When Kaiser Permanente realized that patients' perception of care quality included time management, the health system made saving patients' time "part of [its] standard quality measures"—and accelerated certain patients' hospital-to-home transitions without sacrificing outcomes.
Writing in Harvard Business Review, Nirav Shah, SVP and COO of Kaiser Permanente's Clinical Operations, and colleagues outline how the system redesigned care processes for hip and knee replacement patients.
Such patients generally stay in the hospital for three days post-surgery because "many hospitals are reimbursed for every day a patient is in a bed, and it's easier for the care team to monitor the healing process if all of their patients are in one unit," Shah and colleagues write. But they point out that "the system was created by and optimized for surgeons and hospitals to provide safe care with good outcomes"—not for the patients.
Saving time, one patient at a time
After researching a cross-section of hip-replacement patients treated by the health system, Kaiser Permanente realized that up to 50 percent of such patients could go home the same day as their surgeries—so long as "the entire care team worked according to a set of coordinated procedures, many of which would have to take place outside the hospital."
The program works like this: First, before surgery, a care coordinator will tell the patient and the patient's family about what to expect throughout the process. Then, medical professionals visit the patient at home, prior to surgery, to set expectations about recovery and foster the patient-provider relationship. For instance, a physical therapist will stop by the patient's home to evaluate the safety of the home, a pharmacist will educate the patient about the medications he or she will receive after surgery, and other providers will visit the patient at home to drop off walkers and make sure the patient's bed is on the ground floor.
The surgery itself will be performed from an anterior approach, Shah and colleagues write. While the procedure is more difficult to learn than other approaches, it cuts down on post-operative pain and enables the patient to walk immediately after surgery. In addition, the surgeons will only pick devices from a small, predetermined set of options—that way, other members of the care team can specialize their knowledge around those particular devices, which curbs the rates of complications and infections.
Post-surgery, the patient receives a meal, shows he or she can walk between 30 and 50 feet, and heads home. The following morning, the physical therapist will visit the patient at home for the first of six in-home PT sessions, and a care coordinator will phone to ensure the patient has contact information in case he or she has questions or concerns. Over the next two weeks, before the patient visits the surgeon to close the loop of care, a nurse may drop by to check the patient's vitals at home, and a PA will monitor and update the patient's EHR as needed.
According to Shah and colleagues, Kaiser Permanente provides about 8,000 elective hip surgeries and 15,000 elective knee surgeries every year. Since implementing the program, the system has sent 11 percent of such patients to recover at home without a hospital stay—and the system plans to increase that to 25 by the end of the year and 50 percent by the end of 2018. "And in the metric that matters so much to so many of our patients—saving time—most of the time in a zero-day stay is spent treating the patient," Shah and colleagues write.
Most importantly, Shah and colleagues write, Kaiser Permanente isn't sacrificing outcomes: Data show that the readmission rate for zero-day hospital stay patients is 2 percent—exactly the same as it is for patients who recover at the hospital (Shah, et. al, Harvard Business Review, 5/24; Murphy, Becker's Hospital Review, 5/25).
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Patient volumes are increasing. At the same time, the number of services used per patient is growing. Better outcomes mean that more patients require follow-up care over longer periods of time. This growing demand coincides with increased competition—providers unable to care for patients in a timely manner will lose their volumes to competitors.
Since most cancer centers can't afford more full-time employees or clinical space as a response to long wait times, they need to focus on redesigning the clinic schedule and improving patient throughput instead.