ORTHOPEDICS AND SPINE - HealthLeaders...

MARSHALL K. STEELE, MD | JuDy E. JonES, MS

ORTHOPEDICS AND SPINE

Innovative Strategies for Service Line Success

OrthOpedics and spine: innOvative strategies

fOr service Line success, secOnd editiOn

Marshall K. steele, MD

JuDy e. Jones, Ms

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition is published by HealthLeaders Media.

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Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition iii© 2013 HealthLeaders Media

Acknowledgments ......................................................................................................... ix

Dedication........................................................................................................................ xi

Foreword ........................................................................................................................xiii

Prologue .......................................................................................................................... xv

Chapter 1: Lessons About Service Line Development ...............................................1

Funny Thing About Blue Crabs… ............................................................................2

Perishability ..............................................................................................................3

Bamboo ....................................................................................................................6

Is It Really That Simple? ...........................................................................................7

These Patients Have Really Changed ........................................................................9

Change Is Hard: Yellow Crime Scene Tape ............................................................11

Napoleon’s Mail .....................................................................................................13

It’s All in How You Look at It ................................................................................14

A Confused Mind Always Says “No” ....................................................................15

Ritz Carlton Towels ................................................................................................16

The Perfect Pot Roast .............................................................................................18

Don’t Bruise the Tomatoes .....................................................................................19

Summary ................................................................................................................20

Contents

iv Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Chapter 2: Move Beyond Today’s Status Quo ............................................................21

Current Care and Culture .....................................................................................27

On-Call Dilemma ..................................................................................................30

Destination Centers of Superior Performance .........................................................34

Opportunities Abound ...........................................................................................37

Summary ................................................................................................................39

Chapter 3: Payment Reform: Focus on Increasing Value ........................................41

Medical Tourism ....................................................................................................43

Accountable Care Organizations ............................................................................46

Bundled Payment for Care Improvement ...............................................................49

Service Line Optimization and the Steps to Success in Bundled Payments .............58

Outlook for Surgeons .............................................................................................61

The Role of the Physician in the Future ..................................................................62

Chapter 4: Define and Pursue Excellence .................................................................67

Why Is Excellence Hard to Define? ........................................................................67

Are Centers of Excellence Really Excellent? ...........................................................71

Own the Patient Experience ...................................................................................79

Summary ................................................................................................................84

Chapter 5: Develop a High-Performance Culture .....................................................87

Current Culture ......................................................................................................88

Change Your Culture .............................................................................................89

Summary .............................................................................................................. 111

Contents

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition v© 2013 HealthLeaders Media

Contents

Chapter 6: Create the “A” Team .................................................................................113

Experts ................................................................................................................. 114

Get Them on Your Team ...................................................................................... 116

Strong Physician Relations ................................................................................... 117

Common Vision ...................................................................................................121

Give and Gain Respect .........................................................................................122

Create and Nurture Physician Champions ...........................................................124

Develop a Winning Leadership Team ...................................................................125

Summary ..............................................................................................................136

Chapter 7: Bridge the Physician-Hospital Gap .......................................................137

Motivation to Change ..........................................................................................139

Clinical Comanagement: A Framework for Physician Alignment .........................142

Case Study: A Successful Model ...........................................................................150

Summary ..............................................................................................................153

Chapter 8: Patient-Centric Systems of Preoperative Care ....................................167

A Word About Systems ........................................................................................168

Being Patient Centric ............................................................................................172

Community Service ..............................................................................................173

Primary Care Physicians ....................................................................................... 174

The Specialist’s Office .......................................................................................... 176

Navigation ............................................................................................................178

The Navigation Model .........................................................................................181

Preoperative Preparation ......................................................................................186

vi Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Contents

Consistency in Patient and Family Education and Expectation Setting ................191

Summary ..............................................................................................................194

Chapter 9: Patient-Centric Systems of Postoperative Care ..................................195

Hospital Inpatient Care ........................................................................................195

Post-Hospital Care ...............................................................................................208

Summary ..............................................................................................................211

Chapter 10: The Challenge of Implementation ........................................................213

Build a Program Like a Building ..........................................................................215

Bring the Right Teams Together ...........................................................................216

The Four A’s .........................................................................................................223

Keys to Implementation Success ...........................................................................236

Overcoming Resistance to Change .......................................................................240

Summary ..............................................................................................................245

Chapter 11: The Secret Sauce: Measurement, Knowledge, Management, Innovation ............................................................................................247

Codman and End Results—100 Years of Solitude ................................................248

The Keys...............................................................................................................251

Measurement ........................................................................................................252

Knowledge ............................................................................................................267

Management and Innovation ................................................................................269

Outcomes Measures in the Future ........................................................................273

Case Study: Clinical Care Guidelines Delivery Model ..........................................275

Summary ..............................................................................................................282

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition vii© 2013 HealthLeaders Media

Contents

Chapter 12: Develop the Story and Create Awareness: Branding and Marketing .............................................................................................285

Brands Are About Feelings, Not Facts ..................................................................288

Branding Is the Most Powerful Yet Least Understood Business Strategy ..............290

The Brand Is Not Part of the Business—It Is the Business ....................................291

The Little Things You Do Are More Important Than the Big Things You Say ....293

Every Brand Is a Story. How Will Yours Be Told? ................................................294

Marketing Creates Awareness ..............................................................................296

Outcomes Marketing............................................................................................297

Your Customers ....................................................................................................299

Summary ..............................................................................................................311

Chapter 13: Solving the On-Call Dilemma and Creating a Geriatric Fracture Destination Center ......................................................................313

Geriatric Fracture Care .......................................................................................318

