AAOS Bulletin - August, 2005

AAOS launches patient-centered care initiative

Education, communication, safety and quality are hallmarks of program

By Stuart L. Weinstein, MD

Writing in the January 20, 2005 issue of the New England Journal of Medicine, Sen. William H. Frist, MD, said, “The focus of the 21st-century health care system must be the patient. Such a system will ensure that patients have access to the safest and highest-quality care, regardless of how much they earn, where they live, how sick they are, or the color of their skin. Patients must be the first priority and the focus of the transformed system.”

The concept of patient-centered care (PCC) has begun to filter through all levels of the health care complex—from physicians’ offices and hospitals to the halls of government agencies. Even though the exact definition of patient-centered care varies slightly throughout medical circles, most agree that it establishes a partnership among health care providers and patients and their families to ensure that decisions about medical treatments respect patients’ wants, needs, preferences and values. It has been difficult, however, to reach a general consensus on what patient-centered care really means or how it should be implemented.

In June, the AAOS took a major step forward in defining patient-centered care and its application to orthopaedic surgery. The Board of Directors approved, in concept, a major new patient-centered care initiative.

The multi-year project has four goals:

1. Improve the quality of health care provided to patients with musculoskeletal conditions who are treated by members of the AAOS

2. Increase patient satisfaction with orthopaedic care

3. Increase AAOS member satisfaction with their practices, improve outcomes, decrease liability risk and improve practice efficiency

4. Place the AAOS in a leadership position among physician groups in the PCC movement

Definition of PCC

The AAOS Board adopted the following definition of patient-centered care: Patient-centered care is the provision of safe, effective and timely musculoskeletal care achieved through cooperation among the orthopaedic surgeon, an informed and respected patient (and family) and a coordinated health care team.

The PCC initiative will involve all aspects and levels of the Academy. The scope of the initiative will include:

• Member education: Educating members about PCC and why it is important to their practices

• Patient education: Educating patients about what PCC means to them and why orthopaedic surgeons are playing a leadership role in this movement

• Tools: Providing members with tools to practice PCC and patients with tools to enable them to participate in PCC

• Partnerships: Developing partnerships with outside organizations in demonstration projects that position AAOS as a leader in this important, national movement.

An orthopaedic surgeon who has patient-centered care as a core value in his or her practice will provide safe, effective, timely, efficient and equitable care. As a champion for the patient’s interests, the orthopaedist will ensure that the patient (and the patient’s family) is informed, respected and involved in care decisions and treatment. As a leader in the health care community, the orthopaedist will cooperate with all members of the patient’s health care team to coordinate and deliver care and treatment in a way that respects the patient’s beliefs and needs.

These efforts will result in improved quality of care, increased patient satisfaction, better outcomes, lowered liability risks, improved practice efficiencies and a higher measure of satisfaction by the practicing orthopaedist.

It starts with the patient

Many physicians believe that they perform patient-centered medicine. That may be true, if one uses the definition that first introduced the concept more than 30 years ago. Back then, simply listening to the patient’s complaints and symptoms before making a diagnosis was a paradigm shift in the practice of medicine.

Others will argue that “doing the best thing for the patient” is also delivering patient-centered care. But today’s definition of patient-centered care turns that statement upside down. It is not the physician who decides what’s best for the patient; it is the patient. It is not the physician who drives the treatment by saying “do this”; it is the patient who is the driver by defining his or her goals and asking “how can you help me?”

Until recently, the voice of the patient was often missing from national debates about health care. Now, our patients are demanding a change in the way health care is being delivered. According to the American Hospital Association’s National Survey: Reality Check—Public Perceptions of Healthcare and Hospitals, “The public is deeply concerned and troubled about changes occurring in health care and hospitals. They feel a growing impact upon themselves and their families in terms of reduced access, lower quality, competency of care givers and a trend toward impersonal care.”

