Survey Results from 15 US Perioperative Surgical Home Sites: Lessons Learned
Presenter: Kayla Cline, Texas A&M University
Recorded on: July 30, 2014
And we will now go to today's presenter, Kayla. Go ahead.
>> Hi everyone, is everyone able to hear me?
>> Yes, we can hear you.
>> Okay, great. For those of you that I do not know, my name is Kayla Cline. I am a second year PhD
student here at the Texas A&M Health Science Center in the Department of Health Policy and
Management, and I am working on this project with Dr. Bita Kash.
And Tom Miller at the American Society of Anesthesiologists. I'll be presenting today, but Bita and a
representative from the ASA will be available to answer questions at the end of the presentation. So,
that being said, let's go ahead and get started. As you already know, today we're talking about results
from practitioners and administrators at Perioperative Surgical Home around the country.
So, the first thing we need to do is lay some groundwork for what the Perioperative Surgical Home is. So
taking the broad term used to describe care coordination efforts across the three phases of surgery to
reduce the cost of care, improve the quality of care, and improve patient experience and engagement.
The latest definition in the literature of the PSH describes the PSH model as an innovative, patient
centered, surgical continuity care model that incorporates shared decision making. The University of
Alabama at Birmingham who are heavily involved in developing a PSH program at their organization. The
purpose of this study is kind of a broad study with several aims the first of which is to identify the key
elements of the PSH, what really constitutes a surgical home.
The second aim is to obtain descriptive information about the state of different PSH programs around
the nation. And the ultimate goal of all this data collection and information sharing is to define a
conceptual model of what the Perioperative Surgical Home really is. So, in order to meet these aims, the
first thing that we did last fall was performed a comprehensive literature review.
View of surgical care coordination, literature, pre-intra and post-op care initiative, it was very broad and
far reaching. Based on those findings we developed interview questions and carried out interviews with
PSH practitioners which is what we're going to talk to you about today. To inform our discussion and
really the way that we're framing surgical we look at it as a clinical micro-system.
So this chart here shows you what we're talking you can see the three phases of surgery. Pre-intra and
Postoperative Surgery. And you can see some the activities involved in each of three phases. But you can
also see that the three phases are connected by the arrows, the scheduling, the transition planning, sort
of the care coordination element, and all three of the phases are linked using a feed back and feed
forward loop, to both share patient information, and to improve the process of care coordination and
surgical care going forward.
So this is the framework we've developed to look at the PSH. To give you an idea of what we're talking
about, more specifically when we talk about a PSH program here are some of, kind of detailed pre-inter
and post operative elements that we're talking about. You can see in the pre-operative section, we're
talking about things like clinic and pre-operative assessment, rehabilitation programs, patient triaging
protocols, etc.
It focuses on pain management and on OR efficiency and effectiveness. And then on the post operative
side we see things like pain management, improved coordination of care in transition homes, and
patient and caretaker education. You can read these in more detail on your own time. So these
interviews to learn more about what programs really look like, this is the approach we took.
We were aiming to, based on the scope of our study, we were aiming to identify 15 healthcare
organizations with PSH programs around the country, to get a descriptive profile of what their program
looked like. We chose these 15 organizations through sort of a process of elimination almost. A pretty
easily conducted survey by the ASA yielded 55 potential interview sites, that had some sort of PSH
program for PSH interest.
35 of these sites were selected by the research team to kind of assess who's willing to participate and
whether they were affiliated with a hospital. We're only interested in programs affiliated with one
hospital. So, sorry about that. Basically we asked 35 of these sites about their willingness to participate
and ability to to the hospital and based on this survey and votes of ASA committee members we
selected 15 organization based on interest in participation, progress in PSH implementation, and to
obtain broad geographic representation.
The results of this process is here. We see these are the 15 sites that we talked about, you can see they
range from coast to coast and from north to south. Broad Geographic Representation. You can also see
that in some locations we interviewed more than one respondent. That's because we spoke to both
physicians and clinic administrators at these various locations.
There's 15 locations but there's 24 respondents that spoke with. We asked a total of 54 questions falling
into nine categories you can see here. Focusing on practice demographics, details about their program,
payor profiles, patient profiles, to follow financial relationships with a health care system or hospital,
quality reporting, and then we also asked about similar organizational aspects such as barriers and
enablers of success, and then program performance.
So what they do well and what they could do to improve, and then we finally asked about the future of
anesthesiology as it relates to the peri-operative surgical home and similar efforts. The results for the
most part were easily tabulated into basically a summary table, but there were about ten questions that
we had to perform qualitative text analysis on, and so in 9 of the 10 we were able to use an inductive
approach, which means essentially means we looked at the responses and we sort of built theories to
answer our questions based on commonalities in the responses.
