Health Care System "In Pursuit of Excellence" Case Example

Covenant Health System, Maine

October 2008

The Organization

St. Mary's Health System is a member of Covenant Health Systems, and is one of the largest employers in Maine.  Located in Lewiston, St. Mary's Regional Medical Center is a 233-bed acute care facility that offers a full spectrum of care and a "whole person approach" in meeting the needs of the Androscoggin County area.

St. Mary's mission is to "continue the healing ministry of the Catholic Church in the Spirit of St. Marguerite d'Youville by providing preventive, curative, restorative, and supportive services with compassion and respect for everyone."  The Health System is committed to fulfilling four values as guides to its decisions and behavior: respect, excellence, compassion, and stewardship.

The Initiative - St. Mary's Center for Joint Replacement

In 2006, St. Mary's Regional Medical Center began a strategic planning process with a key focus on quality.  Soon after the planning process began, a local orthopedic surgeon expressed a desire to create a center specializing in the unique needs of joint replacement patients. The concept was an opportunity for the medical center to develop a service which established a patient- and family-centered culture, different from a traditional approach.  The medical center completely renovated hospital space, which formerly served as a medical-surgical unit.  The Center was designed from the patient's perspective, using a combination of patient focus groups and a patient and family advisory council to reengineer the patient experience.   These entities played an integral role in the design, development, implementation, and evaluation of the Center for Joint Replacement.  From the physical layout of the Center to clinical protocols and daily routines, the advisors' input proved invaluable. 

The end result was a Center with 16 quiet, private rooms with personal baths and wireless Internet access.  The facility includes a rehabilitation gym designed to simulate the home environment, furniture that meets a patient's needs after surgery; healthy snacks available at all times for patients and families, and patient education designed to provide an accurate outline of the daily activities prior to admission.   Additionally, an environment was established that is more respectful to the patient and their family by encouraging open and effective communication.  The process views patients and families as vital collaborators in the care of the patient and in the success of the Center for Joint Replacement. 
The new Center has become a model of excellence at the Health System, and has had a significant impact on the organization's long-term thinking and planning.  The board's strategic planning process has become focused on ensuring real patient- and family-centered care, placing the same expectation on every St. Mary's service line.

The Patient and Family Advisory Council. Before beginning development of the Center for Joint Replacement, St. Mary's held a focus group with 20 to 30 former patients to discuss their experience, including pain management, their surgery experience, the coordination of services, and patient education.  Following the focus group, St. Mary's selected five patients to serve as "patient advisors." Patient advisors came to the hospital every 2 to 3 weeks during the planning stages, and provided feedback about the admission process, pain management, coordination of care, discharge instructions, and transition out of the hospital.

During construction, St. Mary's created a mock room to enable clinicians and patient advisors to "test" the space and provide feedback to the architects. Patient critiques were very different from feedback from providers. The patients focused on room aesthetics and efforts to make it feel less sterile, but also on how the room would accommodate the patient's needs functionally.  Patients moved around the room as if they had just had surgery, identifying issues providers hadn't observed.  For example, a patient using a walker discovered the bathroom door couldn't close with the walker inside the bathroom.

The patient advisors also offered insight into many processes.  For example, in the past, all patients were given an epidural for pain control during and immediately following knee replacement surgery.  The approach had a 60 percent success rate, which was considered to be positive.  However, patients complained that the experience was negative because their pain was not under control.  The Center used the feedback to change their pain protocols, which empowered the patient by providing an opportunity to collaborate with the nursing staff to control postoperative pain and made their rehabilitation go more smoothly.

The Patient and Family Advisory Council continues to have a voice in the evaluation of the program.  The group has access to and reviews performance/quality reports and patient surveys. They have agreed to assist the Center for two years and to provide mentorship for new advisors.

Preparing Patients and Families for Surgery.   Although joint replacement patients have always received education prior to surgery, patient feedback from the focus groups and the Patient and Family Advisory Council determined that patients often were not properly prepared for surgery.  Patients needed more information about what the experience would be like and what would be necessary for recovery. 

