UPMC uses patient 'flight plans' to streamline operating room flow

Clinicians and administrators at Magee-Women's Hospital of UPMC in Pittsburgh were concerned that elective back surgery patients and their families did not know in advance how many nights they would likely be spending in the hospital. That uncertainty led to lower patient satisfaction and higher costs.

“Patients received mixed messages about how long they'd stay in the hospital,” said Mary Beth Pais, unit director for orthopedics and urology and at the Rehabilitation Institute at UPMC Montefiore. “Doctors would say, 'You'll be here three, four or five days,' and patients would get it in their heads that they'll be here five days.”

To address that issue, Dr. Anthony DiGioia and Pais led an effort that became the Patient and Family Centered Care Methodology and Practice. The practice includes developing individualized patient “flight plans,” tracking (or “shadowing”) inpatient stays and striving for the ideal patient experience at UPMC, a 13-hospital system affiliated with the University of Pittsburgh Schools of the Health Sciences.

The initiative has reduced lengths of stay, improved patient satisfaction and increased efficiency, DiGioia said. With clinicians on board, he now wants to involve hospital finance staff.

“Its power is that it gives the people who do the work the tools to reach the ideal,” said DiGioia, an orthopedic surgeon who founded the PFCC Innovation Center of UPMC in 2006.

Pais said the flight plans were developed after staff learned that patients were often being told different things by different people. Having a formal, posted plan ensures that “people are singing from the same hymnal,” she said.

As an example, DiGioia said that joint replacement treatment begins 30 days before surgery and ends 90 days after the procedure. Pre-surgery patient activities can include being fitted ahead of time for braces that may be needed after the procedure and tests for methicillin-resistant Staphylococcus aureus, or MRSA, infection.

Patients now are given a “departure” date, but are told that if they are doing well and there are no signs of complications they may leave a day earlier. Patients are kept informed about what issues may affect their departure and what is being done to address those possibilities. “They like the fact that they know what the expectations are,” Pais said. “Families like that they can plan ahead.”

The patient flight plans have reduced patient surges and established a continuous patient flow where patients depart at predictable times. This flow further allows a smooth arrival for new patients. Also, patients recovering from surgery don't wait as long for a room.

Pais and others in her role are called “air-traffic controllers” and keep records for on-time departures, just like an airline. Of the 743 patients admitted to Pais' orthopedics and urology floor in 2010, 312 were discharged on their scheduled day, 246 went home early, and 185 stayed one to six days longer.

Dr. Alexandra Page, a member of the American Academy of Orthopaedic Surgeons' healthcare systems committee, said she likes UPMC's presurgery preparation. Fitting patients for braces before surgery seems like an obvious timesaver, but not everyone does it. Page, an orthopedic surgeon at Kaiser Permanente in San Diego, said surgeons have to think outside of the operating room when evaluating their patients' hospital experience. This could even include ensuring that their trip from the parking lot to the hospital bed is an easy one.

Page also liked that UPMC is engaging patients more in their post-operative care and educating them about what each day will be like after surgery, with realistic expectations set for when they can go back to work and their normal routines.

Dr. William Ward, chairman of the American College of Surgeons' advisory council for orthopedic surgery, cautioned that patients may feel that they are being hurried out the door. Ward, orthopedics chairman for the three-hospital Guthrie Healthcare System in Sayre, Pa., said patients need to be taught that the sooner they leave the hospital, the less likely they will be to develop an infection. They also need to know that the sooner they are mobile, the less likely they will be to get blood clots.

Ward liked that UPMC uses college interns and others just starting their healthcare careers to shadow the patient experience. He said the fresh eyes of observers without preconceived notions may spot problems for patients and their families that others might accept as part of the daily routine.

Pais said the biggest barrier to implementing the Patient and Family Centered Care methodology was staff resistance to change. But, with the PFCC's focus on empowering frontline caregivers to make improvements, the system has become both a patient and staff satisfier.

DiGioia said the process cannot work without shadowing because it helps determine a hospital area's “current state” and forms the baseline from which to measure improvement. “That is the most critical tool of the methodology,” he said. “It forces you to look through the eyes of the patient.”

Though shadowing began with interns and inexperienced personnel, DiGioia said he is now seeking volunteers from UPMC's executive and managerial ranks. “It's eye-opening for them,” he said.

His methodology for process improvement has six basic steps: Select a care experience and define its beginning and end points; establish a guiding council; evaluate the current state using shadowing and care-flow mapping; establish a care experience working group; create a shared vision of the ideal care experience from the patient's and their family's perspective; and form project improvement teams to close the gaps between current care experiences and the ideal.

“None of this is new, but it's repackaged in a way healthcare people can use,” DiGioia said. “It allows for creativity—that's something you don't always get in healthcare.”

DiGioia added that the methodology is now in place for 65 care experiences at eight UPMC hospitals. He frequently hosts “vision quest” workshops to teach the process to other UPMC departments and institutions across the country. Since its start in elective back surgery, the methodology has since expanded into women's cancer care, breast care and bariatric surgery. It has been used to improve patient trauma care experiences, outpatient mental health services, oncology, home healthcare and joint replacement.

These efforts are also part of expanding the focus of the PFCC program beyond clinical and patient satisfaction improvement. The program also wants to bring in finance department staff to work on calculating the true cost of care.

“Of all the silos we have in healthcare, the financial silo is the most separate,” DiGioia said. “For the first time, we are bringing financial people in with clinical people to have a conversation.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks