Perioperative leaders should prepare for an unprecedented increase in surgery volumes, starting in 2014, despite current declines.

At a Glance

To improve performance in the surgical services arena, healthcare leaders should focus on:

  • Improving perioperative outcomes
  • Meeting value-based purchasing quality targets
  • Reducing readmissions
  • Improving the perioperative experience

An estimated 30 million newly insured patients will enter the U.S. healthcare system next year, dramatically increasing the demand for care, much of which will be driven by surgical volume. In addition, provider payment is increasingly linked to clinical outcomes and patients’ experience of care, especially in the arena of surgical services, at a time when per-patient and per-procedure reimbursement from payers is decreasing. In this environment, improving quality and financial performance in the operating room (OR) is essential. 

To improve performance, healthcare leaders should focus on improving perioperative outcomes, meeting value-based purchasing quality targets, reducing readmissions, and improving the perioperative experience. 

Strategies for Improving Perioperative Outcomes

More than half of all medical errors occur in the OR. The OR is a complex, multidisciplinary area, where most care is delivered in a time-compressed episode, presenting significant safety risks for a hospital. Hospitals can mitigate these risks and improve outcomes by adopting a procedures-based management approach, ensuring access to patient data, aligning clinical protocols with quality measures, and creating a culture of safety. 

Adopt a procedures-based management approach. The emphasis should be on outcomes on the front end, not the back end. For example, if the OR staff know that a specific patient has a history of difficult intubations before beginning a surgical procedure, they can prepare in advance by having proper equipment and protocols in place to minimize the risk of problems. This preparation may lead to a better patient experience all around—a smoother surgery, a more comfortable recovery, and a more satisfied patient. The information may be available from prior surgical encounters, readily available preoperative testing results, or thoughtful patient input via a web-based pre-op assessment.

Hospitals are realizing the importance of showing positive outcomes up front, especially when competing for contracts with payers. The key to consistently driving successful outcomes up front is providing comprehensive “patient-centric” data. In the case of the difficult intubation, patient-specific data should be available to the surgical staff, allowing them to prepare and confront a potential complication through proper equipment and procedures, before it became a problem. Hundreds of potential complications could be minimized if brought to light by sharing and using patient-centric data ahead of the surgery. Each problem that can be averted can result in a better patient experience and better patient outcomes. 

Ensure access to patient data. Visibility into data from the OR can enable informed decisions for future care and identify problems before they become trends. It is vital for all caregivers to have access to current, accurate patient data from admission through discharge. With multiple disciplines interacting with the patient, opportunities for communication breakdowns abound. Tools that capture and communicate essential information at every point of the perioperative process are needed to provide an “OR view”—a total picture of the patient (history, medications, vital signs, and milestones)—to all caregivers via electronic boards. By effectively communicating patient-specific information such as antibiotic use and drug allergies, hospitals can improve compliance, support infection prevention, reduce complications, and prevent extended hospital stays.

Align clinical protocols with quality measures. Systems should be put in place to support providers in their efforts to standardize care protocols based on key indicators such as age and medical history. For example, diabetic patients over age 65 undergoing total joint replacement would likely require a different protocol from that indicated for nondiabetic patients under age 65 who are undergoing the same procedure. To decrease risk, all information should flow with the patient using care protocols.

Create a perioperative services culture of safety. A culture of perioperative safety begins outside the OR, with a look at the results of preoperative testing. Using evidence-based practices to mitigate risks that have been uncovered during preoperative testing can help prevent complications and reduce costly procedure delays or cancellations. For example, when preoperative testing indicates that a patient has anemia, measures should be taken up front to avoid the need for a postoperative blood transfusion. During surgery, an up-to-the-minute OR view should provide prompts and checklists to help ensure that antibiotics are administered, allergies are noted, consents are signed, surgical sites are marked and confirmed, and equipment and supplies are ready and available. After surgery, a debrief and handoff that includes a list of drugs used, a record of the patient’s vital signs, and related data will help prepare the post-anesthesia care unit nurse to receive the patient and support a stabilized condition. 

