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.

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. Te 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. Tis 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.Te 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. Tis team’s researched showed how a real-time patient routing system could improve utilization and decrease delays. Tey also proved that anesthesia clinical pathways improved process outcomes and reduced costs (Kash, Cline, 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. Te 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. Tis 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. Te 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. Te physician incorporates the patient’s values and preferences, and the entire care team is involved and attuned to the overall goal. Tis in turn facilitates alignment among all constituents involved in the patient’s care.

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.

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

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. Tese

factors will facilitate the development of standardized clinical pathways. Te 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. Tis 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. Te system noti-fies our team if a patient is falling behind in any of the clinical pathway milestones. Tis 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 signifcantly 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 feld and continuing to develop associated empirical fndings, 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.

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