Suggested Technique to a Speedy Recovery
Open-heart surgery at the Medical Center Hospital of Vermont (佛蒙特州) used to cost patients an average of $26,300. Today it's $3,000 less.
Also saved: patients' discomfort. They used to suffer for about 37 hours after surgery on average with a plastic tube as thick as a thumb running through their mouth or nose and down 11 inches of their throat. The tube assists breathing, but patients say it feels like a fire running through their throat and hurts more than having their chest cut open.
Two years ago, a 15-member team at the 115-year-old teaching hospital, under pressure to cut costs from a health maintenance organization (HMO), was given permission by the hospital's top manager to find a way to get the tube removed sooner. That would ease the pain and help the hospital transfer patients from the intensive (精细的) care area — an area that charges patients or their insurance company $1,600 a day — sooner. The hospital was facing an expensive expansion to the building because of a continual shortage of beds in intensive care. Transferring patients sooner would eliminate the need for additional rooms and beds.
Until recently, many hospitals would have resisted steps that moved patients out of intensive care and into a room that costs $800 a day. But the national effort to reduce health care costs has resulted in dramatic changes in the way hospitals think. Insurance companies and HMOs increasingly are paying hospitals a set amount for each patient, regardless of how long they stay. One HMO was threatening to move its heart-surgery patients from Medical Center Hospital to a different hospital, if the Medical Center Hospital didn't get its costs down.
The team — six doctors, three nurses, three breathing specialists, two drug experts and a manager — studied the situation and came up with improvements that earned the team a special award for quality improvement.
Thanks to the team, the hospital stay of an open-heart surgery patient dropped from an average of nine days to seven days. Some leave in just five days. Patients typically have the tubes in their throats about 29 hours. And death rates have gone down slightly, possibly because fewer infections set in once any foreign object is removed.
Early on, the team used the quality-improvement concept known as benchmarking — adopting the best methods or processes used by other companies. The members borrowed a seven-step problem-solving process from an electric company. Each meeting focused on one step. First, they tried to understand what was wrong with the process (the treatment of heart patients after surgery). At the second meeting, they set a target for improvement.
Team members also studied the medical literature and interviewed new employees who had worked at other hospitals. They discovered some hospitals were removing the tube much faster. The hospitals had cut way back on the large amounts of pain-killing drugs usually given during and after surgery that were used primarily to control blood pressure, not pain.
"This was a story about results," says the judge who gave the team the quality award. "With their new post-surgery process, they have given themselves a greater ability to respond to health care reform."
By using pain-killing drugs that wear off quickly and a simple pain medicine, patients weren't driven into a long sleep and could breathe on their own sooner. They suffered no additional pain, awoke more aware, and the tube was removed quickly — sometimes six hours after surgery.
The team, led by a manager of breathing care, called the process "surgery light" because patients are kept just barely asleep rather than out cold. Nurses had a pleasant surprise: Because patients weren't so heavily drugged, they wake up soon after entering intensive care. The staff still refers to patients as "fresh hearts" because they arrive from surgery cold and pale. But because patients no longer remain sleeping logs, nurses get to know them sooner and help them recover, says one team member. "That's nice."
Although team members knew almost from the start that reducing drugs was the answer, they also faced resistance from those who were used to doing things in the traditional way. They spent six weeks educating everyone about the changes and winning the cooperation of doctors, nurses and breathing specialists — all of whom had grown comfortable with the old procedure.
When a team member who is a doctor first gave lectures to his fellow doctors, he called it a "new technique". About 10 of the 40 doctors resisted the change. He learned to call it a "suggested technique" because people "don't like to be told what to do. It wouldn't have worked if we tried to force people to use it."