orthopedics and spine - healthleaders...
TRANSCRIPT
MARSHALL K. STEELE, MD | JuDy E. JonES, MS
ORTHOPEDICS AND SPINE
Innovative Strategies for Service Line Success
OrthOpedics and spine: innOvative strategies
fOr service Line success, secOnd editiOn
Marshall K. steele, MD
JuDy e. Jones, Ms
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition is published by HealthLeaders Media.
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Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition iii© 2013 HealthLeaders Media
Acknowledgments ......................................................................................................... ix
Dedication........................................................................................................................ xi
Foreword ........................................................................................................................xiii
Prologue .......................................................................................................................... xv
Chapter 1: Lessons About Service Line Development ...............................................1
Funny Thing About Blue Crabs… ............................................................................2
Perishability ..............................................................................................................3
Bamboo ....................................................................................................................6
Is It Really That Simple? ...........................................................................................7
These Patients Have Really Changed ........................................................................9
Change Is Hard: Yellow Crime Scene Tape ............................................................11
Napoleon’s Mail .....................................................................................................13
It’s All in How You Look at It ................................................................................14
A Confused Mind Always Says “No” ....................................................................15
Ritz Carlton Towels ................................................................................................16
The Perfect Pot Roast .............................................................................................18
Don’t Bruise the Tomatoes .....................................................................................19
Summary ................................................................................................................20
Contents
iv Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media
Chapter 2: Move Beyond Today’s Status Quo ............................................................21
Current Care and Culture .....................................................................................27
On-Call Dilemma ..................................................................................................30
Destination Centers of Superior Performance .........................................................34
Opportunities Abound ...........................................................................................37
Summary ................................................................................................................39
Chapter 3: Payment Reform: Focus on Increasing Value ........................................41
Medical Tourism ....................................................................................................43
Accountable Care Organizations ............................................................................46
Bundled Payment for Care Improvement ...............................................................49
Service Line Optimization and the Steps to Success in Bundled Payments .............58
Outlook for Surgeons .............................................................................................61
The Role of the Physician in the Future ..................................................................62
Chapter 4: Define and Pursue Excellence .................................................................67
Why Is Excellence Hard to Define? ........................................................................67
Are Centers of Excellence Really Excellent? ...........................................................71
Own the Patient Experience ...................................................................................79
Summary ................................................................................................................84
Chapter 5: Develop a High-Performance Culture .....................................................87
Current Culture ......................................................................................................88
Change Your Culture .............................................................................................89
Summary .............................................................................................................. 111
Contents
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition v© 2013 HealthLeaders Media
Contents
Chapter 6: Create the “A” Team .................................................................................113
Experts ................................................................................................................. 114
Get Them on Your Team ...................................................................................... 116
Strong Physician Relations ................................................................................... 117
Common Vision ...................................................................................................121
Give and Gain Respect .........................................................................................122
Create and Nurture Physician Champions ...........................................................124
Develop a Winning Leadership Team ...................................................................125
Summary ..............................................................................................................136
Chapter 7: Bridge the Physician-Hospital Gap .......................................................137
Motivation to Change ..........................................................................................139
Clinical Comanagement: A Framework for Physician Alignment .........................142
Case Study: A Successful Model ...........................................................................150
Summary ..............................................................................................................153
Chapter 8: Patient-Centric Systems of Preoperative Care ....................................167
A Word About Systems ........................................................................................168
Being Patient Centric ............................................................................................172
Community Service ..............................................................................................173
Primary Care Physicians ....................................................................................... 174
The Specialist’s Office .......................................................................................... 176
Navigation ............................................................................................................178
The Navigation Model .........................................................................................181
Preoperative Preparation ......................................................................................186
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Consistency in Patient and Family Education and Expectation Setting ................191
Summary ..............................................................................................................194
Chapter 9: Patient-Centric Systems of Postoperative Care ..................................195
Hospital Inpatient Care ........................................................................................195
Post-Hospital Care ...............................................................................................208
Summary ..............................................................................................................211
Chapter 10: The Challenge of Implementation ........................................................213
Build a Program Like a Building ..........................................................................215
Bring the Right Teams Together ...........................................................................216
The Four A’s .........................................................................................................223
Keys to Implementation Success ...........................................................................236
Overcoming Resistance to Change .......................................................................240
Summary ..............................................................................................................245
Chapter 11: The Secret Sauce: Measurement, Knowledge, Management, Innovation ............................................................................................247
Codman and End Results—100 Years of Solitude ................................................248
The Keys...............................................................................................................251
Measurement ........................................................................................................252
Knowledge ............................................................................................................267
Management and Innovation ................................................................................269
Outcomes Measures in the Future ........................................................................273
Case Study: Clinical Care Guidelines Delivery Model ..........................................275
Summary ..............................................................................................................282
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition vii© 2013 HealthLeaders Media
Contents
Chapter 12: Develop the Story and Create Awareness: Branding and Marketing .............................................................................................285
Brands Are About Feelings, Not Facts ..................................................................288
Branding Is the Most Powerful Yet Least Understood Business Strategy ..............290
The Brand Is Not Part of the Business—It Is the Business ....................................291
The Little Things You Do Are More Important Than the Big Things You Say ....293
Every Brand Is a Story. How Will Yours Be Told? ................................................294
Marketing Creates Awareness ..............................................................................296
Outcomes Marketing............................................................................................297
Your Customers ....................................................................................................299
Summary ..............................................................................................................311
Chapter 13: Solving the On-Call Dilemma and Creating a Geriatric Fracture Destination Center ......................................................................313
Geriatric Fracture Care .......................................................................................318
Apply the Core Elements of Excellence to the Osteoporotic Fracture Program ....322
Chapter 14: Creating a Destination Joint Center ....................................................339
Case Study: The Next Level .................................................................................344
Summary ..............................................................................................................347
Chapter 15: Creating a Destination Spine Center ...................................................349
Outpatient Spine Programs .................................................................................350
Operational Excellence Through Triage System ...................................................354
Access and Navigation ........................................................................................358
Getting Spine Patients “Back on Track” ...............................................................368
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Spine Center Results .............................................................................................369
Case Study: Collaborative Spine Care ..................................................................371
The Responsibility of Healthcare .........................................................................375
Primary Care–Surgeon Collaboration ..................................................................375
Summary ..............................................................................................................377
Chapter 16: Stories From Docs ...................................................................................379
The Mary Jane Effect ...........................................................................................379
The Power of the Flower.......................................................................................380
Crimson Tide Football ........................................................................................388
Reflections .....................................................................................................................393
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition ix© 2013 HealthLeaders Media
This edition was only made possible through the efforts of many of our col-
leagues who have extensive experience in service line implementation. Without
their support, this book never would have been written.
