An Innovative Approach Can Reduce The Cost and Complexity of Delivering Care
Mr. Farris is president and chief executive officer, St. Vincent Hospitals and Health Services, Indianapolis.
The patient-focused care concept is relatively new to healthcare organizations in the United States. Although implementing such a program of care entails a major organizational transition, its rewards benefit staff, as well as patients.
Through its Care2001 program, St. Vincent Hospitals and Health Services, Indianapolis, has shown that patient-focused approaches are successful in:
- Fostering an environment in which care givers can be continually responsive to patient, client, and community needs
- Increasing patient and staff satisfaction
- Improving effectiveness and efficiency
- Fostering an environment that is innovative and open to change
The goals of patient-focused care are to maintain or improve the quality of patient care and reduce the overall cost and complexity of delivering healthcare.
Background
Before Care2001 was implemented, St. Vincent patients had consistently received high-quality clinical care. Throughout its 110-year history, St. Vincent had been continually evaluating its service delivery and working to modernize and improve care. Care2001 is another commitment to that excellence in service.
Care2001 grew from a concern that healthcare delivery at St. Vincent—as at many healthcare facilities—had become too complex. The quality of patient care was good, but it revolved around highly specialized, centralized services. Care lacked continuity, and staff spent more time documenting, coordinating, and scheduling services than they did providing direct care for patients.
In-house studies revealed some unsettling findings. A chest x-ray involved 49 steps and 10 staff members. Of the 87 minutes necessary for the procedure, only 13 were spent in direct patient care. Another finding indicated that a patient came in contact with more than 60 staff members during a five-day stay. Most alarming, less than 50 percent of registered nurses' (RNs') time was spent on direct patient care.
St. Vincent needed a new way to deliver healthcare, one that would improve the quality of care and foster an environment for innovation. Therefore in 1988 St. Vincent, with five other hospitals, participated in a year-long study directed by Booz, Allen & Hamilton. Out of the study arose the concept of patient-focused care—a way to streamline operations and permit staff to spend more time with patients.
Principles of Patient-focused Care
St. Vincent labeled its patient-focused care model "Care2001." The goals of this approach are:
- Move care to patients' bedside
- Increase staff members' care-related time
- Reduce scheduling, transportation, and coordination activities
- Provide greater continuity of care
In Care2001 units, care is delivered as close to patients' bedside as possible. This differs from traditional healthcare delivery systems in which patients are moved to points of service. A laboratory, radiology suite, pharmacy, and electrocardiogram (EKG) equipment are on the unit to allow for swift testing and results reporting. Care givers are cross-trained to do many tasks specialized staff from central departments formerly completed. Facility redesign is often necessary to bring care closer to patients.
Simplifying systems and cross-training staff limit the number of persons coming in direct contact with patients. This enhances continuity of care and care givers' familiarity with patients and enables them to provide care when it is required, not when it is convenient for a central department.
Unnecessary bureaucracy and documentation are minimized, and staff members are empowered to continually investigate mechanisms for simplifying and improving patient care.
Steps to Care2001
As a result of the study with Booz, Allen & Hamilton, St. Vincent determined it needed to develop its own patient-focused care pilot program. The Seton Unit opened in January 1990 as a totally revamped, 44-bed general surgical unit. It took nine months to plan, design, and construct the unit and to train its staff.
The Seton Unit, the first of St. Vincent's Care2001 programs, serves a homogeneous group of patients having general, urologic, plastic, or otolaryngological surgery.
Communication St. Vincent administrators recognized that open communication and strong leadership would be essential to getting the Seton Unit pilot program off the ground. Several administrators who championed the patient-focused care concept saw a need to persuade others within the organization of the value of the patient-focused approach to care. They appointed a multidsciplinary steering committee to oversee Care2001 efforts. That committee appointed a project team to develop the Seton Unit pilot program. The team included managers from the nursing, operations research, educational services, and human resources departments, as well as ancillary departments that would be affected by the changes.
To keep staff informed about the Seton Unit's progress, Care2001 committee members met many times with the medical staff, department directors, and other staff members, focusing on the anticipated improvements in patient care. In addition, key administrators met with community business leaders to tell them about St. Vincent's pilot program and what it would achieve: higher-quality care, higher patient and staff satisfaction, and lower costs.
Participant Characteristics The project team decided what type of patients the unit would serve, who their physicians are, and what ancillary services will be needed.
Facility Redesign Nurse servers, located in patients' rooms, contain daily linen packs, loose linen, intravenous (IV) supplies, syringes, dressings, and other supplies.
Three nurses' substations replace the traditional centralized nurses' station. The substations serve two care teams and are near patient rooms, facilitating care and cutting down on the time it takes care givers to get to patients' rooms.
The unit also contains:
- A small, centrally located laboratory where routine tests are run.
