Six Years On: The Growing Pains—and Remarkable Growth—of the Perioperative Surgical Home

Roseanne M. Fischoff, MPP
Economics and Practice Innovations Executive, American Society of Anesthesiologists

• One regional medical center saved $1.5 million in the first year.
• A Midwest academic center reduced average length of stay (LOS) for total joint replacement patients from 4.6 to 2.1 days.
• A pediatric institution reduced the 30-day readmission rate from 8.3 percent to 7.5 percent for laryngeal cleft patients while reducing average cost by approximately 20 percent.
• An academic center reduced costs for cystectomy cases by an average of $10,000 per case.
• A major health system improved room turnover by approximately eight minutes, reduced LOS for hip/knee arthroplasty cases from an average of 110 hours to 51 hours and cut the readmission rate for hip/knee arthroplasty cases in half.

Having devised and championed the concept of the anesthesia care team in the early 1980s, anesthesiologists have been at the forefront of team-based, collaborative care for decades. As healthcare increasingly transitions from an emphasis on volume to one of value, the importance of teamwork becomes ever more crucial.

The American Society of Anesthesiologists (ASA) formally introduced the perioperative surgical home (PSH) in 2012 as an innovative patient-centered model of care designed to achieve the triple aim of improving health, improving the delivery of healthcare and reducing costs.

Perhaps the strongest core feature of the PSH model is the team. Alongside the many thousands of individuals who have been involved in PSH programs throughout the country, the PSH model—and the ASA’s first two PSH Learning Collaboratives— are being increasingly embraced by a variety of influential healthcare organizations. In March 2018, the PSH Learning Collaborative was accepted by the American Board of Medical Specialties Multi-Specialty Portfolio Program, meaning that Learning Collaborative participation will be recognized for Maintenance of Certification Part IV credit by 24 specialty boards, including the American Board of Surgery. Notable PSH partner organizations include the American Academy of Physical Medicine and Rehabilitation (AAPMR), the American Academy of Orthopedic Surgeons (AAOS) and the American Urological Association (AUA).

Practice improvement examples like those at the beginning of this article continue to demonstrate that the PSH is a viable and effective care model that can be incorporated into institutions of any size and for a wide variety of procedures and modalities.

In 2014, the ASA teamed with Premier, Inc., a leading healthcare improvement company, to establish the first PSH Learning Collaborative, which brought together subject matter experts and leading institutions from across the country to learn from each other. The first Collaborative featured 44 groups, and the recently completed Learning Collaborative 2.0 comprised 57 organizations that shared insights about PSH strategies compatible with alternative payment models, including Bundled Payments for Care Improvement, Comprehensive Care for Joint Replacement, the Medicare Shared Savings Program and Accountable Care Organizations.

The nearly 100 institutions and healthcare professionals who participated in the first two Learning Collaboratives reported positive outcomes that have benefited their organizations and their patients in sometimes surprisingly short periods of time. However, no matter how successful any of these nascent PSH models turned out to be, all experienced challenges that informed their actions going forward and served as learning opportunities for their peers.

The individuals below recently shared the successes and challenges of incorporating a PSH model into their institutions.

Christopher Steel, MD
White River Health System
Batesville, Arkansas

Early in their PSH program, Dr. Steel and his group formed preoperative, intraoperative and postoperative teams. They found that in team meetings, each team wanted to focus solely on outcome measures rather than consistently following the established protocols. As a result, they accomplished very little in the first few meetings. Subsequently, the team focused on precision and accuracy. The precision efforts focused on reproducibility of the protocol rather than outcomes. As a result, they were able to create PSH-driven protocols. The accuracy efforts were focused on making small changes to the protocols over time based on the patient outcomes.

Like many other organizations developing PSH models, the White River Health group quickly learned how important it was to name the right leaders. Dr. Steel was originally designated as sole director of the PSH, which he later called “short-sighted.” When his group added orthopedic surgeon Jeff Angel, MD, as co-director, the other orthopedic surgeons became more engaged and the program began building momentum.

A mobile phone app helped to solve their problem of disseminating protocols to team members. This content was at first put on paper and filed in binders strategically placed throughout the hospital. When changes were made, they had to find the appropriate papers and make the change in each binder. Later, a shared computer drive proved unsuccessful because finding a local computer was difficult and the log-in process was too cumbersome. The mobile phone app turned out to be the best way for everyone involved in the patient’s care to access and review up-to-date information.

Dr. Steel indicated that identification of a payment mechanism should be a top priority for institutions that develop a PSH. It’s not necessary to have one at the outset, but eventually everyone must figure out a way for the hospital and providers to be reimbursed for the effort required to accomplish care design. Otherwise, sustained efforts and growth are unlikely.

For Dr. Steel and the White River Health System, the PSH model has, so far, delivered on its core principles. “It doesn’t matter what you call it. Every hospital should strive to improve quality and improve the experience of patients and providers,” he said. “By reducing variation, a PSH or similar model can simplify the delivery of care for the patients and the providers while meticulously ensuring improved quality and usually a decreased total cost of care.”

Leslie Garson, MD
University of California, Irvine

Dr. Garson was an early adopter of the PSH model at his institution and has been fine-tuning his program for several years. Like Dr. Steel and the White River Health System, identification of PSH champions was crucial for success. In Dr. Garson’s case, a surgeon champion and senior leadership support were essential. Non-physician support is also necessary as well. Preferably, this is someone with experience working with clinical pathways who can shepherd the project through the writing of clinical pathways, working with committees and completing order sets.

While leadership support and champions are critical, they are perhaps less important to continued success than collaboration and buy-in from the entire spectrum of team members. Too much reliance on a particular champion—whether a surgeon, anesthesiologist or administrator—can be disastrous if that person leaves and the clinical pathway goes with them.