Included from Stryker Performance Solutions:
• Richard Conn, MD • Geoff Walton, MHA
• David Steele, MD, MBA • Paul Jawin, JD
• Ron Gaunt, RN • Stephen Weller, MBA
• Lori Brady, RN • Greg Wheat
• Leslie Golba, MBA
Other contributors include:
• Thomas Graham, MD • Julie Blatnik, BSN, CNOR
• David Jacofsky, MD • Mary Ann Sweeney, PT
• John Campbell, MD, MBA • Bill Munley, MBA
Acknowledgments
x Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media
Acknowledgments
• Tom Faciszewski, MD, MBA • Matt Reigle, MBA
• James Holstine, DO • Russell Mahoney
• Warren McPherson, MD, MBA • Craig Westling, MS, MPH
• Daryl Travis • Chad McClennan, MBA
• Richard Huseman, PhD • Patrick Vega, MS
• Kim Adeleman, PT, PhD • Shevan Rudkin Clark, BSN
Thanks to Karen Kondilis, our editor, who put up with our many revisions.
Special thanks to our spouses, Terry Jones and Susan Steele, who have encour-
aged us to share our knowledge and experiences with others in the hope of
making healthcare just a little better.
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xi© 2013 HealthLeaders Media
Dedicated to all the future patients who will benefit.
Dedication
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xiii© 2013 HealthLeaders Media
I first met Marshall Steele and Judy Jones at the American Academy of Orthope-
dic Surgeons meeting in 2011. We were in search of a standardized care model for
the orthopedic service line that could enhance the patient experience of care. We
had attended Marshall’s Annual Summit meeting and many of us had read his
first book.
Marshall|Steele, LLC, had an outstanding brand reputation as a trusted advisor
in assisting hospitals with orthopedic service line optimization. However, what
impressed me most in those initial meetings with Judy and Marshall was their
humility and genuine concern for their clients and the communities they served.
They never once spoke to me about their success. They only spoke, like proud
parents, of the achievements they had witnessed working with committed health-
care professionals to transform the patient experience of care. It became very
clear to me that writing a book and starting a company was not just a job. It was
a total devotion to leaving a legacy, a mission to deliver the highest quality of care
for orthopedic patients around the world. They were devoting their lives to
helping others deliver sustainable high-quality orthopedic healthcare for their
communities. They understood the Triple Aim (improving the experience of care,
improving the health of populations, and reducing per capita costs of healthcare)
and lived it each day. They developed a standardized care model with proven
results that enhances overall efficiency and quality while eliminating waste and
Foreword
xiv Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media
Foreword
unnecessary costs. They understood how orthopedic care can help patients main-
tain active lifestyles in order to improve the overall health of our communities.
These authors have not just written a book to transform healthcare. They have
imple mented their philosophy and programs mentioned in over 200 hospitals
around the world. For the past seven years, they have studied and measured best
practices with a devotion to continuous improvement. They have personally
mentored hundreds of healthcare providers who have read their book and attended
their seminars.
I am very fortunate to have met Marshall and Judy. I have a tremendous amount
of respect for their life’s work, and I am blessed to have them as colleagues and
friends. They have enriched my life in so many ways. I hope you enjoy this book.
I am confident it will inspire you in your everyday mission to enhance the patient
experience of orthopedic care.
Sharon Wolfington
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xv© 2013 HealthLeaders Media
Victor Frankl, in his awe-inspiring book, Man’s Search for Meaning, written
six months after leaving a concentration camp in 1945, wrote the following: “It is
fruitless to seek out happiness for happiness only ensues when we dedicate our
lives to a cause greater than ourselves.” We trust people who have a sense of
“why” that is greater than their own self-interest.
Healthcare is a calling like no other. Health quickly becomes the No. 1 priority
of all of us. Ninety percent of all prayers offered relate to health. As Theodore
Roosevelt said, doing work worth doing is one of the greatest prizes life can offer
you. We in healthcare are the luckiest people in the world. We are doing work
worth doing. This book is about how we can do it better.
Judy and I visit hospitals and talk to CEOs and physicians all the time. One of
the questions they often ask us is, “Do I need to build an orthopedic hospital?”
Orthopedic hospitals are efficient and can provide great care. However, the
answer is, “No.”
Our current mandate in healthcare is to create more value. Value is broadly
defined as quality divided by cost. Is creating an orthopedic hospital the best
way to increase this value? Can both high quality and lower costs for orthope-
dics be accomplished within a full-service hospital? Is there any other way to
accomplish this?
