Throughout the United States, hospitals are striving for quality improvement (QI) by partnering with patients and their caregivers to continuously improve outcomes and experiences. One such effort to address this issue was developed by Elizabeth C. Wick, MD, and colleagues at the Johns Hopkins Hospital. They implemented a QI project that involved changing surgical care processes based on evidence-based best clinical practices.
A Standardized Plan
The new standardized care plan, called an integrated recovery pathway, expanded on a pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, ranging from senior leaders to frontline staff. Project leaders developed the pathway with staff and emphasized the need to engage patients and their families as partners in care. The staff continuously reviewed performance using an electronic dashboard, an interactive performance review tool that showed progress on the primary outcomes of length of stay, surgical site infection (SSI) rates, and patient satisfaction. “Our goal was to improve outcomes, value, and satisfaction by engaging patients to be partners with their healthcare team,” Dr. Wick says.
For a study published the Journal of the American College of Surgeons, Dr. Wick and colleagues compared results of 310 patients who underwent colorectal operations before the integrated recovery pathway began with those of 330 patients whose colorectal surgical care involved the pathway over an 11-month period. Both groups had similar demographic characteristics and procedures. The integrated recovery pathway intervention included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia, a restricted intravenous fluids protocol, early mobilization, and rapid resumption of oral intake.
At 11 months after implementing the integrated recovery pathway, recipients of the intervention had hospital stays that were 2 days shorter, on average, than before implementation (5 vs 7 days). In addition, SSI rates decreased by more than half, decreasing from 18.8% to 7.3%. Also, the average direct costs of a hospital stay decreased by from $10,933 to $9,036. Secondary outcomes also improved, including rates of urinary tract infections and DVT.
After reviewing patient satisfaction surveys, Dr. Wick and colleagues observed improvements in almost all domains after implementing the integrated recovery pathway. The greatest improvements were with staff communication about medications, staff responsiveness to patient requests, and pain management.
The study findings have significant implications for spreading surgical QI work, according to Dr. Wick. A key to the program’s success was that it changed the organizational culture to be more patient-centered and help all providers accountable for delivering best practice care. “Our model defined the actions needed from care providers and hospital senior leadership,” says Dr. Wick. “We had executive support coupled with participation from the frontline healthcare staff, making our QI effort was a priority for everyone.”
Dr. Wick adds that hospitals considering this approach should first put into place the infrastructure needed to improve teamwork and communication and a culture of safety from the frontline to the executive leadership. She notes that, as the work evolved, surgical staff received extensive positive feedback from patients about the changes that further inspired providers to strive to deliver better care.
Wick EC, Galante DJ, Hobson DB, et al. Organizational culture changes result in improvement in patient-centered outcomes: implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg. 2015;221:669-677. Available at: http://www.sciencedirect.com/science/article/pii/S1072751515003701.
Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215:193-200.
Ravikumar TS, Sharma C, Marini C, et al. A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts. Ann Surg. 2010 Sep; 252:486-496.