Karen Sendelback, executive director of the American Kidney Fund, which provides direct assistance and education to needy kidney patients, points out that there are important reasons from the patient’s perspective for making the shift to patient-centered care. “Patients want to feel ‘known’ by their providers and to feel that they are valued participants,” she says. “Another important need is to improve patients’ health literacy. Patients often have unrealistic expectations about what medical treatments can accomplish. We need patient education materials that have been developed to inform patients, not reduce liability.”

Government and business also are demanding change. The growing concern about patient safety, the variations in patient care across geographic settings and between racial groups, and an increasing desire on the part of public and private payers as well as consumers for accountability are driving this process. The Centers for Medicare & Medicaid Services (CMS) is particularly interested in patient decision-making. The agency looks for three key elements defining PCC:

• Evidence-based framework

• Safety

• Transparency

Business leaders are also concerned about their employees’ lack of quality information to participate in treatment decisions and make smart decisions about choosing their doctors. These shortcomings result in higher bottom line costs for health care.

AAOS takes the lead

Over the years, the AAOS has implemented a variety of patient-centered care programs, believing it is the right thing to do. Our activities have included:

• Developing print patient education materials and a major patient education Web site—Your Orthopaedic Connection

• Establishing communication skills mentoring workshops and cultural competency programs to assist members in communicating with diverse patient groups

• Creating patient safety programs and materials such as the “Sign Your Site” initiative, surgery checklists and a medical errors prevention video

• Developing evidence-based practice guidelines and outcomes instruments to improve quality of care as well as shared decision-making tools to improve patient care choices

• Publishing reference resources such the Dartmouth Atlas and Improving Musculoskeletal Care in America

• Leading advocacy efforts to help ensure affordable health care, widespread access to care—including specialty care—and appropriate funding for research to improve musculoskeletal health

All of these activities have provided a solid base for a patient-centered culture in orthopaedics, but much more can be done. With the new patient-centered care initiative approved by the Board in June, the AAOS will move forward on a number of projects:

• A special PCC logo and theme will be developed for use on all program materials.

• Patient and member satisfaction surveys will be developed, as well as a program to teach office staff and operating room personnel the principles of PCC.

• A set of videos featuring testimonials from orthopaedic patients who benefited from PCC will be produced for use in members’ practice waiting rooms.

• Six Power Point presentations will be created for members’ use in educating patients on musculoskeletal conditions.

• A patient-centered care pledge for orthopaedic surgeons to patients will be developed and made available to the fellowship for display in their offices.

• A chapter on PCC will be added to the next volume of Orthopaedic Knowledge Update

• Questions on PCC will be included on the Orthopaedic In-Training Exam (OITE).

• The AAOS patient education Web site Your Orthopaedic Connection (http://orthoinfo.org) will be expanded and enhanced.

• A special PCC public service advertising campaign will be developed.

In addition, because communication skills are an essential part of patient-centered care, the AAOS has set a goal of establishing communication skills mentoring programs in all 150 orthopaedic resident programs by 2008 and of training at least 25 percent of the membership by then.

Finally, the AAOS will reach out to partner with orthopaedic specialty societies and other outside patient groups to develop PCC programs and projects.

Implementing the initiative

The PCC initiative approved by the Board is initially a three-year program. But patient-centered care must be an integral part of orthopaedic practice for the long term. Evaluation and management (E&M) services currently generate about 40 percent of an orthopaedist’s income. With the increase in reimbursement for E&M services, and the decrease in reimbursement for procedures, patient-centered care activities will be increasingly important.

E&M services are also a vital part of good patient care, helping to avoid confusion, ensure the patient’s understanding of realistic outcomes, reduce the risk of medical liability lawsuits and contribute to improved patient compliance with treatment protocols.

As the AAOS and our members begin to implement the PCC initiative—in our organization and in our practices, I am confident that the results will be beneficial, particularly for the fellowship. Future issues of the Bulletin will explore the various facets of patient-centered care and provide specific examples of how to incorporate patient-centered care in an orthopaedic practice.

Stuart L. Weinstein, MD, is president of the AAOS and chair of the Patient Centered Care Project Team. He can be reached at stuart-weinstein@uiowa.edu

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