- A centrally located radiology suite.
- A satellite pharmacy, which has an IV hood and sufficient medications to prepare all first doses and change orders.
- A large supply room in a convenient location. It holds a movable supplies cart, used to replenish supplies in nurse servers and backup supplies for the laboratory, the radiology suite, and EKG and respiratory services.
Job Class Reconfiguration
Through personnel studies, St. Vincent found it had 598 job classifications, with an average of 6.2 employees per class. More than half the job categories had only 1 employee.
The Seton Unit uses only five job classifications:
- Unit representative (UR). URs function as business office or administrative support assistants. They preadmit patients by telephone four to seven days before admission. They also process all information during the patient's stay (e.g., coding and abstracting of medical records, precertifying, and recertifying) and provide financial counseling. Four URs support the 44-bed unit.
- Unit support assistant (USA). USAs provide environmental support such as cleaning patient rooms and the unit; ordering supplies and stocking the supply room, nurse servers, and unit kitchen; and maintaining the unit's inventory. They also transport patients. Three-and-a-half full-time-equivalent USAs support the unit.
- Team care specialist (TCS). TCSs are the unit's bedside care givers. TCSs come from a variety of backgrounds, including RNs, licensed practical nurses (LPNs), nurse aides, respiratory therapists, medical technologists, radiology technicians, EKG technicians, and admitting clerks. All TCSs are cross-trained to provide bedside care; make basic chart entries on patient observations; perform other services such as phlebotomy, laboratory tests, routine EKGs, and simple respiratory therapy treatments; and assist with radiology procedures, discharge planning, and patient education.
TCSs are organized into care teams, allowing care givers to spend more time with their patients and better coordinate care at patients' bedside. Each team has three employees (one of whom is an RN). The RN is responsible for directing patient care, supporting other TCSs, and performing functions that require RN accountability, such as assessing patients and planning care. Each team cares for 8 to 10 patients. - Pharmacist. Pharmacists on the unit set all first doses for new patients and for new orders so that patients receive medications and medication changes more quickly than on a traditional unit. They also educate patients about the use of medications and consult with attending physicians. One pharmacist is on duty during each shift.
- Clinical manager (CM). The CM is an RN with a nursing management background who directs all unit activities. All unit staff report to the CM, with a "dotted line" reporting to the appropriate central departments, such as the pharmacy and the laboratory. The CM is also accountable for all unit financial reporting.
Positive Results
The Seton Unit's initial results have been positive. In-house studies indicate the Seton Unit offers better quality care and has increased patient, physician, and staff satisfaction; increased direct care; improved service; and improved cost structure. The Seton Unit was evaluated in eight key areas.
Average Length of Stay Seton Unit patients' average length of stay was 12.5 percent less than that of surgery patients in St. Vincent's traditional surgery unit (4 days versus 4.57 days). For patients over age 65, the average length of stay on the Seton Unit was 4.7 days; average length of stay was 5.6 days on a traditional unit.
Patient Satisfaction Through surveys, anecdotes, and letters of appreciation, patients indicated they felt they had received more direct care from a staff who showed greater concern than on a traditional unit. Patient satisfaction was generally as good as or higher than the overall hospital average. Satisfaction ratings were significantly higher in areas such as overall experience, caring atmosphere, nursing care, housekeeping, and quality of care. Even in areas of the unit where no changes were made, such as dietary, the Seton Unit generally received higher rankings when compared with the hospital average.
Physician Satisfaction All surgeons surveyed indicated they were satisfied or very satisfied with the care their patients received on the Seton Unit, compared with 78.6 percent before the Care2001 program was implemented. Physicians especially appreciated the unit's service in areas such as scheduling, medical records, pharmacy, x-ray, laboratory, and EKG. Ninety percent rated nursing care better or much better on Seton than on traditional surgery units.
Staff Satisfaction
In interviews and questionnaires, staff expressed satisfaction at having greater control over patients' care, a better personal and clinical relationship with patients, expanded responsibilities, and a sense of belonging to a team.
RNs also liked the amount of time they had to plan and manage patient care, the unit's physical changes, and patients' rooms becoming the center of activity. LPNs expressed more satisfaction because they could now do more for their patients.
Technicians felt positive about the cross-training, the job enrichment, and the new challenges. The URs and USAs liked the job enrichment and being an integral part of the unit.
Pharmacists appreciated being a part of daily patient care and being more available to TCSs, physicians, and patients. Pharmacists reported seeing swifter patient improvement because they were able to respond quickly to new and changed medication orders.
All staff reported improved timeliness in reports of laboratory test results, in respiratory therapy treatments, and in responses to changes in patients' conditions. In addition, timely notifications about discharges meant rooms were prepared more quickly, reducing the time patients wait for admission.
