Breaking Down Silos with the Perioperative Surgical Home
Breaking Down Silos with the Perioperative Surgical Home
By Zeev Kain, MD, MBA
In 1967, there was an important development in healthcare: The American Academy of Pediatrics (AAP) created the patient-centered medical home (PCMH) model. Nearly half a century ago, pioneering physicians saw the need to facilitate continuity throughout the patient care journey.
The scope of PCMH grew to become a true partnership approach that includes the patient, family members, clinicians, and caregivers. While the model has gained momentum since the inception of health reform, healthcare leadership has been refining its principles since 1967. In 2002, AAP added 37 specific activities that should occur in the PCMH model (Robert Graham Center, 2007). In 2007, the American Academy of Family Physicians (AAFP), American College of Physicians (ACP), American Osteopathic Association (AOA), and AAP published Joint Principles of the Patient-Centered Medical Home, which stressed the importance of concepts such as whole-person orientation and coordinated care across all elements of our complex system (Patient-Centered Primary Care Collaborative, 2007).
PCMH is a model that requires collaboration and cooperation across the care continuum; therefore, it can be challenging and time-consuming to implement. In many cases, physicians must shatter the barriers formed by healthcare’s silo-based environment. Health reform’s mandate to improve care coordination, however, has made PCMH an important strategic initiative for many providers. Approximately 7,000 primary care practices have deployed the PCMH model, with others in various stages of implementation (National Committee for Quality Assurance, n.d.).
While silos exist in many facets of healthcare, they’re often particularly obvious in perioperative services. This complex and fast-paced environment has numerous stakeholders that operate in their own microcosms, performing their discrete set of patient care activities. These stakeholders often don’t have all of the “big picture” information they need, which can impede both efficiency and patient care. With the advent of healthcare reform—and its goal for aligned, patient-centric care—these silos are increasingly problematic.
In our current environment, all facets of healthcare—especially those in acute care—are trying to align with additional goals of healthcare reform: increased value, coordination, and communication across the continuum of care. It’s clear, however, that the perioperative environment has a long way to go, not because its clinicians aren’t forward-thinking innovators, but because the operating room (OR) is naturally complex. Surgical care accounts for an estimated 52 percent of U.S. hospital admission expenses (Health Care Cost Institute, 2012); therefore, reducing waste would result in significant savings.
Addressing Waste in U.S. Healthcare
Don Berwick cites six sources of waste in healthcare: failure in care delivery, failure in care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse (Berwick & Hackbarth, 2012). Consider a typical perioperative patient who begins with a pre-op clinic visit or a phone call often including lab tests and consults, where clinicians collect a host of data—some that will be electronically accessible to future providers, and others that won’t be. On the day of surgery, the patient moves from pre-op to intraoperative to the post-anesthesia care unit (PACU) and then post-op to the ward. Along the way, she is asked questions, which are often repeated multiple times as she progresses.
This scenario can potentially give way to all six sources of Berwick’s waste. Care coordination is hindered because not all clinicians are privy to the same data. Because all parties, including the patient, failed to develop common goals for the surgery, a lack of alignment and even overtreatment can occur. Administrative complexities are likely due to the lack of information sharing, repetition of tasks, and the silo-based system. Costs may be higher than necessary due to a lack of cohesiveness among perioperative physicians. For example, surgeons may select costlier implants when less expensive versions are just as safe and effective. In a worst case scenario, fraud or abuse is more likely to occur in a fragmented system with a lack of accountability among the care team that spans a broad continuum of care.
As hospitals strive to meet healthcare reform requirements, leadership must make changes in the current perioperative structure. Moving from fee-for-service to value-based payment mandates increased accountability for outcomes and a streamlined workflow for improved efficiency. In addition, better alignment and care coordination throughout the entire patient continuum—the driver for patient-centered medical home—are also vital.
Why the Anesthesiologist? |
| Any physician can be the center of the PSH model, overseeing the patient care plan and ensuring the team meets the pre-defined goals. The anesthesiologist, however, is the optimal choice. Why? Anesthesiologists are uniquely positioned to fulfill this role because of their ability to assess, evaluate, and prepare patients with an array of complex comorbidities, and then manage these comorbidities intra-operatively and post-operatively. This in-depth understanding enables anesthesiologists to drive the standardization of care—one of the most critical components of PSH—thus reducing risk and optimizing outcomes. |
Perioperative Surgical Home
Just as the patient-centered medical home model has emerged to meet health reform’s call for better coordination and alignment of care, the perioperative surgical home (PSH) model enables similar benefits for the complex and silo-based perioperative environment. The PSH is endorsed by the American Society of Anesthesiologists (ASA) as a model that supports the Institute for Healthcare Improvement’s Triple Aim: improving patient health and the delivery of care while reducing healthcare costs (American Society of Anesthesiologists).