Apply the Core Elements of Excellence to the Osteoporotic Fracture Program ....322

Chapter 14: Creating a Destination Joint Center ....................................................339

Case Study: The Next Level .................................................................................344

Summary ..............................................................................................................347

Chapter 15: Creating a Destination Spine Center ...................................................349

Outpatient Spine Programs .................................................................................350

Operational Excellence Through Triage System ...................................................354

Access and Navigation ........................................................................................358

Getting Spine Patients “Back on Track” ...............................................................368

viii Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Contents

Spine Center Results .............................................................................................369

Case Study: Collaborative Spine Care ..................................................................371

The Responsibility of Healthcare .........................................................................375

Primary Care–Surgeon Collaboration ..................................................................375

Summary ..............................................................................................................377

Chapter 16: Stories From Docs ...................................................................................379

The Mary Jane Effect ...........................................................................................379

The Power of the Flower.......................................................................................380

Crimson Tide Football ........................................................................................388

Reflections .....................................................................................................................393

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition ix© 2013 HealthLeaders Media

This edition was only made possible through the efforts of many of our col-

leagues who have extensive experience in service line implementation. Without

their support, this book never would have been written.

Included from Stryker Performance Solutions:

• Richard Conn, MD • Geoff Walton, MHA

• David Steele, MD, MBA • Paul Jawin, JD

• Ron Gaunt, RN • Stephen Weller, MBA

• Lori Brady, RN • Greg Wheat

• Leslie Golba, MBA

Other contributors include:

• Thomas Graham, MD • Julie Blatnik, BSN, CNOR

• David Jacofsky, MD • Mary Ann Sweeney, PT

• John Campbell, MD, MBA • Bill Munley, MBA

Acknowledgments

x Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Acknowledgments

• Tom Faciszewski, MD, MBA • Matt Reigle, MBA

• James Holstine, DO • Russell Mahoney

• Warren McPherson, MD, MBA • Craig Westling, MS, MPH

• Daryl Travis • Chad McClennan, MBA

• Richard Huseman, PhD • Patrick Vega, MS

• Kim Adeleman, PT, PhD • Shevan Rudkin Clark, BSN

Thanks to Karen Kondilis, our editor, who put up with our many revisions.

Special thanks to our spouses, Terry Jones and Susan Steele, who have encour-

aged us to share our knowledge and experiences with others in the hope of

making healthcare just a little better.

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xi© 2013 HealthLeaders Media

Dedicated to all the future patients who will benefit.

Dedication

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xiii© 2013 HealthLeaders Media

I first met Marshall Steele and Judy Jones at the American Academy of Orthope-

dic Surgeons meeting in 2011. We were in search of a standardized care model for

the orthopedic service line that could enhance the patient experience of care. We

had attended Marshall’s Annual Summit meeting and many of us had read his

first book.

Marshall|Steele, LLC, had an outstanding brand reputation as a trusted advisor

in assisting hospitals with orthopedic service line optimization. However, what

impressed me most in those initial meetings with Judy and Marshall was their

humility and genuine concern for their clients and the communities they served.

They never once spoke to me about their success. They only spoke, like proud

parents, of the achievements they had witnessed working with committed health-

care professionals to transform the patient experience of care. It became very

clear to me that writing a book and starting a company was not just a job. It was

a total devotion to leaving a legacy, a mission to deliver the highest quality of care

for orthopedic patients around the world. They were devoting their lives to

helping others deliver sustainable high-quality orthopedic healthcare for their

communities. They understood the Triple Aim (improving the experience of care,

improving the health of populations, and reducing per capita costs of healthcare)

and lived it each day. They developed a standardized care model with proven

results that enhances overall efficiency and quality while eliminating waste and

Foreword

xiv Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Foreword

unnecessary costs. They understood how orthopedic care can help patients main-

tain active lifestyles in order to improve the overall health of our communities.

These authors have not just written a book to transform healthcare. They have

imple mented their philosophy and programs mentioned in over 200 hospitals

around the world. For the past seven years, they have studied and measured best

practices with a devotion to continuous improvement. They have personally

mentored hundreds of healthcare providers who have read their book and attended

their seminars.

I am very fortunate to have met Marshall and Judy. I have a tremendous amount

of respect for their life’s work, and I am blessed to have them as colleagues and

friends. They have enriched my life in so many ways. I hope you enjoy this book.

I am confident it will inspire you in your everyday mission to enhance the patient

experience of orthopedic care.

Sharon Wolfington

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xv© 2013 HealthLeaders Media

Victor Frankl, in his awe-inspiring book, Man’s Search for Meaning, written

six months after leaving a concentration camp in 1945, wrote the following: “It is

fruitless to seek out happiness for happiness only ensues when we dedicate our

lives to a cause greater than ourselves.” We trust people who have a sense of

“why” that is greater than their own self-interest.

Healthcare is a calling like no other. Health quickly becomes the No. 1 priority

of all of us. Ninety percent of all prayers offered relate to health. As Theodore

Roosevelt said, doing work worth doing is one of the greatest prizes life can offer

you. We in healthcare are the luckiest people in the world. We are doing work

worth doing. This book is about how we can do it better.

Judy and I visit hospitals and talk to CEOs and physicians all the time. One of

the questions they often ask us is, “Do I need to build an orthopedic hospital?”

Orthopedic hospitals are efficient and can provide great care. However, the

answer is, “No.”

Our current mandate in healthcare is to create more value. Value is broadly

defined as quality divided by cost. Is creating an orthopedic hospital the best

way to increase this value? Can both high quality and lower costs for orthope-

dics be accomplished within a full-service hospital? Is there any other way to

accomplish this?

