Molding the Patient Care Experience Through 5 Critical Surgical Stages

In the advent of 21st century healthcare, the search for top-notch quality health services and improved patient outcomes is at the forefront of the American healthcare system.  One area that all healthcare organizations across the country focus on is patient satisfaction. Although the healthcare industry has long prioritized patient satisfaction, the patient care experience has taken on a new form since the passage of the Patient Protection and Affordable Care Act, which requires value-based incentive payments under the Hospital Inpatient Value-Based Purchasing Program be made to hospitals beginning this October. Under that program, Hospital Consumer Assessment of Healthcare Providers and Systems scores — or how patients rate their providers on a wide range of metrics — will make up 30 percent of those payments.

The challenge to deliver a satisfactory experience for every patient is made even harder by the multitude of other challenges hospitals face, including "meaningful use", ICD-10 and the ongoing uncertainty around healthcare reform. EM Vitug Garcia, RN, DHEd, DNS, MA, FN-CSp, FACLNC, director of perioperative and perianesthesia care services at Mission Community Hospital in Panorama City, Calif., was tasked with creating the infrastructure to maintain patient satisfaction during the surgical care process.

"We call this framework our ‘cycle of care’, and the primary purpose of that is to identify, develop, integrate, implement and evaluate patient care experiences and processes within the provision of surgical care, treatment and services, therefore influencing the improvement the patient's overall surgical experience," he says.

Dr. Garcia details critical touch points in five surgical stages to ensure quality care and patient satisfaction.

1. Preoperative/Preanesthesia phase. The cycle of care, Dr. Garcia says, begins when a patient books a procedure with the scheduling office. A "surgical practice management" team at Mission Community reviews all scheduled cases two weeks ahead to ensure all procedures are handled smoothly. During these meetings, Dr. Garcia and his team review every case to the most minute details, including specialty needs and requests. These meetings are designed to act as a springboard for the patients' care process.

"Once we have reviewed each scheduled case, we can have an individualized goal for each patient," Dr. Garcia says. "For instance, a patient undergoing a revision of the spine would require special instrumentation, pain management consultation, anesthesia needs and staff members who have expertise in handling spine revision cases," he says.

In addition to the case reviews, hospitals must ensure key clinical leaders meet with the patient immediately prior to their surgery. Nurses must assess each patient prior to his or her procedure to ensure the patient's surgical needs are addressed, and members of the entire surgical team — including the surgeon and anesthesiologist — introduce themselves to the patient. These critical meetings not only ensure the patient undergoes safe surgery by verifying the correct site and surgery but also gives the surgical team and pre-operative nurse a chance to calm the patient during an often scary time.

2. Intraoperative phase. In the next phase of the cycle of care, the patient is transported into the operating room, where he or she receives one-to-one attention by the circulating nurse and anesthesiologist to provide support and undivided attention which relaxes the patient and address any last-moment concerns. The entire surgical team is also present once induction has commenced. "It is important to ensure that the room is kept quiet, out of respect for the patient," Dr. Garcia says.

"The presence of the circulating nurse, surgeon and anesthesiologist is critical during the intraoperative phase because those three faces are the last ones the patient is going to see before they drift to sleep," he says. "Control of the surgical suite or operating room is a standard of care that's often not followed because everyone is busy doing their own work. This process allows us to avoid all that noise in the operating room to ensure it's more of a pleasant experience for the patient."

3. Post-anesthesia phase. A critical touch point immediately after the patient's surgical procedure is completed is between the patient and the post-anesthesia care unit nurse under the supervision of a licensed anesthetist and/or anesthesiologist. At Mission Community, PACU and post-operative nurses are trained to be present in both units, "so patients see familiar faces," says Dr. Garcia. The touch points between the patient and the PACU nurse allow for opportunities to answer questions or address any needs, such as pain management or post-operative/post-anesthesia nausea and vomiting due to anesthesia.

"We've really expanded our professional development program so that the PACU and post-operative units have a familial and cohesive feel to it," Dr. Garcia says. "We really make it a point, particularly for the patients with high anxiety levels, to have some consistency with their nursing care."

Similar to the circulating nurse and anesthesiologist, the PACU nurse must be acutely aware of their sense of responsibility and compassion to the patient. That internal skill set makes all the difference while patients recover from a surgical procedure. After the PACU nurse has tended to the patient, the surgeon who performed the operation is required to also visit and check up on the patient, unless the patient is on a ventilator. Upon request, the surgeon may also visit the family in the waiting room.

"Although surgeons' workloads make it difficult, they make it a point to see their patients during the immediate post-operative care because they went into medicine to take care of people," Dr. Garcia says. "Here at Mission Community Hospital, we've seen how much families appreciate that the surgeons come out to greet them. This cycle is truly a family- and patient-centered approach."

4. Postoperative phase. Once the patient has been moved from the PACU unit to one of the floors, such as a medical/surgical bed, for continued recovery, the surgical practice management team makes rounds to the patient's room, sometimes just to say hello and see how they are doing. Dr. Garcia says this process has left such an impression on patients that they have verbalized their gratitude to the surgical practice management team.

"The patients will express their appreciation of how attentive our staff members and physicians are and how we made them feel good," he says. "The goal is to not limit the surgical team's involvement to only the perioperative and perianesthesia experience but to go beyond expectations, that is, our post-operative clinical rounds."

During the rounds, the surgical practice management team also ensures all concerns are heard and loose ends are tied up before the patient is finally discharged from the hospital. Any concerns, such as ongoing pain, are relayed to the primary physician and related consultants so each concern is resolved in a timely manner.

5. Discharge/Follow-up phase. In the last phase of the cycle of care, staff members at Mission Community conduct a phone survey with each patient post-discharge to go over any lingering concerns or complaints. Dr. Garcia, who sits in on some of the telephone interviews, ensures whatever negative findings are relayed to the director of surgery to investigate what the complaint was and how the hospital can learn and improve from it. This quality improvement process not only identifies issues and addresses care process issues but also prevents risks and liabilities for the organization.

Dr. Garcia says the hospital also plans to launch a new initiative soon to further boost the patient experience. "In the near future, our hospital plans to send each patient a 'Thinking Of You' card, signed by each member of the patient's surgical team."

"I think it's the basic challenge that a lot of hospitals and surgical centers experience is the lack of organizational culture. If the culture of caring lacks regard for the patient-practitioner relationship, the organization will fail in its efforts to provide satisfactory experience and good services will be perceived as unfavorable," Dr. Garcia says. "Organizations need to be creative in its efforts to meet the demands of today's patients. They must establish sound, practical and sensible framework that 'goes outside the box' to influence not only patient and family satisfaction but also improve the care processes."

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