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Fall 2016

The Perioperative Surgical Home: Invest in Good Will

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

 You trade on it every day. It may be your anesthesia group’s most important asset. It’s difficult to quantify, but in the accounting sense, “good will” is the value of your anesthesia group’s assets above and beyond the tangible assets or the net present value of your group’s future cash flows. For example, good will was a substantial portion of the calculus when Disney purchased the Star Wars franchise. Good will is embodied in your relationship with your hospitals, your surgeons and your patients. You unknowingly groom your good will every single day in order to capitalize your business environment.

In this fifth installment of the Perioperative Surgical Home (PSH) series, allow me to posit the PSH as your means of increasing your good will by increasing your value to your hospitals, surgeons and patients. Let us explore the discoveries we’ve made at my institution having initiated pre- and postoperative clinic appointments during this last calendar quarter.

Our PSH clinic targets the 20 percent sickest patients with appointments one week in advance and up to 14 days post-discharge. After initiating clinic appointments with those patients, we quickly noted profound patient gratitude. In most cases, PSH patients already know they are sick and anesthesia is their biggest fear. They’re worried, and our 30- minute appointments result in a relaxed setting where we take the luxury of time to address their concerns. These clinic appointments are the embodiment of true patient access to anesthesiologists. The result is a pool of happier patients and an increased reservoir of community good will toward the entire health system.

Our surgeons also noted their increased access to PSH anesthesiologists. Because of the complexities of anesthesiologist scheduling, often surgeons have no anesthesiologist to consult with concerning complicated patients. Often, the surgeon’s best chance of obtaining an anesthesia consult is three minutes before surgery. Too frequently, the results are canceled cases, frustrated physicians, upset patients and global inefficiency.

On the other hand, the clinic appointment the week before surgery is a fantastic time to partner with surgeons in order to optimize their patients. Surgeons really appreciate a call from the PSH clinic anesthesiologist preparing their next week’s complicated patient.

In your operating room (OR) anesthesia colleagues will similarly appreciate receiving a PSH phone call the night before a complicated surgical patient lands on their lineup. That medical sign-out to your anesthesia colleague doing the case the next day is enormously important to them—a service to their day they have never before experienced. In calling and signing out PSH patients to my colleagues, I am personally gratified by the contribution I can make to their practice—and the feeling is mutual. I have found my OR anesthesia colleagues profoundly grateful for our PSH clearances and sign-outs.

Hospital risk management attorneys are also discovering that the PSH is their new best friend. In our clinic, we conduct full histories and physicals, and place electronic medical record notes that dramatically improve the medicallegal environment.

In one notable case, our PSH anesthesiologist spent an hour with a complicated patient and her daughter. They had an extensive conversation about the anesthesia/surgical risks, benefits and alternatives, and he placed a beautifully detailed note. The patient went on to surgery and eventually passed away from a perioperative complication, but the patient’s family was grateful for the extensive preoperative briefing. Additionally, the detail in the PSH record resulted in near absolution and indemnification for the surgeon, the hospital and the anesthesiologist.

Our Risk Management Department became a big believer after this one case alone. Our chief financial officers and executives are delighted to follow the mounting evidence of the PSH’s financial value. One study from New York University places a value of a preoperative PSH appointment with an anesthesiologist at $1,700 due to decreased length of stay, fewer readmissions and decline in surgical cancellations. This data is being closely followed by CMS and other payers. With the implementation of bundled payments and accountable care organization (ACO) caps, this is data you will want on your side. This is data that your anesthesia group will want to ”own” as you go before the ACO board to present your request for a larger percentage of fixed, capped bundled payments.

The greatest accrual of value, though, may be the motivation and stimulation afforded by the PSH. Stepping out of the OR to redeploy your anesthesia intuition in the perioperative setting is a fantastic management and medical experience. These new challenges can rejuvenate your career by giving you a new sense of purpose. Your own good will toward your colleagues, surgeons, patients and hospital will soar. You will rediscover energy and enthusiasm that had faded with repetitive and routine OR work. It is true that your practice can be new again.

The excitement and renewed sense of purpose that comes with being a PSH clinic anesthesiologist will be transmitted to patients, staff and the hospital. That is the real value of good will. Your new sense of fulfillment will be infectious as it rolls through the health system like a shot of adrenaline, resulting in happier patients, increased rapport between services and more appreciative hospital administrators. While not directly, objectively calculable, it is money in the bank of reputation that secures your exclusive contract with those you serve. Invest in yourself first. Invest in good will.

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 and Loma Linda University for internship and residency. He has been with Pacific Valley Medical Group since 2003. He and his partner have six adopted children in Tanzania, where he serves as Visiting Clinical Anesthesiologist at St. Elizabeth’s Hospital for the Poor in Arusha. He can be reached at