Prologue

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Prologue

Bricks and mortar are expensive. Creating a truly safe environment in an ortho-

pedic hospital will require redundancies in services and equipment (especially

with ancillary services) and increased cost. If you understand the real value of an

orthopedic hospital, you will realize that it isn’t the bricks and mortar. The real

value is the “focus” that it creates. This is what Regina Herzlinger, PhD, a

Harvard professor and author of the landmark book Market-Driven Health Care,

called a “focused factory.”

With focus you can have a dedicated unit and expert staff. With focus people

become experts. Experts do things better, faster, and cheaper. With focus you can

create standardization. Evidence-based standardization reduces errors, improves

efficiency, and reduces costs. With focus you have physicians leading and being

accountable. With focus you can create an effective structure for improvement

and innovation. With focus you can create a patient-centric delivery system from

the patient’s perspective. With focus you can manage the business with specific

metrics and a separate P&L. With focus you can be transparent with the data,

which speeds improvements dramatically. With focus you can transform a low-

performance culture into a high-performance culture.

However, you don’t need bricks and mortar to create focus. Yes, you can spend

millions of dollars on an orthopedic hospital to create focus, but unless your

current facility is out of capacity, it’s not necessary. Buildings are easier to build

but hundreds of times more expensive to build than programs.

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Prologue

Believe us when we say it is not that easy to build programs. We’ve learned how

to do this without the expense of bricks and mortar and, instead, doing the

following:

1. Creating a “hospital within the hospital.”

2. Building a “Destination Center of Superior Performance” that:

– Creates alignment and accountability with your surgeons and staff

– Creates experts

– Builds the service line infrastructure within your own hospital

– Creates a patient-centric delivery system throughout the entire

continuum of care

– Manages the program from specific metrics for that service line

– Helps your providers consistently innovate the program and implement

best practices

– Documents the success of your interventions and quality initiatives

– Measures and shares patient-reported outcomes with all key stakeholders:

patients, primary care physicians, insurance companies, and employers

– Creates a culture of high performance

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Prologue

– Receives third-party designation from organizations such as Blue Distinc-

tion, The Joint Commission, Stryker Center for Advanced Recovery, etc.

3. Getting focused and building programs. This is what will create the

value patients, surgeons, employers, and the government want and need.

This is what will attract patients, surgeons, and staff and will make

you successful.

When you outgrow the capacity in the current facility, that is the time for bricks

and mortar. And then, you will have a great advantage, as you will have created

the alignment, the infrastructure, the delivery system, the metrics, and the inno-

vation that will be firmly rooted into your high-performance culture. And you

will have the money and the reputation for superior performance.

Marshall K. Steele, MD

In the early 90s, after being a sports medicine orthopedic surgeon for 15 years,

my partners and I decided to subspecialize. I was chosen to be the total joint

surgeon. I created my own minifellowship for three months and brushed up on

surgical techniques. I returned ready to take on the world, but I soon realized that

I had to deal with a variable that had not been present in my sports practice: the

hospitalized patient.

My sports medicine patients did not have an inpatient stay. The turning point

came one year later when I was “fired” by a patient who had a good surgical

outcome with her first knee replacement but had a poor hospital experience.

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xix© 2013 HealthLeaders Media

Prologue

Because of her experience, I couldn’t convince her to let me do her second knee

and, therefore, had to find her an alternative surgeon.

This was a game changer for me and led me to create an entirely different hospital

experience for all our patients. The result was so positive that one of my patients

named it “Joint Camp.” Two individuals were influential in my thinking: John

Barrett, an orthopedic surgeon in Florida, and Regina Herzlinger, as noted above.

Their thoughts, combined with the support of hospital administrators Bill Bradel,

Chip Doordan, Sue Patton, RN, and my orthopedic colleague Stephen Faust,

made this a reality. Lori Brady, RN, and Julie Pastrana, RN, two wonderful

nurses, made it happen. Our goals were simple: create a “wow” patient and

family hospital experience; improve and prove outcomes; and reduce unnecessary

variation, waste, and cost.

Physician alignment, specialized units, effective leadership structures, account-

ability, creative delivery systems, metrics, and a performance culture were cre-

ated. Our results were extraordinary: We improved the patient experience, family

participation, quality of care, and profitability. The out-migration of the past

became in-migration as we doubled market share and increased volumes from

200 to 1,800 total joint replacements. Perhaps more importantly, these programs

led to much better physician-physician and physician-hospital collaboration. We

created similar successful models in all the surgical services at Anne Arundel

Medical Center. As a result, Anne Arundel expanded its number of ORs from

6 to 26.

xx Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Prologue

These successes were noted both domestically and internationally. More than

250 hospitals visited us to observe the program. We even provided the visitors a

manual with detailed program implementation outlines. However, postvisit surveys

by a college student I hired revealed that few hospitals were able to implement this

model themselves. This wasn’t surprising. A few years ago, I came across an article

from Harvard Business Press that stated 90% of all well-formulated strategies fail

due to poor execution. There were many reasons for the lack of success:

• Hospitals lacked knowledge of all the elements required to build a suc-

cessful service line

• Current staff members were too busy

• Hospitals did not have expertise in project management

• There was no physician champion

• Hospitals tried to improve incrementally

• Hospitals implemented only parts of the program

These were all common roadblocks. The hospitals failed to realize that we were

advocating transformation, not reformation of their old systems. Many of you

reading this book run the risk of making the same mistake.