Prologue
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Bricks and mortar are expensive. Creating a truly safe environment in an ortho-
pedic hospital will require redundancies in services and equipment (especially
with ancillary services) and increased cost. If you understand the real value of an
orthopedic hospital, you will realize that it isn’t the bricks and mortar. The real
value is the “focus” that it creates. This is what Regina Herzlinger, PhD, a
Harvard professor and author of the landmark book Market-Driven Health Care,
called a “focused factory.”
With focus you can have a dedicated unit and expert staff. With focus people
become experts. Experts do things better, faster, and cheaper. With focus you can
create standardization. Evidence-based standardization reduces errors, improves
efficiency, and reduces costs. With focus you have physicians leading and being
accountable. With focus you can create an effective structure for improvement
and innovation. With focus you can create a patient-centric delivery system from
the patient’s perspective. With focus you can manage the business with specific
metrics and a separate P&L. With focus you can be transparent with the data,
which speeds improvements dramatically. With focus you can transform a low-
performance culture into a high-performance culture.
However, you don’t need bricks and mortar to create focus. Yes, you can spend
millions of dollars on an orthopedic hospital to create focus, but unless your
current facility is out of capacity, it’s not necessary. Buildings are easier to build
but hundreds of times more expensive to build than programs.
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xvii© 2013 HealthLeaders Media
Prologue
Believe us when we say it is not that easy to build programs. We’ve learned how
to do this without the expense of bricks and mortar and, instead, doing the
following:
1. Creating a “hospital within the hospital.”
2. Building a “Destination Center of Superior Performance” that:
– Creates alignment and accountability with your surgeons and staff
– Creates experts
– Builds the service line infrastructure within your own hospital
– Creates a patient-centric delivery system throughout the entire
continuum of care
– Manages the program from specific metrics for that service line
– Helps your providers consistently innovate the program and implement
best practices
– Documents the success of your interventions and quality initiatives
– Measures and shares patient-reported outcomes with all key stakeholders:
patients, primary care physicians, insurance companies, and employers
– Creates a culture of high performance
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Prologue
– Receives third-party designation from organizations such as Blue Distinc-
tion, The Joint Commission, Stryker Center for Advanced Recovery, etc.
3. Getting focused and building programs. This is what will create the
value patients, surgeons, employers, and the government want and need.
This is what will attract patients, surgeons, and staff and will make
you successful.
When you outgrow the capacity in the current facility, that is the time for bricks
and mortar. And then, you will have a great advantage, as you will have created
the alignment, the infrastructure, the delivery system, the metrics, and the inno-
vation that will be firmly rooted into your high-performance culture. And you
will have the money and the reputation for superior performance.
Marshall K. Steele, MD
In the early 90s, after being a sports medicine orthopedic surgeon for 15 years,
my partners and I decided to subspecialize. I was chosen to be the total joint
surgeon. I created my own minifellowship for three months and brushed up on
surgical techniques. I returned ready to take on the world, but I soon realized that
I had to deal with a variable that had not been present in my sports practice: the
hospitalized patient.
My sports medicine patients did not have an inpatient stay. The turning point
came one year later when I was “fired” by a patient who had a good surgical
outcome with her first knee replacement but had a poor hospital experience.
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xix© 2013 HealthLeaders Media
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Because of her experience, I couldn’t convince her to let me do her second knee
and, therefore, had to find her an alternative surgeon.
This was a game changer for me and led me to create an entirely different hospital
experience for all our patients. The result was so positive that one of my patients
named it “Joint Camp.” Two individuals were influential in my thinking: John
Barrett, an orthopedic surgeon in Florida, and Regina Herzlinger, as noted above.
Their thoughts, combined with the support of hospital administrators Bill Bradel,
Chip Doordan, Sue Patton, RN, and my orthopedic colleague Stephen Faust,
made this a reality. Lori Brady, RN, and Julie Pastrana, RN, two wonderful
nurses, made it happen. Our goals were simple: create a “wow” patient and
family hospital experience; improve and prove outcomes; and reduce unnecessary
variation, waste, and cost.
Physician alignment, specialized units, effective leadership structures, account-
ability, creative delivery systems, metrics, and a performance culture were cre-
ated. Our results were extraordinary: We improved the patient experience, family
participation, quality of care, and profitability. The out-migration of the past
became in-migration as we doubled market share and increased volumes from
200 to 1,800 total joint replacements. Perhaps more importantly, these programs
led to much better physician-physician and physician-hospital collaboration. We
created similar successful models in all the surgical services at Anne Arundel
Medical Center. As a result, Anne Arundel expanded its number of ORs from
6 to 26.
xx Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media
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These successes were noted both domestically and internationally. More than
250 hospitals visited us to observe the program. We even provided the visitors a
manual with detailed program implementation outlines. However, postvisit surveys
by a college student I hired revealed that few hospitals were able to implement this
model themselves. This wasn’t surprising. A few years ago, I came across an article
from Harvard Business Press that stated 90% of all well-formulated strategies fail
due to poor execution. There were many reasons for the lack of success:
• Hospitals lacked knowledge of all the elements required to build a suc-
cessful service line
• Current staff members were too busy
• Hospitals did not have expertise in project management
• There was no physician champion
• Hospitals tried to improve incrementally
• Hospitals implemented only parts of the program
These were all common roadblocks. The hospitals failed to realize that we were
advocating transformation, not reformation of their old systems. Many of you
reading this book run the risk of making the same mistake.
