In the United States, the full continuum of care before, during, and after surgery is expensive, fragmented, and associated with a high number of complications. We believe the current segmented care model must become an integrated care model based on excellent coordination throughout the entire perioperative system, from the minute the surgeon and the patient decide a procedure is needed until the patient is discharged and transferred to his or her primary care provider or medical home.

This new model, which was originally proposed by the Perioperative Surgical Home (PSH) of the American Society of Anesthesiologists, is built on tandardizing care and reducing systemrelated variability throughout the entire surgical journey.

Disruptive Innovation

There are two contrasting approaches to innovation: a modular approach and an integrated approach. A modular approach is often seen in mature industries, where innovation tends to be incremental because it arises from improvements to individual components. Look inside a personal computer (PC), for example, and each part has a different function and comes from a different manufacturer.

As a result ongoing innovation in the PC industry has included faster processors, bigger hard drives, and more memory over time. Yet despite these powerful improvements the fundamental function and purpose of PCs remains unchanged over time.

In contrast, an integrated approach within the context of computers is one in which a single entity controls and coordinates the entire product’s design, build, and assembly.

Apple is probably the best current example for such an approach and has built a reputation on creating innovative and transformative products that “just work.” Apple transforms not only a product’s capacity or speed, but also the very way that people engage and interact with it. Indeed, Apple successfully disrupted the PC market of desktop and laptops when it introduced phones and tablets that dramatically changed how people use technology in their daily lives.

Perioperative Care Delivery

Previous efforts to improve perioperative care delivery, as it is currently constructed in the United States, are best described as taking a modular approach. Surgeons, anesthesiologists, nurses, hospitalists, administrators, physical and respiratory therapists, and information technology experts are really just a loose assemblage of components asked to work together to deliver care. Despite ongoing criticism over the quality and cost of the overall perioperative care system, each component has in fact improved exquisitely year after year.

As an example, the field of anesthesiology has continuously improved its performance and safety through the years. But as a system, the perioperative period of a patient’s care is still fragmented and variable, accounting for more than 50 percent of all hospital costs. Indeed, it is simpler to improve care within each of the system’s specific components, but none of this incremental innovation fundamentally improves the overall care we deliver to our surgical patients. We believe that a completely new architecture is required to move from perioperative care’s current modular approach to an integrated design.

The underlying tenet of the Perioperative Surgical Home (PSH) is better coordination of care by adopting a team approach throughout the entire perioperative continuum, from the minute the surgeon and the patient decide a procedure is needed until 30 days after discharge. Other essential components of this new model include reducing variability through the standardization of clinical and non-clinical care. (To clarify practices, processes, and outcomes will always vary depending on a patient’s specific underlying clinical conditions and individual needs, but variability related to the perioperative system itself needs to be reduced to eliminate preventable medical errors and to reduce the cost of care.)

Another critical feature of the PSH is that it is inclusive and highly collaborative. Most important is the partnership between anesthesiologists and surgeons. However, all the stakeholders that touch a patient in any way—
including hospitalists, nurses, IT, decision support, and hospital administration—play a major part in the PSH.

A Patient-Centric Model

So how does the journey look different for a patient in the PSH model? This model is patientcentric, and patients are part of the initial decision to undergo surgery, receiving education on the surgical procedure from the very beginning. The preoperative clinic no longer focuses on “clearing the patient for surgery,” but rather “optimizing the patient for surgery.” The focus shifts from asking “can the patient ‘medically tolerate’ the surgical procedure?” to “how will the patient thrive after surgery?”

The preoperative process includes evaluation and instruction on smoking cessation, diet, relaxation techniques, and appropriate exercise to get the patient to the best place possible before surgery — efforts that lead to better post-operative outcomes. Similarly, the intraoperative phase focuses on reducing variability in the various anesthetic and surgical techniques used and incorporating of practices that have been shown to improve post-operative outcomes such as Goal Directed Therapy and Enhanced Recovery After Surgery.

Standardized hardware such as implants, as well as standardized processes used by care providers such as nurses are of high importance. Under this new model (Figure 1), a consistent team will be coordinating care to ensure that the patient is progressing nicely along the clinical pathway all the way to his or her successful return home. If a deviation from the clinical pathway is identified or if the patient exhibits new symptoms, care can be escalated quickly. These are also the patients whose condition we have the best chance of optimizing prior to surgery

A final critical part of this new model is clear communication between a patient’s Patient Centered Medical Home, primary care provider (PCP), or third-party payer’s care coordinator. A Perioperative Surgical Home should be seen as a complement to these other models. A ‘handshake’ between these models should occur with each patient before they enter the perioperative environment and once they leave it. All too often patients are discharged after surgery without their PCP’s knowledge, and all too often these patients are being re-admitted to the hospital because of their noncompliance with medication or preventable complications.

