Anesthesia Leadership in the Preoperative Clinic
Bart Edwards, MBA, MHS
Vice President of Client Services, ABC
Anesthesia practices looking to optimize their value proposition at their respective facilities have sought a greater role in the preoperative preparation of their patients. The emphasis on efficiency and the continuity of care in recently suggested models of healthcare reimbursement, including Accountable Care Organizations, have drawn renewed attention to opportunities within the preoperative clinic. The economic reality is that providers and facilities are not getting paid to provide those services under current reimbursement rules. Preoperative clinics can provide benefits in quality of care and cost reduction, in addition to the significance of improving patient and surgeon satisfaction. Anesthesia practices are in a unique position to develop the preoperative clinic into a valuable resource.
The expenses of a poorly performed preoperative assessment are borne by both the surgical department and anesthesia provider (as well as by the patient) in the form of poor utilization. Patient satisfaction and outcomes are affected by delays and improper risk minimization strategies. The increased costs of surgical setup, sterilization, and vacant room time for each delay or cancellation are measurable and significant. Reduced productivity for ancillary staff, surgeons and anesthesia providers may be the most painful financial consequence of poor preoperative preparation.
Parish Management Consultants’ Preanesthesia Clearance and Evaluation (PACE) Clinic
Parish Management Consultants, LLC is one of many anesthesia practices that are seizing the opportunity to improve the surgical care experience for its surgeons and patients. Several Louisiana hospitals have approached Parish for assistance in reducing same day cancellations and improvement in on-time starts by initiating or improving preop clinics. Parish has partnered with multiple facilities in Baton Rouge, Lafayette and New Orleans to establish a Preanesthesia Clearance and Evaluation (PACE) Clinic.
Al Patin, RN, MBA, Regional Vice President for Parish Management Consultants admits, “We had a huge issue getting patients to the room on time.” The facility at which the first PACE was developed and the practice set to work. They selected increasing the number of on time starts as the primary metric to monitor progress. Other indicators include surgeon satisfaction surveys and cancellation rates. Mr. Patin indicates, “The goal is to keep patients and surgeons happy, and efficiency does that.”
There is some debate regarding the type of provider to staff the PACE clinic. While an RN can perform many of the necessary functions, Parish recommends a nurse practitioner as the manager of its PACE clinic. Parish Management Consultants signs a Collaborative Practice Agreement, accepting the opportunity along with its hospital partner to guide the nurse practitioner in this role. Another Parish facility is considering a CRNA in that position, which is higher from a cost perspective. “Some facilities will pay the premium to place a CRNA in that role, either as an employee or out of subsidized dollars.” The benefits of increased efficiency and increased user satisfaction are not hard dollars, but the cost of the provider is black and white. This is compounded by decreasing reimbursement opportunities overall, and for preoperative evaluation services in particular.
Most facilities will provide surgical schedulers with a telephone guideline to select the patients who must present for personal preop screening prior to the day of surgery, often based on ASA Physical Status. Other practices have triaged the scheduled patients into tiers based on co- morbidity, age and planned procedure. At one facility, one hundred percent of the surgical patients come through its PACE clinic. “All patients come through the PACE, but anesthesia does not touch them all.” The Parish doctors set up an algorithm based on the ASA guidelines for the preoperative assessment. The nurse practitioner calls in an anesthesiologist for sicker patients, but the hope is that even this can be reduced with greater experience.
With the training and process in place, “We let her go,” said Mr. Patin. In many cases, the nurse practitioner is able to provide a more detailed history and physical to supplement that provided by the surgeon. This is of significant value to the anesthesia provider. Evidence-based algorithms for necessary preoperative testing are used instead of standing orders for routine exams to tamp down overutilization and expenses. The results of the assessment are recorded in the patient’s electronic medical record (EMR).
The long list of items that needs to be coordinated prior to surgery can include evidence-based lab testing, EKG, radiology study, informed consent, and patient education. Further challenges for preoperative assessment include risk identification, stratification and reduction. The PACE clinic collects and maintains these results and reviews them in a single location prior to the schedule procedure date. The complete preop workup is then made available on the day of surgery to the assigned anesthesia provider and the entire perioperative team within the EMR.
The impact of the increased attention to the preop clinic has been positive. In the first three months one Parish facility has seen the percentage of its on time starts improve 25%. In fact, most delays are now surgeon driven. “We learned that we had trained our surgeons to be late,” said Mr. Patin. The clinic is a first step, “it starts with the process – not people or supplies.” The hospital performs annual surveys, and it is expected that the increased efficiency will yield higher surgeon satisfaction scores. Regarding the goal of the program, Mr. Patin stated “Ultimately efficiency dictates whether the surgeon will be comfortable coming back.”
Increased anesthesia direction in the preoperative clinic can reduce stress and provide a more streamlined experience for patients. The better trained and monitored clinic providers can correctly identify and accommodate co-morbidity in advance of the scheduled procedure.
For the anesthesia practice, fewer delays and cancellations decrease the unused operating room time and drive up utilization. More work can be done by each scheduled provider, with higher efficiency and a better return per hour worked. The increased responsibility and integration through the clinic strengthens the relationship with the facility. The further benefit will be to demonstrate anesthesia’s added value in the preoperative clinic when discussing non fee-for-service reimbursement models.