As its name suggests, PSH is patient-centered, with all care activities coordinated by a team of individuals led by one key clinician. This model emphasizes developing clinical pathways and reducing system-related variability. Like many models that require significant process change, PSH evolved into its current state over the course of several decades. When PCMH was developed in 1967, primary care was an entirely separate entity. As a result, the headway primary care physicians made with care coordination didn’t apply to the surgical environment. Advancements in health information technology throughout the 1970s and 1980s, however, began to yield greater care continuity and coordination throughout the perioperative process.
The improvements implemented 20 to 30 years ago within the context of the PCMH didn’t address the entire perioperative care continuum or create a fully integrated care team—factors addressed by PSH. In addition, inefficiencies and waste remained a key problem. Consequently, in the 1990s, the University of Pittsburgh’s anesthesiology department developed the “perioperative process” to improve cost containment. This team’s researched showed how a real-time patient routing system could improve utilization and decrease delays. They also proved that anesthesia clinical pathways improved process outcomes and reduced costs (Kash, Cline, Menser, & Zhang, 2014). These findings lay the groundwork for ASA’s current definition and guidelines for PSH.
As ASA’s involvement in PSH would suggest, the clinician most often leading a hospital’s PSH program is the anesthesiologist. The anesthesiologist is often already involved in pre-op, intra-op, PACU and post-op care on the ward. With this physician’s guidance, the patient’s entire perioperative experience is treated as one continuum of care rather than discrete episodes in areas such as pre-op and PACU.
Besides guiding the patient through the entire surgical experience, the anesthesiologist has another critical role: working with the patient to establish the desired outcome or goal and working with clinicians to achieve that goal. This is an important difference between the standard OR experience and PSH. While all clinicians are working to provide high quality care in a non-PSH environment, they aren’t necessarily striving to reach a pre-defined goal. The PSH model leverages tools such as the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator to facilitate discussions between patients and physicians regarding risks and desired outcomes. The physician incorporates the patient’s values and preferences, and the entire care team is involved and attuned to the overall goal. This in turn facilitates alignment among all constituents involved in the patient’s care.
Benefits |
| When developing a business plan to gain buy-in, it’s important to make sure there is alignment between the goals of the organization and the goal of PSH. Also, remember to show how PSH can deliver ROI in financial, material, and clinical areas:
Financial
Material
Clinical
|
Achieving Triple Aim and Moving from Volume to Value
With PSH, the continuity of the perioperative experience extends from when a patient and physician decide to move forward with surgery until 30 days after discharge. While the traditional perioperative model doesn’t extend care beyond discharge, PSH includes follow-up action on a number of initiatives, i.e., medication adherence, rehabilitation, and diet.
Much like the PCMH, this model allows both patient and care team to have better communication and alignment, while also creating a more streamlined and efficient process. To that end, PCMH has been successful and has furthered the goals of healthcare reform, but it has left a critical gap: inpatient care. PSH closes this gap in one of the most complex and often convoluted workflows in the inpatient setting. Further, it holds the entire care team to a higher level of accountability because everyone is aware of the goal and has transparency regarding actions and outcomes. In the current trajectory of healthcare, a focus on value rather than volume is becoming increasingly necessary. Shifting this focus in such a complex and frequently disjointed environment is difficult, but PSH provides the framework to make it happen.
Pioneering PSH at the University of California Irvine Health
With the support of the COO and chairs of orthopedics and anesthesiology and perioperative care, the University of California Irvine Health implemented the PSH model for primary joint replacement surgery (hip and knee). During implementation, multidisciplinary teams with anesthesiologists, surgeons, nurses, pharmacists, physical therapists, case managers, social workers, and IT experts met weekly.
A key component of the implementation process was value stream mapping for every perioperative process. These value stream maps provided standardized clinical care pathways developed with evidence-based protocols. In each case, the team used level 1 evidence for the pathway; if this wasn’t available, they adopted a practice guideline with a lower level of evidence. In all cases, adoption of care pathways required consensus among team members, thus setting the stage for PSH’s philosophy of full agreement—and full communication to the team—regarding outcome goals for each case. While PSH does not require Lean Six Sigma, the UC Irvine Health PSH team leveraged this methodology as the project’s cornerstone to further their goal of improved outcomes via standardization and reduced variability.
