Duke University Health System launched a care redesign initiative in 2016 to manage quality and achieve standardization of patient care processes in selected specialties. The Division of Urology focused on aligning clinical pathways, policies, and procedures specifically associated with prostatectomies and nephrectomies. As a result, patient outcomes and quality metrics improved significantly in less than one year.
Urologist Michael Ferrandino, MD, led the multidisciplinary team of surgeons, nurses, anesthesiologists, postanesthesia care unit staff, and pain management specialists tasked with enhancing the entire management strategy of patients undergoing the two procedures.
Less than one year after the initiative began, Ferrandino reports positive results in four major areas:
- Improvement in patient satisfaction survey scores, particularly in the areas of pain control and discharge instructions
- Reduction in hospital length of stay following prostatectomy and nephrectomy surgeries—approximately 60 fewer days than before the initiative started for prostatectomy alone
- Decrease in overall readmission rates
- Reduction in opioid prescriptions
“In our division, there are four surgeons who perform prostatectomies and seven surgeons who perform a variety of nephrectomies,” Ferrandino explains. “When we looked at pre-, intra-, and postoperative pathways, as well as perioperative instructions, we found they were highly variable among clinicians. That was leading to a lot of confusion and extra staff time to ensure the patients were receiving the care their surgeon specified.”
Ferrandino says the team studied all of the protocols involved with care for patients undergoing the procedures in order to align them, reduce variability, and develop a more cohesive management structure for treatment.
Among the protocols the team reviewed were pain management strategies to minimize the use of perioperative, intraoperative, and post-discharge opioids; dietary and exercise orders; guidelines on the timing of catheter removal following procedures; and discharge instructions. “Our work was as evidence-based as possible,” he says, “and where there was no evidence, we debated the topic as a team to develop or fine-tune our existing protocols.”
In addition to showing improvements in these areas, the data revealed opportunities for improvements in other areas. “For example, our program data showed a small increase in our patients returning to the Emergency Department for a variety of reasons,” says Ferrandino, “so we’re developing protocols and patient slots to help our triage staff get these patients into clinic as opposed to the ED.”
With the rollout of the initiative completed, the next steps involve continuing to refine treatment protocols, optimizing workflows, and ensuring compliance from all clinicians and staff with the resulting changes in practice—a process that Ferrandino says will be ongoing.
“This program shows Duke Urology’s desire and commitment to improving patient care and making the Duke experience better and better for patients,” says Ferrandino. “Although it started as an initiative, we’ll never be finished—these optimizations will just become a natural part of our practice.”