For one question, we had to use an adaptive approach so we took theory that we've already established
and used that theory to interpret the findings from the questions. Still belongs to the actual highlights of
what we found. Most practices that we interviewed were part of an Academic Anesthesia Group, and
most were fully integrated into the hospital or system.
We'll touch on this a little bit more later, but I think said that being fully integrated into a hospital
system enables the practitioners to get more support for the finance and in terms of leadership and staff
to carry out the home and care coordination process. So being a fully The system seems to be a bit of a
plus in that sense.
And we'll talk more about that later. Most of the groups served both an academic medical center, a
tertiary care academic medical center, and an ambulatory surgery center. And about half are involved at
a community hospital. But that being said, most of the programs reported that the PSH program was
really only being implemented at one of the locations, usually the tertiary care medical center, for scope
reasons or just because it's most applicable there.
The mean annual number of cases was 32,595. And they were carried out in an average of 50 ORs and
12 non-OR locations, serviced by the anesthesiologists that we spoke with at the location. Looking at
what was actually being done, we can see here that early patient engagement, which would be
contacting the patient early to get histories.
Ensure that they know, hopefully know what they're getting in to, education about the procedure and
the recovery and so on. That was a very commonly implemented element. Coordinated pre-op testing
was also very commonly implemented, and that’s largely because of a significant number of these
programs developed from a preoperative clinic.
So that was the first step of these programs is developing a preoperative clinic. Some programs were
involved in things like lifestyle counseling and anemia management. Although, these were not that
common as pre-op testing and early patient engagement. Other elements our respondents mentioned
included seizure assessment, transitioning care for chronic conditions to primary care physicians, and
implementing pre-operative care protocols.
Moving on to the intraoperative side. You can see that almost all reported as being involved in
essentially all of the elements that we asked about. And if you look at what we asked about, we asked
about things like scheduling, reduced delays, quality initiatives, facilities optimization, and so on.
And from what I could tell, most of the respondents were, the PSH program participants were involved
in these initiatives. But this was largely a hospital, the hospital is sort of the impetus for these things. So
the PSH is not, was involved in doing all these things, reducing delay of scheduling and so on, but it was
not necessarily the impetus.
It was kind of the means to achieve this, or one of the means to achieve this. So I think that's why it was
so widespread for all the practices that we spoke with, and administrators, and so on. Other elements
mentioned included supply chain management, which is touched on a little bit in some of these
categories, medication management and patient safety initiatives.
Moving on to the post operative elements that programs reported being involved in, the most common,
in fact, 100% of the programs reported being involved in postoperative pain management. Which sort of
follows with working with the anesthesiologist, kind of makes sense. Reducing length of stay was also
frequently reported.
Again, I think that kind of goes along with what we talked about in the intraoperative phase. A lot of
these programs were doing this before the PSH program, outside of the PSH program, and also in the
PSH program. Nausea and vomiting protocol were very common, but it was less common for
organizations to be involved with discharge planning, discharge phone calls, and rehabilitation.
And in fact, some of the programs we've spoke with seemed kind of surprised to hear this as being a
part of a peri-operative surgical home. The post operative side definitely seemed to be the least
developed of the three phases for most programs, although not all of them. Other elements that
respondents mentioned were co-morbidity management after surgery, ICU step down, patient
satisfaction assessments within 48 hours, and the use of regional blocks for pain.
All but one program was involved with some sort of acute pain management. In terms of quality
reporting, 8 of the 15 programs used an EHR to report quality data. And you can see here that most of
them were involved in some sort of external quality reporting, organization or registry.
AQI was the most popular, and some of the others were popular as well. Ten programs used claims data
either instead of or to supplement EHR records for the external quality reporting and for internal quality
reporting measures or initiatives. Now we're moving on to more of the organizational side of things,
some of the more ordered data that we got.
So interestingly about 40% of the programs that we interviewed used the name surgical home or
perioperative surgical home for their PSH-type program. But many of the other programs used other
names, or some of them didn't really have a name at all. Other names used included surgical
neighborhood, center For perioperative services, perioperative care pathways, and reengineered
perioperative services, among others.
A few respondents mentioned that there was push back to the name perioperative surgical home. And
one of the reasons for this was that some people don't believe it's a close enough corollary to the
patient centered medical home, since the patient centered medical home is kind of long-term home for
a patient.
And a surgery is really just kind of one large episode of care, not necessarily a long-term relationship. So
some of the push back from the surgical home idea was that it wasn't similar enough to the patientcentered medical home. And some of the other practitioners, surgeons or hospital administrators just
didn't like the name surgical home, for whatever reason.
So that was some of the push back that we heard about from respondents. Most of the PSH programs
were pretty informally structured. It's possibly because of a lot of them were very new and so they
haven't figured out the formal structure yet. So some of the combinations that we saw included work
groups or management committees that involved different anesthesiologists or nurse practitioners or
hospitals with different teams to look at and manage the perioperative process.