PSH required new behavior from all constituents, including patients. Prior to surgery, each patient participated in both joint replacement education and mind-body surgical preparation classes. Two to four weeks prior to surgery, they consulted with a nurse practitioner supervised by an anesthesiologist and underwent pre-op risk stratification and optimization processes along with patient education.
Achieving Operational, Clinical, and Patient Safety Outcomes
UC Irvine Health realized a variety of positive outcomes in the first 30 days of the program. Ninety-two percent of cases began at 7:15 a.m., which is the organization’s earliest start time, and turnover time averaged 28 minutes—a 30 percent improvement compared to pre-PSH data. Regarding safety, no patients had major complications or received an intraoperative blood transfusion. All SCIP indicators were at 100.0 performance for all 146 cases.
Also, UC Irvine Health’s readmission rate for total hip arthroplasty patients is zero percent, and the rate for total knee arthroplasty patients is 1.1 percent, compared to a national average of 2.6 and 4.2 percent, respectively (Pugely, Callaghan, Martin, Cram, & Gao, 2013).
In addition to better overall care alignment, the team (including the patient) has realized post-operative benefits due to two factors: While at the hospital, patients are scheduled to attend a coagulation clinic two to three weeks after discharge, as well as a follow-up visit with the orthopedic surgeon two weeks post-surgery. Also, the PSH team follows outcome-oriented, pre-defined guidelines for discharge orders, instructions, medication, wound care, and follow-up visits. The program calls for clear communication between the patient and multiple members of the care team regarding all post-discharge instructions. Since patients have been integrally involved in their care and are likely more accustomed to communicating with the PSH team, they are more likely to be engaged when receiving this guidance.
With early success in the primary joint replacement program, the team received a UC Center for Health Quality and Innovation award and began the first phase of the urological PSH program. After building value stream maps with clinical pathways, the program recently launched and now includes all elective orthopedic inpatients and outpatients as well as some urological patients. The team is driving continuous improvements; for instance, it is currently implementing tactics to enhance post-op care management.
Building a PSH Program: Insights and Lessons Learned
UC Irvine Health’s PSH team can offer several insights to perioperative teams that would like to launch a similar program:
Gaining Buy-In and Seeking Funding
Healthcare executives outside the perioperative environment may need to be sold on the benefits of PSH. They may ask, “If we’re not getting paid more, what’s the value? Is it worth the time and resources?” Having a business plan that includes a cost benefit analysis can show return on investment (ROI) along with softer gains such as patient engagement and satisfaction. With total hip or knee replacement, the ROI is both decreased length of stay (LOS), reduced rate of postoperative complications, reduced rate of re-admissions, lower cost of implants and lower utilization of resources such as imaging and pharmacy.
In your business plan, consider stakeholders such as payers that want to avoid readmissions and post-discharge complications – the same payers that are beginning to move to value-based payment. PSH also addresses bundled payments by promoting the optimal, evidence-based clinical pathway that is likely to get the best results while minimizing potentially avoidable complications. The PSH model drives positive clinical outcomes based on accepted criteria such as NSQIP and SCIP. In addition, patient satisfaction should be considered as it now has an impact on reimbursement and referral patterns.
The other key factor in a cost-benefit analysis is reduced cost per case. PSH can lower personnel costs via standardization and alignment, which leads to a more efficient workflow and greater productivity. These same principles can also reduce implant costs, as all purchasing decisions will be pre-defined according to consensus and an objective decision-making process with an emphasis on value.
Building the Optimal Program
First, as you create your PSH team, be aware of the different skills required to build the program as opposed to maintain it. During development, anesthesiologists must have strong team-building skills and be versed in change management techniques such as Lean and Six Sigma. Many anesthesiologists aren’t already skilled in change management, but the desire to learn is really the key. Also, consider making these change management and performance improvement skills a part of your future residency programs.
Once the PSH program is developed, staffing will also require a specific skill set. Anesthesiologists must also have expertise—or be willing to obtain it—in post-op management of complex surgical patients. Again, adding more post-op care training in the residency program can ensure ongoing excellence in areas that may not currently be addressed in an in-depth fashion.
Next, when creating a pilot program, select a stable procedure that has relatively little variability and few complications. It should also have a relatively healthy population. These factors will facilitate the development of standardized clinical pathways. The UC Irvine Health team also selected total knee and hip replacements because they are very common procedures and would provide a strong sample for a pilot program.