This Perioperative Surgical Home model was launched at the University of California Irvine in October of 2012 with patients undergoing hip and knee replacement. Early results indicate low incidence of major complication [0.0, 0.0–7.0 percent] and of perioperative blood transfusion [6.2, 2.9–11.4 percent]. In-hospital mortality was 0.0 (0.0–7.0 percent) and 30-day readmission was 0.7 (0.0–3.8) percent. The median length of stay for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95 percent confidence interval [interquartile range]) 3 (2–3) [2–3] and 3 (2–3)[2–3] days.

Following the success of this pilot at UCI, the initiative was expanded to include two procedures in urology (nephrectomy and cystectomy) and then to spine and shoulder surgery. To date this initiative has resulted in savings in the excess of $1.2 million. Most of these savings are the results of shorter length of stay and lower pharmacy and radiology costs. This decrease in length of stay as a result of implanting the PSH is particularly important since most hospitals are now being paid by a Diagnosis Related Group methodology (which is essentially inpatient bundle).

Just like any change, implanting the PSH needs to be done using a deliberate, detailed plan. As a first step, a “burning platform” needs to be established and a vision for the future be articulated. An interdisciplinary team is essential for the success of the model. A total of 68 individuals from 16 hospital departments in UC Irvine participated in a one-day retreat at the onset of the Orthopedic PSH. These 16 departments included orthopedic surgery, anesthesiology and perioperative care, nursing, hospital medicine, information technology, nutrition, case management, social work, and many more.

This team needs to meet frequently and follow a prescribed timeline and process improvements methodologies such as LEAN or Six-Sigma. Hardwiring of the clinical pathways are best hard wired into the electronic medical record to assure high levels of compliance. Perhaps the most important barrier to the successful implementation of the PSH is lack of communication on the burning platform, the lack of a future vision, and poor teamwork. Absence of commitment of key members in the team such as the surgeons or decision support team will greatly hinder the implantation of this process.

The American Society of Anesthesiologists recently launched a collaborative of 43 hospitals from many areas in the US to examine the viability of this model in large-scale settings. Much like transformative innovations that have taken hold in other industries, this approach is ultimately about delivering what customers want. In health care, and in perioperative care in particular, that means continuing to improve quality and outcomes, but also improving value.

Innovations In Care Delivery

Associated Topics: Health Professionals, Quality
Tags: Chronic Care, Nurses, Physicians, Policy, Quality

It is widely understood that poor coordination resulting from silos within the healthcare system reduces the quality of care and increases healthcare costs. But there is another serious, but often overlooked effect for physicians— the increased risk of malpractice allegations.

During a typical hospital stay, the average surgery patient is shuttled between numerous departments, eventually seeing up to 27 different medical professionals. Ideally, the patient’s records, medical history and treatment plan are shared seamlessly between the surgeons, anesthesiologists, nurses, and other medical staff who coordinate their care.

In reality, inefficient communication patterns often make for a disjointed experience, with providers working separately toward different objectives, cobbling together disparate pieces of data, and sometimes operating with missing information.

This type of miscommunication is probably one of the biggest contributors to costly and dangerous medical mistakes. Conservative estimates put the number of deaths related to medical error at more than 250,000 each year — and that number is likely much higher.

Dr. Zeev Kain reviewed this topic within the context of orthopedic surgery during our January 2017 VBC conference and indicated many of these medical errors could have been prevented with better communication between providers and better care coordination.

Part of the problem lies with the fragmented healthcare system in the United States, which hinders effective coordination between providers, insurers and patients.

Even in a single hospital, where teams of physicians and nurses work together to treat patients, poor interpersonal relationships and ineffective communication often inhibit the effective coordination of care.

Now, medical teams have become larger and more specialized, forcing nurses to communicate with many more people in order to care for a patient.

At the same time, advances in electronic record-keeping has transformed the way we manage and share information. While this can help improve coordination, it also means a single mistake or a failure to record a key piece of data can lead to errors in treatment that often go unnoticed until it’s too late.

According to a landmark study in Mayo Clinic Proceedings, the demands of electronic record keeping also contribute heavily to “physician burnout,” which more than half of doctors experience. CMS regulatory demands, as well as complicated compensation schemes such as MACRA and MIPS, are likely to make this an even bigger problem. One of the underlying issues is that most EMRs in the US today were originally designed to be utilized for billing purposes rather than to enhance clinical care or the coordination of care.

Add to this a toxic work environment created by the high-stakes settings found in hospitals and you’ve got a recipe for disaster. When factors like long shifts, constant rotations, time constraints, administrative burden, and life-or-death situations combine, medical staff may take out their frustrations on each other.

The Nurse-Physician Relationship

Several studies have shown that poor relationships between hospital staff, especially physicians and nurses, can affect patient outcomes negatively.