Meeting Value-Based Purchasing Quality Targets 

Of the 13 clinical process-of-care measures that are part of the Centers for Medicare & Medicaid Services’ Value-Based Purchasing (VBP) Program total performance score, eight are Surgical Care Improvement Program (SCIP) measures that relate to the perioperative period, as shown in the sidebar at left. It is therefore important that all cases be properly performed and documented as SCIP-compliant as the failure to do so in as few as one or two cases per week can negatively affect a hospital’s score and result in lost revenue. 

The OR management team should take steps to ensure that data are being captured and reported in the appropriate timeframe to show that value-based purchasing target scores are being met. The team should have a clear understanding of the implications of noncompliance as well as the quality and financial benefits of improved scores.

Additional staffing and information tools, such as a perioperative information system, may be needed to provide timely, comprehensive data to identify and address issues related to SCIP compliance. Providers can further enhance their efforts to properly capture and report data by investing in analytics. Dashboards that display performance on key quality measures improve the ability to track compliance with various regulations through accurate and comprehensive documentation. Drill-down capabilities can help identify factors that contribute to, or detract from, compliance achievement. A collaborative OR leadership structure that includes administration, surgeons, nurses and anesthesiologists working together is a key prerequisite for meeting compliance goals and improving clinical and financial performance.

Reducing Readmissions

In research conducted in 2011, HFMA found that nearly four in 10 organizations surveyed were not measuring the margin impact of readmissions (Value in Health Care: Current State and Future Directions, HFMA). Furthermore, HFMA found that just 20 percent were measuring the impact of readmissions and using that data to drive improvement.

The need for readmissions analytics is greater than ever, especially in light of new Medicare guidelines that impose financial penalties on hospitals with high 30-day readmission rates. Hospitals and health systems stand to lose money as a result of postsurgical complications such as infections, bleeding, and adverse reactions to medications. To prevent readmissions due to such events, they should take the following steps. 

Establish care protocols. Providing postsurgical care instructions in a uniform and systematic way supports follow-through with proper incision care, rehabilitation services, dietary restrictions, medication management, and follow-up appointments. Variables include a patient’s age, medical condition, and surgical procedure. Age is a critical factor: Failure to adjust medications and treatments for older adults can result in higher readmission rates for these patients. 

Educate staff, patients, and families. Miscommunication and inconsistent documentation among caregivers can lead to inaccurate patient education about needed postsurgical care. Proper education and communication can improve preparation for discharge and care transitions, which may significantly reduce readmission rates. 

Monitor patients’ progress. Frequent communication helps ensure access to timely, comprehensive patient data. Hospital and health system care providers should identify high-risk patients, follow care protocols, schedule follow-up appointments, and communicate daily or weekly via telephone call or other interactive tools such as electronic patient portals to identify issues before readmission becomes necessary. 

Improving the Perioperative Experience

Addressing the needs and priorities of patients, families, and physicians is essential to achieving the best outcomes at the lowest possible cost, especially now that patient satisfaction scores are publicly available. Hospitals and health systems should strive to ensure satisfaction of all stakeholders.

Patient satisfaction. Information about preadmission testing and the patient’s medical history should be included in a complete patient profile, giving caregivers access to all data in one place and saving the patient from having to repeat information to different care team members. 

When interviewing a patient, a nurse can quickly view medical history in the profile to confirm accuracy. For example, the nurse might say, “I see you’re allergic to codeine, and you were recently diagnosed with asthma.” 

Making sure the right information gets to the right people at the right time is a key element of patient satisfaction. Toward this end, streamlining the preadmission testing process should be a top priority—one that requires shared responsibility of the surgeon, nurses, and anesthesia provider to help ensure a safe and efficient surgery. 

The role of the anesthesia provider is especially important to patient safety and satisfaction. Integrating anesthesia and nursing documentation improves documentation accuracy, which can contribute to a positive patient experience. Patients want their special concerns to be recorded and addressed by the entire team. 

Accurate documentation also helps ensure correct billing, which is another important element of patient satisfaction. Information should flow seamlessly with the patient from scheduling through postsurgical care. 

Family satisfaction. Families want up-to-the-minute information about the status of the surgery and their loved one’s condition. A customized “family view” displayed on an electronic board in the waiting room can give family members and friends the information they want and go a long way toward relieving the frustration and anxiety of waiting. 