Seton staff members also reported that improvements in patient care management, problem solving, and increased efficiency contributed to higher-quality care. Staff believed quality improved because care givers could spend more time with patients and had improved working relationships with physicians.
Quality of Care Clinical indicators such as rates of infection, medication error, patient falls, and IV administration error were lower on the Seton Unit than for a similar surgical unit. Each month, Seton results were below the threshold (a goal based on the past five years' data) and generally were below the results on St. Vincent's traditional surgery unit.
Direct Patient Care A care team spent 60.2 percent of its time giving direct patient care, compared with the 46 percent nurses provided on a traditionally staffed unit. The Care2001 unit provided more staffed hours (7.96 hours per patient day versus 6.2 hours per patient day on the traditional unit). Also, Seton offered 4.79 hours of direct care per patient per day, while the traditional unit only provided 2.85 hours of direct care per patient per day.
Cost Although a complete financial analysis of the patient-focused care concept has not been completed, preliminary estimates indicate it will reduce work hours at least 10.6 percent—perhaps as much as 18 percent—compared with traditional healthcare delivery.
A Flexible, Innovative Environment The Seton project team and staff were empowered to change any operation, procedure, or function that could improve the patient care process. In addition, the entire hospital staff began to recognize that cooperation makes change possible. A new working relationship is developing among departments, focusing all efforts on improving the patient care process.
Implementation on Additional Units
The patient-focused care concept is succeeding at St. Vincent, and the organization is committed to implementing the concept hospital-wide-despite several unresolved issues (see "Unresolved Issues in Patient-Focused Care" at the end of this article). In April 1991 Care2001 expanded to a medicine unit, and in December 1991 the Seton Unit expanded to 88 beds. St. Vincent also introduced a Care2001 cardiac unit in 1991. Earlier this year a Care2001 neurosurgery unit was opened.
By implementing the patient-focused care concept, St. Vincent is overcoming traditions and structures that impede change in healthcare facilities. As a result of Care2001, the organization has developed a new vision statement: "We envision St. Vincent as the leader in caring for body, mind and spirit, building partnerships in health services, education and research, compassionately reaching out to all who need God's healing touch." This new vision not only encompasses the organization's philosophy, mission, and values, it helps focus its strategies by guiding decision making and inspiring action.
SYNOPSIS
Objective St. Vincent Hospitals and Health Services, Indianapolis, implemented the patient-focused care concept, Care2001, to maintain or improve the quality of patient care and to reduce the overall complexity of delivering healthcare, which adversely affected St. Vincent's efficiency. With the streamlining possible using the patient-focused approach, St. Vincent hoped to realize cost savings as well.
Pilot Program In January 1990 St. Vincent introduced the Seton Unit, a patient-focused care pilot program serving a homogeneous group of surgery patients.
Program Design
The Seton Unit required:
- Facility redesign, such as replacing the traditional central nurses' station with nurse substations
- Job class reconfiguration, which established five job classifications: unit representative, unit support assistant, team care specialist, pharmacist, and clinical manager
Results
The Seton Unit initially offered better quality care and increased patient, physician, and staff satisfaction; increased direct care; reduced length of stay; improved service; and reduced costs. After the initial impact of Care2001, satisfaction levels dropped somewhat, necessitating refinements. Satisfaction levels have since improved.
Implications The patient-focused care concept is succeeding at St. Vincent. The hospital has already expanded it to other units and is committed to implementing the concept hospital-wide.
UNRESOLVED ISSUES IN PATIENT-FOCUSED CARE
Although the patient-focused care concept has worked on many units at St. Vincent Hospitals and Health Services, several issues have not yet been resolved:
- Is cross-training feasible organization-wide? What are the limits of cross-training? How will St. Vincent help employees who cannot master all necessary skills?
- How can the organization maintain a cross-trained staff's skill levels and competency?
- Will the patient-focused care concept be an attractive recruitment-retention vehicle?
- How will professional societies and associations respond to the patient-focused care concept?
- Will the patient-focused care concept continue to bring cost savings?
- Can St. Vincent overcome space limitations to expand the patient-focused care concept?
MAKING PATIENT-FOCUSED CARE WORK
Care2001, the patient-focused care concept implemented by St. Vincent Hospitals and Health Services, has succeeded, but not without setbacks. To avoid the pitfalls, St. Vincent suggests the following:
- Commit to a broad vision rather than narrowly focusing on details. Allow staff to develop the "how" to accomplish the vision.
- Establish a clear implementation plan.
- Empower staff at all levels across the organization to be prepared for and to suggest changes.
- Work with professional associations to plan appropriate training to enhance staff members' skills.
- Develop partnerships among patients, physicians, staff, and community.
- Set realistic, flexible time lines for implementation.
- Establish a method for evaluating the program's success.
- Communicate realistic expectations.
- Continue fine-tuning the patient-focused care concept.