My college intern encouraged me to develop an implementation company. When

building a destination center, principles and people must be synchronized with

structure and processes to achieve optimal results. This is the only way to

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xxi© 2013 HealthLeaders Media

Prologue

transform care. In 2005, I retired from surgery after 31 years and launched

Marshall Steele & Associates with Judy Jones.

Judy E. Jones, MS

I was a former hospital corporate executive who managed and oversaw service

lines, starting with bariatrics. The power of this focused approach was evident to

me. I then began working in orthopedics, providing tools and materials to hospi-

tals to help with their systems and marketing. I realized that marketing and

educational materials were only part of the solution. And what I was doing wasn’t

enough. Superior care wasn’t marketing. We needed to take a much more clinical

and metric-driven approach to create value. I met Dr. Steele, who was the chair-

man of my company’s advisory board at the time. He had my same vision, and so

we started our implementation company. We knew that we needed a team of

experts who had implemented programs successfully; therefore, we created our

team to help other hospitals achieve their vision.

Our Question

One question we both had: Could we make a significant impact in hospitals

without actually being full-time employees there? With unbelievable support from

our clinical project managers, the answer has been a resounding “yes.”To have

any chance for success, we realized that we needed to launch an implementation

company—not a consulting company. Implementation is possible, and improving

patient experience and quality and reducing costs can be done. Using the four A’s

xxii Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition© 2013 HealthLeaders Media

Prologue

approach—assess, architect, assemble, and assure—we have now accomplished

this in more than 180 hospitals.

Stryker

Our company was acquired by Stryker Corporation in October 2011. Stryker is a

medical device product company that is in every hospital in the United States. It

provides everything from beds to video equipment to implants. Stryker realized

that to be successful, it needed to help its hospitals and surgeons succeed.

Therefore, it began a services division to partner with hospitals and surgeons to

deal with some of their most pressing needs, especially related to orthopedics and

spine. This is a model that many other product companies in other industries have

pursued, the most notable being IBM. We became part of Stryker’s services

division, and it has been well received by hospitals and surgeons.

Great People, Poor Systems

Traveling the country and visiting hospitals has only strengthened our respect for

and belief in the absolute desire of physicians, nurses, allied health professionals,

and administrators to do the right thing. Healthcare is full of great people, but

our systems and culture are lacking. Sometimes these great people just haven’t

been exposed to “the why,” “the how,” and “the what.”

All of us need ideas, support from others, and effective tools to be able to be

successful and bring greater value. We are still learning. The ideas in this book

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition xxiii© 2013 HealthLeaders Media

Prologue

come not just from us and our experiences but from the experiences of a variety

of other people in a variety of roles.

This book is all about some of “the whys,” “the hows,” and “the whats” to create

systems to accomplish this. Working together, we can transform healthcare and

make it better for our patients, for our staff, and for ourselves. We hope you will

join us in being part of this transformation.

Marshall and Judy

DownloaD your MaTErIals now

Sample tools and documents from this book, as well as additional content not

featured in this book, are available online at the website listed below. This is an

additional service provided by HealthLeaders Media. Additional material includes:

• Operating room best practices

• Medical device relationships and managing supply costs

• Creating a destination sports medicine program

• Creating a hand or foot/ankle destination center

• Applying Lean to your service line

• Understanding the differences between administrators and physicians

• The importance of leadership

Thank you for purchasing this product!

Website available upon the purchase of this product.

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition 1© 2013 HealthLeaders Media

Lessons About ServiceLine Development

C h a p t e r 1

Creating and managing effective service line organizations inside hospitals is a

difficult, often thankless job. Finding the time between the crises of the day to

work on something that requires so much focus, persistence, and managerial

courage is not easy to do. Along the way, you will find plenty of reasons and

opportunities to abandon the project. Your supporters will be few and largely

silent, while your critics will be legion. Even so, the rewards are ultimately worth

the effort; and your patients, teammates, and surgeon colleagues will be the

better for it—so don’t give up!

I am from the South, and people who are raised in the South communicate and

learn with stories. I grew up around some world-class storytellers and very much

admire the skill. Stories provide a rich visual imagery that makes a lesson easier

to understand and to remember. And so, I have selected a few stories I have

collected over the years in my work helping hospitals in service line development.

Some are true, some are “almost true,” but all have been important to my under-

standing of people and processes in hospitals.

Contributor: Greg Wheat

2 Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition

Chapter 1

© 2013 HealthLeaders Media

Funny Thing About Blue Crabs…

I live in a place referred to as the “Redneck Riviera,” Panama City Beach, Fla. It

is truly a great and beautiful place to live, especially in the spring and fall. In late

summer, blue crabs come into the shallow water on the beach to mate, and

sometimes there are hundreds of them, scuttling around your feet in the clear,

blue-green water.

About this same time, the beach is covered with tourist families from all over the

Southeast. However, there is also a television phenomenon called “Shark Week,”

which often coincides with this same time in the summer. As a result, many of the

kids are afraid to go into the water, having watched “Shark Week” on the hotel

TV the night before.

One day, I saw a young boy defying the odds, waist-deep in the crab (and shark)-

infested waters of the Panama City Beach Gulf. He had a white mesh net on a

long wooden pole, and he was chasing blue crabs around his feet with the net.

When he would catch one, he shouted a triumphant victory shout and crab-

walked out of the shallow water to a white plastic 5-gallon bucket on the sand,

just above the surf line. In plopped his prize catch, and back to the water he went,

on the hunt for more blue crabs.

I watched him for a while, impressed with his enthusiasm and enterprise and

mostly impressed that he was the only kid brave enough to be in the water during

“National Shark Week.” Another thrust of his net, another hapless blue crab, and

he was off to the beach to secure his prize in the white plastic bucket.

