UPMC matches a method to patient-centered care model
January 6, 2010 8:00 PM
Dr. Anthony M. DiGioia III, orthopedic surgeon and developer of the patient- and family-centered care program for UPMC, in his office at Magee-Womens Hospital in Oakland.
By Pohla Smith Pittsburgh Post-Gazette
Duane Troutman of Emlenton was riding his motorcycle in the Allegheny National Forest on June 16, 2008, when out of the corner of his eye he spotted a wild turkey gliding down out of its roost into his path.
"I thought 'Ah, crap,' and lay down backwards with my left hand on the handlebars," said Mr. Troutman, 61, who does financial planning and estate work for American Equity Service Corp.
The turkey winged Mr. Troutman's windshield and kept on going.
Mr. Troutman didn't get off as easily.
The collision and his braking threw the bike to the left and over, and it "skipped like you skip a rock off water."
He broke his collarbone, nine ribs and two bones in his left foot, sustained a big bruise on his left hip, and "lost a lot of skin" from his left forearm and up toward the shoulder. But, he added, "if I had stayed upright and collided with him I probably wouldn't be talking to you."
It took a while for Mr. Troutman and some good Samaritans who stopped at the accident to get a cell phone signal out, but eventually an ambulance arrived and took him to Brookville Hospital. There he later was loaded into another ambulance for transport to UPMC Presbyterian Hospital.
Medicated for pain, "I lost a day," he said. During that time, his wife, Diane, who had been in Ohio at the time of the accident, made it to Presby.
She did not have a pleasant experience, especially when she compared it to an earlier experience she had visiting her injured daughter in St. Elizabeth Health Center in Youngstown, Ohio.
"Finding where you go is the first [bad] thing," Mrs. Troutman said of her inaugural trip to Presby. "You're all shook up, your husband has been Life-Flighted, you're driving, and you don't know Pittsburgh. You're totally bewildered. In the hospital, it's the same thing. You're looking for the emergency room. ... You have to ask a whole lot of questions."
The bad comparisons to St. Elizabeth continued. "Our experience [at St. Elizabeth] was much easier for the first few days in that when you walked into the ER they told us where to go," Mrs. Troutman said. "The waiting room was different. There were two different ones for when you first came in and then one if you wanted to get away from everyone. ...
"St. Elizabeth also had an area with a coffee shop and cubicles and computers to e-mail family and friends. For a bad situation they had provided for families what you need to do, too."
Those kind of amenities weren't available at Presby, and by the time Mr. Troutman was discharged, he and his wife had vowed they'd never return.
But now they've changed their minds after helping Presbyterian tweak a UPMC-invented methodology for a relatively new paradigm in hospital care called patient- and family-centered care.
The nonprofit Institute of Medicine, in a March 2001 report, "Crossing the Quality Chasm," called for a new health system that is safe, effective, patient-centered, timely, efficient and equitable.
The IOM defines patient-centered care as "care that informs and involves patients in medical decision making and self-management; coordinates and integrates medical care; provides physical comfort and emotional support; understands the patients' concept of illness and their cultural beliefs; and understands and applies principles of disease prevention and behavioral change appropriate to diverse populations."
Maureen Bisognano, executive vice president and chief operating officer of the nonprofit Institute for Healthcare Improvement in Cambridge, Mass., defined it by giving examples of work being done by the county health care system in Jonkoping, Sweden, and by the National Health Service in Great Britain.
The latter was particularly illustrative. It was an anecdote about an injury to the father of an English health colleague of Ms. Bisognano's.
"This past summer, he fell and broke his hip," Ms. Bisognano said of her colleague's father. "The ambulance arrived in nine minutes and took him to the emergency room. There, he didn't have to show his card. Care began immediately. The focus was on his injury, not his insurance.
"He had his hip repaired and was in the hospital for a few days. The day before he was supposed to go home, 'the squad' arrived at [his] house. It was a multidisciplinary team designed to ready the home and [his wife] for the arrival of the patient after discharge.
"They saw there was no grab bar in the tub, so they installed one," Ms. Bisognano added. "They put an extension on the toilet seat. They tacked down loose rugs and told her what food he could eat. She got his prescriptions and pain pills. So the odds of his having to be rehospitalized were minimalized.
"And that's what patient-family-centered care really is."
It's also providing edible food for patients whenever they want it; it's good directional signage for families; it's comfortable chairs and Internet access in family rooms; it's installing a system that keeps patients' clothes and belongings safe. Most of all, it's keeping the patient informed and giving him and his family input on necessary medical decisions.
"You can have good care but not have a good experience for the patient," said Dederia Nicholas, trauma nurse coordinator at Presbyterian, who also holds the title of clinical champion for the Trauma Care Experience patient- and family-centered care. "So what we're trying to do is not make those mutually exclusive, but make those coincide, so we can provide you with the best medical care, but you also have a good experience coming to our hospital."
Other hospitals around the world, including Allegheny General and West Penn Hospital-Forbes Regional Campus, have or are installing patient-centered care programs.