Dr. Garson emphasized that clinical pathways need to be as hard-wired as possible. This means explaining to the entire team, again and again, that clinical pathways are not “cookbook medicine,” but rather a scaffold or skeleton of evidence-based care that can be endlessly modified and customized for the 20 to 30 percent of patients who need more individualized treatment protocols.

“A PSH program provides the ability to implement a continuum of care plan in the perioperative period for a patient’s episode of care—be it joint replacement, colon resection or any of a myriad of other procedures—that is developed in a multidisciplinary, collaborative manner ensuring good communication and seamless care management across all touch points by all providers for that patient.”

Gary Stier, MD, MBA
Loma Linda University

Dr. Stier and his group at Loma Linda found out early in their PSH journey that they had underestimated the difficulty of navigating the byzantine information technology (IT) landscape typical of a large medical institution. IT support is crucial, but with limited available resources at their institution, gathering data, creating analytic tools and customizing their electronic health record (EHR) for enhanced workflow presented significant challenges. In response, they mapped the IT structure and governance to better understand who in IT to talk to and how to navigate the system. Frequent communication with appropriate IT staff helped to build crucial relationships, leading to a better overall understanding of the PSH model and how it fit into the organization’s mission.

The importance of adequately sharing the vision of the PSH does not stop with IT staff. Dr. Stier stressed the necessity of educating administrators and other surgical colleagues about the PSH model, calling the process “an uphill journey.” Surgeons, for instance, are surely aware of and most likely pushing for the development of enhanced recovery after surgery (ERAS) programs and the institutional resources needed to develop them. The PSH champion must focus on educating all stakeholders that the PSH model is, in fact, a more comprehensive ERAS delivery model developed to enhance both surgical service line care and to facilitate, create and implement procedure-specific ERAS protocols.

The group also found it imperative to emphasize to their department members that the PSH model is a complementary part of the anesthesiology group’s practice. They created a voluntary anesthesiology PSH team that embraced the model and talked positively about its value to department members. By demonstrating positive outcomes, such as reduced LOS, patient satisfaction and surgical team satisfaction, and presenting an acceptable pro forma, they were better able to obtain faculty support and funding for the PSH. Regular meetings with key stakeholders ensured ongoing awareness of and support for the program.

As with any new patient care paradigm, the reality of implementing a PSH lies in the conflict between the time and resources required to perform clinical and administrative duties. In response to the challenge, Dr. Stier and his group initially performed needed administrative activities on personal time; however, once organizational funding for the PSH program was secured, the finances needed for the administrative duties were no longer an issue.

For those thinking of developing their own PSH model, Dr. Stier recommended acquiring at least a basic knowledge of project management, process improvement, study design, statistical analysis and data gathering methods, much of which can be attained through existing institutional programs, books and online resources.

Dr. Stier also recognized that focusing group efforts early on in creating and implementing timely protocols and order sets for the surgical services they partnered with would have allowed them to more effectively reduce surgical practice variation and improve outcomes sooner. In addition, publishing a paper on their PSH outcomes likely would have moved the program forward much sooner.

As the PSH Learning Collaborative moves toward its third incarnation (PSH Learning Collaborative 2020), Dr. Stier emphasized the characteristics that make it patently unique: “The numberone advantage of participating in the PSH Learning Collaborative is the collaborative nature of membership—sharing resources and building relationships. PSH teams can clearly become experts in the development and implementation of perioperative care coordination programs, perioperative chronic disease management, facilitating the creation of clinical pathways and order sets, navigating the IT landscape and financial management of such programs. Creating successful PSH programs can ensure job security and career.”

The PSH Learning Collaborative 2020

Recruitment for the PSH Learning Collaborative 2020 is now under way. The collaborative will begin in May and run for two years. This iteration of the collaborative will assist facilities in PSH pilot implementation, optimization and expansion into new service lines or system-wide conversion.

It will also help facilities overcome the challenges they face with making the change to value-based payment. Organizations will be guided through participation in mandatory and elective bundles and understanding the impact that the Quality Payment Program (QPP) of the Medicare Access and CHIP Reauthorization Act of 2017 (MACRA), including the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) will have on their organization.

This effort is important because value-based payment is quickly being adopted by private as well as public payers.

To meet the unique needs of organizations interested in healthcare redesign, institutions can choose from two participation options:

The first, the Core Collaborative, is designed for organizations interested in learning more about the PSH model of care and those in the early stages of implementing a PSH pilot.

The other, the Advanced Cohort, is designed for organizations looking to optimize or expand their PSH pilot. Advanced Cohort participants also can be part of the Bundles Payment Add-On option, which allows them to assess their facility’s benefits and risks in participating in the various bundled payment programs.

Regardless of which learning track an organization chooses, institutions will complete the program with the confidence, tools and resources to begin the next phase of PSH pilot implementation.

To learn more about the PSH Learning Collaborative 2020, visit asahq.org/psh-learn or email PSH@asahq.org.

Roseanne M. Fischoff, MPP, serves as the Economics and Practice Innovations Executive for the American Society of Anesthesiologists (ASA). In this role, Ms. Fischoff develops and implements policies and operating structure to advance the ASA’s economic and practice innovation agenda. This work includes ensuring that the interests of anesthesiologists in regulatory affairs are well represented as they intersect with payment and practice management issues. Ms. Fischoff leads the promotional, educational and advocacy efforts for the perioperative surgical home initiative. She also serves as a catalyst for product and service innovation to support ASA members engaged in redefining the future of the specialty. She can be reached at R.Fischoff@asahq.org.