Orthopedics and Spine: Innovative Strategies for Service Line Success, Second Edition 3

Lessons About Service Line Development


Finally, while he was searching the waters just in front of my beach chair, I had to

ask, “Son, you are doing a great job catching those crabs; but, after all your hard

work, aren’t you afraid they will just get away? There is no lid on the bucket.”

Leaning on the long wooden net pole, he looked up at me and smiled a knowing

smile. He shook his head and said, “No, sir. You see, I’ve learned something about

these crabs. Just about the time one claws his way to the top and almost climbs

out, the other crabs grab him by the legs and drag him back into the bucket.”

There is a fundamental law of gravity in healthcare—maybe in most industries—

that makes it very hard to step outside the box, to try to do things a different

way. There is an army of your colleagues who will give you 1 million reasons

why your idea won’t work: our patients are different, our surgeons are different,

our market is different. They will find ways to “pull you back into the bucket”

to that narrow band of mediocrity that unfortunately characterizes most

organizations.

Perishability

I am told by orthopedic surgeons that many of their total joint patients play

golf and that returning to the golf course, free of pain, is a big incentive—and

concern—for these patients. I met a terrific and very affable surgeon in Sydney,

Australia, who came up with a unique twist on this idea.

He called me one day, very excited, and told me he had created a successful

process within his joint replacement program.


Chapter 1


“It’s called ‘patient-accelerated rehabilitation.’ Don’t you get it, Greg? PAR!”

After surgery, the physical therapists roll out one of those carpeted putting greens

on the nursing unit, and the joint patients have golf putting contests.

“The patients really love it! Visitors even come from around the hospital to watch.

It gets the patient out of bed and feeling better, and now when they ask how soon

they will be able to play golf again, I tell them, ‘The day after surgery!’”

I told that story to many hospitals and several actually adopted the idea, with

similar results. One day, a marketing director in a large Florida hospital asked me

if I thought the idea would work for patients who had undergone open heart

surgery. She told me that the heart patients also were very focused on returning to

normal activities, and something like this may reinforce that feeling of wellness. It

sounded like a good idea to us both, so the program was instituted for the heart

patients one month later.

The results were incredible. Again, patients loved the activity and socialization.

Family members and even visitors from other parts of the hospital came to watch

these patients, who were recovering from major heart surgery and putting golf

balls down the hallway of the nursing unit. One of the 10 largest newspapers in

the country printed a full-page story with color photographs about the hospital’s

novel way of recovering these open heart patients. The hospital had never received

such accolades and publicity for its program. It was just fantastic!




Now, my confidence level was over the top. At every opportunity, I told the story

to hospitals and encouraged them to implement similar programs. PAR programs

were springing up all over the country.

Then, one day about one year later, I ran into that same marketing director from

the heart hospital. I could not wait to ask her how the program was going,

anxious to hear more great success stories.

“We had to stop doing the golf putting program,” she said, to my astonishment.

Now, every fear imaginable started creeping into my head: Had someone gotten

hurt or suffered some terrible complication as a result of the program? Little

beads of sweat started popping out on my forehead as I thought of all the hospi-

tals I had encouraged to implement this program.

“I thought it was going great. What happened?” I asked, not really sure I wanted

to know the answer.

“Oh, it was going very well, but the nurse who owned the putter left the hospital.”

The greatest threat to successful programs in hospitals is perishability. Often, the

most trivial detail can derail even the best programs unless the hospital leader-

ship keeps an eye on the ball. Staff changes, tight budgets, and new initiatives all

can cause months’ or years’ worth of effort to go by the wayside. Keeping a

service line program alive requires daily discipline and reinforcement. It requires

commitment and attention from administration, surgeons, and from your staff.

It is a journey, not a destination!


Chapter 1


Bamboo

Bamboo is a remarkable plant. It grows in humid, semitropical areas and is used

for many commercial purposes after it is cultivated.

In the early spring, the bamboo seeds are planted in long rows. The rows are

fertilized and watered every day of the growing season, and the farmer pulls the

weeds and cultivates between the rows during the season for that first year. And

nothing happens.

The next spring, the farmer pulls the weeds and cultivates between the rows. He

waters and fertilizes the rows every day of the growing season in the second year,

and again nothing happens.

In the third year, again, the farmer pulls the weeds and cultivates between the

rows. He waters and fertilizes the rows every day of the growing season. You

guessed it—nothing happens.

This process continues every spring for five years. The weeds are pulled and the

ground is cultivated between the rows. The farmer waters and fertilizes the rows

every day of the short growing season; still, nothing shows above ground.

In the spring of the fifth growing season, the farmer pulls the weeds and culti-

vates between the rows. He waters and fertilizes the rows every day, and in two

weeks, the bamboo grows to be 40 feet tall!




Now, the question is, “How long did it take the bamboo to grow 40 feet?” The

correct answer is five years. If at any time during those five years the process was

not followed exactly, without fail, there would have been no harvest in year five.

We are creatures who crave immediate satisfaction. Perhaps in healthcare, the

condition is worse, particularly among surgeons, who tend to be creatures of the

moment, with little patience. Unfortunately, process change often requires an

investment of time to nurture, germinate, and bloom. Progress is sometimes slow

and hard to discern. However, if we become frustrated and lose sight of the

mission, sometimes all the work done is wasted. It is critical to keep the vision

and to continue nourishing the change, even with baby steps, to ensure that

success is on the horizon.

Is It Really That Simple?