My college intern encouraged me to develop an implementation company. When
building a destination center, principles and people must be synchronized with
structure and processes to achieve optimal results. This is the only way to
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xxi© 2013 HealthLeaders Media
Prologue
transform care. In 2005, I retired from surgery after 31 years and launched
Marshall Steele & Associates with Judy Jones.
Judy E. Jones, MS
I was a former hospital corporate executive who managed and oversaw service
lines, starting with bariatrics. The power of this focused approach was evident to
me. I then began working in orthopedics, providing tools and materials to hospi-
tals to help with their systems and marketing. I realized that marketing and
educational materials were only part of the solution. And what I was doing wasn’t
enough. Superior care wasn’t marketing. We needed to take a much more clinical
and metric-driven approach to create value. I met Dr. Steele, who was the chair-
man of my company’s advisory board at the time. He had my same vision, and so
we started our implementation company. We knew that we needed a team of
experts who had implemented programs successfully; therefore, we created our
team to help other hospitals achieve their vision.
Our Question
One question we both had: Could we make a significant impact in hospitals
without actually being full-time employees there? With unbelievable support from
our clinical project managers, the answer has been a resounding “yes.”To have
any chance for success, we realized that we needed to launch an implementation
company—not a consulting company. Implementation is possible, and improving
patient experience and quality and reducing costs can be done. Using the four A’s
xxii Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media
Prologue
approach—assess, architect, assemble, and assure—we have now accomplished
this in more than 180 hospitals.
Stryker
Our company was acquired by Stryker Corporation in October 2011. Stryker is a
medical device product company that is in every hospital in the United States. It
provides everything from beds to video equipment to implants. Stryker realized
that to be successful, it needed to help its hospitals and surgeons succeed.
Therefore, it began a services division to partner with hospitals and surgeons to
deal with some of their most pressing needs, especially related to orthopedics and
spine. This is a model that many other product companies in other industries have
pursued, the most notable being IBM. We became part of Stryker’s services
division, and it has been well received by hospitals and surgeons.
Great People, Poor Systems
Traveling the country and visiting hospitals has only strengthened our respect for
and belief in the absolute desire of physicians, nurses, allied health professionals,
and administrators to do the right thing. Healthcare is full of great people, but
our systems and culture are lacking. Sometimes these great people just haven’t
been exposed to “the why,” “the how,” and “the what.”
All of us need ideas, support from others, and effective tools to be able to be
successful and bring greater value. We are still learning. The ideas in this book
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xxiii© 2013 HealthLeaders Media
Prologue
come not just from us and our experiences but from the experiences of a variety
of other people in a variety of roles.
This book is all about some of “the whys,” “the hows,” and “the whats” to create
systems to accomplish this. Working together, we can transform healthcare and
make it better for our patients, for our staff, and for ourselves. We hope you will
join us in being part of this transformation.
Marshall and Judy
DownloaD your MaTErIals now
Sample tools and documents from this book, as well as additional content not
featured in this book, are available online at the website listed below. This is an
additional service provided by HealthLeaders Media. Additional material includes:
• Operating room best practices
• Medical device relationships and managing supply costs
• Creating a destination sports medicine program
• Creating a hand or foot/ankle destination center
• Applying Lean to your service line
• Understanding the differences between administrators and physicians
• The importance of leadership
Thank you for purchasing this product!
Website available upon the purchase of this product.
Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition 1© 2013 HealthLeaders Media
Lessons About ServiceLine Development
C h a p t e r 1
Creating and managing effective service line organizations inside hospitals is a
difficult, often thankless job. Finding the time between the crises of the day to
work on something that requires so much focus, persistence, and managerial
courage is not easy to do. Along the way, you will find plenty of reasons and
opportunities to abandon the project. Your supporters will be few and largely
silent, while your critics will be legion. Even so, the rewards are ultimately worth
the effort; and your patients, teammates, and surgeon colleagues will be the
better for it—so don’t give up!
I am from the South, and people who are raised in the South communicate and
learn with stories. I grew up around some world-class storytellers and very much
admire the skill. Stories provide a rich visual imagery that makes a lesson easier
to understand and to remember. And so, I have selected a few stories I have
collected over the years in my work helping hospitals in service line development.
Some are true, some are “almost true,” but all have been important to my under-
standing of people and processes in hospitals.
Contributor: Greg Wheat
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Funny Thing About Blue Crabs…
I live in a place referred to as the “Redneck Riviera,” Panama City Beach, Fla. It
is truly a great and beautiful place to live, especially in the spring and fall. In late
summer, blue crabs come into the shallow water on the beach to mate, and
sometimes there are hundreds of them, scuttling around your feet in the clear,
blue-green water.
About this same time, the beach is covered with tourist families from all over the
Southeast. However, there is also a television phenomenon called “Shark Week,”
which often coincides with this same time in the summer. As a result, many of the
kids are afraid to go into the water, having watched “Shark Week” on the hotel
TV the night before.
One day, I saw a young boy defying the odds, waist-deep in the crab (and shark)-
infested waters of the Panama City Beach Gulf. He had a white mesh net on a
long wooden pole, and he was chasing blue crabs around his feet with the net.
When he would catch one, he shouted a triumphant victory shout and crab-
walked out of the shallow water to a white plastic 5-gallon bucket on the sand,
just above the surf line. In plopped his prize catch, and back to the water he went,
on the hunt for more blue crabs.
I watched him for a while, impressed with his enthusiasm and enterprise and
mostly impressed that he was the only kid brave enough to be in the water during
“National Shark Week.” Another thrust of his net, another hapless blue crab, and
he was off to the beach to secure his prize in the white plastic bucket.
