In 2014 Jess Jacobs, a director in an innovation lab, started blogging about her experience as she received treatment for two rare diseases. Jess was trained as a Six Sigma Green Belt. So unlike your average patient, she described one 12-hour wait in the ER as having a “7% process cycle efficiency.” Likewise, she determined that just 29% of her 56 outpatient doctor visits were useful. She made 20 visits to the emergency room and spent 54 days in the hospital across nine admissions, but her calculations showed that just 0.08% of that time was spent treating her conditions. “Stop wasting my time,” Jess wrote in one blog entry. “Stop wasting my life.”
Jess’s writing was unique, but her attitude wasn’t. Like many patients, Jess felt her providers were delivering very little quality of care when defined by the one metric that mattered most to her: time.
While Jess didn’t get her care at Kaiser Permanente, we are working to improve on this metric. But to do so, we have had to upend traditional paradigms and make saving our patients’ time a part of our standard quality measures.
For example, the average hip or knee replacement surgery in the United States requires a three-day stay in the hospital. This is largely because many hospitals are reimbursed for every day a patient is in a bed, and it’s easier for the care team to monitor the healing process if all of their patients are in one unit. The system was created by and optimized for surgeons and hospitals to provide safe care with good outcomes. But what about our patients?
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Because of Kaiser Permanente’s integrated model of care, which combines care and coverage, we were able to study a broad cross-section of our hip replacement patients’ experiences. Amazingly, we concluded that up to half of our patients could safely go home the same day as their surgeries — but only if the entire care team worked according to a set of coordinated procedures, many of which would have to take place outside the hospital.
Here’s how it works. Before surgery, a care coordinator educates the patient and their family about what to expect. A physical therapist visits them at home to conduct a safety evaluation and reinforce their education. Then a pharmacist goes over the medications the patient will need (if any). Other care team members come by the patient’s home to deliver properly sized walkers and to make sure the patient’s bed is on the ground floor. Not only do these actions set expectations for a home recovery, but they also give the patient the chance to become acquainted with — and develop trust in — the care team.
On the day of the surgery, orthopedic surgeons perform the surgery from an anterior approach. While this may be more difficult for them to learn, it greatly reduces the pain of surgery and recovery, allowing the patient to walk immediately after the operation. Likewise, orthopedic surgeons select from a small, predetermined set of standardized devices. As a result, nurses and other members of the team only have to learn to handle these few devices. That expertise with fewer devices, we’ve determined, decreases the rate of complications and infections.
After surgery and a meal in the recovery area, the patient demonstrates that they can get dressed and safely walk 30 to 50 feet, and then they go home. The next morning, a physical therapist arrives at the house, ready to begin the first of six in-home PT sessions. The care coordinator calls to check in and make certain the patient has a phone number for any questions or concerns. A nurse may arrive to take vitals. A physician’s assistant reviews the electronic health record and, if necessary, makes changes to the care regimen. About two weeks later, the patient visits the surgeon in their office, which closes the loop.
Throughout the process, reliable, excellent care with multiple safety nets is provided in a psychologically safe environment where it’s everyone’s job to speak up, and team members are collectively responsible for responding to patient needs and ensuring the best clinical outcomes. However, this scenario only works if standards and protocols are strictly followed. If the physical therapist doesn’t show up the day after surgery, the system fails. If the patient doesn’t feel safe and doesn’t know what to expect, they’ll go to the emergency room, where they may be admitted.
Most important, every workflow is created for, and with, patients in mind. After all, what is the hospital-acquired infection rate for a zero-day hospital stay? Surely a lot closer to zero than for a multiday stay. What are the visiting hours at home? Generous. How about the quality of the food? We hope it’s better than at the hospital. The satisfaction scores patients give their experience in their own homes? Outstanding. And how much quality time do we give back to patients, so they can recover in the comfort of their own homes, surrounded by family, far from the constant din of the hospital? More than three days.
In Southern California, where we practice, Kaiser Permanente physicians perform about 8,000 elective hip surgeries and 15,000 elective knee surgeries each year. Recently, 11% of our hip and knee patients have recovered at home with no hospital stay. By the end of this year, we hope to grow that number to 25%. By the end of 2018 it will be 50%. And in the metric that matters so much to so many of our patients — saving time — most of the time in a zero-day stay is spent treating the patient.
The approach might sound appealing, but what about the results? Our data shows that the readmission rate for our patients who go home immediately after surgery is about 2% — exactly what it is for patients who recover in the hospital.
As we expand this approach across all of Kaiser Permanente, we think a lot about people like Jess Jacobs. By Jess’s calculations, less than one-tenth of 1% of the time she spent getting care was actually spent treating her conditions. Put another way, Jess spent 54 days — almost two months — in the hospital waiting instead of healing. Tragically, Jess Jacobs died in August, at the age of 29. Imagine what it would have meant to her to have those two months back.