Determining the True Cost to Deliver Total Hip and Knee Arthroplasty Over the Full Cycle of Care: Preparing for Bundling and Reference-Based Pricing.

The Affordable Care Act accelerates health care providers' need to prepare for new care delivery platforms and payment models such as bundling and reference-based pricing (RBP). Thriving in this environment will be difficult without knowing the true cost of care delivery at the level of the clinical condition over the full cycle of care. We describe a project in which we identified true costs for both total hip and total knee arthroplasty. With the same tool, we identified cost drivers in each segment of care delivery and collected patient experience information. Combining cost and experience information with outcomes data we already collect allows us to drive costs down while protecting outcomes and experiences, and compete successfully in bundling and RBP programs.

A case for integrating the Patient and Family Centered Care Methodology and Practice in Lean healthcare organizations.

Many healthcare organizations using Lean are becoming interested in the Patient and Family Centered Care Methodology and Practice (PFCC M/P). We suggest that integrating the two approaches can accelerate the pace of improvement and provide a powerful mechanism to keep the patient and family as the primary focus of improvement activities. We describe the two approaches and note the ways in which they are complementary. We then discuss the ways in which integrating the PFCC M/P adds value to patients, families, providers, and organizations and accelerates transformation. Finally, we suggest ways to implement PFCC M/P within Lean healthcare organizations.

Improving outcomes: understanding the psychosocial aspects of the orthopaedic trauma patient.

The care of orthopaedic trauma patients with multiple injuries has dramatically improved in the past 25 years. The understanding of the physiology of trauma has evolved, new surgical approaches have been developed, and technologic advances have created better implants. New methods of treating fractures include fluoroscopic and computer-assisted imaging. Surgical interventions have changed from extensive and prolonged dissections to more limited and effective percutaneous and minimally invasive techniques. The lives of patients are being saved, and radiographic outcomes are improving; however, medical and surgical advances that achieve better radiographic and anatomic outcomes do not always improve functional outcomes. Understanding and optimizing the management of the psychosocial factors that affect trauma patients can improve outcomes.

Integrating patient- and family-centered care with health policy: four proposed policy approaches.

Achieving patient-centeredness in health care delivery has been difficult, in large part due to the lack of a replicable methodology. We describe the Patient- and Family-Centered Care Methodology and Practice (PFCC M/P), designed specifically for health care, to establish and sustain patient-centeredness in any care setting. The PFCC M/P meets the needs of all stakeholders--patients, families, providers, payers, and government--in improving the patient experience, patient safety, and clinical outcomes while decreasing waste and cost. We also propose options for aligning the PFCC M/P with policy as a means of bringing about widespread transformation in health care delivery.

A paradigm shift toward systemwide quality improvement education: meeting the needs of a rapidly changing health care environment: meeting the needs of a rapidly changing health care environment.

BACKGROUND: Widespread changes in the health care landscape require a paradigm shift from an educational model where quality improvement (QI) expertise is centralized to a model where foundational and functional QI knowledge is widespread through all levels of a health care organization. METHODS: To support a new educational structure prioritizing QI education as a stand-alone priority, a 6-month educational course was introduced for operational leaders (requiring completion of a real-life improvement project) and a second, introductory QI education set of 5 stand-alone classes was introduced for managers and frontline staff; the latter is provided at centralized sites, on-site, and via webinars. Additional QI courses have been introduced for board members. RESULTS: Sixty operational leaders attended the first 2 offerings of the 6-month course and completed 50 associated QI projects, as of July 2012; nearly 1500 participants have attended the "Just-in-Time" classes, representing 13 University of Pittsburgh Medical Center hospitals and affiliated facilities. Eighty-three percent of recent participants rated the 6-month course a 4 or 5 in terms of efficacy. Two-thirds of participants from both 6-month series reported that they continued to work on their project once the class was over. DISCUSSION: The number of course attendees and their feedback regarding efficacy of this educational approach, as well as the volume of associated completed projects, indicate success in providing greater numbers of staff at all levels of the organization with QI education and tools. This educational format shows promise for further refinement and replicability.

Turning patient-centeredness from ideal to real: lessons from 2 success stories.