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Finally, while he was searching the waters just in front of my beach chair, I had to
ask, “Son, you are doing a great job catching those crabs; but, after all your hard
work, aren’t you afraid they will just get away? There is no lid on the bucket.”
Leaning on the long wooden net pole, he looked up at me and smiled a knowing
smile. He shook his head and said, “No, sir. You see, I’ve learned something about
these crabs. Just about the time one claws his way to the top and almost climbs
out, the other crabs grab him by the legs and drag him back into the bucket.”
There is a fundamental law of gravity in healthcare—maybe in most industries—
that makes it very hard to step outside the box, to try to do things a different
way. There is an army of your colleagues who will give you 1 million reasons
why your idea won’t work: our patients are different, our surgeons are different,
our market is different. They will find ways to “pull you back into the bucket”
to that narrow band of mediocrity that unfortunately characterizes most
organizations.
Perishability
I am told by orthopedic surgeons that many of their total joint patients play
golf and that returning to the golf course, free of pain, is a big incentive—and
concern—for these patients. I met a terrific and very affable surgeon in Sydney,
Australia, who came up with a unique twist on this idea.
He called me one day, very excited, and told me he had created a successful
process within his joint replacement program.
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“It’s called ‘patient-accelerated rehabilitation.’ Don’t you get it, Greg? PAR!”
After surgery, the physical therapists roll out one of those carpeted putting greens
on the nursing unit, and the joint patients have golf putting contests.
“The patients really love it! Visitors even come from around the hospital to watch.
It gets the patient out of bed and feeling better, and now when they ask how soon
they will be able to play golf again, I tell them, ‘The day after surgery!’”
I told that story to many hospitals and several actually adopted the idea, with
similar results. One day, a marketing director in a large Florida hospital asked me
if I thought the idea would work for patients who had undergone open heart
surgery. She told me that the heart patients also were very focused on returning to
normal activities, and something like this may reinforce that feeling of wellness. It
sounded like a good idea to us both, so the program was instituted for the heart
patients one month later.
The results were incredible. Again, patients loved the activity and socialization.
Family members and even visitors from other parts of the hospital came to watch
these patients, who were recovering from major heart surgery and putting golf
balls down the hallway of the nursing unit. One of the 10 largest newspapers in
the country printed a full-page story with color photographs about the hospital’s
novel way of recovering these open heart patients. The hospital had never received
such accolades and publicity for its program. It was just fantastic!
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Now, my confidence level was over the top. At every opportunity, I told the story
to hospitals and encouraged them to implement similar programs. PAR programs
were springing up all over the country.
Then, one day about one year later, I ran into that same marketing director from
the heart hospital. I could not wait to ask her how the program was going,
anxious to hear more great success stories.
“We had to stop doing the golf putting program,” she said, to my astonishment.
Now, every fear imaginable started creeping into my head: Had someone gotten
hurt or suffered some terrible complication as a result of the program? Little
beads of sweat started popping out on my forehead as I thought of all the hospi-
tals I had encouraged to implement this program.
“I thought it was going great. What happened?” I asked, not really sure I wanted
to know the answer.
“Oh, it was going very well, but the nurse who owned the putter left the hospital.”
The greatest threat to successful programs in hospitals is perishability. Often, the
most trivial detail can derail even the best programs unless the hospital leader-
ship keeps an eye on the ball. Staff changes, tight budgets, and new initiatives all
can cause months’ or years’ worth of effort to go by the wayside. Keeping a
service line program alive requires daily discipline and reinforcement. It requires
commitment and attention from administration, surgeons, and from your staff.
It is a journey, not a destination!
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Bamboo
Bamboo is a remarkable plant. It grows in humid, semitropical areas and is used
for many commercial purposes after it is cultivated.
In the early spring, the bamboo seeds are planted in long rows. The rows are
fertilized and watered every day of the growing season, and the farmer pulls the
weeds and cultivates between the rows during the season for that first year. And
nothing happens.
The next spring, the farmer pulls the weeds and cultivates between the rows. He
waters and fertilizes the rows every day of the growing season in the second year,
and again nothing happens.
In the third year, again, the farmer pulls the weeds and cultivates between the
rows. He waters and fertilizes the rows every day of the growing season. You
guessed it—nothing happens.
This process continues every spring for five years. The weeds are pulled and the
ground is cultivated between the rows. The farmer waters and fertilizes the rows
every day of the short growing season; still, nothing shows above ground.
In the spring of the fifth growing season, the farmer pulls the weeds and culti-
vates between the rows. He waters and fertilizes the rows every day, and in two
weeks, the bamboo grows to be 40 feet tall!
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Now, the question is, “How long did it take the bamboo to grow 40 feet?” The
correct answer is five years. If at any time during those five years the process was
not followed exactly, without fail, there would have been no harvest in year five.
We are creatures who crave immediate satisfaction. Perhaps in healthcare, the
condition is worse, particularly among surgeons, who tend to be creatures of the
moment, with little patience. Unfortunately, process change often requires an
investment of time to nurture, germinate, and bloom. Progress is sometimes slow
and hard to discern. However, if we become frustrated and lose sight of the
mission, sometimes all the work done is wasted. It is critical to keep the vision
and to continue nourishing the change, even with baby steps, to ensure that
success is on the horizon.
Is It Really That Simple?
