Patient-Centered Surgery

Elyas Bakhtiari, for HealthLeaders Magazine , May 12, 2010
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"If you survey families at same time as patients, families are really concerned about the transitions of care—meaning going from outpatient to inpatient, but particularly coming home. They'll be the care providers when patient comes home. Everything we do by including the family and starting the education process weeks ahead of time sets the stage to reduce anxiety during these portal experiences." Family-centered initiatives have to be sensitive to patients' individual circumstances. Some may not have close family available, and some may simply not want family participation. But it is increasingly important to offer family education as an option, because it helps not only with recovery and rehabilitation, but with the quality of the overall care experience.

Success Key No. 3: Listen to patients
The best way to find out how to make surgery more patient-centered is to simply ask the patients. What steps in the care process do they find most frustrating? What do they like about the current process? What would they like to see changed? Ask them, and they will tell you.

Surveys are one of the most common tools for collecting and quantifying patient feedback, but many hospitals aren't getting quality information because the go-to survey for patient feedback, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, wasn't really designed for surgery, says LSU's Opelka, who is also a member of the American College of Surgeons Health Policy and Advocacy Committee. That could change soon, however. The ACS has been working with the Agency for Healthcare Research and Quality to tailor a new CAHPS survey specific to surgical services. New questions will dig into issues that are unique to operating room procedures and give surgeons a better idea of what patients think after a surgery.

For example, the general CAHPS survey lacked questions about informed consent, shared decision-making, and postoperative instructions and access, all of which are issues patients find to be important when it comes to surgery. "Some surgeons might not like it because they could hear something from patients they don't want to hear. But if we use the surgical CAHPS we'll get a better understanding of our patients' experience and learn what we need to improve," Opelka says. Soliciting feedback can involve much more than surveys. When rolling out a new patient-centered initiative, DiGioia encourages care teams to participate in an exercise where they shadow patients and families through their care and then redesign the care experience completely from the patient's perspective.

"We tell them to throw away the rules—financial rules, operational rules—and we ask them to write as if they were the patient. We write that story and that becomes the ideal goal," he says. "When you force everyone to look through the patient's eyes and the family's eyes, you begin to knock down those silos, which are extremely important to get rid of if you're going to deliver exceptional care experiences."

Success Key No. 4: Improve OR efficiency
While a lot of the changes to make surgery more patient-centered happen before and after the actual surgery, the quality and speed of the operation is one of the most important patient satisfiers. Needless to say, a patient who has a wrong-site surgery or another surgical mistake isn't going to have a great care experience. And ultimately, patients want to get in and out and home as quickly as possible.

Operating room teams have been working for years to improve the efficiency and safety of hospital ORs, and many of the best improvements have come from other industries, says Opelka. The surgical checklist, similar to one pilots use before each flight, is perhaps the most well-known example, inspiring a recent book from author and surgeon Atul Gawande. But many surgical teams have also adopted simulation team training from the airline industry to prepare for emergency situations, Opelka says.

"Our research at LSU is showing dramatic changes in team performance improvement from simulation training," he says.

After-action reports adopted from other industries and other methods of analyzing performance after a surgery are also helping operating teams learn from every operation to improve the overall process and, most important, the performance.

To discover ways to improve the OR workflow and increase overall efficiency, DiGioia and his team mounted several video cameras in the operating room to record a series of hip and knee operations. This allowed surgeons and nurses to perform their normal routines, but it provided a way to time each stage of the operation and identify areas for improvement.

For instance, simple steps like introducing the anesthesiologist in the room could take anywhere from two to nine minutes. Many of the steps for preparing and finishing the surgery had wide variation, and the care team learned that they could standardize some of those tasks and cut down on the overall turnaround time and significantly improve overall efficiencies.

"OR efficiency is not only good for the hospital and the OR team, but the patient as well," says DiGioia. "But remember, it's good to look at OR efficiency, but the patient's care experience involved a lot more than just the surgery."

Elyas Bakhtiari is a freelance editor for HealthLeaders Media.
Surgical CAHPS

The new surgical Consumer Assessment of Healthcare Providers and Systems has questions not found on the original CAHPS survey, including the following:

  • Q: During your office visits before your surgery, did this surgeon tell you there was more than one way to treat your condition?
  • Q: After you arrived at the hospital or surgical facility, did this surgeon visit you before your surgery?
  • Q: Before you left the hospital or surgical facility, did this surgeon discuss the outcome of your surgery with you?
  • Q: After you arrived at the hospital or surgical facility, did this anesthesiologist visit you before your surgery?
  • Q: Did this surgeon or a health provider from this surgeon's office warn you about any signs or symptoms that would require immediate medical attention during your recovery period?
  • Q: During your office visits before your surgery, did this surgeon or a health provider from this surgeon's office use pictures, drawings, models, or videos to help explain things to you?
  • Q: Did this surgeon make sure you were physically comfortable or had enough pain relief after you left the facility where you had your surgery?
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