PEER-REVIEWED RESEARCH Patient-and Family-Centered Care Initiative – Implementation at the Medical College of Georgia

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    Abstract
    In 2003 the Department of Neurosurgery at the Medical College of Georgia embraced the institution-wide patient- and family-centered care plan in an attempt to improve productivity and patient satisfaction and reduce hospital costs. This initiative included the creation of a neuroscience center with large state-of-the-art rooms that can serve as floor or intensive care unit beds and that can offer unrestricted patient visiting hours and a family resource library. A bed management board composed of neurosurgery faculty and residents, rehabilitation professionals, social workers, and nurses was established to provide a multidisciplinary approach to patient care. Input from all members of the team is considered and utilized in creating therapeutic and discharge planning for every patient. The patient plan then is discussed with individual patients and their families at regular intervals. Following implementation of these new principles in the Department of Neurosurgery, patient satisfaction increased from average scores of 79.2 percent in 2002 to 84.6 percent in 2004. The average length of stay decreased from 6.58 days in 2003 to 4.59 days in 2005. Elective admissions increased from 35.1 patients per month in 2002 to 52.3 patients per month in 2005. With the evolution of medicine into a multidisciplinary business, cost, productivity, and patient satisfaction must be integrated into the healthcare process. The implementation of the patient- and family-centered care plan has increased the number of patients cared for in the department, decreased the cost of hospitalization, and improved the quality of care received by each patient.
    Introduction
    In 2003, the Department of Neurosurgery at the Medical College of Georgia embraced the institution-wide patient- and family-centered care plan in order to increase productivity, decrease cost, and improve patient satisfaction. Implementation of this plan included the creation of a neuroscience inpatient and intensive care unit with input from patients and their families, nursing staff, and physicians. In addition to regular information gathering rounds conducted by residents and faculty, a bed management board was established. This group of neurosurgery residents, social workers, charge nurses, physical therapists, occupational therapists, speech therapists, and neurosurgery faculty members, who preside over the meeting, assembles once a week to discuss each patient’s care.

    The universal rooms serve patients in intensive care, stepdown ot floor status.

    Methods
    The bed management board convenes once every week to discuss all aspects of patient care on an individual basis. Input from all members of this multidisciplinary team is considered and utilized in creating therapeutic and discharge planning for every patient. This information is then discussed with individual patients and their families at regular intervals.

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    A new multimillion-dollar neuroscience center was created with the needs of physicians and patients in mind. This has included a neurosurgery intensive care unit with universal rooms that can serve as intensive care, stepdown, or floor beds (Figure 1). All rooms are spacious and equipped with couches and foldout beds, an arrangement that allows family members to remain with their loved ones during hospitalization and visiting hours to be eliminated. (Figure 3). In addition, a resource center was created with Internet access and information pamphlets for patients and their families.

    Administrative records for the Department of Neurosurgery adult section were reviewed from 2002 to 2005. These records were kept and organized by the department’s business administration office. Length of stay for patients on the floor and in the intensive care unit was evaluated. Average cost for an intensive care and floor bed is estimated to be $1,400 and $800 per night respectively at our institution. Patient satisfaction scores also were reviewed for this period. Patients were given questionnaires prior to discharge allowing them to rate their overall hospital experience on a scale of 0 to100. This scale represents the overall satisfaction of the services received by patients during hospitalization each month. The number of participating patients varied monthly from approximately 40 percent to 80 percent.

    Results

    Patient Satisfaction and Volume
    Analysis of patient satisfaction scores and patient volume was performed. The mean patient satisfaction score in 2002 was 79.2 percent (low 64.6/high 87.1). For 2003 the score increased to 81.8 percent (low 70.3/high 89.8). During 2004 the mean patient satisfaction score again increased to 84.6 percent (low 76.3/high 88.2). With the exception of a score of 76.3 percent, all other scores were above 80 percent in 2004. It is important to note that movement of these percentage points indicates real process improvements and not statistical aberrations. During this same period our elective admissions increased from 35.1 patients per month in 2002 to 52.3 in 2005. Our elective admissions for 2003 and 2004 were 42.3 and 49.5 patients per month respectively (Figure 2).

    Both average patient satisfaction scores and average patient volume trended upward from 2002 to 2004. The percentage of increase in average patient satisfaction scores was 6.8 percent between 2002 and 2004, and the percentage of increase in average patient volume was 41 percent for the same period.

    Patient Length of Stay and Hospitalization Costs
    Patient length of stay was reviewed from January 2002 to September 2005. The average length of stay initially increased from 5.72 days in 2002 to 6.58 days in 2003. Average length of stay continually decreased after 2003, to 5.34 days in 2004 and to 4.59 days in 2005 (Figure 4).

    Spacious rooms with seating and foldout beds allow family members to stay with patients, eliminating the traditional visiting hours.
    A Kruskal-Wallis test was performed to determine whether any differences exist between the length of stay medians for years 2002 to 2004 (Figure 5). Since there was a significant difference between the three years, three Wilcoxon tests were performed to determine where the differences were located (Figure 6). Statistical significance was determined at p < 0.05 for the Kruskal-Wallis test, and a Bonferroni adjustment was used to obtain a familywise error rate of 0.05 for the three Wilcoxon tests. A Wilcoxon test was considered statistically significant when the p < 0.05/3 = 0.0167. Statistical significance was noticed for the data between all three years.