The Institute of Medicine's 2001 Crossing the Quality Chasm report established patient-centeredness as 1 of 6 core principles for health system redesign. Yet, turning aspiration into accomplishment has proven arduous. Patient-centered care has components that challenge established professional norms, and the term itself has not always been clearly defined. However, these barriers can be overcome using Rogers' principles of diffusion of innovation, as is shown by 2 case histories. One involves care at an urban academic medical center, the other outpatient care at multiple physician sites located in urban, suburban, and rural locations. At the University of Pittsburgh Medical Center, the Patient- and Family-Centered Care Methodology and Practice has become the new "operating system" in 60 clinical areas, using a 6-step approach to engage patients and families as codesigners of ideal care. Meanwhile, the Health Coach Program at Mercy Clinics, Inc, Des Moines, Iowa, has used a "high-tech/high-touch" combined approach to change the organizational culture through patient-centered initiatives. By doing so, it has put the organization in a position to accept risk for populations of patients. Importantly, both programs have been financially and clinically successful, are accepted by frontline physicians and senior management, and are nationally recognized. Common principles include physician leadership, comfort with uncertainty during innovation, organizational structures that send a consistent message about expectations, and quality improvement as a constant cycle with no end point.

Digital video recording in the inpatient setting: a tool for improving care experiences and efficiency while decreasing waste and cost.

The need to significantly improve patient centeredness and efficiency, while reducing waste and cost, in health care is an area of focus for health policy leaders. We employed digital video recording on a postsurgical inpatient unit as a method of understanding care delivery through the eyes of patients, families, and caregivers. Key findings of the study included identification of the total number of staff (by function)-to-patient contacts and the percentage of time patients spent in their room during recovey. The use of digital video recording eliminated the impracticality of real-time observation in the inpatient setting and should be considered as a tool for helping to achieve necessary transformation in care delivery.

Care experience-based methodologies: performance improvement roadmap to value-driven health care.

BACKGROUND: The literature contains proposals for creating value by creating exceptional patient experiences rather than simply improving services. However, few articles describe replicable applications focused on the patient experience. QUESTIONS/PURPOSES: We (1) describe the refinement and exportation of an approach that focuses on the patient and family experience; and (2) report changes in patient satisfaction, infection rates, length of stay, mortality rates, clinical indicators, staff turnover, and cost. METHODS: The Patient and Family-Centered Care Methodology and Practice (PFCC M/P) is a six-step process: (1) selecting a care experience needing improvement; (2) establishing a guiding council; (3) evaluating the current state; (4) developing a permanent working group; (5) creating a shared vision of the ideal experience; and (6) identifying improvement projects to address the gap between the current and ideal experience. We assessed patient satisfaction, changes in clinical indicators, staff turnover, and cost in three clinical programs. RESULTS: In TJA, patient satisfaction is at the 99th percentile; length of stay, infection rates, and mortality rates are substantially better than the national average. In trauma, patient satisfaction increased, time in cervical collars decreased, staff turnover decreased, and the incidence of lost patient belongings was eliminated. In orthopaedic spine, patient satisfaction is higher than the national average, average time for transfer to bed decreased (%), length of stay decreased, and average discharge time decreased. Each of these would have a positive impact on cost. CONCLUSIONS: PFCC M/P offers a road map for redefining value as what is important to patients and families.

Separating predictable and unpredictable work to manage interruptions and promote safe and effective work flow.

Predictable and unpredictable patient care tasks compete for caregiver time and attention, making it difficult for patient care staff to reliably and consistently meet patient needs. We have piloted a redesigned care model that separates the work of patient care technicians based on task predictability and creates role specificity. This care model shows promise in improving the ability of staff to reliably complete tasks in a more consistent and timely manner.

Energy capacity model for nurses: the impact of relaxation and restoration.

OBJECTIVE: This study assessed the effect of stress management techniques and a restoration room on energy renewal of nurses. BACKGROUND: Nursing stress is linked to increased turnover, decreased well-being, and decreased decision-making capabilities. Energy renewal may be an effective method of addressing stress-induced exhaustion and its negative effects. METHODS: Stress reduction techniques and a restoration room were provided on a pilot unit. Results were measured with the Nursing Stress Scale (NSS), payroll data, and room usage diaries. RESULTS: There was an overall reduction in NSS scores. The room was used less often than anticipated. The sample size was inadequate to measure reduction in unplanned time off. Anecdotally, nurses felt positive about the room and continue to use it. Results were limited by sample size and a positive baseline work environment but promising enough to explore further. CONCLUSIONS: Results suggest that further study is warranted with a larger sample in Magnet® and non-Magnet settings.

