June 01, 2009
4 min read

Patient-centric approach to total joint arthroplasty: Be proactive in patient care

Marshall K. Steele, MD, answers 4 Questions about his unique program for patient care.

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We can be proactive and develop improved and more standardized care in our individual hospitals or wait and respond to eventual regulations and requirements. It is desirable to measure and know the outcomes in our patients and at our institutions. We need this information to advise patients of potential complications and anticipated successes seen in our settings for the more commonly performed procedures. This approach seems to be best done by a team of individuals working together and committed to similar goals.

I have asked Marshall K. Steele, MD, to share some of his experiences in this area. It is certainly easier to learn from the experience of others then each one of us trying to reinvent programs on our own.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: When and why did you start your patient-centric team approach to joint replacement and how long did it take to become established?

4 questions

Marshall K. Steele, MD: Stephen Faust, MD, an orthopedic colleague of mine who performed both joint and spine surgery, and I were dissatisfied with the inconsistent “It-depends” experiences and care our patients were receiving in the operating room and on the floor. Occasionally all the stars lined up and the patient got all the right people saying and doing all the right things, but too often this did not happen. Everyone involved in caring for the patient could best be described as a professional doing what he or she thought was right. However, we did not function as a professional team within a coordinated system.

In September 1995, we started our journey by focusing on every point of care that total joint arthroplasty patients experienced from when they first entered the system — usually from community education or primary care — to the specialist’s office, preoperative preparation, surgery and recovery a year or more later.

We then created a leadership and multidisciplinary performance improvement team that revamped the model of care including patient and primary care education, dedicated unit and team standardized protocols, new educational tools and materials, formal family involvement, and measurement of results. This resulted in a list of over 300 items to be completed. We set a timeline for completion of every item and launched it 6 months later. In 1998 we created the spine center. After 14 years, these performance teams still meet monthly.

Marshall K. Steele, MD
Marshall K. Steele

Jackson: How did you get the hospital administration and the other orthopedists to buy into this approach?

Steele: Well, we had to educate administration on the reality of the situation. They already believed the care was excellent. We needed to convince them that many other things besides complications were important, including the patient/family experience, reducing pain and nausea, speed of recovery, measuring the outcome of the surgery (6 months or more later), and physician/staff satisfaction.

The best way to do this while making joints profitable was to create a leadership team, a new system of care and a collaborative multidisciplinary team that could make changes. I found one influential hospital administrator, Bill Bradel, now CEO of Flagstaff Memorial in Arizona, who embraced this concept and convinced the rest of administration that the model we proposed was the right one.

The other orthopedists didn’t need convincing that we could be better. However, there was skepticism as this idea was being promoted by competitors. Initially some were resistant, but then they saw the depth of the program. Now, 14 years later, all nine surgeons who perform joint surgeries at our institution participate and contribute. The spine surgeons (both orthopedic and neurosurgery) after seeing the results of the joint program didn’t need convincing, they asked for it.

Jackson: Has the program achieved measurable benefits?

Steele: Our program has changed much of the culture, not only of joint and spine care but all patient care in our institution. This has transformed us from a community hospital to a regional destination center with specialty service lines. Our joint and spine units have received national awards for patient satisfaction and our vascular center is now renowned.

Satisfaction has created such word-of-mouth marketing that our spine and joint volume increased five to seven fold — making these services among the busiest in our state. Our speed of recovery-to-home changed dramatically with patients going home much faster than state and national averages. The program results have made it easy for our community orthopedic and neurosurgical practices to hire some of the best-trained surgeons available. Financially, joint and spine surgery have the highest contribution margin and net income. Other hospitals, where we have implemented this program, have experienced similar results. However, the greatest benefit that can’t be directly measured is that we have a system that encourages constant hospital-physician collaboration, innovation and learning that can now be applied to all patients.

Jackson: What do you look for when deciding who are good candidates for your team?

Steele: I have evaluated more than 100 hospital joint and spine programs many of whom consider themselves excellent. Most lack half or more of the core elements of excellence. However, it is not unusual for hospitals and surgeons to be comfortable with the status quo even if they know they can be better. I look for at least one surgeon and one hospital administrator who are unwilling to be to accept this situation.

Leadership must understand that excellence is not a marketing slogan but implementation of all the core elements that result in excellence. Volume is not the issue, commitment is. Waiting until you have enough volume is like the restaurant owner waiting until his restaurant has enough volume to serve good food. It will be a very long wait. Commitment from a few and teamwork with the many is what is required. If you want to understand how you can create the patient-centric team approach to care and get these results, call or send an e-mail to the address below.

For more information:
  • Marshall K. Steele, MD, is Medical Director of Anne Arundel Medical Center Joint Center and CEO of Marshall Steele and Associates. He can be reached at 410-271-1785; or e-mail: msteele@marshallsteele.com.