One day, I was touring a joint center with a group of administrators and surgeons

from a hospital in the Netherlands who had traveled to the United States to learn

and understand the elements that made this program so successful, so they could

implement them in the Netherlands. Their country had recently enacted legisla-

tion requiring standards in patient satisfaction. They had read about the incred-

ible results in patient satisfaction achieved by these centers and were anxious to

find the “secret sauce” that was responsible.

Like all good scientists, administrators, and bureaucrats, they came looking for

complex processes, systems, and perhaps even technology that was the real reason

behind why this joint center enjoyed such great success financially, clinically, and


Chapter 1


from a patient satisfaction perspective. They were taking copious notes (in Dutch)

as they toured the operating room (OR), the post-anesthesia care unit, and the

other clinical areas of the perioperative suite. I think, too, they were probably

more than a little skeptical of this “American” phenomenon and might have liked

nothing better than to find some reason to debunk the myth of its success.

We walked onto the patient floor where all the total joint patients spent the

three- to four-day recovery period after surgery. (I know that sounds like a long

time, but keep in mind this was the late 1990s.) There was one small, elderly lady

sitting in the waiting room, reading a McCall’s magazine. As she saw this troupe

of “suits” walk past the waiting room door, she looked up, and her glasses fell

down low across her nose. We all politely spoke and smiled as we crossed the

doorway, and she spoke to us.

“You know, Dr. Williams did a knee replacement on my left knee two years ago

in this very hospital,” she said.

My group all smiled and nodded approvingly, and then one of the “scientists”

could not resist—he asked the question.

“And, so, how is your knee doing?” he asked.

Now, our group looked like one of those E.F. Hutton commercials from the

1980s. Everyone leaned into the doorway, hoping to hear some comment (prob-

ably bad) that would throw a little bucket of reality on this joint center phenom-

enon. I really think they were expecting to hear a long diatribe of complaints,

complications, and criticism from this patient. But they did not.




“Oh, my knee did fine; I was up and walking the next day. But, did you know,

after my surgery, they sent a girl to my room to fix my hair? It was just wonder-

ful. My husband, Henry, is in the OR right now. Dr. Williams is replacing his

hip,” she said.

One of the Dutch surgeons turned to me and asked sincerely, “Is it really

that simple?”

We don’t concentrate enough on delivering value to our customers in the lan-

guage they understand. Never underestimate the power of simple gestures of

kindness and paying attention to the expectations of our patients. By institution-

alizing a few of these simple gestures, often we can produce landslides in results

from how our patients perceive their experience. Imagine how many people the

patient in the story above told about her experience over the years. The knee

surgery itself was almost a given; it was the other human touches that made the

experience memorable.

These Patients Have Really Changed

During my career, I met orthopedic surgeons who constantly looked for ways to

enhance the patient experience in ways that created value for the patient, the

caregiver, and the hospital. One of those ways was to defy the conventional

wisdom of meals being served on over-bed tables in the patient rooms. The idea

was to get all the patients out of bed and let them meet for lunch in a group room

with other patients and family members. It was felt that socialization was a great

way to combat the anxiety and depression after surgery and that the sheer act of


Chapter 1


getting out of bed and walking to the group room for lunch offered great clinical

benefit for the total knee and total hip patients in the practice. Sounds obvious

and easy, right?

Each week, I met with Susan, the nurse manager of the orthopedic floor, and told

her about our surgeon’s vision to get all the patients up at mealtime, go to the

group room, and have meals together. Susan was incredulous, to say the least, but

agreed to give it a try. I planned to check on the results on Thursday of the

following week.

“How many joint patients do we have on the unit this week?” I asked Susan.

“Six.”

“How many got out of bed to have lunch in the group room?” came my next

question, with a hopeful smile.

“None, I’m afraid,” was Susan’s answer.

“Not even one; what happened?”

“Mr. Smith was just too stiff. Mrs. Jones was sleeping most of the time, and

Mrs. Johnson just refused and wanted her tray brought to her. Several patients

said they were feeling nauseated. The rest just did not want to do it.” What had

we not done to set the expectation for these patients?




The next week, the same dialogue was repeated, with pretty much the same

results; however, the nurses were able to get two patients to group lunch. “Great

work,” I told Susan. “Let’s keep trying and see if we can do even better.”

Each week, we were successful at getting one or two more patients to the group

lunch with lots of expectation setting, education, and a little prodding, until at about

the ninth or tenth week, Susan was able to say, “All 12 patients on the unit were

able to go to group lunch today. You know, these patients have really changed!”

Had the patients really changed or just the way we looked at the patients? More

importantly, had we done a better job of setting expectations for the patients:

namely, that group lunch was an important part of the clinical process and

would help them recover more quickly?

Change Is Hard: Yellow Crime Scene Tape

Today, thanks to the innovation of many far-thinking surgeons, physical thera-

pists, and nursing care coordinators, group exercise class for total joint patients

has become a standard of care. The patients enjoy it and invariably do better in

their recovery, and it saves countless dollars for the healthcare system and over-

burdened physical therapy departments. But it was not always that way.

Historically, and even today in many hospitals, physical therapy after joint

replacement is performed individually at the patient’s bedside. Normally, there are

two sessions per day, lasting about one hour each.


Chapter 1


There is nothing clinically wrong with this approach; however, there are prob-

lems. There has always been a chronic shortage of physical therapists in the

hospital, resulting in unpredictable therapy sessions for joint patients. Patients

who miss therapy become stiff and, often, continuous passive motion machines

are used to replace active bedside therapy.

The advantages of group therapy sessions are many. Most importantly, the

patients really enjoy it and the socialization with other patients and family mem-

bers and the friendly competition help them improve quicker. In this scenario, it

takes only one or two therapists to provide therapy for 10 to 12 patients simulta-

neously, saving enormous staff time and cost for the department.

