Quality within cost containment: a study of the satisfaction of patients and healthcare providers with the introduction of a pre-admission program at St. Clare's Mercy Hospital

Valvasori, Greta (1995) Quality within cost containment: a study of the satisfaction of patients and healthcare providers with the introduction of a pre-admission program at St. Clare's Mercy Hospital. Masters thesis, Memorial University of Newfoundland.

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Abstract

Surgery patients constitute a large percentage of in-house hospital patients. While once customary, admitting elective surgical patients' one to two days before surgery is no longer an accepted practice. With pressure increasing to contain health care costs, hospital stays are becoming shorter. As health care dollars decrease and shortages of surgical beds increase, most hospitals are looking for ways to improve their efficiency with decreasing resources. As a result, same day admission for many procedures is rapidly becoming a commonplace hospital cost containment program. In such programs, patients undergoing elective surgery receive preoperative testing, preparation, and education on an outpatient basis. Patients are admitted to hospital on the day of surgery. St. Clare's Mercy Hospital, in St. John's, Newfoundland, Canada, introduced its pre-admission clinic in November 1993. The Same Day Admission program now consists of two components: the pre-admission clinic visit and the same day admission service. This study endeavoured to determine the effectiveness and the effects of a cost containment strategy on the quality of patient care of the Same Day Admission program, at St. Clare's Mercy Hospital. The objective of the study was to detect any problems in the process and quality of patient care and to make recommendations for continuous improvement. "Plan-Do-Check-Act" (PDCA) Cycle (Walton, 1986) was the conceptual framework used to focus the research. The research questions were placed in the "Check" phase of the PDCA Cycle. Conclusions were drawn about the efficiency, the effectiveness, and the quality of patient care for this program through a review of a) patient outcomes and clinical indicators, and b) patient and healthcare provider satisfaction with the program. The population for the patient interviews was patients who were prepared for surgery in the Pre-Admission Clinic (PAC) and admitted to hospital on the day of surgery during the first six months of the program. The population for the healthcare provider focus groups and interviews was physicians who referred patients to the Same Day Admission program and a stratified sample of other healthcare providers who provided services to these patients. Information obtained from the patient and healthcare provider focus groups, patient and physician interviews, and a review of clinical indicators allowed the researcher to answer the following research questions: -- 1. Do the program outcomes indicate patient satisfaction with the process? -- 2. Do the program outcomes indicate healthcare provider satisfaction with the process? -- 3. Do patient clinical indicators indicate quality health care? -- 4. Do decreased length of hospital stay and low re-admission rates support the program as a cost containment program? -- 5. Do the program outcomes indicate attainment of program objectives? -- The analysis of the data was presented according to the research questions of this study. Patients' interview statements were examined and displayed through frequency and relative frequency distributions. The overall degree of patient satisfaction was very high at 90.73 %. The interview and focus group data were analyzed, according to the healthcare subgroup, using procedures outlined by Zemke and Kramlinger (1985). Most of the physicians' statements were very positive. They perceived the Same Day Admission program as being very positive for patients. Patients were accessing the necessary services, consultations were being organized, and patients were being educated about their entire surgical experience. Healthcare providers had both positive and negative perceptions of the care being provided to these patients. Their perceptions of the advantages of the program included the following: early identification of patients with discharge needs; patients were more educated as to what would be happening to them before, during, and after their surgical procedures; patients were more prepared for their surgery and their return to the community; services needed for patients' discharges were being identified before admissions to hospital; with decreasing lengths of hospital stay, more patients were accessing the services; improvement in patients' satisfaction; and improved access to preoperative consultations. Healthcare providers were also concerned with the assessment criteria for referring patients to the Pre-Admission and Same Day Admission program versus inpatient admissions. Nurses and therapists also voiced concerns with the incompleteness or absence of information for preoperative and postoperative patient assessment and care. Physicians did identify areas needing amelioration. These areas were: 1) dedicated medical resources for patient assessment and completing the History and Physical in the clinic; 2) internist and anaesthetist schedules to include Pre-admission consultations; and 3) increased resources (human and financial) to continue the work of the program. The objectives of the program focused on improved bed utilization, improved patient satisfaction, and enhanced quality patient care. These objectives were to be achieved through early identification of preoperative medical problems, initiation of early discharge planning, and provision of patient and family education Among the recommendations made was consideration be given to establishing an appropriate forum to address healthcare providers' concerns with the incompleteness or absence of information needed for preoperative and postoperative patient assessment and care. The researcher also recommended the Pre-Admission Committee establish protocols or assessment criteria for determining appropriateness of referring patients to the Pre-Admission and Same Day Admission program versus inpatient admissions. Consideration should also be given to further studying the length of hospital stays for same day admission patients and comparable Case Mix Groups of inpatients.

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