Perioperative Surgical Home -Optimizing the Patient’s Surgical Experience

Even as hospitals across the country focus on finding ways to deliver higher quality care at lower cost, there is a growing realization that healthcare itself is undergoing a major “attitude shift”.  “Pay for volume” is inexorably morphing into “‘pay for value”.

A new paradigm has been proposed by the ASA:  the perioperative surgical home.

 PSH, a model built around standardized, evidence-based perioperative strategies, involves team-based care. The team is structured as follows:

●    Head anesthesiologist

●    Dedicated nursing team

●    Nurse Practitioners / Physician Assistants

●    Specialist physicians as required

This team structured, value-based model, enables the patient’s pre-, intra-, and postoperative care to be provided by a single PSH team, eliminating the previously fragmented approach to delivering these services through several departments. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995011/

 PSH – Continuation and Disruption

 From the discovery of ether in 1846 to epidural anesthesia and rapid-acting agents, disruptive innovations in anesthesia have advanced the practice of medicine. PSH represents a modern-day disruption in that it changes the way surgical care is handled. Care that was previously fragmented and involving several departments is now coordinated and handled by a single PSH team.

 The period of care begins the moment the surgery is scheduled to thirty days after discharge. The focus is on implementing standardized best practices to which all team members have agreed.

 The Anesthesiologist’s Role in Perioperative Surgical Home

 The anesthesiologist’s involvement in PSH is to help lead the team to provide the best surgical care for the patient. In the past, the anesthesiologist’s role was often limited to the period from pre-anesthetic examination just before surgery to the postoperative care unit. The surgical team would provide most of the preoperative preparation and postoperative and post-discharge care of the patient. In recent decades, the role of anesthesiologists in perioperative care has been expanding, and PSH is seen as a natural extension of this trend. https://www.ncbi.nlm.nih.gov/books/NBK333510/

 Benefits of Perioperative Surgical Home

 In institutions where the Perioperative Surgical Home concept has been adopted, it has resulted in improvements in just about every category. Post-operative complications have been reduced. Cancellations and delays in the OR have dropped. Cost-savings are being realized while lengths of hospital stay decrease. Most importantly, patient satisfaction has improved.

 A perioperative surgical home represents a ‘needed’ disruption in surgical care, with anesthesiologists assuming an expanded leadership role. As we at Concordia Anesthesiology assist in the formation of PSH teams, we are proud to be part of the newest initiative enabling greater efficiency in surgical care. https://www.concordiaanesthesiology.com

Maximizing Operating Room Efficiency

In almost every hospital the OR is the “lion”, bringing in the largest share of revenue (as much as 70%) - and eating up a large share (an estimated 40%) of a hospital’s total expenses. It is easy to understand, therefore, why hospital administrators, always in search of ways to reduce costs while maximizing profitability, are focused on the OR. https://www.openanesthesia.org/or_costs_labor_vs_materials

Efficient Case Scheduling - Secret to a Well-Run OR

Operating room costs can be categorized as fixed or variable. Fixed costs include such things as a mortgage, administration, and salaried employee costs. Variable costs are largely driven by caseload and associated labor costs that occur outside of normal operational hours. The takeaway is simple - the most efficient ORs are those that can schedule the greatest percentage of cases (and case add-ons) within “normal” OR hours, minimizing additional compensation while maximizing efficiencies. 

Case Start Times – Avoiding Tardiness is Key

Tardiness can sabotage even the best functioning OR. A single thirty-minute late start on a morning case can result in playing catch-up the rest of the day. OR managers can minimize tardiness by having every patient’s medical records available and complete before the case start time. Anesthesiologists, surgeons, and other clinical team members must arrive on time. 

Patients should be told to arrive at precisely the right time in advance of their procedure.  https://www.beckershospitalreview.com/or-efficiencies/6-cornerstones-of-operating-room-efficiency-best-practices-for-each.html

Managing Case Flow and Handling Case Add-Ons

Scheduling cases on a scale of “most predictable” to “least predictable” (the longest) can help reduce the likelihood of the day running over schedule.

Case add-ons must be prioritized based on the acuity of the patient, anticipated length of the procedure, and availability of resources. A prediction bounds analysis by the OR manager will assist in determining the best placement within the existing schedule. https://pubs.asahq.org/anesthesiology/article/89/5/1228/37145/Method-to-Assist-in-the-Scheduling-of-Add-on

OR Turn-Over Times – Reducing Them May Not Be Beneficial

Trying to improve efficiency in the OR by reducing turn-over times is not worthwhile. In reality, these segments are usually less than one half-hour in length and are needed for proper sterilization. Shortening the time only leads to added stress, impacting both patient and staff safety.  https://www.bfwinc.com/5-ways-to-improve-operating-room-efficiency/

Non-Operating Room Anesthesia (NORA)

Significant cost savings can be realized by cases being performed under anesthesia administered outside of the OR. While the procedure may require the use of available equipment (CT, MRI, etc.) it can be scheduled without using the skilled personnel or sterile environment of the OR.  http://anesthesiaexperts.com/uncategorized/nonoperating-room-anesthesia-nora/

In the final analysis, while great management and scheduling of cases are key to an efficient OR, reducing costs must never come at the expense of patient or provider safety. 

