By Suzanne Graziano, RN, MSN, ONC, CNS
The impact of patient education on outcomes can be difficult to quantify. To better gauge the value of its patient education programs, the Hospital for Special Surgery (HSS) in New York recently conducted an analysis of data gathered from users of its Interdisciplinary Spine Preoperative Patient Education Program (ISPPEP).
Data collected since 1994 conclude that patient education for surgical patients increases patient satisfaction and reduces length-of-stay (LOS). The staff witnessed that a comprehensive patient education program reduced patient anxiety and actively involved patients and their families in the healing and rehabilitative process. The education program was instituted to address patient satisfaction and LOS and to repair the fragmented patient education process. The program was designed to bring together patients and practitioners from all stages of care to open the lines of communication and to ensure the highest quality of health care delivery and patient outcome
HSS’s interdisciplinary team of 21 clinical experts and professional caregivers included therapists, nutritionists, social workers and nurses (including the Vice President of Nursing, nurse managers, the clinical nurse specialist and staff nurses). The team developed the ISPPEP over a 16-month period.
Key building blocks
The interdisciplinary team structured the program around four key “building blocks:”
As part of the program’s development, the team surveyed HSS postsurgical spine patients, focusing on key areas related to adequacy of surgical preparation, expectations during recovery and recommendations for preoperative education. Prior to implementation of the program, 67 percent of patients surveyed indicated they did not feel adequately prepared for surgery and recovery. Patients said they needed more information about pain management after surgery and instructions about the best ways to recover from surgery and return to normal activities.
As a result, the ISPPEP was designed to address the following needs for patients, family members and the hospital:
Once the necessary building blocks were in place and the team understood the needs to address, they implemented the program. The four key components of the ISPPEP are preoperative education, individual assessment, personalized discharge plan and the manual.
No longer than one week before surgery, both the patient and family member(s) participate in a 90-minute classroom-based program. The session includes a lecture, discussion, demonstration and active participation. The program takes place in a specially designed classroom, outfitted like a hospital room, so that hospital equipment will be familiar to the patient.
Participants may choose to practice getting in and out of bed, using assisted devices (i.e. walkers, canes) and practicing with inspirometers to strengthen lung endurance prior to surgery. The nurses, physical therapists and case managers discuss preoperative preparation and exercises, as well as the surgical day and procedure itself, anesthesia and the course of recovery from the postanesthesia care unit to discharge. In addition, staff members teach about milestones for patients during several postoperative phases, including the hospital recovery period, at six weeks, three months and six months postsurgery.
Lastly, the classroom setting exposes patients and family members to others who will undergo the same surgery; patients are able to form their own support groups if they wish to do so.
Each patient receives an individual assessment in the classroom. When staff members meet with patients (and family members), they make use of a specifically designed tool to document functional status, psychosocial needs, medical history and pain assessment for each patient. The staff members who conduct these assessments identify special needs and potential risks for each patient and communicate them to the HSS team.
A discharge plan is developed for each patient. The staff knew from experience that planning for discharge before surgery is a critical part of a successful patient experience. Because the classes range from six to 18 patients, there is time to discuss the kinds of obstacles patients will encounter in their own homes and to share questions with other patients anticipating the same surgery. The case manager participates in the program to ensure that any special postoperative care patients might need is established.
Each patient receives the manual, Your Pathway to Recovery: Spine Surgery. This fully illustrated manual was developed and designed specifically for spine patients, informing them of every aspect of surgery and recovery. It is the patient’s main reference tool for the entire continuum of care from presurgical preparation through discharge.
Both the class and manual stress the importance of a patient’s active participation in recovery. In addition, orthopedic nurse clinicians are available to field calls and answer questions from patients and family members, Monday through Friday, from 7 a.m. to 5 p.m.
Documenting measurable improvements
HSS ran a pilot program of 30 patients over a four-month period befor fully implementing the ISPPEP. Patients and family members who attended the classes indicated that the program provided critical information that helped prepare them for surgery, postoperative pain management, physical therapy and hospital discharge.
Of the 30 patients participating in the pilot project, fully 100 percent either “strongly agreed” or “agreed” that the program adequately prepared them for surgery (67 percent strongly agreed; 33 percent agreed). In addition, 97 percent of those surveyed either “agreed” or “strongly agreed” that the program adequately prepared them for the postoperative hospital phase. Also, 83 percent agreed they had a better understanding of postoperative pain management and fully 100 percent “agreed” or “strongly agreed” that the program adequately prepared them for discharge from the hospital. Lastly, 100 percent of patients surveyed rated the program as excellent or very good (80 percent excellent; 20 percent very good).
HSS also measured staff satisfaction with patient preparedness for surgery, and the results were equally positive. Fully 100 percent of the 24-member staff thought that patients in the program were prepared for hospitalization. Survey results since the program’s inception have validated these pilot findings: the preoperative education program has dramatically improved both patient and staff satisfaction. In addition to being more satisfied, patients are more compliant and many achieve functional milestones early.
The staff also cited a more efficient, effective discharge planning process and more effective resource utilization as ancillary results of program implementation. Lastly, since the program’s inception, patient LOS has decreased, reducing costs without adverse effects to patients. See the accompanying chart on LOS comparison which shows LOS reduction from the program’s inception through 2002.
Based on practice and evidence, the HSS philosophy is that successful patient education needs to occur throughout the continuum of care. More specifically, because it has been documented that attitude greatly affects recovery rates, patients need information about what to expect when they are admitted. They also need to understand that their active participation in their care before, during and after hospitalization is necessary for a complete and successful recovery.
It is critical to the continued success of any patient education program that the staff listen to and learn from patients. HSS continually tracks and measures outcomes (such as LOS, patient satisfaction, and other metrics) and seeks to improve the program based on patient feedback, outcomes, and new technology.
Suzanne Graziano, MSN, RN, ONC, CNS, is a clinical nurse specialist in the division of nursing at New York’s Hospital for Special Surgery. She can be reached by phone at (212) 606-1263 or via e-mail at email@example.com.