How Are We Doing? Evaluating Your Wound Clinic Operations

  After a seemingly interminable amount of time, your wound center is open. You are seeing patients and helping them with their chronic wounds. Everything is going well.

  Or is it? How is the wound center really doing? Are you practicing thorough, efficient, efficacious, cost-effective, evidence-based wound care? Are your patients doing well — ie, healing and/or comfortable? Are they happy with the way care is provided? Are you making any money (a distasteful but realistic question)? How do you know (ie, is any of this documented)? These difficult questions must be answered if you are to provide patients the best care available in a fiscally responsible manner.

  Our hospital-based wound center has been in operation for 14 years. We have found that periodic consideration of these questions is a must. Not only do we discover if our therapies are working for our patients, but we also learn whether our patients are pleased with the services we are providing and if we are fiscally sound.

Measuring Success

  At our center, we have three considerations relevant to ensuring our wound care program is operating successfully. The first is to determine whether we are providing evidence-based wound care and, if so, whether our outcomes are comparable to local and national standards and results in the literature. The second is to evaluate how our patients perceive our provision of care. The third, and probably the least important to us as clinicians but most important to administrators, is to ascertain if we are we financially healthy.

  Is care evidence-based? Determining whether you are practicing evidence-based care is fairly easy. Most wound centers treat patients based on protocols or algorithms. If current wound care practices in your center follow evidence-based protocols, you should be providing good patient care. However, while protocols may offer direction and consistency, not all patients respond the same way to identical treatments. Douglas Hyde, CEO of OshKosh, once said, “There is only one way to do something and that is the right way.” The right way for each of our patients is the way that works best for them as individuals within the parameters of the protocols. Rigidly adhering to only one therapy may not result in successful outcomes for all patients, even those with similar problems.

   How you assess how patients are responding to treatment depends on how your center tracks patients. If you have an electronic medical record (ECM), outcomes data are available at the touch of a button on your computer. If a computer database of some type is not available, chart review will be necessary. Healing rates, complication rates (such as infection), amputation rates, and other data should be evaluated for each major wound type treated in the center. Once collected, the information should be compared to national standards and randomized, controlled clinical trial results for the particular wound type being treated.

  If your center’s outcomes are comparable to published data, pat yourselves on the back — then try to better your figures. If your center’s outcomes do not quite measure up, do not presume you are treating the worst patients on the planet. Use this as an opportunity to evaluate your treatment regimens and techniques and improve outcomes. Perhaps more recently published algorithms should be considered and protocol changes made. If you are unsure how to proceed, contact someone you consider an expert in wound care and seek his/her advice. Most everyone with whom I have worked would be happy to provide assistance to you and your center.

  Are people satisfied? The second consideration is satisfaction levels at the wound center. This may be the most critical area to evaluate. Three factors should be addressed: 1) satisfaction of the staff working in the center, 2) satisfaction of the patients receiving the care, and 3) satisfaction of the referring physicians. Each is equally important and must meet high standards if the wound center is to function successfully.

  Staff satisfaction. Satisfaction of the staff working in the center is crucial to your success. If the staff are not happy in their jobs caring for patients with wounds, the entire care process can be slowed or stalled. The provision of efficient wound care depends on each staff member knowing his/her task and being willing and eager to perform it. Disgruntled or envious employees compromise the wound center atmosphere.

  In our wound center, we see between 60 and 80 patients per day. How well the staff work together is a factor in the care of our patients. I am familiar with wound centers where certain staff members perform specific tasks — if someone is unavailable to do the task, the rhythm of operations is disrupted or ceases while everyone waits until the job is done. This does not make for a happy staff or happy patients and certainly does not portend an efficient operation. Everyone in the center must be dedicated to making the wound center operate smoothly. For any operation to work efficiently, every staff member must be committed to doing whatever it takes to make the organization function.

  Patient satisfaction. The next group that must be satisfied with provision of care is the patients. Dr. Bruce Gerwertz, University of Chicago School of Medicine, says, “People receiving a medical treatment have the most relevant perspective of success (of that treatment).”1 If patients are not satisfied with the care they are receiving or if they are not pleased with the way they are receiving the care, they will not cooperate with care plans or disappear. Patients may not say much except to complain how long they have to wait. Also, they are aware of center “culture.” They notice how people do their jobs as well as the attitude with which they are performed. They notice whether staff treat one another with professional respect. They are particularly aware of how staff address patients — whether patients are respected as individuals with medical problems or herded through the office for a dressing change and out the door.