As Concordia Anesthesiology partner’s with hospitals, patient safety remains our highest priority in the operating room.  https://www.concordiaanesthesiology.com

Evaluating the Anesthesia Staffing Model for Efficiency

Without a doubt, the operating room (OR) brings in the lion’s share of a hospital’s revenue, amounting to as much as 70% or more.

So, why aren’t hospitals developing and expanding the OR? A tight market, staffing shortages, and a rise in performance-based payment systems makes it hard for hospital executives to find additional funds for existing OR services, let alone expand them.

 Still, with the OR a prime revenue-generator for any hospital, its operation should be scrutinized to see where cost-savings might be implemented. While few administrators would consider reducing the number of surgeries (that would strangle the golden goose!) to improve the bottom line, changes to the existing anesthesia staffing model may help.

https://enhancehc.com/resources/anesthesia-101-coverage-models/

The Three Anesthesia Staffing Models:

 The optimal hospital staffing model should:

1.   improve efficiencies

2.   add revenue streams

3.   support clinical excellence

 Let’s look at the three most common staffing models for anesthesia delivery in the United States:

1.  All MD

 In this model, (most prevalent in one-or two-room surgery centers and less common in large ambulatory surgery centers), all anesthesia care is provided by medical doctors only, specifically physician anesthesiologists. The benefits of this model are that there are fewer providers involved and less supervision needed. From a cost-per-provider standpoint, this is the most expensive staffing model. In addition, providers in this model may be reluctant to participate in non-revenue producing, value-added services.

2. Anesthesia Care Team (ACT)

This model incorporates a physician anesthesiologist who supervises CRNAs (certified registered nurse anesthetists), with resident physicians-in-training who ultimately administer the anesthetics. While the increased number of providers requires a higher level of supervision, the added availability of another physician to work with OR nursing enhances efficiency. This model offers an intermediate level of costs.

 2.   CRNA Only

Under this model, anesthesia care is delivered by CRNAs independently, without the involvement of an anesthesiologist. In states where supervision is required, CRNAs practicing in this model can be supervised by any licensed physician. Because there is no anesthesiologist available to assist CRNAs with difficult cases, some surgeons may feel uncomfortable working in this staffing model.  However, this model is typically the most affordable of the three staffing models.

 At Concordia Anesthesiology, the process of analyzing the anesthesia staffing model to discover the appropriate provider ratios and staffing is the first step to improved efficiencies. It is an analysis focused on patient-centered care and alignment with hospital goals. Our model includes the placement of a Concordia-trained Director of Anesthesiology as the head of the local anesthesia department. In addition to overseeing day-to-day operations, the Anesthesia Director is responsible for creating an OR action plan, setting best practice standards, liaising with hospital administration, and ensuring proper staffing.

Maximizing efficiency in the OR helps hospitals increase revenue. Most important, improved efficiency results in improved patient care.

Anesthesia Practice Management – Improving Efficiency and Productivity

The most successful anesthesia departments never stop improving, always working to better their:

1.   operating room efficiency

2.   patient service revenue

3.   physician and patient satisfaction

To assist those that are struggling in these areas, many hospitals are now soliciting the services of outside consulting firms or Management Service Organizations (MSO’s) to design a more cost-effective, customer-focused model that optimizes clinical quality and customer service.

A bolder option consists of completely turning over complete administrative control of the anesthesia operation to a partner. As a turnkey operations company, Concordia Anesthesia develops a model based on operational requirements. Rapid staffing and support ensure.

  Providers’ time is leveraged to where their skills are best suited, and all procedures focus on patient safety, efficiency, cost, and viability. A comprehensive Perioperative Management model drives cost-saving initiatives.

 www.ccianesthesia.com/hospitals/anesthesia-consulting

 www.concordiaanesthesiology.com

 Regardless of whether anesthesia services are provided in-house or through an outside team (Concordia) of highly trained anesthesiologists and CRNAs, improvements in anesthesia practice management should include a focus on the following areas:

www.changehealthcare.com/insights/improving-anesthesia-practice-management

Profitability Through Efficiency

Surgical programs everywhere depend on the strength of their anesthesia partner. A well-functioning anesthesia service will keep the operating room (OR) running on schedule. Anesthesia departments must be empowered to make the necessary decisions that will improve throughput while reducing costs. Compensation for anesthesia departments must be based less on hospital subsidies and more on performance improvements in these areas.

The Compensation Structure of CRNAs

 Changes in how anesthesia departments are compensated should not only include a more direct alignment with improved efficiencies but also involve an examination of how CRNAs (Certified Registered Nurse Anesthetists) are paid. As hospitals, clinics, and practices look for ways to improve revenue, the pay structure of these highly trained professionals can change:

 ·      from hourly to salaried rates

·      to offer bonuses for meeting key performance.

Where Anesthesia Providers Can Work

 Hospital administrators should allow their anesthesia clinicians the flexibility to also work at other facilities such as ambulatory surgery centers (ASCs). Allowing anesthetists and CRNAs to staff these additional facilities increases the revenue-per-partner, reduces turnover, and improves recruitment of new providers.

 In summary, the best anesthesia-managed departments will have incorporated data-driven efficiencies and cost-effective solutions into their daily operation. That must be done without losing focus on the most important objective - the elevation of both physician and patient satisfaction.

 The most successful anesthesia departments never stop getting better. Partnering with an anesthesia practice management improves efficiency, productivity - and the bottom line!