One day, I was touring a joint center with a group of administrators and surgeons
from a hospital in the Netherlands who had traveled to the United States to learn
and understand the elements that made this program so successful, so they could
implement them in the Netherlands. Their country had recently enacted legisla-
tion requiring standards in patient satisfaction. They had read about the incred-
ible results in patient satisfaction achieved by these centers and were anxious to
find the “secret sauce” that was responsible.
Like all good scientists, administrators, and bureaucrats, they came looking for
complex processes, systems, and perhaps even technology that was the real reason
behind why this joint center enjoyed such great success financially, clinically, and
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from a patient satisfaction perspective. They were taking copious notes (in Dutch)
as they toured the operating room (OR), the post-anesthesia care unit, and the
other clinical areas of the perioperative suite. I think, too, they were probably
more than a little skeptical of this “American” phenomenon and might have liked
nothing better than to find some reason to debunk the myth of its success.
We walked onto the patient floor where all the total joint patients spent the
three- to four-day recovery period after surgery. (I know that sounds like a long
time, but keep in mind this was the late 1990s.) There was one small, elderly lady
sitting in the waiting room, reading a McCall’s magazine. As she saw this troupe
of “suits” walk past the waiting room door, she looked up, and her glasses fell
down low across her nose. We all politely spoke and smiled as we crossed the
doorway, and she spoke to us.
“You know, Dr. Williams did a knee replacement on my left knee two years ago
in this very hospital,” she said.
My group all smiled and nodded approvingly, and then one of the “scientists”
could not resist—he asked the question.
“And, so, how is your knee doing?” he asked.
Now, our group looked like one of those E.F. Hutton commercials from the
1980s. Everyone leaned into the doorway, hoping to hear some comment (prob-
ably bad) that would throw a little bucket of reality on this joint center phenom-
enon. I really think they were expecting to hear a long diatribe of complaints,
complications, and criticism from this patient. But they did not.
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“Oh, my knee did fine; I was up and walking the next day. But, did you know,
after my surgery, they sent a girl to my room to fix my hair? It was just wonder-
ful. My husband, Henry, is in the OR right now. Dr. Williams is replacing his
hip,” she said.
One of the Dutch surgeons turned to me and asked sincerely, “Is it really
that simple?”
We don’t concentrate enough on delivering value to our customers in the lan-
guage they understand. Never underestimate the power of simple gestures of
kindness and paying attention to the expectations of our patients. By institution-
alizing a few of these simple gestures, often we can produce landslides in results
from how our patients perceive their experience. Imagine how many people the
patient in the story above told about her experience over the years. The knee
surgery itself was almost a given; it was the other human touches that made the
experience memorable.
These Patients Have Really Changed
During my career, I met orthopedic surgeons who constantly looked for ways to
enhance the patient experience in ways that created value for the patient, the
caregiver, and the hospital. One of those ways was to defy the conventional
wisdom of meals being served on over-bed tables in the patient rooms. The idea
was to get all the patients out of bed and let them meet for lunch in a group room
with other patients and family members. It was felt that socialization was a great
way to combat the anxiety and depression after surgery and that the sheer act of
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getting out of bed and walking to the group room for lunch offered great clinical
benefit for the total knee and total hip patients in the practice. Sounds obvious
and easy, right?
Each week, I met with Susan, the nurse manager of the orthopedic floor, and told
her about our surgeon’s vision to get all the patients up at mealtime, go to the
group room, and have meals together. Susan was incredulous, to say the least, but
agreed to give it a try. I planned to check on the results on Thursday of the
following week.
“How many joint patients do we have on the unit this week?” I asked Susan.
“Six.”
“How many got out of bed to have lunch in the group room?” came my next
question, with a hopeful smile.
“None, I’m afraid,” was Susan’s answer.
“Not even one; what happened?”
“Mr. Smith was just too stiff. Mrs. Jones was sleeping most of the time, and
Mrs. Johnson just refused and wanted her tray brought to her. Several patients
said they were feeling nauseated. The rest just did not want to do it.” What had
we not done to set the expectation for these patients?
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The next week, the same dialogue was repeated, with pretty much the same
results; however, the nurses were able to get two patients to group lunch. “Great
work,” I told Susan. “Let’s keep trying and see if we can do even better.”
Each week, we were successful at getting one or two more patients to the group
lunch with lots of expectation setting, education, and a little prodding, until at about
the ninth or tenth week, Susan was able to say, “All 12 patients on the unit were
able to go to group lunch today. You know, these patients have really changed!”
Had the patients really changed or just the way we looked at the patients? More
importantly, had we done a better job of setting expectations for the patients:
namely, that group lunch was an important part of the clinical process and
would help them recover more quickly?
Change Is Hard: Yellow Crime Scene Tape
Today, thanks to the innovation of many far-thinking surgeons, physical thera-
pists, and nursing care coordinators, group exercise class for total joint patients
has become a standard of care. The patients enjoy it and invariably do better in
their recovery, and it saves countless dollars for the healthcare system and over-
burdened physical therapy departments. But it was not always that way.
Historically, and even today in many hospitals, physical therapy after joint
replacement is performed individually at the patient’s bedside. Normally, there are
two sessions per day, lasting about one hour each.
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There is nothing clinically wrong with this approach; however, there are prob-
lems. There has always been a chronic shortage of physical therapists in the
hospital, resulting in unpredictable therapy sessions for joint patients. Patients
who miss therapy become stiff and, often, continuous passive motion machines
are used to replace active bedside therapy.
The advantages of group therapy sessions are many. Most importantly, the
patients really enjoy it and the socialization with other patients and family mem-
bers and the friendly competition help them improve quicker. In this scenario, it
takes only one or two therapists to provide therapy for 10 to 12 patients simulta-
neously, saving enormous staff time and cost for the department.