Patient and family shadowing: creating urgency for change.

The Patient- and Family-Centered Care (PFCC) method and practice has been developed over the past 4 years as a means of improving care experiences by viewing all aspects of a patient's care experience through the eyes of the patient and family. One of the most powerful components of the method, evaluating care through patient and family shadowing and the accompanying care experience flow mapping, is described. An overview of the PFCC method can be found in the authors' article in the December 2010 issue.

A patient-centered model to improve metrics without cost increase: viewing all care through the eyes of patients and families.

The need for patient-centeredness in care delivery has been articulated for decades, yet meaningful progress toward patient-centered healthcare has been hobbled by the lack of a replicable patient-centered care model and method. The authors describe the patient- and family-centered care method, built around viewing every care experience through the eyes of the patient and family, and its outcomes proving the approach is replicable and sustainable while improving outcomes without additional cost. A follow-up article on patient and family shadowing will be published in the January 2011 issue.

Care management redesign: increasing care manager time with patients and providers while improving metrics.

In many hospitals, addressing increasing financial and regulatory requirements has resulted in a decline in care managers' time spent communicating directly with patients, families, and healthcare providers. The authors discuss the redesign of a hospital care management model that increased the time care managers spend with patients, families, and other care professionals, while patient satisfaction increased, labor cost remained neutral, length of stay decreased, and the payment denial rate remained among the country's lowest.

Building an evidence-based practice infrastructure and culture: a model for rural and community hospitals.

The need to address the disparity between healthcare research findings and the implementation of findings into clinical practice is an essential factor in healthcare reform. Exponential growth over the past decade in health-related knowledge and technology has made access to research findings increasingly available. The authors describe a process initiated at a rural community hospital to support the integration of evidence-based practice into daily nursing practice.

Ticket to ride: reducing handoff risk during hospital patient transport.

A significant number of medical errors occur during patient handoffs, leading to less than optimal care, patient harm, and even death. The Joint Commission National Patient Safety Goals require hospitals to implement a standardized approach to "handoff" communications. The authors describe an initiative that focuses on standardization of the physical and informational handoff during hospital transport; outcomes are promising in terms of both patient safety and patient satisfaction.

Rapid improvement event: an alternative approach to improving care delivery and the patient experience.

The most common quality improvement methodologies used in healthcare involve repetitive testing of ideas for rapid-cycle quality improvement. They typically take place over weeks or months, as identification of problems and root causes and tests of change occur. The authors describe an alternative approach to care delivery redesign, which reduces the time frame of problem identification and implementation of tests of change from weeks or months to days.

Transforming care at the bedside: an ambulatory model for improving the patient experience.

Transforming Care at the Bedside is a nationwide effort to design a model for improving care to hospitalized patients. With the projected growth of ambulatory services, it is increasingly important to focus on potential methods to increase patient satisfaction and care delivery improvement in the outpatient setting, as well. The authors describe the University of Pittsburgh Medical Center Hillman Cancer Center's adaptation of the Transforming Care at the Bedside care delivery improvement model to its ambulatory services arena and its promising results.

Patient and family-centered collaborative care: an orthopaedic model.

Despite both longstanding and recent interest in patient-centered care, there are few published models or methods for defining and implementing patient-centered care in the office and hospital setting through a full cycle of care from the patient's perspective. We describe patient- and family-centered collaborative care as a low-technology, systems-based solution to many current problems and suggest ways to provide safe, effective, timely, and efficient health care. We presumed such a patient- and family-centered collaborative care model would provide high quality health care. We prospectively collected data on 618 consecutive patients undergoing THA or TKA within a dedicated patient- and family-centered collaborative care program. We found a high level of patient satisfaction with an overall satisfaction score of 91.4 using the Press Ganey Survey. Infection and mortality rates were 0.3% and 0.1%, respectively. Average length of stay was 2.8 days for TKA and 2.7 days for THA with 91% of all patients being discharged directly home and 93% walking without handheld assistance at the time of discharge. The patient- and family-centered collaborative care model is not just another clinical pathway but a comprehensive systems-based approach that focuses on the full cycle of care while placing patients and their families as the top priority to provide high quality health care.