May 1, 2013
Volume 77, Number 5
Evolution of Value-Added Services
Linda B. Hertzberg, M.D. Committee on Practice Management
There were many highlights at PRACTICE MANAGEMENT 2013 in Las Vegas last January, but I was especially excited by the talk given by Angela Bader, M.D., M.P.H., of the Weiner Center for Preoperative Evaluation at Brigham and Women’s Hospital. She spoke on “Demonstrating the Value of a Preoperative Clinic” during the Advanced Practice Management Pre-Conference and provided insight on successful approaches to perioperative care. Dr. Bader’s talk and my own experiences speaking with residents at the conference on issues related to value-added services, to me, points a way toward a path for the successful evolution of anesthesiology services.
Dr. Bader has the good fortune to work in an integrated system that encourages a systematic approach to perioperative care. As such, the Center for Preoperative Evaluation sees all patients who are scheduled for procedures at Brigham and Women’s Hospital. Clinic staff do the preoperative histories and physicals, coordinate with primary care physicians and surgeons offices, and order and obtain necessary consults, laboratory, radiologic and other clinical data prior to surgery. The reported cancellation rate for patients who have passed through this sort of screening in a clinic coordinated and managed by anesthesiologists is vanishingly low. In an ideal world, this would be this first piece of, and the foundation upon which, a true Perioperative Surgical Home model could rest. The Perioperative Surgical Home “would pioneer the role of anesthesiologists acting to coordinate the services provided by other health care professionals during the perioperative period. Such a model may, if executed properly, help to manage the full spectrum of surgical episodes, reduce costly complications and improve the efficiency of care.” www.asahq.org/for-members/advocacy/washington-alerts/asa-seeking-partners-in-the-cmmi-challenge-perioperative-surgical-home-grant-proposal.aspx.
For a number of years, I have given a presentation at the resident portion of the conference titled “Providing Value- Added Services to Your Hospital: Pre-Anesthesia Assessment, PACU and O.R. Management.” As the concept of the Perioperative Surgical Home model of care developed and gained traction within ASA, I have tried to tie the items in the talk into this larger concept. I personally practice as a member of a medium-sized, private practice, all-physician group in California. We work at a large tertiary care hospital, a smaller surgical hospital and several ambulatory surgical centers. We do not work in an integrated system and do not currently have an integrated IPA or PHO with other specialties, although one is under development. As a result, we are not part of a true Perioperative Surgical Home model, or even a model of
complete preoperative evaluation and care as described by Dr. Bader. Consolidation of smaller- and medium-sized groups into larger and possibly more integrated entities is currently a
frequent and common occurrence, as discussed in a number of sessions in the main practice management conference. However, absent a true integrated system for the delivery of total perioperative care, groups of all sizes will need to be involved in the items I discuss with the residents.
If this concept does not resonate with you and your group members, I urge you to read an article published in the California Society of Anesthesiologists (CSA) blog (CSA Online First) by Keith Chamberlin, M.D., M.B.A., published last year titled “Someone Wants Your Practice! (And they’ll take it with help from your CEO and surgeons ...)” http://members.csahq.org/blog/2012/01/30/someone-wants-your-practice-and-they’ll-take-it-help-your-ceo-and-surgeons. Dr. Chamberlin astutely describes how anesthesia groups are at risk for loss of contracts or takeover if they do not demonstrate measurable value and good citizenship in their practice settings.
One relatively simple way to start doing this is on the clinical level by being involved with the separate pieces of preoperative assessment and O.R. and PACU management where you practice. For a medium-sized private practice group such as mine, this has meant coordinating with surgeons’ offices and hospital and ASC pre-admission testing clinics to set up oversight of these areas by the O.R. manager or anesthesia medical director. We have developed protocol-driven processes for screening by RNs and consistency in standards, algorithms and processes within the anesthesia group and across facilities. An anesthesiologist is available at each facility to review patient charts and data and make recommendations should questions arise about patient readiness for surgery that do not fall within the standard algorithms. Once such a system is up and running with the appropriate baseline data, it should be possible to demonstrate a decrease in surgical delays and/or cancellations.
Similarly, in the context of O.R. management, at a minimum someone from the anesthesia group should be involved in coordinating with hospital personnel in the day-to-day management of O.R. case scheduling. This will improve flow and turnover in the O.R., facilitate the handling of urgent and emergency add-on cases, and improve personnel and resource allocation by both the anesthesia group and the hospital. By being involved in this manner, the anesthesia group can influence hospital processes in quality and financial incentives, strengthen relationships with surgeons and O.R. staff and increase visibility of the anesthesia department. The goal is to eventually become indispensable to the running of the O.R.
Lastly, PACU management will involve the creation of standardized order sets, protocols for things such as pain control, nausea, BP control, epidural and nerve block catheters, and discharge criteria for Phase 1 and 2 PACU areas. It is important that someone such as the O.R. manager or other anesthesiologist be available for unanticipated clinical issues. In addition, good PACU management will involve coordination with surgeons or the hospitalist service in the care and disposition of clinically complex patients. This will help the hospital facilitate the flow of patient discharge to home or other areas of the hospital.
Done properly, the consequence of these value-added services will be many: patients better prepared for surgery and anesthesia, improved scheduling, flow and resource allocation in the O.R., and consistent care in the PACU and postoperative period. By creating a better working environment and demonstrating value to surgeons and administrators, the position of the anesthesia group will become less vulnerable and more integrated with hospital operations. As models of the Perioperative Surgical Home are developed and implemented in the future, hospitals will look to those groups of anesthesiologists who have already demonstrated they can participate and innovate in the perioperative setting to help implement new practice models. It is imperative that groups find a way now to have added, measurable value in their practices by practicing good citizenship and becoming involved in all aspects of their hospital and practice settings. Only in this way can we “advance the practice and secure the future.”
Linda B. Hertzberg, M.D. is a partner, Anesthesia Consultants of Fresno, Fresno, California.