Problem Addressed

• Empirical evidence on the need for patient- and family-centered care: Research suggests a need for low-end, systems-based processes to improve outcomes and patient and family satisfaction with the quality of care.¹
• Patient demand for patient- and family-centered care: Patient surveys suggest there is a strong, unmet demand for patient- and family-centered care; a recent survey of more than 350,000 patients identified the following desired attributes in a health care system, all of which relate to better meeting the needs of patients and families¹:
  • Respect for patients’ values, preferences, and expressed needs
  • Access to care
  • Emotional support
  • Information and education
  • Coordination of care
  • Physical comfort
  • Involvement of family and friends
  • Continuity and transition

Description of the Innovative Activity

• Care Givers: The initiative defines "Care Givers" as any person within the health care setting whose work touches a patient’s or family’s care experience. Care Givers include doctors, nurses, therapists, technicians, dietitians, appointment schedulers, parking attendants, janitors, and even the hospital leaders, purchase and supply chain employees, and financial representatives whom patients and families may never see. All Care Givers are encouraged to tear down traditional “silos” and codesign patient care so that resources and personnel are organized around the needs of patients and families rather than around hospitals or Care Givers.
• Patient and family shadowing: Care Givers follow (or "shadow") patients and families to observe and record what actually happens during the care process, and compare the actual experience with the ideal experience at each step. While shadowed, patients and families (and even Care Givers) give shadowers real-time feedback about problems as they arise, thus providing the Care Givers with the patient and family perspective on the experience.
• Timely feedback and weekly care team meetings: Once the shadowing is complete, the shadower reviews the information and presents his or her findings to Care Givers involved in the care step at which the shadowing took place. The presentation contains observations made by the shadower, comments from the patient and family, and recommendations for change, which can be implemented rapidly based on this timely feedback. Members of the care team meet weekly to discuss patient and family feedback and shadowers' shadowing observations.
• Presurgery visit: A 2-hour office visit 3 weeks before surgery focuses on wellness (not sickness) and reducing anxiety for patients and their families. Visits also include the following patient-centered services:
  
  • Education to prepare patients and families for their surgery and rapid recovery program
  • Encouragement to select a patient advocate or "coach"
  • An opportunity to meet Care Givers and other patients scheduled for surgery the same day
  • A meeting with a social worker and case manager to discuss the discharge and home care plan
  • Scheduling of a postoperative followup appointment
  • Routine preoperative testing program
• The surgical procedure: Care Givers strive to provide an anxiety-free experience on the day of surgery that focuses on meeting the needs of patients and families:
  • Presurgical meeting: The physician meets with the patient and family in the surgical holding area to answer questions, provide reassurance, and mark the surgical site.
  • Meeting with anesthesiologist: The patient meets the anesthesiologist to learn more about special anesthesia techniques and the pain management program.
  • Experienced surgical staff: Dedicated operating room staff assist the surgeon during the procedure. All staff members have extensive experience in total joint replacement procedures, which helps improve quality and productivity, and reduce variability, waiting times, and stress for the surgeon, Care Givers, and patients.
  • Protocol usage: The surgical team uses evidence-based protocols that formed the basis for the Center for Medicare & Medicaid Service/The Joint Commission jointly-developed measures for the Surgical Care Improvement Project regarding antibiotic use to prevent surgical site infections.
  • Standardized care: The dedicated operating room staff follow a standardized process during the procedure, which they refer to as medical resource management. This process, an adaptation of the aviation industry's crew resource management, encourages staff to voluntary report process inconsistencies.
• Rapid rehabilitation: Rehabilitation begins the day of surgery using the following patient- and family-centered procedures by focusing on wellness:
  • Return to normal activity: Patients are encouraged to dress themselves in regular clothes as soon as they return to their room. Later that same evening, physical and occupational therapists help patients get out of bed, move from the bed to a chair, and begin walking. Patients are also encouraged to put on their shoes and socks by themselves, with no restrictions on range of motion (even after total hip replacement surgery).
  • Rehabilitation therapy: Patients receive physical and occupational therapy twice a day throughout their hospital stay, participating in group therapy in the on-unit gym. Before going home, patients are able to climb stairs and get in and out of a car safely.
• Specialized staffing: The postdischarge unit is staffed by a specialized team that is trained to focus on meeting both the emotional and medical needs of patients and families.
• Patient- and family-friendly physical space: The unit is designed to be a comfortable, relaxed setting that makes patients and families feel at home. For example, all rooms are equipped with Internet access. The unit includes a state-of-the-art gym and fitness area as well as cafe-style room service for meals, which are available 24 hours a day, 7 days a week. The unit has a special family community room, designed to feel like home with a kitchen and living room. This room provides a relaxing environment with rocking chairs, couches, massage chairs, a big screen television, and a fully stocked refrigerator. Patients can enjoy time out of their rooms by gathering in the room as they would at home. Other amenities for patients include massage therapy, monogrammed T-shirts and water bottles, which help create a calming atmosphere and a sense of community.
• Discharge classes: Patients and families are invited to attend group discharge classes offered in the evening in the family community room. Care Givers review discharge procedures and care instructions, allowing time for questions to be answered by the care team.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• High satisfaction: Press Ganey survey results indicated a mean overall patient satisfaction score of 91.4, which represents a high level of satisfaction with the program. Information provided in April 2010 indicates that the overall Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for the reporting period between July 1, 2008 and June 30, 2009 was 82 (99th percentile), compared with the national average of 64. Information provided in June 2011 indicates that Press Ganey survey results indicated a mean overall patient satisfaction score of 90.7, which represents a high level of satisfaction with the program. Information provided in April 2011 indicates that the overall HCAHPS score for the July 1, 2009 to 30 June 2010 reporting period was 81 (99th percentile), compared with the national average of 65.
• High functional status: Ninety-three percent of patients could walk without hand-held assistance at the time of discharge. Pain had no effect on the ability of 99 percent of patients to perform postsurgical physical therapy, including therapy starting the same day as surgery.
• High compliance with evidence-based protocols: Information provided in June 2011 indicates that 99 percent of patients received antibiotics within the 1-hour window before surgery, and the vast majority of hip replacement patients (95 percent) and knee replacement patients (94 percent) had their antibiotics discontinued within 24 hours after surgery. In addition, the appropriate antibiotic was selected for 100 percent of total hip replacement and 100 percent of total knee replacement patients.
• Low infection rate: The overall infection rate for all patients in the total joint replacement program was 0.3 percent, compared with national rates of 0.86 to 2.52 percent for total knee replacement, and 0.88 to 2.26 percent for total hip replacement (average rates vary depending on the risk profile of the patient).²
• Low length of stay: Information provided in June 2011 indicates that average length of stay was 3.0 days for total knee replacement, below the national average of 3.9 days, and 2.6 days for total hip replacement, also below the national average of 5.0 days.³
• Well-above average rates of discharge to home: Information provided in June 2011 indicates that 92 percent of patients undergoing total joint replacement were discharged directly to home, compared with national averages of 29 percent for patients undergoing total knee replacement and 23 percent for patients undergoing total hip replacement.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Development of Innovation Center: The Innovation Center, part of Magee-Womens Hospital, provides training and education to support programs related to the patient- and family-centered methodology and to act as a resource to Care Givers inside and outside the institution.
• Development of care team: Physicians, nurses, therapists, and ancillary Care Givers were recruited to serve on the care team based on their commitment to meeting and exceeding the needs of patients and families.
• Development of program priorities: The staff of the Innovation Center along with the total joint replacement Care Givers set the following priorities and goals for the patient- and family-centered total joint replacement program:
  • To provide appropriate, timely education to patients and families
  • To use less invasive techniques whenever possible
  • To use multimodal anesthesia and pain management techniques
  • To promote recovery through use of rapid rehabilitation protocols
  • To elicit timely feedback from the patients’ and the providers’ perspectives
  • To create a learning environment and culture
  • To develop a sense of community, competition, and teamwork among patients and between patients and Care Givers
  • To promote a wellness rather than a sickness approach to recovery
• Staff training: The entire team of physicians, nurses, therapists, and ancillary staff were trained on the Disney Corporation’s model of treating customers well from their first experience to their last, with the goal of constantly exceeding expectations.
• Expansion: The Innovation Center is increasing the number of working groups at the institution and will continue to focus on the exportation and adoption of the methodology and practice.