"But there's no methodology. That's the unique part of [UPMC's]," said Dr. Anthony M. DiGioia III, 52, the civil/biomedical engineer and orthopedic surgeon who created the process behind the patient- and family-centered care program now being used at eight UPMC hospitals. A total of 16 working groups, such as Presbyterian's Trauma Working Group, have been installed at those hospitals, and four more are to come onboard soon. There will be two more at Presbyterian; one at DiGioia's home base of Magee-Womens Hospital of UPMC and another at UPMC Passavant.
"[Patient- and family-centered care] has been an abstract concept for many years, [back] to the '50s," Dr. DiGioia said, "but one of the weaknesses to the term was that it was very abstract and meant different things to different people. We developed a true methodology to establish PFCC, and to our knowledge, no one has done that."
"A lot of people think it's a project," Ms. Nicholas said. "It's not. We're really trying to change the culture."
And everyone who draws a paycheck within a UPMC working group is expected to be part of the effort.
"We define caregivers as anyone in the organization who touches a patient's or family's care experience," Dr. DiGioia said. "It includes the entire experience ... parking, food delivery ... things like home health experiences, the lobby, and the ways of finding things, employee inclusion. It also includes finance, purchasing and that group. They all affect care.
"We don't want the patient or family to think they're in a doctor's office or a hospital. This is wellness."
A visit to Dr. DiGioia's Orthopaedic Working Group in a previously empty maternity wing at Magee reveals warm and inviting facilities.
There are pieces of attractive art and historic photos of Magee on the walls and bentwood-style rocking chairs all over the public rooms. A big family center includes an old-fashioned kitchen with a big refrigerator, a big-screen TV, and a kiosk with online capability plus the capacity for computer games.
The patient rooms, 90 percent of which are singles, have mini-desks, safes for valuables, and small refrigerators. All the rooms have wireless capacity, as does the rest of the hospital.
"We don't have a rehabilitation center. It looks like a gym," Dr. DiGioia said. "It makes a theme of fitness. Patients are in there together [and] family, too." Along with the requisite mats for rehabilitation are exercise bikes, a treadmill and a mirrored barre area. There also are a set of steps and a miniature car on which his joint replacement patients can recover confidence in doing those at-home skills.
There are interactive games, as well. "Competition works," he said.
The amenities at Magee look like the kind of things that could raise, rather than lower, the cost of health care, but Dr. DiGioia says that's not the case.
"Two hours a week of a caregiver's time is the cost, and it eventually comes to be part of their work," he said.
"There is a commitment of one hour per week as part of the PFCC working group meetings and then an additional one hour a week for project team meetings. The initial commitment is minor, but we have found that the PFCC mindset eventually becomes the way that everyone works day in and day out, which is how the PFCC culture develops."
Presbyterian nurse David Bertoty, clinical director of emergency and trauma services, certainly has bought into it while serving as clinical champion for the Trauma Care Experience patient- and family-centered care.
"We swear by the six steps [of DiGioia's methodology]," Mr. Bertoty said. "We all drank the Kool-Aid. We've seen it work."
So have Duane and Diane Troutman. The changes made at Presbyterian on the basis of complaints and suggestions by members of the patient advisory council they served on have made them fans of the hospital.
"At the first meeting, we talked about our [UPMC Presbyterian] experiences," Mr. Troutman said. "At the second meeting, we talked more about the patient's experience when we got in. Then we were able to share our different experiences." The Troutmans talked about the amenities they had liked when their daughter was hospitalized at St. Elizabeth in Youngstown.
"At the third meeting, UPMC showed us what they were trying to implement," Mr. Troutman said. Among the improvements he cited: a computer a family can use to e-mail other relatives and friends or, employing a PIN, access an update from medical staff.
Also new: a folder for families with directions to various places in the hospital and tags that identify them as family of trauma patients. Presbyterian employees are expected to offer help to anyone wearing the tag.
"That's a feather in its cap as far as I'm concerned," Mr. Troutman said of the improvements that were made on the basis of patient/family complaints and suggestions.
UPMC's program also is getting kudos nationally.
It was one of six included in The Shaller/Darby Report "High-Performing Patient- and Family-Centered Academic Medical Centers" prepared for The Picker Institute, which sponsors education and research in the field of patient-centered care.
"The leadership at UPMC has successfully combined both a grass-roots and top-down approach," the Picker report said. "The culture of innovation and entrepreneurial activity has provided a fertile environment for the development and spread of PFCC at multiple levels throughout the system."
Ms. Bisognano of the Institute for Healthcare Improvement, who calls patient- and family-centered care "the solution to health care reform," also praised the UPMC methodology.
"I know the UPMC work, and it is ground-breaking for the United States," she said.
"You're leading the nation, but we still have a long way to go as a country," she added. "Many [hospitals] are committed to it, but few are as far along as the hospitals in Pittsburgh."
Correction/Clarification: (Published Jan. 7, 2010) Maureen Bisognano is executive vice president and chief operating officer of the nonprofit Institute for Healthcare Improvement in Cambridge, Mass. Her name was misspelled in this story as originally published Jan. 6, 2010 about patient- and family-centered care at the University of Pittsburgh Medical Center.