Issue: October 2008
October 01, 2008
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A team approach to orthopedics: Hospitals and physicians need to work together

Issue: October 2008
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A recently published book caused me to examine what some of my colleagues have done in their orthopedic practices in terms of adopting a team approach to health care in an effort to offer higher quality and efficiency. In Redefining Health Care, Michael E. Porter and Elizabeth Olmsted Teisberg propose that the nation’s health care system is using “21st-century technology delivered with a 19th-century system” and that our sector of the economy is one of the last to have significant reconfiguring.

Porter and Teisberg emphasize that hospitals should closely follow cases, track survival rates, recovery times, and patient satisfaction, etc. They note that someone needs to consider the different visits, different buildings, different times and ensure the doctors and studies are available within a reasonable and efficient time period for the patient.

One stumbling block in this transformation will be, “Physicians no longer should see themselves as isolated,” Porter writes. “They need to see themselves as part of a team.” To me, this means the solo fighter-pilot mentality of many orthopedic surgeons (including yours truly) will have to change to flying more in formation. That will mean more oversight with standardization, documentation and regimentation in our practices. This change is proposed to benefit patients and increase efficiencies for all.

Douglas W. Jackson, MD
Douglas W. Jackson

Personal experience

This year I came to appreciate the potential for the team approach to medical care when members of my family were evaluated and treated at two different centers using this method. They had a head physician of international stature and a center approach to the diagnosis as well as numerous supporting physicians, physician assistants and other dedicated professional staff. The laboratory studies and data collections were not that intrusive on our time. We could do much of the data entry in advance on the Internet, during the visit and/or with a research assistant. The centers provided their specific outcomes on proposed treatments as well as their failure and complications rates, which we found helpful in the decision-making process.

Our visits and treatments were coordinated so they could usually be completed in 1 day or less when possible and our appointment was dedicated to individual care. While I was pleased with the medical care, it involved travel, staying in an adjacent hotel the night before, and in some cases arguing with the insurers as the treatment was considered not being the standard of the community — lacking peer-reviewed, published articles with 2 year follow-up.

The treatment was more expensive then what is available locally, but it was worth the slightly higher costs to my family. The alternative would have required more of our time and frustration trying to get all the results and recommendations in one place at one time. I realize all community hospitals cannot have the volume, physician specialization, donations and grants to support the impressive team approaches, research documentation and follow-up we experienced. However, all can start applying some of the techniques to those specific areas where they do have the most volume.

Time-saving approach

As orthopedic surgeons in the outpatient environment, we can more easily achieve (and most of you have) the benefits of the team approach to the practice of orthopedics. This involves a streamlined approach from the preoperative setting through treatment and follow-up. Many individual orthopedic outpatient practices have made restructuring adjustments to allow the patient to obtain an expert opinion, have necessary imaging done on site and a treatment decision in one visit.

Compare this approach to having multiple visits to various locations and follow-up visits. For example, having a MRI and/or ultrasound immediately available is something I appreciate. This saves the patient time, by allowing him or her to only miss a half day of work and leave that appointment with a recommendation(s).

Think of yourself and the value of your time. Patients need to be treated the same way. It even has the potential to save in overall costs. One of the current stumbling blocks is obtaining pre-authorizations. This may delay this whole process of minimizing visits for consultations and tests. Most current systems are not concerned about the patient’s hours missed from work and the time they spent traveling back and forth for care, tests, consultations, return visits and waiting for results.

Hospital support

Orthopedic success with the team approach when it involves inpatient care is dependent on mutual cooperation, buy-in and support from hospitals. The hospital becomes a partner and facilitates the approach through its administration and professional staff. Some institutions have utilized well-established team approaches for some time. Emulating aspects of these existing programs can be easily done.

Most of the institutions with successful team approaches have strong physician leadership, a progressive administrative staff, and innovative nurses and therapists in common. Additionally, they often benefit from significant yearly philanthropic donations (nonpatient-generated revenue). In some cases these funds enabled new bricks-and-mortar to establish centers of excellence, supported establishing specialization in areas of new treatment options, and supported innovative programs for nonrevenue-generating professional staff.

Many programs receive grants to help fund their research arms and programs for the needy. The hospital’s demographics and payer mix certainly impacts the availability of this potential additional support to ensure these innovative programs are financially maintainable.

There are examples of team approaches to orthopedic care that do function well and efficiently and strictly within the patient revenue stream. The more organized and efficient they are, the more likely they can reduce overall costs and benefit from volunteerism and the support of patients and family members who have benefited from the higher standard of care.

Orthopedic example

In many institutions, joint replacement is one example of a treatment that has benefited greatly from the team approach. Strong institutions and dedicated physicians have developed this team approach and have viable functional programs currently from which we can all learn.

My personal experience trying to implement many aspects of the team approach to ACL and knee replacement has increased my patients’ quality of care over the past few years. It has included an experienced and trained nurse who coordinates the admission process, collates necessary studies and consultations, plans and coordinates discharge and anticipates after-care needs and conveniences.

We have a dedicated orthopedic nursing service and section of the hospital performing joint replacements. We have excellent therapists and established a new and effective pain control program with the anesthesia department.

In the future, hospitals will be forced to become “team players” with physicians as there will be more pay-for-performance initiatives and “bundling experiments” in which Medicare will make one payment to cover a treatment or procedure and the physicians and hospital will decide how it is distributed. That may or may not be good news, however, the bad news is the proposed bundled reimbursement to be divided with the hospital and the physicians will be less then the current sums paid individually.

Douglas W. Jackson, MD
Chief Medical Editor

For more information

Reference:

  • Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press; 2006.