CMS Wants More Tender Loving Care?
It’s really not that hard, says a seasoned orthopedic researcher. To make patients happier—and to help ensure that you get the appropriate reimbursement—all that is required is a bit more TLC. Brent Morris, M.D. is with the Vanderbilt Orthopaedic Institute Center for Health Policy. Dr. Morris and his colleagues recently examined the issue of patient satisfaction as related to trauma patients. He tells OTW:
“Making patients happy may sound like the fluff side of medicine but it is being emphasized more and more. We have to do more to improve patient satisfaction. More than ever, CMS [Centers for Medicare and Medicaid Services] is trying to adequately define and measure quality of care…patient satisfaction is a huge part of that. In fact, CMS is making incentive payments to acute care hospitals based, in part, on the results of patient satisfaction surveys completed by patients after they are discharged.
One study showed that 90% of medical inpatients were not able to name the treating physician upon discharge. It was even more challenging for orthopedic patients who are admitted via the emergency department (ED); past research has shown that individuals admitted through the ED are less able to identify their treating physicians. My team and I decided to measure patient satisfaction amongst trauma patients, i.e. those individuals meeting doctors on one of the worst days of their lives. The care is acute and unplanned.
Our most encouraging finding is that even simple interventions can improve the patient’s feelings about his or her medical experience. We distributed biosketch cards to orthopedic trauma patients in order to improve patient recognition of the attending surgeon. Our early results show improved physician recognition and increased patient satisfaction scores, even in this challenging population. Some things other than biosketch cards that can help improve patient satisfaction include basics ways to improve patient-physician communication. Physicians being empathetic and acknowledging the difficulty of the patient’s situation, the doctor refraining from interrupting the patient when obtaining a history, and appropriately setting patient expectations for the goals of surgery can all help to improve patient-physician communication and ultimately improve patient satisfaction.
Going forward we need better data to evaluate patient satisfaction so that we better stratify and standardize our results. We know that patient satisfaction varies based on the type of surgery required for the patient. Variables such as pain control and depression also affect outcomes and patient satisfaction, so we must control for these variables. Ultimately, it is hard to use a ‘one size fits all’ approach to measure patient satisfaction, and we need to tailor our outcome measures and interpret results accordingly.”
Simulation or Hands-on Bioskills?
“All hands on deck!” is the latest cry for those in training. Peter J. Millett, M.D., M.Sc., Director of Shoulder Surgery at The Steadman Clinic in Vail, Colorado, says that there is an increasing emphasis on hands-on training in orthopedics. He tells OTW:
“The power of hands-on surgical training is undeniable. Industry has recognized this and now several major manufacturers offer fellowship courses that are focused on lab experience. As part of our fellowship training program, we have a bioskills lab that is incorporated into the academic curriculum. It’s like a flight simulator for pilots. You create potentially real surgical scenarios where it’s acceptable for the trainee to be less than perfect so they can practice, improve, and learn from their mistakes. In a bioskills lab the trainee receives tactile feedback and can take as long as they need (not something we can always do in real life).
Perhaps the most challenging aspect of this is that we must determine how exactly to measure surgical performance. Testing one’s surgical skills would have to evaluate the ability to perform major steps in a procedure correctly and to do the surgery in a technically proficient manner. Moreover, we would of course have to do this for many surgeries. For example, in arthroscopic shoulder surgery, trainees would learn basic procedures like diagnostic arthroscopic evaluation of the shoulder, rotator cuff repair, shoulder instability procedures, and a Bankart tear repair. One of the challenges of measuring performance is determining how exactly can we say that a given repair is satisfactory?
It seems incredible, but we still don’t have a method to evaluate a core set of surgical skills that residents and fellows should acquire during their training. There is no checklist of what people have accomplished…it’s just, ‘oh, well look at the calendar, your year is up. What cases did you do? Good luck.’ We need a more objective method to measure surgical skills and better methods for teaching surgeons these important skills. The credentialing bodies are trying to make headway in defining these things, but we still have a long way to go. And it’s not just orthopedic surgery; other surgical specialties haven’t figured any of this out either.”
