The Perioperative Surgical Home: Our Partnership with the C-Suite

“CMS’ pay-for-performance reimbursement changes are looming. As members of the Huntington Accountable Care Organization (ACO), anesthesia recognizes the need to improve surgical outcomes. Our collective financial future is tied to solid quality improvements that only increasingly coordinated care can deliver. We will double down on our cooperative effort with our hospital in order to improve medical outcomes, to lower costs and to improve the patient experience.” – Pacific Valley Medical Group, Pasadena, CA.

Summary of Recent Events

The Centers for Medicare & Medicaid Services (CMS) is pushing quality, the American Society of Anesthesiologists (ASA) is pushing the perioperative surgical home (PSH) and our 30-partner Pacific Valley Medical (anesthesiology) Group (PVMG) in Pasadena, CA is picking up both causes. In our commitment to a PSH clinic staffed and managed by anesthesiologists, we are fully embracing the concept of transitional care & perioperative medicine. This is our contribution to our patients and to our Huntington Memorial Hospital’s (HMH) Readmission Reduction Program.

This past summer, we made rapid progress toward putting these concepts into operation. In June, two members of our group attended the ASA conference on the PSH. In July, we recruited a few more of our partners. In August, our anesthesia group hosted a presentation by Zeev Kain, MD, MBA of the Department of Anesthesia, University of California, Irvine to our administrators and surgeons. In September, several of us divided up the work (below) and in October, we presented the concept and proposed a partnership with the Huntington Memorial C-suite.

Presentation to the C-Suite

Our hospital administrators have long been aware of the issues of costly readmissions, looming CMS changes and marginal patient experience for some. They can be forgiven for being unaware, though, of how an engaged anesthesia group can help with those issues. Like many anesthesia groups, they were unaware of how an active, mature PSH partnership can meet their needs. In our presentation, then, we started by defining the PSH as (1) a concept, (2) a process and (3) a physical presence.

As a concept, the PSH is the idea that patients experience better surgical outcomes when anesthesiologists are fully engaged in the entire perioperative continuum. Complicated patients do especially better when physician anesthesiologists take responsibility for pre-surgical optimization, in-room anesthesia, immediate post-op care and transitional care medicine. Who better than anesthesiologists to understand the surgical challenges presented to patient physiology? Who better, then, to optimize pre-operative physiology and surveil post-operative outcomes? If not us, who? If not now, when? As an aside, anesthesia groups absolutely must understand their value to the concept of the PSH. Individual anesthesiologists must realize and exercise their superior medical management abilities relative to other care givers. The concept is the ASA’s investment.

As a process, the PSH is the engagement and coordination of anesthesia services throughout the entire continuum of surgical care. From the decision to operate to final disposition of the patient, anesthesiologists must make themselves available to patients, to their surgeon partners and to hospital administrators. In the case of Huntington’s 11,000 annual surgical cases, that seems a very tall order. In order to target resources toward those most at risk, PVMG will design systems to triage our surgical patients. We will assign 20 percent of the sickest to MD pre-op clinic visits, MD operating room anesthesia and MD post-discharge transitional care medical management by anesthesiologists. The remainder will be seen in a pre-op clinic by mid-level providers under MD management. PVMG will invest a full time equivalent anesthesiologist to manage the clinic and to work up patients. The manpower is our practice's investment.

As a physical presence, the PSH is necessarily a location with staff and support from the hospital. It is a substantial investment of both finances and administrative effort in managing 11,000 patients more effectively. Currently, the majority of those elective patients present to the hospital and the pre-operative holding suites the morning of surgery. You can imagine the resulting cancellations and delays that result from last-minute pre-op work that could have been done weeks before the very day of surgery. This patient and information flow is no longer acceptable. It wastes resources and it exposes patients to sub-optimal outcomes. Huntington Memorial is already in process of expanding the physical capacity of this clinic to accommodate all the surgical patents. This physical facility and support staff are the hospital’s investment.

