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Fall 2015

The Perioperative Surgical Home: “Right for Our Group?”

Rick Bushnell, MD, MBA
Director, Department of Anesthesia, Shriners Hospital for Children, Los Angeles, CA and
Huntington Memorial Hospital, Pasadena, CA

Our Pacific Valley Medical Group (PVMG) in Pasadena, California consists of 29 partners. We’re an independent, single specialty group primarily serving Huntington Memorial Hospital and Shriners Hospital for Children, Los Angeles. We love our practice, our hospitals and our community, and as a group we think we do a great job.

As is true for most anesthesia practices, the delivery of our standard, elective anesthetic involves meeting a patient three minutes ahead of time, delivering anesthesia in the OR, landing that person in recovery and moving on to the next; “wash, rinse and repeat.” We delegate pre-operative management and post-discharge care to others. But many of us are now asking “Is this the best we can do? Is this our best effort?” Many think not. Patients, payers, administrators and our partner surgeons are beginning to expect more from our practice in this pending era of ‘pay for performance.’

The healthcare funding debate is now over. The Centers for Medicare and Medicaid Services (CMS) and private payers will be reducing their costs by coupling reimbursements to quality and patient outcomes. Anesthesiologists will be held directly economically accountable for transfusions, length of stay and a growing number of other cost and quality metrics. As anesthesiologists, we want to participate in perioperative medical care in order to prevent the cancellations, to optimize the acute phase and to reduce readmissions. We are moving now to improve our quality of care in direct response to the demands of many. We understand that agencies, administrators and patients alike will rate our professional practice relative to our peers.

In addition to CMS reductions, economic pressure on MD anesthesiologists continues to grow from mid-level, non-physician, lower cost providers. When the outcomes are much the same, how then will anesthesiologists continue to justify their presence as a physician specialty? If we expect to bill at higher rates than mid-levels then we must provide additional value, proving our relevance. We must be willing to assume more responsibility by providing the critical pre-operative and post-discharge management that only anesthesiologists can deliver.

As individual anesthesiologists, we also know that we can improve the patient experience. Patients intuitively understand that anesthesia is a big deal, and commonly anesthesia is their biggest concern. They are frequently disheartened by having such a hugely important part of their medical care seemingly taken so lightly. As anesthesiologists, self-relegating our own importance to a three minute pre-op interview is to diminish, in the perception of many, the importance of our specialty. We can do better for our patients and our specialty.

As a group, we understand that our hospitals are struggling with their own CMS challenges, and they are hungry for physician leadership. All hospitals and Accountable Care Organizations (ACOs) need solid physician partners to creatively drive and participate in quality improvements. PVMG intends to be that partner for Huntington and Shriners. We intend to be the specialty group that coordinates the perioperative push for improved surgical outcomes. We intend to be those physicians that most understand the entire continuum of anesthesia care. We intend to do more than magically appear, spin the Sevo dial and walk out anonymously at the end of the day. We’ll place an MD in clinic to see our patients both pre-operatively and post-discharge.

More fundamentally, though, we want to elevate our own practice of anesthesia. As physicians we know that meeting medically complicated patients three minutes before surgery is sub-optimal. Can we get them through surgery? In most cases, yes, but we know we can do better. Who better to optimize surgical patients than anesthesiologists? We are that physician specialty that knows best the surgical challenges presented to patient physiology. Delegating pre-op and post-discharge care solely to others is no longer good enough, and PVMG intends to more actively manage complicated patients. It’s fundamentally outstandingly good medicine to have anesthesiologists more involved.

The American Society of Anesthesiologists (ASA) is advancing the concept of the perioperative surgical home (PSH) in order to increase physician anesthesiologist involvement in the entire surgical process. We recognize the PSH as the ASA’s central strategy for increasing the relevance of our specialty. PVMG will pick up that cause by partnering with our hospitals to establish a perioperative surgical home in Pasadena in the form of pre-op and post-discharge clinics.

At Shriners Hospital for Children, Los Angeles, we’ve stationed a physician anesthesiologist to evaluate every child in the ambulatory clinic days to weeks before surgery. The same anesthesiologist admits and discharges each patient on the day of surgery and follows them up in post-discharge clinic during their first follow-up visit with their surgeon. At Shriners Hospital, Los Angeles, the continuum of anesthesia care encompasses the entire perioperative continuum; from the decision to operate to final dispensation.

Our clinic model for both pre-operative and post-discharge evaluation by the same physician is based on increased patient satisfaction and a high priority placed on the continuum of patient management. We also recognize clinic processes as separate learning curves and skill sets apart from OR skill sets. Clinic physicians must necessarily be familiar with national guidelines for pre-op evaluation and optimization protocols. They also must develop additional clinical intuition and interventional strategies for post-discharge patients who are about to fail: those at highest risk of readmission. The combination of seeing patients both pre-operatively and post-discharge is a major advantage in preventing the readmissions so costly to our organizations. The continuity also serves physicians well in that seeing post-discharge patients is an excellent education that immediately raises physician pre-op evaluation skill sets.

This model, the popularity and the results of this clinic are self-evident in the near-zero cancellation rate, the zero readmission rate and in patient satisfaction surveys. Because of this success and the encouragement of the ASA, PVMG will now bringing this model to Huntington Memorial. Huntington’s 11,000 surgical cases pose a different challenge, though. The large adult population presents entirely different medical demographics and the sheer volume forces us to concentrate on those patients at highest risk.

Our most immediate goal for the Huntington Memorial clinic will be for our MDs to concentrate on the most complicated 20 percent of patients. We’ll also be recruiting the help of our surgeon partners in our effort to triage this population. The range of surgeries is likewise diverse, even including labor and delivery patients. In this triage effort, we also know that we’ll need the help of a data management vendor.

To introduce this effort, in August we held our own first annual perioperative surgical home conference. We are grateful to Zeev Kain, MD, the face of the ASA’s PSH, for his wonderful introduction of this concept to our gathering. In attendance that evening was the majority of the C-suite, a healthy selection of surgeons, mid-level hospital administrators and PVMG anesthesiologists. The result: our Huntington Memorial CEO is hosting a mid-September strategy meeting. We’re all taking this effort seriously and we’re determined to form a strong, productive Huntington-PVMG partnership.

Our group recognizes the perioperative surgical home and anesthesia clinics as great public relations, excellent physician leadership and fundamentally good medicine. As important, though, if our specialty is to maintain its relevance, then as anesthesiologists we must assume more responsibility. We must extend and improve our management to include the complete perioperative process, a continuum from the moment of decision to operate to the completion of recovery.

Relevance in the future will be defined by cost, quality and patient experience. Our Pacific Valley Medical Group in Pasadena is determined to elevate the specialty of anesthesia and deliver better outcomes to our patients, our hospital and our payers.

Yes, the perioperative surgical home is indeed “right for our group.”

Rick Bushnell, MD, MBA, is the Director of the Department of Anesthesia, Shriners Hospital for Children, Los Angeles, CA and a Clinical Anesthesiologist at Huntington Memorial Hospital in Pasadena, CA. Dr. Bushnell graduated from the University of Illinois College Of Medicine and attended the University of Pittsburgh Medical Center, Pittsburgh and Loma Linda University for internship and residency. He has been with Pacific Valley Medical Group since 2003 and consults with Shriners Hospital for Children, Los Angeles. He and his partner have six adopted children in Tanzania where he serves as Visiting Clinical Anethesiologist at St. Elizabeth’s Hospital for the Poor in Arusha. He can be reached at