Physician satisfaction. Surgeons need the support of a “well-oiled machine” to deliver optimal performance and best outcomes at the lowest cost. The organization should therefore ensure that surgeons are equipped with appropriate supplies and implants, patients are well prepared, patient data are comprehensive and accessible, and block time and patient throughput are managed efficiently. 

Hospitals and health systems use data from the OR to measure quality outcomes and compare surgeons’ performance. The organizations should provide dashboard metrics that help surgeons track and measure their own performance on metrics such as block time use, case time and cost by procedure, clinical complication rate, and length of stay. Greater efficiency and better outcomes can be achieved by monitoring data and tracking trends.

Driving Smart Growth 

With government incentive programs under way, healthcare organizations will need more than electronic health records to deliver actionable information that can be used to measure and improve outcomes. Electronic documentation is the first step. Using advanced business and clinical analytics advances the process and closes the loop. 

Addressing new challenges will require collaboration, innovation, and cost-effective growth strategies. Perioperative analytics allow surgeons, other clinicians, and hospital executives to easily view and drill down into data to identify trends and opportunities for improvement—driving smart growth without adding infrastructure. 

Perhaps more than any other department, the OR influences a hospital’s financial and clinical health. With collaborative leadership and effective strategies in place to support improved quality and efficiency, perioperative services can serve as a model for maximizing ROI in business intelligence and performance improvement. 

Ed Daihl is CEO, Surgical Information Systems, Alpharetta, Ga..

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Results Achieved in a Perioperative Performance Improvement Initiative 

In 2009, clinical leadership at a not-for-profit integrated delivery system (IDS) based in North Dakota designed a proactive plan for performance improvement while implementing a perioperative information system to help measure, analyze, and improve outcomes. 

Gaps in documenting performance on SCIP measures were a chief concern. In many instances, correct steps were being followed, but inconsistent documentation made it impossible to measure them. To address the problem, the IDS used a system of electronic flags and checklists to promote proper medication administration and documentation throughout the perioperative process. 

Another issue involved missing documentation of venous thromboembolism (VTE) prophylaxis treatments to help prevent potentially life-threatening blood clots. The solution was a series of electronic prompts for nurses: Was there an order for VTE prophylaxis? What kind of prophylaxis was administered to the patient? What time was it administered? These changes resulted in an increase in SCIP compliance from 67 percent to 96 percent.

Bottom line: Appropriate care was delivered, SCIP requirements for capturing and reporting data were satisfied and consistency improved, and unexpected financial gains were attained—specifically, a dramatic decrease in missed charges—from an estimated $40,000 to $50,000 per month down to $12,000 every three months.

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SCIP Measures for Value-Based Purchasing 

The Surgical Care Improvement Project (SCIP) was created in 2003 by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention to reduce the incidence of surgical complications. Starting in FY13, hospital performance on the following SCIP measures (along with 18 other measures) will determine, in part, how much hospitals are paid by Medicare.

SCIP-Inf-1: Prophylactic antibiotic received within one hour prior to surgical incision
SCIP-Inf-2: Prophylactic antibiotic selection for surgical patients
SCIP-Inf-3: Prophylactic antibiotics discontinued within 24 hours after surgery end time
SCIP-Inf-4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose
SCIP-Inf-9 (for FY14-15 only): Urinary catheter removal on postoperative day 1 or postoperative day 2
SCIP-Card-2: Surgery patients on a beta blocker prior to arrival who received a beta blocker during the perioperative period
SCIP-VTE-1 (for FY13-14 only): Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered
SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery
Source: CMS Medicare Learning Network, Hospital Value-Based Purchasing Program.

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Tips for Improving the Perioperative Experience for Patients and Families 


  • Implement web-based scheduling to schedule appointments to avoid multiple calls or delays. 
  • Reduce day-of-surgery delays and cancellations due to lack of pre-operative testing data.
  • Provide up-to-the-minute information for families via electronic waiting room status boards.


  • Provide clinicians with notifications about allergies and medications to help ensure positive outcomes.
  • Provide the care team with visibility into a patient’s status and next steps to reduce “speed bumps” in the care process.

Accurate Patient Billing

  • Avoid confusion and stress related to hospital bills so patients can focus on recovery.
  • Collect accurate charges throughout the patient encounter.
  • Transmit the correct charges to third-party payers.

Publication Date: Monday, December 02, 2013

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