Hospital/physician alliance creating new care model
Collaborative approach improves care processes
A unique partnership between SSM St. Joseph Hospital of Kirkwood, MO, and six physician groups has created a separate new company to manage a pilot nursing unit designed to develop and test new patient care processes for the future SSM St. Clare Health Center.
St. Clare, which will open in March 2009 in southwest St. Louis County, will replace St. Joseph. The health care professionals are using Lean Six Sigma techniques to identify opportunities to improve care processes and to find solutions.
"We have designed a new building that will support exceptional patient care; now we need the right processes," says Sherry Hausmann, RN, president of St. Joseph. "We felt we needed a microcosm to pilot; we knew other industries had done this and it just made sense."
What led to the creation of this new group? "We needed some engaged staff, and hoped to have a smaller staff to enable rapid cycle testing," says Hausmann. "We looked for staff with a rapid-cycle mind frame and physicians to do it with." The positions were posted in-house and many of the new staff came from within the hospital (they were given the first opportunity to sign up), but staff were also supplemented from the outside, says Hausmann
Co-management model
Hausmann had heard of co-management models being used in a specialty setting and thought "it seemed to make sense" for what she had in mind. "I started to talk to our physicians about partnering, and they felt as frustrated [about wanting to change processes] as we were; I asked six of them to join, and they all opted in."
The six practices participating in the partnership include more than 80 physicians. According to local press reports, the physician groups own 75% of the new company and the hospital owns 25%. The hospital then pays the company to provide management services.
"We wanted to create a vehicle to give the physicians ownership; that's why a company made sense," Hausmann continues. "In a more traditional structure you may have committees, and the doctors will come in for a quarterly meeting, provide some input, but then go back to their busy practices. They don't really own the process. We wanted to create that sense of ownership and their response has been phenomenal. They have started meeting on their own and driving processes so quickly; they are extremely vested in the staff, and are working with them differently."
Seeing the difference
Mary Brobst, RN, MSN, clinical director of the new St. Clare pilot unit, has seen that difference first-hand. "They are actively engaged and come to the table in a whole different mindset; they just want to be involved," she says. "They are not only seeking to help their own flow, but flow for nurses as well. We are collaborating together, in what was clearly a needed partnership."
"What we've seen on the floor has been phenomenal," adds Hausmann. "We were 'short' a couple of evenings recently. The nurses stepped up and helped, and the docs later went up and thanked them."
The news of this collaborative approach "spread through this place like wildfire," says Hausmann. "It sparked discussions of patient care processes not seen in committee settings," she asserts. "To see collaboration like this between nurses and physicians is just amazing."
Making real change
Of course, good will and team spirit do not by themselves improve processes, but this new "med/surg" unit represents a real change from similar St. Joseph units in many ways. "Typically, on a med/surg unit the [nurse-patient] ratio changes from shift to shift, with the night shift having a larger ratio," notes Brobst. "When the night shift gives a report, it is typically inefficient; if you try to do a face-to-face [handoff] you might have to wait for two or three different people."
So in the new unit there is a six-to-one ratio around the clock. "We have 'podded' the patients into three groups of six," Brobst explains. "They are in the same vicinity, and we balance acuity as we make bed assignments. We don't want staff congregating in the central [nursing station] area; we want them out there with our patients."
In the new facilities, she notes, nurses and care partners will be able to work in decentralized nursing stations, complete with a countertop work area. In addition, many items for the caregiver — such as the computer and medications — will be in the patient rooms, which will allow for more one-on-one time between the nurse and patient.
"There is great efficiency gained with only one nurse talking to one nurse when you turn over the whole assignment," she explains. "It also allows you to do walking rounds, where you can introduce the next caregiver to the patient."
Speaking of rounding, the goal for this pilot unit is that no physicians will round on the floor by themselves. "They either will be with the primary nurse, the patient care manager, or the clinical director," says Brobst. As they round, she says, "They will always talk about what the goal is for that patient for the day and what questions we have, so we make the most efficient use of our time." If questions come up about orders, for example, they can be corrected prior to the physician leaving the floor. "In the old world, you did not round with the doc, so if he made a note and you couldn't read it, you had a problem," she notes.
Every week one of the heads of the six physician groups is on call, or serves as the "go-to" person, Brobst explains. "We typically round early, and then they meet with myself, the patient care manager, and case management," she says. "We look at who out of our patients meet any criteria for CMS core measures and do concurrent reviews to see if we are meeting the guidelines. We serve as a kind of oversight committee, and we try to be proactive."
The patient care manager (there is one available 24/7) frees other staff members of certain care responsibilities. "They are a buffer; if I am overloaded with patients, the manager steps in and helps, or if a physician on the floor needs help, they can hang blood," says Brobst. "It is the old 'head nurse' mentality — one person who knows pretty much all that's going on with every patient."
Improving processes
In just a few short months, says Brobst, processes have already been improved. "The docs had asked for all morning labs to be drawn, resulted, and on the charts by 6 a.m.," she recalls. "In any typical lab you try to do draws at a reasonable hour so the patient is not awakened at 3:30 or 4 in the morning and you get a rush of requests for phlebotomists."
The staff wanted to see if they could meet this goal while being more patient friendly. "Our theme is to put the patient at the front of every process change," Brobst explains. "Staff nurses know that in the old world if a patient was awake at 3:45, to take care of their needs they would help them get settled in and back to bed and the phlebotomist might show up 45 minutes later for a draw, which would be a huge dissatisfier. We approached the staff nurses and for two weeks trialed having the nurses draw the a.m. labs when the patient was awake. This seems to be working very well."
Care enhanced
Hausmann says the new initiative already has enhanced patient care. "We've seen the improvement in continuity already," she asserts. "Just the fact that someone is always rounding with the physician creates more continuity and patient education. The important messages are reinforced if the family has questions and the nurse has heard what's been communicated by the doctor."
The focus on core measures is also critical, Hausmann continues. "The doctors and nurses work together to get 100% performance," she says. "The alignment of the goals and incentives will create outcomes that were not possible before."
"We went 32 days before the first fall," notes Brobst. "And in February we were in the 98th percentile [Press Ganey] and in March we were in the 99th."
As part of the new management agreement, Brobst continues, the metrics they use are tied to how they perform on core measures. They are also benchmarking their performance against other facilities.
The Lean initiative, Hausmann adds, is being carried out across the entire SSM system. She is convinced other facilities could replicate what St. Joseph has done. "I don't think the size of the hospital or community [would make a difference], but I would suggest you start out small," says Hausmann. "And your staff must be dedicated. We'd like to replicate this across the house, but until we work out the kinks and have piloted processes and standards across the house, starting small serves us best."
One key to success, Hausmann emphasizes, is letting the frontline staff drive the improvements. "We did not come up with a prescription for this unit; we're not controlling in what is expected of them," she explains. "We hired people with the right mindset, we framed a vision, and we made sure we shared that vision with the doctors and set it out before they were hired. We created an environment, and then got out of their way."
[For more information, contact:
Sherry Hausmann, RN, President, SSM St. Joseph Hospital, Kirkwood, MO. Phone: (636) 947-5000.]
A unique partnership between SSM St. Joseph Hospital of Kirkwood, MO, and six physician groups has created a separate new company to manage a pilot nursing unit designed to develop and test new patient care processes for the future SSM St. Clare Health Center.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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