Leveraging the Right Tools for Success
Because PSH requires ongoing communication among all members of the care team across the entire continuum, a strong perioperative-focused technology infrastructure is needed to capture and share patient data. This collection should include all pertinent information from surgery decision through 30 days post-discharge, and the team can expedite this process by using the electronic health record as much as possible. It is also ideal to capture all the various inventory used throughout the care continuum to aid standardization of materials. Another necessary tool is technology to capture analytics. While the moment-to-moment emphasis is on patient care, every piece of information collected will enable the PSH to evaluate myriad factors; for instance, outcomes for populations and the efficiency of workflows.
Realizing the Role of Analytics
Metrics are the cornerstone of continuous improvement. By collecting them from multiple sources such as patient scheduling, pre-op assessments, order sets, drug administration, nursing flow sheets, anesthesia records, inpatient and outpatient progress notes, and patient feedback forms, leadership can make informed decisions regarding clinical, operational, and financial changes. Assimilating actionable data from so many sources can be difficult, though, especially in such a busy and fast-paced environment. Ideally, a PSH program will be able to leverage an analytics tool that collects and presents this abundance of data in a meaningful way.
At UC Irvine Health, the PSH team leverages Surgical Information Systems’ perioperative IT solutions and integrated anesthesia capabilities to gather monthly summary metrics for executive dashboards to show progress and ROI; specifically, these reports show financials, clinical outcomes, and patient feedback. Reports with daily metrics are used in almost real time to drive clinical decisions. The system notifies our team if a patient is falling behind in any of the clinical pathway milestones. This helps us circumvent complication risks and delayed discharges.
Readiness in the Face of Rapid Change and New Demands
Healthcare reform efforts will continue to drive patient engagement. All providers—especially those in acute care—will need to increase their efforts to promote patient-centered, fully aligned care. Reform will also propel the realization of value-based care. All of these factors contribute to a more challenging and demanding environment—one that would be better served by a model that facilitates evidence-based, standardized, patient-centered care with an eye toward pre-defined goals.
If the most talented, hardworking, and experienced professionals are building your new home but they’re not communicating with each other or don’t have access to the detailed master plan, the end result may be passable at best or severely faulty at worst. It certainly won’t be a masterpiece. At various steps, miscommunication can result in errors and the need for “do overs.” Architecture isn’t patient care, but the analogy holds true for PSH: A silo-based environment without communication and alignment can create problems despite individual skills and diligence. In patient care, “do overs” don’t exist. Clinicians need to everything in their power to get it right the first time. In the OR, PSH is the model that can make this happen.
Zeev Kain is professor and associate dean for clinical operations at the University of California, Irvine. His medical degree is from Ben Gurion University of the Negev in Israel, and his master’s degree in business administration is from Columbia University in New York. Kain is an expert in the clinical management of perioperative fear and anxiety and management of children undergoing invasive medical procedures. Kain’s research has resulted in significantly fewer children in the U.S. and around the globe taken into operating rooms and sedation suites awake, alone, and afraid. By promoting the conceptual importance of this field and continuing to develop associated empirical findings, Kain intends to markedly improve the quality of evidence available to anesthesiologists, pediatricians, and surgeons making clinical decisions regarding management of children’s distress and pain during the perioperative period. Kain may be contacted at zkain@uci.edu.
References
Perioperative Surgical Home. Retrieved February 14, 2105, from American Society of Anesthesiologists web site: https://www.asahq.org/psh
Berwick, D. M. & Hackbarth, A. D. (2012, April 11). Eliminating waste in U.S. health care. JAMA, 307(14), 1513-1516. doi:10.1001/jama.2012.362.
Health Care Cost Institute. (2012, September). Health care cost and utilization report: 2011. Retrieved from http://www.healthcostinstitute.org/files/HCCI_HCCUR2011.pdf
Kash, B. A., Cline, K. M., Menser, T., & Zhang, Y. (2014, June 12). The perioperative surgical home: A comprehensive literature review for the American Society of Anesthesiologists. College Station, TX: Texas A&M University Health Science Center, Center for health Organization Transformation.
National Committee for Quality Assurance. (n.d.). The future of patient-centered medical homes: Foundation for a better health care system. Retrieved from http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdf
Patient-Centered Primary Care Collaborative. (2007, February).. Joint principles of the patient-centered medical home. Retrieved from http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf
Pugely, A. J., Callaghan, J. J., Martin, C. T., Cram, P., & Gao, Y. (2013). Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: Analysis from the ACS-NSQIP. Journal of Arthroplasty, 28, 1499–1504.
Robert Graham Center. Center for Policy Studies in Family Medicine and Primary Care. (2007, November). The patient-centered medical home: History, Seven core features, evidence and transformational change. Retrieved from http://www.aafp.org/dam/AAFP/documents/about_us/initiatives/PCMH.pdf