But change is hard. Many years ago, at one of the first hospitals to try the group

exercise concept, a few upset members of the physical therapy department actually

wrapped yellow crime scene tape around the door to the group room to show their

contempt for the new process. However, our team persisted in insisting that the

group concept was an important part of the program. The staff agreed to try it for

a couple weeks. Thankfully, that attitude has dramatically changed and physical

therapists are now always among the most vocal supporters of the program.

A friend of mine said, “You can tell who the pioneers are. They are the ones with

the arrows stuck in their backs.” They are the leaders and everyone else is trying

to catch them.




Napoleon’s Mail

I have been told that Napoleon Bonaparte opened his mail only every two weeks.

He did this for a specific operational and strategic purpose: He believed that his

time was precious, as the leader of an enormous empire. He believed he could not

afford to be distracted by the minutia of the day or week but should confine his

time and attention to those things that required his specific involvement.

Therefore, he opened his mail only every two weeks, assuming that anything that

truly required his personal attention would not be jeopardized by a two-week

delay. Anything that required action within two weeks should be attended to by

his lieutenants; after all, that’s what lieutenants were for.

Now, I don’t know if any of us can imagine waiting two weeks to open our email.

Unthinkable. But are we truly becoming more efficient, or are we just being

dragged into the minutiae that Napoleon felt was not worth his time and effort

and could be handled by his lieutenants?

Perhaps we could learn a little lesson from this story about priorities and delega-

tion. Too often we become consumed by small things, either because they are

easy to respond to, or because some of the bigger issues are just too daunting. As

a result, we sometimes accomplish lots of tasks that could have been resolved by

others, while the issues that demand our personal attention languish.


Chapter 1


It’s All in How You Look at It

There is a story from World War II about a commander in the field who found

himself totally surrounded by the enemy.

It was the winter of 1944 in the Ardennes Forest. His command was running low

on ammunition and food. He finally made contact with his headquarters, who

asked for a report on his immediate situation.

“The enemy has just landed fresh paratroops to our north. On the south, there

are two enemy divisions of heavy artillery and tanks. To the west, I just learned

that reinforcements have joined the three divisions of infantry already in the field

against us; and to the east, I can see the enemy with heavy fortifications and

preparing an assault.”

“Good God,” came the response from headquarters. “Your situation sounds

hopeless!”

“No sir, not at all. I think we can successfully attack in any direction.”

Unfortunately, our world in healthcare seems to continually add more adversity,

more regulation, more challenges to success for our organizations and even for

our patients. There is not much support for stepping outside the box and not

much reward for taking on new responsibilities. However, there is a satisfying

and career-enriching feeling associated with at least trying to make a difference.

Our world is a “target-rich environment” of challenges, both short term and




long term. Accept this as just the way it is, and relish the chance to take it head

on. We, too, can pretty well successfully attack in any direction, so stay positive.

A Confused Mind Always Says “No”

One day, I went shopping for an electric piano. I could play a pretty mean guitar

but was looking to broaden my musical horizons by learning piano. I walked into

a music store in Largo, Fla., not necessarily where one might seek the wisdom of

the ages, but it was here I learned a lesson that has stuck with me for 20 years.

I only wished I had learned it 20 years before.

A salesperson with long black hair and an encyclopedia of tattoos across his arms

and shoulders greeted me in the keyboard section of the store. He wore a Van

Halen t-shirt that was faded from too many washes. He had a great, friendly smile

and must have been a drummer, because he couldn’t stand still; his fingers tapped

a rhythm on the counter while he moved to some imaginary rhythm in his head.

“I’m looking for a keyboard,” I said, interrupting his drum solo.

“Cool. Do you want weighted keys or nonweighted? Do you need midi input and

recording line outputs? Are you looking for monochromatic or polychromatic? I

mean, do you want something for recording or for, like, the road?”

I stopped for a moment and tried unsuccessfully to decipher what the sales/rocker

was asking me. “I . . . I just want a simple keyboard that I can play basic stuff.

In fact, I’m sorry, but I really don’t even understand the questions you were

asking me.”


Chapter 1


The salesman paused and took a step back. He stroked his four- or five-day

scraggly beard with his heavily-ringed fingers and said one of the most profound

things anyone ever said to me.

“You know, I’ve noticed that a confused customer always says no.”

When human beings are confronted with complexity, their natural instinct is to

just shut down. Too often, we overwhelm our patients and our staff with com-

plexity that we think of as patient education or “informed consent.” Healthcare

is also a sales position. We are constantly trying to convince patients and our

colleagues to do things they may not want to do. It is our responsibility to

deliver the information and the mission in a way they are not threatened or

confused by. As the saying goes, “If you want something to be successful, you

need to get it low enough for the ponies to eat!”

Ritz Carlton Towels

There is a great management story, which I am told actually happened in a Ritz

Carlton hotel many years ago. This hotel was having chronic complaints about

the room service food arriving cold at the guest rooms. Given the reputation for

excellence that Ritz Carlton fostered, this was totally unacceptable. And so they

brought in all manner of consultants and food service specialists to diagnose and

solve the problem.

They checked the delivery carts for insulation value and measured the tempera-

ture of the food as it left the kitchen. They checked the thermostats and heating

elements in all the ovens to make sure they were perfect and even measured the




distance each cart had to travel from the kitchen to the guest rooms. They timed

and measured each food type’s ability to hold heat and evaluated the menu

choices for their heat-holding potential. They evaluated new insulated plate

holders and tray systems that used hot water to keep plates hot during delivery.

