Patient-Centered Service Lines

Marshall K. Steele, MD, for HealthLeaders Media , March 19, 2008
More than a decade ago, one of my patients told me that the result of her knee replacement surgery was terrific but that her experience in our hospital was so negative that she would not return for her second knee replacement.

It was at that moment that I realized the patient experience is absolutely critical to the success of my practice and that my patients' time in the hospital had been neither effective, efficient, or patient/family friendly. A new model of care was needed.

It didn't take much investigating to see that the patient care process at the hospital was disjointed. Each department lived in a self-contained silo with little, if any, interaction with other silos, other than some casual hall conversation amongst the various caregivers. No one was focusing on service from the patient's point of view.

Patients don't perceive the episode of care as a hand-off from one caregiver to another. They actually think that everyone is working together and that providers communicate regularly with each other. As a surgeon, I had to stop complaining and collaborate with the administration and clinical staff to develop a solution. With the hospital as a partner, I led a team that set out to develop a vastly improved model of patient care. The hospital could not develop a service line for us surgeons; it could only do it with us. A service line is, after all, a team effort.

The continuum of care
As part of our evaluation, I learned that the education I provided for my patients often conflicted with the information provided at the hospital. For example, I might tell the patient that the length of stay would be three days, but the hospital pre-admission testing might indicate a four day stay, leaving the patient confused.

When developing the service line, each patient interaction must convey the same messages, in and out of the hospital, to create a seamless continuum of care. Here is how the cycle should work on a step-by-step basis:

Step 1: Community education. The patient knows he or she has a problem and wants to learn more about the causes and the solutions. This is the information-seeking phase. Quality information can be provided through educational seminars, the hospital Web site, health screenings, articles in newsletters, and interactive electronic Q&A sessions. This is when the patient becomes aware of your branded service line.

Step 2: Primary care physicians. PCPs are looking for help and should be involved in the service line. They welcome help with their patients through educational information, seminar and screening dates, in-service education on the developing service line, and direct links to specialist's offices. They are not equipped to answer all questions about specialty areas so the program becomes a great asset to them.

Step 3: Specialists' offices. All parts of the office should be learning centers for the patient and their family members. Verbal education is often inconsistent and ineffective; it takes a great deal of time but very little of the information is retained by the patient. Therefore, I provided education through videos, written materials, and physician/patient interaction. This saved hours of my time and provided much better education/retention for the patient.

Step 4: Pre-operative teaching and testing. One thing that we learned early in our service line development: It is essential to set expectations for both the patient and the family. Therefore, we established a pre-op class for about two weeks before the surgery. This prepares everyone for pre-operative readiness, the hospital stay, and discharge preparation. As a result, the patient does better and the family members feel comfortable bringing the patient home.

Step 5: Designated team and designated unit within the hospital. In order to become a branded service line, there has to be a designated interdisciplinary team for the program and a designated space for it--with a sign. The designated team of nurses and therapists become experts in this area of care. In addition the team becomes a valuable resource for the surgeon. A dedicated team is able to assess clinical protocol changes and their effectiveness.

Step 6: Post-operative follow up. We realized that it was critical to involve extended care facilities, home health organizations, and outpatient physical therapy in the continuum of care. Transitional treatment plans were developed so that these caregivers would follow our pathways. We also developed vehicles for the transfer of information.

Step 7: Measurement/outcomes/results. To complete the continuum of care, we realized that patients want to know the effectiveness of the service line. More than 10 years ago we began tracking outcomes, aggregating the data, and posting the results for everyone to see. This served several purposes. First, measurement kept our pulse on the areas of the program that were strong as well as those that needed further attention. Second, it let us know if new clinical elements (anesthesia protocols, physical therapy exercises, pain or nausea prevention treatments, etc.) were effective. And third, monthly patient luncheons (focus groups) provided relevant information on the patient experience.

This new model of care has led to some very positive results, including: Increased patient satisfaction, lower per case costs, increased volumes, rapid recovery, improved surgeon efficiency, and community/regional recognition. With the increase in competition, developing a service line from the patient's perspective connects all stakeholders into a unified and educated voice. As a result of this model, the hospital has become well-known for its care of joint patients.

Marshall K. Steele, MD, is the President of Marshall Steele & Associates. He has consulted with over 250 hospitals and now leads a team that provides service line development services for hospitals nationwide. He can be reached at or
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