In 2008, the Joint Commission, which accredits healthcare organizations, found that disruptive or unprofessional behaviors, including shouting at colleagues, throwing objects and berating each other were common among hospital staff.

Not surprisingly, the frustration, lack of concentration, increasing workload, physician burnout and fundamental mistrust created by such incidents actually led to errors in administering treatment.

Complicating matters further is the power dynamic between doctors and nurses, a holdover from earlier days when nurses functioned more like assistants to the “all-knowing” physician. It’s not uncommon for a doctor to ignore nurses’ suggestions for patient care and resent what they see as overstepping. Nurses may feel powerless to report harmful behaviors because they fear retaliation or simply believe hospital administration is complicit.

In a 2015 study published in The Online Journal of Issues in Nursing, 55 percent of nurses said their care decisions were impacted by the way physicians behaved, such as whether doctors treated nurses with respect and how well they communicated about patients’ care plans. What’s more, the nurses and doctors perceived their relationship differently, suggesting a fundamental disconnect between both sides’ values and expectations.

But poor communication between medical staff is not just a problem for workplace morale: it can lead to patient injury and death. In fact, miscommunication is one of the biggest contributing factors in malpractice claims brought against hospital staff.

The Role of Communication Errors in Medical Malpractice

While most hospital visits end positively for patients, medical errors are still a big problem.

In fact, medical error may be the third most common cause of death in the United States, behind cardiovascular disease and cancer. What’s worse, most of these mistakes go unreported, according to a 2016 study published in BMJ.

Even the most careful physicians make honest mistakes, but among the complaints that come up frequently, many are preventable. Consider the numbers:

• A recent analysis of data from a national database of paid malpractice claims found that between 1992 and 2014, the top three allegations were related to incorrect diagnoses, surgery-related errors and incorrect medication.
• Analyzing 25 years of paid malpractice cases, the BMJ Quality and Safety reports that “among malpractice claims, diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.” Between 1986 and 2010, malpractice cases related to diagnostic errors cost $38.8 billion payouts, and that’s just for the most severe cases.

 

So what causes medical errors like incorrect diagnoses and can they be prevented?

It turns out miscommunication is the second most common contributing factor in malpractice lawsuit cases, according to MedPro, a liability insurance company for physicians and dentists owned by Berkshire Hathaway.

In many cases, it’s a lapse in communication between doctors and patients. But poor communication between healthcare providers often leads to medical error as well. And the more providers involved, the greater the risk for this kind of breakdown.

Perhaps the most common area where avoidable communication errors take place is during handoff — when responsibility for a patient, including their history and care plan, is transferred between caregivers. Ineffective handoff can result in lost records, incorrect medication, delays in treatment, and in the most severe cases, permanent injury or death.

Within a single hospital, this can happen when staff change shifts without relaying critical information, like a patient’s allergy to a certain medicine, to the incoming nurse before signing out.

But the problems are even more rampant when you zoom out to look at the entire continuum of care. Take for example, a surgery patient who must deal with their referring doctor, the surgeon, an anaesthesiologist, lab technician, and various other specialists. In most cases, each clinician operates within individual silos, rarely talking to each other directly.

As Harvard Law Professor Einer Elhauge points out in his book The Fragmentation of U.S. Health Care: Causes and Solutions, it’s often the patient that is responsible for coordinating the efforts of the various doctors — a task which is not only time-consuming and costly, but also requires professional experience.

Without a proper system in place to improve communication between the growing number of people involved in a patient’s care, it can be difficult to tell just who is responsible for following up when things fall through the cracks.

Reducing risk through patient-centered integrated care

One key solution for breaking down the existing silos and improving patient outcomes is an integrated care model, which has received a lot of attention recently with the push toward value-based care under the Affordable Care Act.

Specifically for surgery-related care, the Perioperative Surgical Home (PSH) and enhanced recovery models have tackled many of the inefficiencies and barriers to communication that results from the current fragmentation in the system.

Under the PSH model, surgeons, anesthesiologists, nurses, hospital administrators and everyone involved in a patient’s care work together toward a single set of predetermined objectives. The underlying theme of this clinical model is significantly enhanced communication across the entire surgical journey from booking the surgery until 90 days after discharge. That is, communication will be improved both cross-sectionally as well as longitudinally.

An important component in radically transforming the problematic organizational structures in hospitals is greater transparency among various stakeholders. For example, different departments can increase data sharing to understand things like how many times patients are asked to provide the same information. The increased collaboration also reduces the kind of “tunnel vision” that can lead to dangerous diagnostic errors when a clinician focuses only on their area of specialty and ignores the potential consequences of a method of treatment in other areas.

Studies have already shown that this evolving model reduces costs and improves patient outcomes in health care facilities that have implemented it. And this approach, which is rooted in value-based healthcare, promotes greater alignment not just at the hospital level, but between insurance providers and policymakers as well. In other words, it’s a win for everyone.