But change is hard. Many years ago, at one of the first hospitals to try the group
exercise concept, a few upset members of the physical therapy department actually
wrapped yellow crime scene tape around the door to the group room to show their
contempt for the new process. However, our team persisted in insisting that the
group concept was an important part of the program. The staff agreed to try it for
a couple weeks. Thankfully, that attitude has dramatically changed and physical
therapists are now always among the most vocal supporters of the program.
A friend of mine said, “You can tell who the pioneers are. They are the ones with
the arrows stuck in their backs.” They are the leaders and everyone else is trying
to catch them.
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Napoleon’s Mail
I have been told that Napoleon Bonaparte opened his mail only every two weeks.
He did this for a specific operational and strategic purpose: He believed that his
time was precious, as the leader of an enormous empire. He believed he could not
afford to be distracted by the minutia of the day or week but should confine his
time and attention to those things that required his specific involvement.
Therefore, he opened his mail only every two weeks, assuming that anything that
truly required his personal attention would not be jeopardized by a two-week
delay. Anything that required action within two weeks should be attended to by
his lieutenants; after all, that’s what lieutenants were for.
Now, I don’t know if any of us can imagine waiting two weeks to open our email.
Unthinkable. But are we truly becoming more efficient, or are we just being
dragged into the minutiae that Napoleon felt was not worth his time and effort
and could be handled by his lieutenants?
Perhaps we could learn a little lesson from this story about priorities and delega-
tion. Too often we become consumed by small things, either because they are
easy to respond to, or because some of the bigger issues are just too daunting. As
a result, we sometimes accomplish lots of tasks that could have been resolved by
others, while the issues that demand our personal attention languish.
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It’s All in How You Look at It
There is a story from World War II about a commander in the field who found
himself totally surrounded by the enemy.
It was the winter of 1944 in the Ardennes Forest. His command was running low
on ammunition and food. He finally made contact with his headquarters, who
asked for a report on his immediate situation.
“The enemy has just landed fresh paratroops to our north. On the south, there
are two enemy divisions of heavy artillery and tanks. To the west, I just learned
that reinforcements have joined the three divisions of infantry already in the field
against us; and to the east, I can see the enemy with heavy fortifications and
preparing an assault.”
“Good God,” came the response from headquarters. “Your situation sounds
hopeless!”
“No sir, not at all. I think we can successfully attack in any direction.”
Unfortunately, our world in healthcare seems to continually add more adversity,
more regulation, more challenges to success for our organizations and even for
our patients. There is not much support for stepping outside the box and not
much reward for taking on new responsibilities. However, there is a satisfying
and career-enriching feeling associated with at least trying to make a difference.
Our world is a “target-rich environment” of challenges, both short term and
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long term. Accept this as just the way it is, and relish the chance to take it head
on. We, too, can pretty well successfully attack in any direction, so stay positive.
A Confused Mind Always Says “No”
One day, I went shopping for an electric piano. I could play a pretty mean guitar
but was looking to broaden my musical horizons by learning piano. I walked into
a music store in Largo, Fla., not necessarily where one might seek the wisdom of
the ages, but it was here I learned a lesson that has stuck with me for 20 years.
I only wished I had learned it 20 years before.
A salesperson with long black hair and an encyclopedia of tattoos across his arms
and shoulders greeted me in the keyboard section of the store. He wore a Van
Halen t-shirt that was faded from too many washes. He had a great, friendly smile
and must have been a drummer, because he couldn’t stand still; his fingers tapped
a rhythm on the counter while he moved to some imaginary rhythm in his head.
“I’m looking for a keyboard,” I said, interrupting his drum solo.
“Cool. Do you want weighted keys or nonweighted? Do you need midi input and
recording line outputs? Are you looking for monochromatic or polychromatic? I
mean, do you want something for recording or for, like, the road?”
I stopped for a moment and tried unsuccessfully to decipher what the sales/rocker
was asking me. “I . . . I just want a simple keyboard that I can play basic stuff.
In fact, I’m sorry, but I really don’t even understand the questions you were
asking me.”
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The salesman paused and took a step back. He stroked his four- or five-day
scraggly beard with his heavily-ringed fingers and said one of the most profound
things anyone ever said to me.
“You know, I’ve noticed that a confused customer always says no.”
When human beings are confronted with complexity, their natural instinct is to
just shut down. Too often, we overwhelm our patients and our staff with com-
plexity that we think of as patient education or “informed consent.” Healthcare
is also a sales position. We are constantly trying to convince patients and our
colleagues to do things they may not want to do. It is our responsibility to
deliver the information and the mission in a way they are not threatened or
confused by. As the saying goes, “If you want something to be successful, you
need to get it low enough for the ponies to eat!”
Ritz Carlton Towels
There is a great management story, which I am told actually happened in a Ritz
Carlton hotel many years ago. This hotel was having chronic complaints about
the room service food arriving cold at the guest rooms. Given the reputation for
excellence that Ritz Carlton fostered, this was totally unacceptable. And so they
brought in all manner of consultants and food service specialists to diagnose and
solve the problem.
They checked the delivery carts for insulation value and measured the tempera-
ture of the food as it left the kitchen. They checked the thermostats and heating
elements in all the ovens to make sure they were perfect and even measured the
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distance each cart had to travel from the kitchen to the guest rooms. They timed
and measured each food type’s ability to hold heat and evaluated the menu
choices for their heat-holding potential. They evaluated new insulated plate
holders and tray systems that used hot water to keep plates hot during delivery.