After thus explaining the PSH, we presented the PSH anesthesia team to the C-suite: those of us (initials below) who had coalesced into a working group, self-selecting ourselves into areas of responsibility based on our individual natural interests. There will be much other work and room for the remainder of our group, but in addition to seeing patients in clinic our initial responsibilities were divided in this manner:

AF - Goal directed therapy, regional block room, liaison to cardiothoracic section
RY - Data management, research, metrics, liaison to ObGyn section
JH - Pre- & post-operative work-up protocols, liaison to HMH quality committee
LK & AC - Pain management, liaison to orthopedic section
TC - Financial management, billing, negotiations
JM - Executive leadership, politics, liaison to general surgery section
RB - Experience in establishing prepost- op clinic, pace, focus & vision
MM – Liaison to ambulatory surgical centers, clinic duties
MA - Scheduling, office management, clinic duties
CK - Pre- and post-discharge protocols, NICU, PICU and fetal surgery section

The proximate result of the presentation of our team was the demonstration of our interest, our motivation, our research and the medical resources we were offering our Huntington C-suite administrators. We wanted them to sense an enthusiastic, well-motivated team, who offered a progressive physician partnership and a well-conceived plan.

Our Initial Goals Included

• Reducing day-of-surgery cancellations by 90 percent by the end of the 1st year
• Reducing surgical length of stay by 20 percent by the end of the 2nd year
• Reducing readmissions by 50 percent by the end of the 3rd year

To accomplish this, we specifically asked our C-suite to consider actively supporting the following program:

• Having every one of our 11,000 elective surgery patients appear in the PSH clinic,
• Triage and identify the sickest 20 percent of patients for pre-op clinic appointments with an anesthesiologist, with assignment to anesthesiologists intra-op, post-op and in post-discharge clinic,
• Improvement of pain management services with a dedicated operative suite nerve block room manned by those anesthesiologists most skilled at ultrasound regional nerve blocks, and
• Establishment of RN/NP/PA/ CRNA intervention teams to improve post-op and post-discharge surveillance and intervention on the hospital floor, in the home setting, in the emergency department and in the post-discharge clinic.

In response, and to our Huntington Memorial C-suite’s great credit, their explicit #1 priority was to improve the patient experience and surgical outcomes. They elaborated their faith in our PVMG anesthesia group as a worthy partner. Demonstrating intuitive understanding of the PSH, the CEO, the CFO and the VP of Quality found this project a worthy investment of their administrative energies and hospital finances. Our C-suite administrators then asked by what means they could facilitate the project.

We offered to provide the physician manpower and leadership. Our group would increase the presence of an anesthesiologist in clinic as the patient and management demands increased. We would compensate that physician ourselves (more on physician billing and reimbursement in a future article) and not request a stipend from the hospital. In return, we presented the specific wish list below that included:

• Appoint a Huntington Memorial PSH administrative champion
• Appoint an anesthesiologist physician champion
• Expand the pre-op clinic facilities and increase the nursing staff
• Establish PA/NP/RN/CRNA discharge planning, home health and ER intervention teams
• Expand the role of quality committee to include mid-level HMH administration managers
• Improved collection of patient outcome data within
• Public relations help with and leadership of the effort; HMH as our partner
• HMH must be able to follow the cost, reimbursement and profit on each surgery
• Administrative support in same day surgery for nerve block room to improve the quality of pain management
• Patient data mining and patient triage support

Conclusion

At the end of our presentation, PVMG and Huntington Memorial shook hands on a new partnership.

Huntington named both anesthesiologist and administrative champions. The two of us immediately established weekly standing meetings. Huntington has also offered to support our second evening PSH conference with a presentation from a world class speaker, Maxime Cannesson, MD of the Department of Anesthesia, University of California, Irvine. Sponsored by Edwards Life Sciences, Dr. Cannesson will present the concept of Goal Directed Fluid Therapy and provide updates related to both invasive and non- invasive hemodynamic monitoring.

PVMG has selected anesthesiologists who are ready to see patients in clinics. Our Huntington administrators are fully on board and engaged. Our group is committing physician leadership manpower and Huntington is committing administrative energies and financial support. Together PVMG and Huntington Memorial have forged a progressive Anesthesia/C-suite partnership.

Now more than ever, the PSH is right for our patients, our hospital and our group.