Resources Used and Skills Needed

• Staffing: Information provided in June 2011 indicates that the Innovation Center has 11 full-time equivalent staff members, including individuals with experience in clinical care, technology, quality improvement, research and development, and management. The center also has a summer intern program in which up to six medical and college students from all over the country assist in shadowing projects and process analyses. Interns come from a wide range of backgrounds, including journalism, liberal arts, and engineering.
• Costs: There are no incremental costs associated with adopting the program; staff members incorporate activities as part of their daily duties. The Innovation Center is available to serve as a resource to potential adopters at no cost.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

The following suggestions for getting started were provided in April 2010:

• Select a care experience: Select a patient care experience (e.g., total joint replacement), and determine the scope of the project. The care experience selected for improvement can be as broad as the entire episode of care (e.g., a trauma patient’s care experience from initial report to paramedics through arrival at hospital, evaluation, day of surgery, recovery, and rehabilitation or home care) or as narrow as a specific segment of care (e.g., a patient's visit to a doctor’s office).
• Establish a guiding council of program champions: Care Givers interested in adopting the Patient- and Family-Centered Care Methodology and Practice should form a small guiding council of committed, enthusiastic, and organized professionals to serve as champions and as the primary communicators for expanding the care transformation process. The council, which meets initially once a week for 30 minutes, should include a clinical champion, administrative champion, facilitator, and scribe, each with the seal of approval from the organization’s leadership to guide change, plus someone charged with coordinating and communicating information to all involved in Patient- and Family-Centered Care Methodology and Practice.
• Review "current state" performance: Evaluate "current state" performance by using innovative tools that consider all processes through the eyes of the patient and family; such tools should include shadowing providing real-time patient feedback, care experience flow maps, patient stories, patient and family surveys, and existing reports (such as patient satisfaction survey results). Assess this information with an eye toward identifying opportunities for improvement. 
• Develop and empower a working group: Members of the guiding council should invite individuals to serve on a working group to transform care. Council members pick Care Givers from each care step to serve on the working group. Working group members, which may number between 10 and 40 Care Givers, may include physicians, nurses, aides, operating room staff, therapists, social service providers, dietitians, parking attendants, information technology staff, pharmacists, and others, as needed. The hospital’s chief operating officer or vice president should be part of the group and attend weekly meetings, as should the hospital president/chief executive officer, who would attend meetings periodically. It is essential for working group members to come from all departments and all levels of the organization. At this point, members of the guiding council become part of the larger working group.
• Create a shared vision: The working group should first create a shared vision. This can be accomplished by writing a story of the ideal patient and family care experience and then comparing the ideal with the reality; if the real and the ideal are not the same, focus on what can be done to make them align.
• Identify projects: Identify potential improvement projects by comparing the "current state" of care with the ideal patient experience; prioritize these projects based on patient and family needs and feedback, and form teams to work on these projects. Keep "Active," "Completed," and "Future" project lists to track and prompt progress.

Sustaining This Innovation

• Get feedback: Obtain and act on the feedback of patients, families, and staff throughout their entire experience.

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