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An anesthesiologist communicates handoff with a physician to coordinate care for a postoperative patient. (Photo: TeamHealth Anesthesia)
Missing lab work and last-minute diagnostic tests no longer derail the surgical schedule at Martin Health System, Stuart, Fla. For the past six months, the three-hospital health system has been using a perioperative surgical home (PSH) model to better coordinate surgical care for its patients.
“Hospital executives and surgeons dread having a surgery cancelled, particularly on the same day the surgery is scheduled,” says Sharon Andre, RN, MS, FACHE, assistant vice president and administrator for the perioperative service line. “It’s not good for the patient, the surgeon, or the hospital. Through our perioperative surgical home, we have been able to virtually eliminate same-day surgery cancellations.” The PSH model also has reduced unnecessary testing and improved pain scores and other clinical outcomes.
Originally proposed by the American Society of Anesthesiologists (ASA), the PSH model is designed to be an alternative to the disjointed perioperative system that persists in the United States. It is a physician-led, patient-centered approach to coordinate care across the entire continuum—from the moment the decision to have surgery is made through surgery, recovery, and 30 days post-discharge.
“The perioperative surgical home sets up a framework and a model to ensure there is a system for optimizing the care of the surgical patient,” Andre says. “It includes evidence-based processes to ensure the standard of care is provided and that excellent outcomes are achieved for the patient as well as for the efficiency of the healthcare system.”
The Perioperative Surgical Home Model
Martin Health is one of 44 organizations participating in a PSH pilot launched by ASA with a national healthcare performance improvement alliance. An outsourcing anesthesia and pain management service organization—that is assisting Martin Health with its PSH model—has implemented and currently maintains seven of the PSH pilot sites within the collaborative.
To roll out the PSH model, leaders at Martin Health followed a series of steps.
Identify a physician champion. The physician champion is responsible for leading the perioperative team that will manage patient care during the surgical episode (as soon as surgery is planned through 30 days after the patient leaves the hospital). The leader can be an anesthesiologist, surgeon, hospitalist, or primary care physician.
The physician champion should possess a strong desire to improve patient care, exceptional communication and change management skills, and keen emotional intelligence. At Martin Health, the physician champion is a facility medical director employed by the outsourced anesthesia service organization.
Select an operational champion. This leader should have the authority to help assemble resources, such as IT and PI teams, to support the work of the PSH team. An operational champion may be a COO, perioperative services director, or senior nursing leader. For example, at Martin Health, Andre is that champion, and she has the influence to bring different operational groups together.
Other members of the PSH team include leaders from finance, nursing, laboratory, pharmacy, radiology, IT, central supply, and social services.
Focus on the “burning platform” to build credibility and momentum. The PSH team should prioritize initiatives based on physicians’ biggest concerns. For example, two surgeons at Martin Health were passionate about revamping how preadmission tests were ordered through the electronic health record (EHR). Before the model was in place, primary care physicians were responsible for ordering tests, which sometimes led to redundant or unnecessary testing prior to surgery. Now, when surgeons order a surgical procedure through the EHR, they simply check a box for preadmission testing. This launches a preadmission testing workflow led by an anesthesiologist, who can access decision support tools in the EHR to determine which tests the patient needs.
To gain buy-in from primary care physicians before launching the new process, the director of anesthesiology visited primary care practices and explained how the PSH model would standardize patient care and improve efficiency. Prior to the model’s implementation, even low-risk patients were required to visit a primary care physician for a history and physical before surgery, which bogged down physicians’ schedules. Now, low-risk patients have a “fast track” to preadmission testing, and an anesthesiologist can order any tests the patients may need prior to surgery. Primary care physicians have more time to better optimize high-risk patients and can see post-acute care patients quicker to help prevent readmissions.
Having anesthesiologists coordinate preadmission testing has reduced unnecessary tests and eliminated same-day surgery cancellations due to missing tests. To manage this process, Martin Health added another anesthesiologist FTE to its roster.
Implement new order sets for postoperative care. Borrowing lessons from population health management, PSH models use risk stratification to focus on patients who are at the greatest risk for complications, readmission, or other negative outcomes.
For example, the PSH team at Martin Health developed a risk assessment and order set to manage patients with postoperative nausea before they have surgery. The results have been significant: The percentage of patients who need anti-emetics in the recovery room has dropped from 65 percent to less than 30 percent.
Similar order sets have been hardwired into the EHR to standardize care for surgical patients with obstructive sleep apnea, multimodal pain, and other conditions.
Enlist the pharmacy. At Martin Health, pharmacists review surgical patients’ pain medications and pain scores, and design alternative pain-management strategies when needed.
A pharmacist also reviews the medication reconciliation for every surgical patient prior to discharge. In addition, pharmacists and pharmacy students provide one-to-one medication counseling for patients at high risk for readmission. The PSH team worked with IT to build prompts into the EHR to trigger these activities, so care is consistent across the surgical population.
Engage social workers and care managers early on. In a PSH model, the team starts planning postoperative care before the patient has surgery. At Martin Health, social workers, financial counselors, and care managers are prompted by the EHR to identify community resources that patients need upon discharge, weeks before the actual surgery.
Build on early results. In addition to eliminating same-day surgery cancellations, Martin Health has improved its on-time starts since implementing the PSH model. In addition, they have achieved almost 100 percent chart completion 24 hours prior to surgery.
The PSH team also reduced blood utilization in surgical patients by 20 percent and improved pain scores. Patient experience scores also have improved. “The perioperative surgical home model has been a big win for me and my patients,” says Matthew Peebles, MD, chief of surgery at Martin Health System. “The pre-op process has grown into a robust screening, optimization, and patient engagement program, and the perioperative enhanced recovery aspects have improved outcomes and patient satisfaction significantly.”
ASA’s nationwide PSH pilot runs through the end of this year. The collaborative plans to analyze financial and clinical data from preoperative, intraoperative, and postoperative care in all 44 organizations.
Early anecdotal evidence suggests the PSH model is improving performance at other organizations as well. One Arkansas hospital has increased the number of discharged surgical patients entering home health, as opposed to nursing homes, by 20 percent. Another provider decreased the LOS for pediatric spine surgery patients by 1.5 days in the first 30 days of implementing a PSH model.
By re-engineering the perioperative process, providers can help reduce variability across the continuum and be better positioned as the industry moves toward value-based care. “All health systems are going to be paid less in the future, so improved efficiency is critical,” says Robert L. Lord, Jr., COO, Martin Health. “Also critical are better coordination of care and the involvement of the entire care team to achieve improved outcomes. This program does all of those things. That is the reason we view it as critical to our mission.”
Perioperative Surgical Home Executive Dashboard for Lower Extremity Joint Replacement
Successful Physician-Hospital Alignment
Admission Plan Eases Patient Transition and Care Coordination
Sonya Pease, MD, is CMO, TeamHealth Anesthesia, Palm Beach Gardens, Fla.
Mike Schweitzer, MD, MBA, is vice president of healthcare delivery system transformation, VHA Southeast, Tampa, Fla.
This article is based in part on a presentation at the Congress of the American College of Healthcare Executives in Chicago in March 2015.
Quoted in this article:
Sharon Andre, RN, MS, FACHE, is assistant vice president and administrator for the perioperative service line, Martin Health System, Stuart, Fla.
Matthew Peebles, MD, is chief of surgery, Martin Health System, Stuart. Fla.
Robert L. Lord, Jr., is COO, Martin Health System, Stuart, Fla.
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