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
team approach to joint replacement and how long did it take to
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 specialists 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.
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
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 didnt 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 didnt
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 cant 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: firstname.lastname@example.org.