Checklists Cut Death Rates 47%
When WHO tested the surgical checklists at eight hospitals from around the world, says Kamal Ibrahim, M.D., president of the Scoliosis Research Society (SRS), their death rate decreased by 47%. Kamal Ibrahim is clinical professor of Orthopedics and former chief of division of Pediatric Orthopedic & Scoliosis Surgery at Loyola University in Chicago. He tells OTW:
“When I began my tenure as president of the SRS last September I decided to focused on the issue of safety in the OR. We began discussing this topic with other societies, building on initiatives that have been underway in different areas of surgery over the last ten years. In 2004 the World Health Organization [WHO] determined that there were seven million people injured during surgery globally, and one million deaths.
They compiled a surgical checklist that was published in 2010; this list covered things the staff should do before anesthesia, before the operation, and afterwards. Is this the correct patient, have the antibiotics been given, does everyone in the room know what needs to be done. They then tested that checklist in eight hospitals around the world—including the U.S. and UK—and got very impressive results; the death rate decreased by 47%, the infection rate decreased by 50%, and the reoperation rate decreased by 25%. Largely as a result of this work, checklists are now mandatory in England.
Just this year a Harvard study found that only 25% of American hospitals use checklists. It became clear to me that the push for increased awareness was going to have to come from surgeons and hospitals. So I put together a task force of SRS members to study the topic of checklists; then we set out to create a checklist specifically for spine surgery. We will debut the checklist in Lyon this September at SRS annual meeting. Surgeons can use this upcoming checklist when doing deformity surgery. This is meant to help them be aware of changes in neuromonitoring and to follow well-organized steps of management to elevate the neurological problem (is the patient’s blood pressure stable, did the room temperature change, etc. all the way to the wake up test). The SRS will advise its members to use this checklist going forward. I just presented this checklist at a recent spine societies meeting organized by North American Spine Society and it generated quite a lot of interest from the other societies. When I presented the checklist at the recent International Meeting on Advanced Spine Techniques ‘IMAST’ in Vancouver there was significant interest, to the point where people from around the world approached me and asked me for my slides. I’m so pleased to be a part of this process as it becomes an increasingly standard part of our quality control efforts.”
Marketing 101 for Surgeons
Surgical skills aside, brand awareness may be the most important tool a medical specialty society has when it comes to reaching potential patients. Steven L. Haddad, M.D., the newly elected president of the American Orthopaedic Foot & Ankle Society (AOFAS), told OTW that a major focus for the AOFAS today is public education and outreach.
“The public often doesn’t understand that our training as orthopedic surgeons differentiates our members from other non-M.D./DO practitioners who treat foot problems,” said Dr. Haddad, who also serves on the faculty of the Illinois Bone and Joint Institute. “There is no doubt that AOFAS members are the most qualified to treat both common and complex foot and ankle problems.
“One issue facing AOFAS members, particularly those who are younger, is hardened referral patterns within their communities and increasingly within hospital systems. Many physicians, and even many of our own orthopedic colleagues, refer patients with foot problems to non-M.D./DO practitioners,” said Dr. Haddad. “They do not really understand the value that our comprehensive training as orthopedic surgeons brings to treating both common and complex foot and ankle problems. Our goal is to increase awareness of the value we bring in delivering safe, cost-effective care to patients.”
“One way to raise that awareness is through better marketing. The AOFAS is using social media to reach out and educate the public on the reconstructive foot care our members provide, the sports injuries and trauma they treat, and new technology available that allows patients to maintain mobility and improve their quality of life,” said Dr. Haddad. “We must also help internists and family physicians understand that referring patients to a non-orthopedic practitioner may be easier but the quality may not be the same. This educational process is truly a call to arms for our younger colleagues.”
“Fortunately, increased interest in the AOFAS and its mission is helping build the orthopedic foot and ankle brand. The AOFAS membership is steadily growing, and we now have more than 2,000 members,” said Dr. Haddad. “Over the past few years, there has been an increase in applications for our foot and ankle fellowship programs and an increase in the number of young members.”
“We have also seen a significant increase in attendance at our annual meetings, as well as growth in the number of manuscripts submitted for our Foot & Ankle International journal,” he added. “These are all good signs for our organization, and coupled with new technology available for treating foot and ankle problems, the future is bright for the AOFAS.”