  Many wound clinic patients have chronic problems and may be in your care for a long time. Some of our patients seem like family — most importantly, we treat them as family. When this attitude is conveyed, patients are more willing to cooperate with care instructions and to persist with treatment of their difficult wounds. Patients want to understand their problems and be involved in the development of their plans of care. It is extremely important for the caregiver to address the patient’s concerns in words he/she can understand, answering questions such as, What is this wound or condition? What can I expect from the treatment? What should I look for when things are not right? The patient’s ability to participate in his/her care will greatly enhance his/her satisfaction with the wound center, the treatment, and the staff.

  Every year or so, we have our patients fill out a Patient Satisfaction Questionnaire. Many are available but we developed our own (see “Questionnaire”).

  Physician satisfaction. An often forgotten group whose satisfaction with your program is most important is the referring physicians. Many patients seen in the wound center come as a result of a direct physician referral. It is imperative to inform these physicians of your treatment plans and outcomes. It is our practice to send a letter to the referring physician and the patient’s primary care physician (if different) after the first visit and after the patient is healed. If the patient needs to be referred to another specialist, the referring physician and the primary care physician are notified and asked to whom they would like the patient referred. If the patient needs hospitalization, these physicians are again notified and given the opportunity to participate in the care while the patient is in the hospital.

  The need for thorough and frequent communication between the wound center and the referring physician cannot be overemphasized. A satisfaction questionnaire sent to the referring physicians also might be a good idea. This would provide definitive information as to how clinic-physician communication is perceived. Remember, if referring physicians are not kept informed about their patients, they may not refer any other patients to your wound center.

  Are we making any money? It would seem obvious that no wound center can continue providing care unless the costs of providing care are covered. However, the bottom line on a balance sheet is not the only reflection of the financial viability of the center.

  Wound care is a volume business — ie, the center must see a certain number of patients to create a positive cash flow. The bottom line number of patients that must be seen will depend on the center’s overhead: salaries, rent, utilities, cost of supplies, and other expenses. It has been our experience and the experience of others that financial success is difficult to attain if professional charges are the sole source of income. Generating a facility charge when a procedure (eg, debridement) is performed is fiscally more helpful (although this is not possible unless the center is an outpatient department of a hospital). Obviously, this additional charge can be assessed only when a procedure is performed but this practice has ensured our financial survival.

  This is not to say that free-standing wound centers cannot survive. Some excellent centers around the country providing evidence-based wound care are not associated with hospitals, but “independence” seems to require an extra measure of diligence and financial savvy. This makes providing wound care for all patients who come to the center a more significant challenge.

  A wound center can help itself financially by performing “extracurricular” procedures in the center. Vascular evaluations with Doppler and TcPO2 studies and measurement of ankle-brachial indices (ABI) can generate charges for the center and enhance the bottom line. Our center is initiating a program to provide our own outpatient IV antibiotic therapy. This will allow our patients to come to a familiar location for their IV antibiotics and give wound center staff the opportunity to keep a close eye on the patient’s wound. Other outpatient services, such as an outpatient ostomy clinic, could be located in the wound center, providing good patient care while maximizing the expertise of the wound center staff and facility.

  Another important consideration regarding the wound center’s financial health is whether the center is a part of the hospital. The additional referrals to the hospital from the wound center for laboratory evaluations, microbiology, x-rays, nuclear medicine scans, MRI scans, arteriograms, and even admissions add to the hospital’s financial viability. The wound center should keep track of these visits for administrators to consider when evaluating the financial value of the wound center to the hospital.

  Public perception. The status of the wound center in the community adds value to the hospital. Wound centers treat a sometimes forgotten group — ie, patients with chronic, hard-to-heal wounds. The fact that a hospital cares enough for those patients to have a wound center will send a positive message to the community about the hospital. People often come to our hospital for services unrelated to wound care just because they know the hospital cares enough about patients to provide for chronic wound patients. Patients also know that if they develop a wound complication during their treatment in the hospital they will not have to go elsewhere for care.

Summary

  A wound treatment center is a unique place that specializes in treating a special group of patients. Several relevant factors must be considered when evaluating the performance and success of any wound treatment facility. If you provide good, evidence-based care, demonstrate concern for your patients and their problems, and are diligent/resourceful stewards of your resources, your center can be professionally and financially successful.

Dr. Treadwell is Medical Director, Institute for Advanced Wound Care, Baptist Medical Center South Montgomery, Ala; and the president of AAWC. He can be reached via email at tatread@aol.com.

References

1. Gerwertz B. Editorial. Contemp Surg. 2001;57(7): 322.