Patient- and Family-Centered Care Initiative is Associated With High Patient Satisfaction and Positive Outcomes For Total Joint Replacement Patients

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 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 over 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

• Patient and family shadowing: Interns follow (or "shadow") patients and families to observe and record what actually happens at each step of the care process, and to compare the experience to what should have happened at each step. While they are being shadowed, patients and families give interns immediate feedback about problems as they arise, thus providing the interns with the patient and family perspective on the experience.
• Timely feedback and weekly care team meetings: Once the shadowing is complete, the intern reviews the information and presents his or her findings to staff members who work in the area where the shadowing took place. The presentation contains observations made by the intern, 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 interns' observations from the patient shadowing process.
• 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 hospitalization
  • An opportunity to meet the staff and other patients scheduled for surgery the same day
  • A meeting with a social worker to discuss the discharge and home care plan
  • Scheduling of a followup appointment with the physician
  • An opportunity to select a patient advocate or “coach”
  • Routine testing
• The surgical procedure: The hospital strives to provide a predictable process on the day of surgery that focuses on meeting the patient’s and family’s needs:
  • Presurgical meeting: The physician meets with the patient in the surgical holding area to answer questions, provide coaching and reassurance, and mark the surgical site.
  • Meeting with anesthesiologist: The patient meets the anesthesiologist to learn more about special anesthesia techniques and options for managing pain after surgery.
  • Experienced surgical staff: Dedicated operating room staff assist the surgeon during the procedure. All staff have extensive experience in total joint replacement procedures, which helps improve quality and productivity, and reduce variability, waiting times, and stress for the surgeon and staff.
  • Protocol usage: The surgical team uses evidence-based protocols that formed the basis for the Center for Medicare and 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:
  • 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 post-discharge 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 as a kitchen and living room, that creates a sense of community among the patients and families. This room provides a relaxing environment with rocking chairs, couches, 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. There is also a massage therapist for patients and massage chairs for family members and staff.

References/Related Articles

Contact the Innovator

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.
• High functional status: Ninety-three percent of patients could walk without handheld 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: Ninety-eight percent of patients received antibiotics within the 1-hour window before surgery, and the vast majority of hip replacement patients (93 percent) and knee replacement patients (94 percent) had their antibiotics discontinued within 24 hours after surgery. In addition, the appropriate antibiotic was selected for 99 percent of total hip replacement and 98 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 to national rates of 0.86–2.52 percent for total knee replacement, and 0.88–2.26 percent for total hip replacement (average rates vary depending on the risk profile of the patient).²
• Low length of stay: Average length of stay was 2.8 days for total knee replacement, below the national average of 3.9 days, and 2.7 days for total hip replacement, also below the national average of 5.0 days.³
• Well-above average rates of discharge to home: Ninety-one 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?)

The evidence for this pilot program consists of post-implementation data on measures such as patient satisfaction, functional status, adherence to evidence-based care protocols, infection rates and length of stay. For some measures, national averages are available for comparison purposes.

Context of the Innovation

Planning and Development Process

• Development of Innovation Center: The Innovation Center, part of Magee-Womens Hospital of University of Pittsburgh Medical Center, provides technical assistance, training, research, and education to support programs of departments throughout University of Pittsburgh Medical Center interested in adopting the patient- and family-centered methodology. The Innovation Center houses a training and education center that contains a mock patient room, operating room, computer-assisted simulation, classroom/conference room, and offices. The Center is currently working with staff at Carnegie Mellon University's Human Computer Interaction Department to examine the application of game technologies to rehabilitative services.
• Development of care team: Physicians, nurses, therapists, and ancillary staff 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 staff 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 caregivers
  • 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 that will implement the patient- and family-centered care methodology.

Resources Used and Skills Needed

• Staffing: The Innovation Center has five full-time equivalent staff members, including individuals with experience in clinical care, technology, quality improvement, research and development, and management. The Center also has an intern program in which up to 20 medical and college students from all over the country assist in special 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 patient- and family-centered care methodology; 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

Magee Women's Hospital of the University of Pittsburgh Medical Center

Tools and Other Resources

Getting Started with This Innovation

• Define the scope of the project: Select a patient care experience (e.g., total joint replacement ), and determine the scope of the project.
• Establish a guiding council of program champions: Establish a patient- and family-centered care "guiding council," including clinical and administrative champions and a scribe. 
• 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 might include care flow maps, patient stories, patient and family shadowing, 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: Use the care flow map to identify the members of a working group that will oversee the implementation of patient- and family-centered care in a particular area (such as total joint replacement). Develop a regular schedule of meetings (typically weekly), and allow the working group access to a small budget so that needed items can be purchased quickly. 
• 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.

Sustaining This Innovation

• Get feedback: Obtain and act on the feedback of patients, families, and staff throughout their entire experience.
• Identify and prioritize new projects: Identify potential projects by comparing the "current state" of care with the ideal patient experience; prioritize these projects based on patient and family needs and feedback. Keep Active, Completed, and Future project lists to track and prompt progress.

Use By Other Organizations