    The maintenance cost of hospital beds used for our center was $2,642,640 in 2002, $3,647,952 in 2003, $3,453,912 in 2004, and $3,150,576 in 2005.

    Discussion

    Background
    Neurosurgery historically has been a specialty of few practitioners. Every year fewer than 160 individuals enter neurosurgery residency programs (2). Recently, economic and legal pressures have led some neurosurgeons to change where and how they practice or to opt for early retirement. As the number of neurosurgeons practicing in community facilities has decreased, the volume of patients at academic centers has increased. In the past, a strategy for handling increasing workload was to have neurosurgery residents spend more hours in the hospital. However, with the introduction and enforcement of the 80-hour resident workweek in 2003, residents are no longer able to compensate for the expanding volume of patient care with longer workdays.

    Patients have become much more informed about their healthcare due in part to the widespread availability of the Internet beginning in the 1990s. Information regarding specific illnesses and therapeutic modalities is widely available. Individuals also are able to compare physicians, programs, and hospitals throughout the country. With the availability of all of these resources, patients and their families have come to expect more from their physicians and their hospitals. Today many patients and their families prefer to take an active role in the daily decision-making process of their healthcare. However, many patients are frustrated with the healthcare system. Bruster et al. demonstrated this frustration in a national survey of hospital patients published in 1995. More than 5,000 patients were interviewed at 36 different hospitals. The main complaint was lack of communication by physician to patient. Fifty-six percent reported that they had not been given written or printed information regarding their medical status or discharge summary at time of release from the hospital. Another 70 percent stated that they were not informed of any warning signs or symptoms related to their illness at time of discharge (1).

    A New Approach
    In order to provide excellent healthcare and increase patient satisfaction in a framework of an 80-hour resident workweek, we created a patient- and family-centered care plan. Utilization of universal beds allows patients to remain in one location throughout their hospital course as they progress from an intensive care unit setting to a floor setting. Creation of a resource center allows patients to actively search for information regarding their ailment, empowering them to participate fully in their healthcare. The incorporation of a multidisciplinary approach to patient care has formalized the process for medical personnel to include the patient and the family in the healthcare process. During bed management meetings, neurosurgery faculty and residents, nursing staff, social services, and rehabilitation services all convene to outline treatment and discharge planning for each individual patient. Simultaneous input from this multidisciplinary team allows fragmented goals from each group to coalesce in a comprehensive treatment plan.

    In this manner hospital and discharge planning for each patient is clearly defined and understood by each member of the multidisciplinary team. Each provider is aware of the ultimate goal and the contributions from each team member to obtain that goal. The team member is then able to tailor his or her objectives in the context of the team plan in order to achieve the set goals. This plan is then communicated to patients and family members by residents and faculty. In addition, because each member of the multidisciplinary team is aware of hospital and discharge planning, this information can be relayed to patients and families by multiple individuals. This allows for greater efficiency in patient management.

    FIGURE 5
    Results of Kruskal-Wallis Test
    Kruskal-Wallis TestTest Statisticsp Value
    2002 vs 2003280258.50.0003
    2002 vs 2004359253.50.0122
    2003 vs 2004496768.5< 0.0001
    FIGURE 6

    Pairwise Comparisons of Three Years
    With Wilcoxon Tests

    Chi-Square Test StatisticsDifferentialp Value
    39.77842< 0.0001

    Identified Improvements
    Review of our administrative records provides objective support for the idea that a multidisciplinary approach to patient care allows for better delivery of healthcare in a neurosurgical setting. Over the past several years there has been a dramatic increase in the number of patients treated at our institution. With the utilization of our new neurosciences system, we have been more efficient in taking care of these patients. This is evident in the decreased length of stay over the past several years. Taking into account the cost for hospital rooms, decreasing the length of hospital stay for even one day correlates to savings of thousands of dollars annually for hospitals, allowing these resources to be utilized elsewhere. We have noted a substantial decrease of $500,000 in operational costs associated with hospital bed use over the past three years, even though our volume during the same period has increased by more than 15 percent. With implementation of our patient-centered care principles, the quality of care at our institution has continuously improved as is evidenced by the increase in patient satisfaction scores over the past several years. Review of patient comments reveals that our patients were most satisfied with the unrestricted visiting hours and the continuous updates regarding hospital and discharge planning. We are now able to successfully balance an increasing volume of patients within the confines of a shortened resident workweek.

    Conclusion
    With the evolution of medicine into a multidisciplinary business, cost, productivity, and patient satisfaction must be integrated into the healthcare process. With the creation of our patient- and family-centered care plan, we have increased our patient satisfaction and decreased the length of hospital stay for each patient. This has allowed us to take care of more patients effectively with an associated decrease in the cost of hospitalization.

    References
    1. Bruster S, Jarman B, Bosanquet N, Weston D, Erens R, Delbanco TL: National survey of hospital patients. BMJ 310(6984): 938–9, 1995

    2. San Francisco Matching Programs, www.sfmatch.org

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