To ensure that patients had the necessary information in advance, the Center began offering a two-hour class for patients prior to surgery.  Part of the class involved determining each patient's discharge plan to help them transition back to home and continue with their rehabilitation exercises.  At the same time, the Center expanded the time between patient consent for the surgery and the date of surgery from two weeks to four weeks, allowing patients more time to seek support for making the transition home.  Since the class began in July 2007, patients who participate in the class prior to surgery have shown higher satisfaction rates and a slightly higher rate of discharge to home.

The Center also instituted a "coaching" program for the patient's family or friend who was going to assist with the patient's recovery at home.  This program was instituted for several reasons.  First, several Patient/Family Advisors had mentioned that they would have been more comfortable during their hospitalization if a family member was able to stay.  The Patient/Family Advisors also reported that their families were ill prepared to assist with care at home.  It was at this point that St. Mary's began to recognize the value and importance of involving families or friends in the patient's care.  The "coaches" would be involved in all patient education sessions, instructed on how to perform care and assist patients with the home exercise program, and were invited to stay throughout the hospitalization if the patient and family member so desired.  The outcome of this initiative has been better engaged families, higher patient satisfaction scores, and an increased number of patients who are able to go directly home after discharge.

Weekly Patient Satisfaction Report Card.   St. Mary's contracts with a national organization that measures patient satisfaction; however, results are delayed by approximately three months.  The Center realized that a minor change in treatment may have a significant impact on patient satisfaction, but that they might not find out for up to three months after the dissatisfaction had occurred.  This could result in providers unknowingly providing care that caused other patient dissatisfaction for several additional months.  To ensure a rapid response to patient concerns, the Center developed a weekly satisfaction report card.

The report card is based on information provided by patients at discharge the previous week, and allows the Center to make immediate adjustments. The survey asks patients detailed questions about their experience, the coordination of care, and pain management.  For example, at one point a surgeon made a change to the pain management medication used.  The surgeon believed that the new medication would be just as effective in managing pain as the previous medication, but patient concerns about pain control were immediately identified based on that week's patient satisfaction report card.  The Center was able to identify a change in a medication was the source of the pain management problem and quickly responded to make adjustments, bringing patient satisfaction scores back up the following week.  Thus, patients' feedback from one week will directly impact the care and service in successive weeks.

Ensuring Coordination of Care. Prior to developing the Center, joint replacement patients had the potential to get "lost in the system" as they were treated by multiple providers at multiple locations.  To ensure a seamless experience, the Center hired a full-time nurse dedicated to coordinating patient care.  The Care Coordinator nurse helps guide each patient from the time of consent, to the time of admission, and again after discharge.  Patients know whom to contact should they have any questions about their care, or if they need assistance scheduling tests or follow-up appointments. 
Having one contact point removes some of the uncertainty for patients and helps build a support system.  The Care Coordinator also conducts rounds with physicians, providing continuity for patients.

In addition to a dedicated nurse, the services patients receive throughout their hospital stay are now scheduled in advance and coordinated.  Before the Center was established, patient care in the hospital was not scheduled, so a physical therapist might come to a patient's room to provide care and find the patient had gone for a test (such as an x-ray).  In addition, patients were frustrated because they did not know what their schedule would be, so they could not plan in advance for when to take pain medication, use the restroom, or visit with family.  By ensuring that both the patient and their care providers know the daily schedule, providers are more efficient and can ensure that patients are properly prepared for upcoming appointments, and patients feel as if they have more control over their care.

Applying the Patient- and Family-Centered Concept Throughout the Medical Center.   The success of the Center for Joint Replacement's patient- and family-centered approach has been embraced by the St. Mary's board and leadership.  This new way of thinking is being applied in other parts of the organization, including three units currently under construction.  The new emergency department, skilled rehab unit, and ambulatory care center projects are forming their own Patient and Family Advisory Councils.  Throughout the development of each unit, patients/families and staff are asking themselves if each component is patient- and family-centered.  Each time the question is asked, new ideas are incorporated, from signage to room design to parking.

Engaging Local Payers. St. Mary's is working closely with local payers to communicate the unique approach employed at the Center for Joint Replacement.  For example, in 2007 a local payer was highlighted in the newspaper for sending their patients to Singapore for elective surgeries.  St. Mary's invited representatives to tour the Center to learn about its patient- and family-centered approach. After learning about various aspects of the Center, the payer asked the Center to be a preferred provider for patients in their plan.  This validated that the Center was on the right path in ensuring patient satisfaction as well as efficiency and cost-effectiveness.


