Abstract
This presentation describes our journey and process of developing a transdisciplinary integrated service that caters to elderly patients undergoing major surgery in our hospital. This service that had been developed and refined over a period of 15 years. It focuses on returning elderly patients that undergo major surgery to good function and goes beyond short-term outcomes.
A framework which forms the foundation of the service will be described. This framework includes the themes of: integrated risk stratification, team dynamics, care planning, outcomes that matter to patients, management of complications and financial sustainability.
Within this framework, we engage surgeons, nursing staff and allied health professionals to evolve into a transdisciplinary system and empower patients to work for their functional recovery as part of the team.
We use CUSUM methodology to monitor for the consistency of success in our care delivery and integrate value-based driven outcomes to maintain quality.
Through this process, we have obtained a clinical quality index that is the highest for colorectal surgery for elderly patient in our nation. We have also published data that demonstrate consistency in our results. We have since scaled this service to cater to all subspecialties of general surgery and urology.