Still they got complaints about food arriving cold.
One afternoon, the hotel manager was standing outside the kitchen, near the
service elevator, where a room service clerk was waiting with a room service cart
to deliver to waiting guests.
“I just can’t understand why the food gets cold before it gets to the room. We
have studied everything in the kitchen and can’t find an answer,” grumbled the
manager, a little under his breath.
“We need to put more towels in the guest rooms,” said the room service clerk.
“I beg your pardon?” the manager asked the shy clerk.
“Yes sir, if you just put more towels in the guest rooms, the food wouldn’t be
cold. You see, we get calls all day from guests wanting additional towels, which
housekeeping is constantly delivering to the floors. Because there is only one
service elevator, housekeeping ties up the elevator, and we have to wait a lot, so
the food gets cold.”
The manager immediately began stocking guest rooms with extra towels, and the
complaints about cold food stopped literally overnight.
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Often in hospitals, the problems and solutions are not completely linear in
nature. Processes and systems in healthcare are incredibly convoluted, with lots
of overlap and many unintended consequences. Sometimes the solution to an
operational problem is not obvious. There are two lessons in this story. First,
make sure to spend lots of time talking to the folks who actually do the work, to
see what they think; and, second, don’t assume that the answer is obvious and
that only the most obvious solutions are the correct ones.
The Perfect Pot Roast
When I was young and first married, my bride and I moved into our first house
together. Anxious to impress her new husband, my wife wanted to cook my
favorite meal, which was a special beef pot roast, the way my mother had cooked
it for me all my life.
Just to be sure she got the recipe exactly right, Ann called my mother to double-
check how she had prepared that famous pot roast I had bragged about. “First
thing you do,” my mother coached Ann, “is to take your pot roast, cut it in half,
and put it in two separate roasting pots, and then you start to add your
seasonings.”
“Two separate pots? Why do you cut the roast in half and put it in two pots?”
Ann quizzed my mother.
“Well,” she said, “I don’t know for sure, but I learned the recipe from my mother,
and she always taught me to do it that way when I was a little girl. And her pot
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roast was the best I ever tasted. But now you’ve got me curious. Let’s call her and
ask why she always cut the roast in half before she cooked it.”
Later that afternoon, my mother and Ann finally got my grandmother on the
phone to solve the mystery of her famous pot roast recipe. “Mother, you
always taught me to first cut a roast in two and put it in separate roasting pots
before cooking it, and you made the best pot roast ever. Why did you always cut
it in half?”
“I never had a big enough pot,” she said.
Many times in hospitals, we carry on processes, procedures, or systems simply
because we have always done things that way. There seems to be a built-in
cynicism toward change for any reason that makes it hard to change ingrained
practices, even though, often, no one questions the origin of those practices.
Sometimes, maybe quite frequently, the reasons for the practice may have been
valid at one time but have long since gone away. Sometimes it pays big dividends
to question the original reasons for why we do things the way we do, just to
make sure those reasons still exist.
Don’t Bruise the Tomatoes
Hospitals are funny places. There seems to be sometimes a competition among
managers and staff to outdo each other for finding the most esoteric reasons that
something won’t work. It is truly amazing how many details smart folks can
dredge up to make what initially seems like a great idea turn into a good idea.
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After a little more discussion, it becomes a marginal idea or maybe a bad idea.
If the conversation continues long enough, invariably the idea will metamorphose
into a terrible idea, and the group will disband, satisfied they have avoided once
again the need for change.
It reminds me of folks in the vegetable section of the market, searching for a
perfect tomato, because they need only one. In the process, they will pick up and
handle a dozen or more, turning them this way and that, and squeezing them from
every angle, looking for exactly the correct degree of ripeness. This one is a little
too green, this one is a little too ripe, this one is too small, and these are too large.
In the process, a dozen or so perfectly acceptable tomatoes are bruised, ruined, and
discarded in the quest for one that is perfect, which invariably can never be found.
Sometimes in our quest for a perfect solution to a problem, we overlook several
good solutions that may lead us to success. It is tempting in group think to
disqualify ideas that don’t fit everyone’s concept of perfection. Too often, the
result is organizational paralysis and nothing is gained, because a universally
acceptable solution never surfaces. Great ideas are almost never perfect but
should not be neglected because we have “bruised” them with too much analysis.
Sometimes, we need to just move ahead and adapt as needed to reach the goal.
Summary
There are lots of lessons to be learned here. We all need to read and reread this
section so that we can clear our mind of the confusion we face every day.
ORTHOPEDICS AND SPINE
Innovative Strategies for Service Line Successby Marshall K. Steele, MD | Judy E. Jones, MS
The next 5–10 years will see huge changes in healthcare delivery as value, not volume, is rewarded. Most hospitals and physicians are not organized for superior performance in this environment. The principles in the book—written by a team of diverse medical professionals who have been in the trenches themselves—have been tested and proven in over 200 orthopedic and spine destination centers of superior performance around the world.
Since the first edition of Orthopedics and Spine, there have been major changes in healthcare. This book addresses how to overcome the challenges associated with these changes, such as:• Understanding the future of healthcare • Preparing to take on risk • Proving value• Bridging the hospital-physician gap• Addressing the on-call crisis• Incorporating Lean and its culture into everyday hospital practice
This edition also contains chapters dedicated to physicians and administrators sharing their personal experiences to illustrate the importance of patient-centered care, the challenges of change, communicating effectively, the need for simplicity, and how to stay positive through it all.
For more on HealthLeaders Media’s complete line of healthcare leadership resources, visit www.healthleadersmedia.com.
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