Still they got complaints about food arriving cold.

One afternoon, the hotel manager was standing outside the kitchen, near the

service elevator, where a room service clerk was waiting with a room service cart

to deliver to waiting guests.

“I just can’t understand why the food gets cold before it gets to the room. We

have studied everything in the kitchen and can’t find an answer,” grumbled the

manager, a little under his breath.

“We need to put more towels in the guest rooms,” said the room service clerk.

“I beg your pardon?” the manager asked the shy clerk.

“Yes sir, if you just put more towels in the guest rooms, the food wouldn’t be

cold. You see, we get calls all day from guests wanting additional towels, which

housekeeping is constantly delivering to the floors. Because there is only one

service elevator, housekeeping ties up the elevator, and we have to wait a lot, so

the food gets cold.”

The manager immediately began stocking guest rooms with extra towels, and the

complaints about cold food stopped literally overnight.


Chapter 1


Often in hospitals, the problems and solutions are not completely linear in

nature. Processes and systems in healthcare are incredibly convoluted, with lots

of overlap and many unintended consequences. Sometimes the solution to an

operational problem is not obvious. There are two lessons in this story. First,

make sure to spend lots of time talking to the folks who actually do the work, to

see what they think; and, second, don’t assume that the answer is obvious and

that only the most obvious solutions are the correct ones.

The Perfect Pot Roast

When I was young and first married, my bride and I moved into our first house

together. Anxious to impress her new husband, my wife wanted to cook my

favorite meal, which was a special beef pot roast, the way my mother had cooked

it for me all my life.

Just to be sure she got the recipe exactly right, Ann called my mother to double-

check how she had prepared that famous pot roast I had bragged about. “First

thing you do,” my mother coached Ann, “is to take your pot roast, cut it in half,

and put it in two separate roasting pots, and then you start to add your

seasonings.”

“Two separate pots? Why do you cut the roast in half and put it in two pots?”

Ann quizzed my mother.

“Well,” she said, “I don’t know for sure, but I learned the recipe from my mother,

and she always taught me to do it that way when I was a little girl. And her pot




roast was the best I ever tasted. But now you’ve got me curious. Let’s call her and

ask why she always cut the roast in half before she cooked it.”

Later that afternoon, my mother and Ann finally got my grandmother on the

phone to solve the mystery of her famous pot roast recipe. “Mother, you

always taught me to first cut a roast in two and put it in separate roasting pots

before cooking it, and you made the best pot roast ever. Why did you always cut

it in half?”

“I never had a big enough pot,” she said.

Many times in hospitals, we carry on processes, procedures, or systems simply

because we have always done things that way. There seems to be a built-in

cynicism toward change for any reason that makes it hard to change ingrained

practices, even though, often, no one questions the origin of those practices.

Sometimes, maybe quite frequently, the reasons for the practice may have been

valid at one time but have long since gone away. Sometimes it pays big dividends

to question the original reasons for why we do things the way we do, just to

make sure those reasons still exist.

Don’t Bruise the Tomatoes

Hospitals are funny places. There seems to be sometimes a competition among

managers and staff to outdo each other for finding the most esoteric reasons that

something won’t work. It is truly amazing how many details smart folks can

dredge up to make what initially seems like a great idea turn into a good idea.


Chapter 1


After a little more discussion, it becomes a marginal idea or maybe a bad idea.

If the conversation continues long enough, invariably the idea will metamorphose

into a terrible idea, and the group will disband, satisfied they have avoided once

again the need for change.

It reminds me of folks in the vegetable section of the market, searching for a

perfect tomato, because they need only one. In the process, they will pick up and

handle a dozen or more, turning them this way and that, and squeezing them from

every angle, looking for exactly the correct degree of ripeness. This one is a little

too green, this one is a little too ripe, this one is too small, and these are too large.

In the process, a dozen or so perfectly acceptable tomatoes are bruised, ruined, and

discarded in the quest for one that is perfect, which invariably can never be found.

Sometimes in our quest for a perfect solution to a problem, we overlook several

good solutions that may lead us to success. It is tempting in group think to

disqualify ideas that don’t fit everyone’s concept of perfection. Too often, the

result is organizational paralysis and nothing is gained, because a universally

acceptable solution never surfaces. Great ideas are almost never perfect but

should not be neglected because we have “bruised” them with too much analysis.

Sometimes, we need to just move ahead and adapt as needed to reach the goal.

Summary

There are lots of lessons to be learned here. We all need to read and reread this

section so that we can clear our mind of the confusion we face every day.

ORTHOPEDICS AND SPINE

Innovative Strategies for Service Line Successby Marshall K. Steele, MD | Judy E. Jones, MS

The next 5–10 years will see huge changes in healthcare delivery as value, not volume, is rewarded. Most hospitals and physicians are not organized for superior performance in this environment. The principles in the book—written by a team of diverse medical professionals who have been in the trenches themselves—have been tested and proven in over 200 orthopedic and spine destination centers of superior performance around the world.

Since the first edition of Orthopedics and Spine, there have been major changes in healthcare. This book addresses how to overcome the challenges associated with these changes, such as:• Understanding the future of healthcare • Preparing to take on risk • Proving value• Bridging the hospital-physician gap• Addressing the on-call crisis• Incorporating Lean and its culture into everyday hospital practice

This edition also contains chapters dedicated to physicians and administrators sharing their personal experiences to illustrate the importance of patient-centered care, the challenges of change, communicating effectively, the need for simplicity, and how to stay positive through it all.

For more on HealthLeaders Media’s complete line of healthcare leadership resources, visit www.healthleadersmedia.com.

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