The Center for Joint Replacement's patient- and family-centered model has resulted in shorter lengths of stay and improved rates of discharge to home.  In 2006, patients with primary knee replacements had an average length of stay of 3.5 days and a 44% discharge to home rate.  In contrast, in the third quarter of 2008 primary knee replacement patients had an average length of stay of 3 days and a 75% discharge to home rate.

Improved Patient Outcomes Result in Lower Costs.   A shorter length of stay not only lowers hospital costs, but also reduces patients' risk for hospital-acquired infections. In addition, by transitioning patients back home after discharge instead of to a skilled rehab facility, total costs are lowered even further.

The Patient- and Family-Centered Approach Identifies New Ways to Improve Care.  Ongoing analysis of patient satisfaction and patient outcomes allows employees to continually make adjustments that improve patient care.  For example, evaluation of patient data found that female patients tended to progress to walking more quickly than male patients.  A deeper analysis of the differences in patient treatment helped caregivers recognize that by walking to the bathroom, female patients were recovering more quickly, while male patients' recovery was impeded because they were able to use a urinal in bed with minimal movement.  To ensure a more speedy recovery, all patients now walk to the restroom.

Limitations Encountered.   When the new model was first communicated to providers, their initial reaction was that they had always been patient and family-centered, and some were offended by the emphasis placed on something in which they already prided themselves. The Center brought providers to several Patient and Family Advisory meetings, and the providers quickly realized that the experience they thought they were giving patients and the experience that patients were receiving were very different.  The challenge was shifting providers' thinking from doing everything for the patient to partnering with the patients.

In addition, determining the reporting structure for the Center's program coordinator took some time.  While the coordinator reported to the Medical Center's Chief Operating Officer, the position also required interfacing with multiple leaders within the organization and at times there was no clear documentation about who should be included in reports and decisions.  Developing a matrix-type reporting structure helped clarify roles and improve communication.
Finally, while the success of the patient- and family-centered care model has improved patient care and outcomes in the Center, patients do not necessarily receive care in the same manner when they are transferred to other departments within St. Mary's or to other facilities the Center partners with (such as rehabilitation or home health).  Patients have expressed frustration that they do not feel as much in control of their care when they are in other care settings.  For example, if a patient is transferred out of the Center due to additional medical needs, they still have the expectation that they need to continue to move to improve their mobility.  However, the providers on the unit they are transferred to may not have the same understanding of the original care plan.  In addition, providers in other departments or organizations may not have access to the patient's care schedule throughout the day, and have little or no knowledge about the patient's scheduled therapy appointments or tests.  This lack of coordination of care and patient communication can lead to a decline in patient satisfaction.

Advice for Organizations Implementing a Similar Approach.   When implementing a similar model to the Center for Joint Replacement, begin by clearly articulating the mission and long-term goals.  Then utilize patient focus groups to guide decision-making, if possible, forming a smaller group of volunteer patients committed to helping develop and test the program. 

Do not let clinicians or leaders focus too much on the latest equipment or technology.  Rather, the focus should be on changing the patient- and family-centered culture and philosophy.  To help with this shift, engage clinicians in the program development and encourage them to have meaningful conversations with the patient focus groups.  It is critical that providers break through the denial of thinking that they are already patient- and family-centered, shedding light on what patients experience and helping providers understand why patients may not perceive existing care as patient- and family-centered.


Although St. Mary's has not calculated the actual cost savings to the organization, reducing average length of stay saves the Health System money.  In addition, involving patients as part of the care team ensures that patients are in a safer environment.  In this regard, patients and their families are more likely to make sure their medications are correct; are better able to recognize signs and symptoms of potential complications; are better able to understand and perform their exercise programs; and are more comfortable to ask questions in preparation for discharge.
Improved patient and family involvement and patient satisfaction also strengthens their relationship with their caregivers.  From a risk-management perspective, if something does not go according to plan, patients are more likely to work with their provider to work out a solution.

Contact Name:   Lee Myles
Title: CEO
Tel:  (207) 777-8802
Fax:  (207) 777-8800

Contact Name:   Len Farinas
Title: Program Coordinator, Center for Joint Replacement
Tel:  (207) 333-4733
Fax:  (207) 333-4722



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