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With the industry’s focus on value-based care, musculoskeletal service line leaders responsible for transforming processes and programs must be responsive both to payment reform and to the increasing expectations of healthcare consumers for ease and convenience. Everyone’s sights are set on delivering better outcomes, greater patient satisfaction, and lower costs.

The 2018 Musculoskeletal Leadership Summit brings orthopedic and spine thought leaders together to share best practices and lessons learned, presenting a unique opportunity to provide orthopedic and spine program excellence without the need to reinvent the wheel.

In Part One of our latest series, we spoke with Sarah K. Mondano, Director of Musculoskeletal Services at Indian River Medical Center, about her top strategies for patient-centered care.

Sarah MondanoTell us about your background in program development, clinical operations, and quality and performance improvement. How has the shift to value-based care and the increasing expectations of healthcare consumers influenced the work that you do?

Most of my background is in the post-acute world, dealing largely with the sector of home health and hospice, as well as rehab and physician practices. I have a really good understanding of what happens when a patient leaves the hospital – and the gaps that exist when it’s not well orchestrated. I also have a strong understanding of care coordination and the need for working seamlessly together with patients and post-acute providers, and making sure that the patient is at the center of that.

From a personal perspective, family members and I have been caught in that conundrum of not having that care coordination. At the heart of it all, I want to make sure the patients have a really wonderful experience and that they’re really well educated. We know that patients and families are very savvy consumers, much more so than they were even five or 10 years ago.

A little over two years ago, the CEO of the hospital I’m currently working at called and asked me to come and pull together a service line. I’m amazed at what we’ve done in two years. My experience that I described definitely helped me pull the team together. I’m not one to discount the surgeon or the therapists in my department, but it was really led by nursing leadership. Nurses, we spend the most amount of time with the patient; we give them intimate care, we’re the ones to translate everything that’s been said or done.

As you know, the 2018 Musculoskeletal Leadership Summit presents an opportunity for service line leaders to connect and participate with surgeons and other clinicians. Why is this type of collaboration important for clinical transformation?

One of the largest drivers of patient dissatisfaction with our service line is the uncertainty of what to expect at all points along the care pathways. It’s important that the multi-disciplinary team—including therapy, nursing, pharmacy, surgeons, anesthesia, case management, pre-admission testing, right down to the office staff of the surgeon—pulls together to look at the patient experience. We understand what your role is in that, but what is the patient experiencing along all touch points – before surgery, during, and after?

When we started this, the multidisciplinary team had difficulty envisioning opportunity for improvement, that is, until that patient perspective and experience became our viewing lens. It was an “aha” moment, because they all thought they were doing a good job, but it was really siloed. And in order for all of this to work, you have to have buy-in from all the team members.

I’m probably at the top of my game when it comes to pulling a team together. You’ve got to have the trust. It can’t just be someone dictating, “Here’s what we’re going to do.” The big piece for me was to gain their trust. But until the patient’s perspective and their experience became our viewing lens, we weren’t going to move forward.

Your speaking topic for the summit is, “A Nurse Led Initiative to Improve the Experience, Outcomes, and Value of a Total Joint Replacement Program.” Why is this topic important to you personally?

At some point in time, we’re all going to be patients.

Being able to take an orthopedic surgical service and turn it into not just a surgical service but also a patient experience is probably the most professionally gratifying experience for me.

One of the simplest things you can ask a patient is: “What’s important to you today?” When they’re in the hospital, they expect you to give good care. But when you ask what’s important to them today, sometimes you get the most unexpected answer – it may not have anything to do with their postoperative pain.

I saw a patient the other day that had fallen off a roof, and he had some fractures. He was a nice gentleman, probably in his 60s. I went in and asked the typical questions, “How are you doing today; how’s your pain?” Then I said, “Is there anything I can do for you today? What’s important today?” And he said, “I just need to know when I’m going to get this MRI.”

Long story short, I walked down to radiology, found the manager, and within an hour and a half, he had his MRI. You’d think I had moved a mountain, just by communicating with another department in the hospital. All he wanted to know was what time he’d have his MRI. He didn’t say, “I need to go now, and I want you to bump everyone else,” which is what I ended up doing. To me, that’s when you’re looking through the lens of the patient.

Can you share some examples of the ways you are working to improve the experience, outcomes and value of the total joint replacement program at Indian River Medical Center?

When we redesigned the patient experience for joint replacement, everything we did along the way was centered on the patient. Now obviously there were undertones of either nursing care or surgical care, or anesthesia, or therapy, but we made sure it was always through the eyes of the patient. We literally took apart every piece of that patient experience and turned it around to ask: What is the patient experiencing and what is the patient seeing, and why?

“What matters most to you today?” – that’s my standard question. All my staff is trained to ask that. Most of the time, the answer is, “I’ve got to get out of here,” or “I want to be able to walk the hallway,” or “I want my pain to be a three instead of a six.” But sometimes you get an answer like, “I’m worried about my wife who’s home alone.” Or someone says, “I really need a real cup of coffee, Sarah,” and then off I go and I find them a real cup of coffee.

When they get that HCAHPS survey, and the question asks, “How often did nurses listen carefully to you?” and they can choose between “always, usually, sometimes, or never,” I want to make sure it’s an “always.” What they’re going to remember is that cup of coffee or if they had their MRI.

When you start out on any kind of process improvement project, you’re obviously going to get a baseline. And then after you’ve initiated your process improvement, you’re going to ask, “are we improving in those metrics? Has our attendance at joint class increased, have our HCAHPS scores increased? Has our re-hospitalization decreased because we’re optimizing patients pre-operatively?”

On top of that, we also have a patient population within this service line that is now under a mandatory bundle. So looking at our bundle, are we performing financially below where we need to be, but still having the same quality outcomes? You can get down and get cheap with being below your target price, but if you have a high re-hospitalization rate, or very poor HCAHPS scores, you’ve got to be able to balance quality outcomes and cost.

When we started out, we had a haphazard joint camp class with less than 10% of our patients attending. We’re at about 95 to 96% attendance now. People rave about it. We looked at how we were conducting the class, when the class was, what we taught in the class. It was information we wanted to share, but was it really information the patient wanted to hear? Just redesigning that pre-op education piece, looking at it through the lens of the patient and their caregiver, it gave us a whole new perspective.

What about the Summit are you most looking forward to?

I’ve been to two Summits so far, and I’m hoping to see a lot of the people that have been there the last couple of years – we’ve all gotten to know each other, and I’d like to hear what they’ve done since the last time. But I’m also hoping there are new people who either want to hear what we’ve done, or share their own best practices and unique opportunities.  A lot of us are feeling we have a good handle on things, but then we hear something new and think, “Oh that’s a great idea, I can change things up a bit.”

I’m looking forward to hearing from Bill Munley again. Thanks to Bill, we pulled our fracture program together without having to reinvent the wheel. It would’ve taken me forever to do that, and Bill just threw it out there, saying, “here it is.”

The greatest thing about the Summit is that everyone who’s there is willing to share what they’re doing because we’re from all over the country. Obviously if it’s a hospital in the same town, they’re probably not going to want to share. But I’m not competing with Bill, or with St. Francis in Connecticut. Now, would I want those patients to come to Florida? Yeah! (laughs) Come to sunny Florida!