeons (1998) and our vascular surgeons (2002). Their results have mirrored ours. This has a positive effect throughout the hospital. AAMC received #1 status for patient satisfaction by the Jackson Survey /2004 and “Top 100 Hospital” distinction by Solucient / 2005.
You Can Do It
This model will work in your hospital as well. Over 300 hospitals have visited AAMC from the US and over 15 countries abroad. Those that implement this model have reported similar results, including thirty-one hospitals in Holland. The cost and time involved is easily offset by the operational efficiencies, cost reductions, increased volume and patient satisfaction. The continuous emphasis on “quality care and service” with a focus on “value” has benefits for everyone. This “healthcare model for the future” combined with surgeon leadership provides a remedy for some of the most pressing problems in healthcare today and creates a culture in our hospitals that will ensure ongoing improvement.
It’s Time to Sharpen Your Saw
Marshall K. Steele, MD, President, Marshall Steele and Associates a healthcare consulting company. He is a Board
Certified Orthopedic Surgeon, Founder and Director of the “Center for Joint Replacement at Anne Arundel Health
Systems” and the Medical Director of the Surgical Clinical Initiative for Business Development/ Strategic Planning for Centers of Excellence. Dr Steele lectures throughout the country on joint replacement surgery and served as a
consultant to a major orthopedic company for 8 years to develop the “Effective Office”, “Joint Concepts” and “Rapid Recovery” programs. He is also the author of 2 books -“Sideline Help” An Immediate Guide to the Care of Sports
Injuries, featured by NFL subsidiary and “Notebook for Knees/ Hips” a comprehensive manual for total joint patients. msteele@marshallsteele.com
|