We also saw that some organizations established a medical directorship for perioperative services. And
other organizations were more focused, rather than developing a surgical home to coordinate care, in
general. They were focused on developing cross function teams focused on protocol development and
enforcement across the perioperative spectrum. So some surgical homes were a little bit more focused
on protocol development enforcement than others.
In terms of stage of implementation, we kind of touched on this already. We asked the respondents
what stage they consider their PSH program to be in. And when we asked this question, we asked about
four stages, planning, early implementation, late implementation, and sustainability. And you can see
here on this slide what we're talking about when we talk about each of these.
About planning we're talking about where you're identifying the problem, figuring out what resources
you have to address that problem, and starting to look into potential solutions. Early implementation is
when solutions are being applied on a small scale. Maybe a pilot study, maybe just part of the solution, a
small scale implementation of the solution selected in the planning phase.
In the late implementation, You kind of rolled out the full solution to all practitioners or all segment. And
in the sustainability and future growth space, you are working out the kinks to make things more
efficient and effective and you're looking to improve on the initial solution. So you can see here in this
pie chart the breakdown of the different phases.
Most programs claim to be in the planning stage, 40%. Other large percentages fell into early
implementation or late implementation, and only few claim to be in the sustainability phase. What was
interesting about this question, a lot of respondents had a very hard time answering this question, and it
was at least in part because most of these programs have either only implemented, basically they
implemented different parts of the surgical home at different times.
So they may have rolled out the preoperative clinic ten years ago, but they were just starting to work on
the postoperative discharge aspect. And so while the preoperative side is perhaps in the sustainability
phase, the postoperative side of it is still in planning. So it's very difficult for many respondents to put
their surgical home into one of these categories in terms of patient implementation.
Organizational leadership. So the practioners that we spoke were personally heavily involved in the
organizational leadership. And other anesthesiologists involved with the PSH were heavily involved with
organizational leadership. Almost all the practices interviewed had committee heads or medical
directorships within their practice, and many of these these medical directorships, as we talked about
earlier, pertained to perioperative management of some kind or preoperative clinic management.
And then most programs were also involved with some sort of pharmacy standardization or ordering
either in a hands-on role or in an advisory role. One of the major topics that we asked about were
barriers and enablers of surgical home success. Starting with the barriers, one of the biggest barriers
were the finances, and really this was talked about by many of the respondents many times throughout
the interview.
The question is who's gonna pay for this surgical home. This isn't reimbursed by most insurance
companies, and so there's not a line item to get paid for care coordination. So the question is the
paperwork takes resources, this takes staff, this takes facilities, but this isn't reimbursable in a lot of
organizations.
So who's gonna pay for this? Whose gonna foot the bill? So that was a major stumbling block for many
of the organizations. And really, the solution that a lot of the organizations came to is that they had to,
the anesthesiology practice, or department, or whatever, had to foot the bill initially, prove that it
worked, prove that it lowered costs and improved patient care to leadership.
And the leadership was more and more willing to allocate some money and some resources to help
them out. Another common barrier to PSH success that was mentioned was resistance to change by
staff and other people that they're working with. It's the new way of doing work, and it's new work for
some people, and so It was difficult for some organizations to get staff onboard.
Another common issue that we talked about was medical specialty territory issues. Some organizations
mentioned that the hospital is threatened by anesthesiologist involvement in the perioperative surgical
process. Either because it was things, it involved things that these groups had been doing before, or they
were just afraid of being taken over and being told what to do.
So some sort of territory issue is mentioned by several of the anesthesiologist administrators that we
spoke with. Another barrier to success was the lack of evidence for the PSH. The PSH itself Is a very new
concept and surgical care coordination is not a concept that's been well developed in the literature or
well studied, and so there's not a lot of evidence to prove that coordinating care will reduce costs or will
improve quality or will improve patient experience.
So you can argue that there's not a lot of evidence at this point to prove that out, and that's what we're
working on in this project. Another barrier would be IT capabilities. Coordinating patient care means
you've gotta get information from the people working with the patient in the pre-op phase to the interop phase to the the post-op and you've gotta make sure that that all gets translated into a patientfriendly discharge package, essentially.
So all that information sharing requires a lot of IT capabilities, and if that's not there, that makes it
difficult to coordinate care. So several organizations mentioned that. Now moving on to the enablers of
success. It's interesting a lot of the enablers are just a flip side of these barriers, but we'll get to that in
just a second.
The number one enabler of success was organizational leadership and support at the healthcare system
or hospital level. If you have leadership support you're more likely to have financial support, you're
more likely to have facilities and you're more likely to be able to overcome obstacles as they come up.
So leadership support was very frequently cited by the respondents as an extremely important enabler
of PSH implementation success. Another factor that I thought was interesting that was mentioned by a
lot of the respondents that a patient-centered focus for the healthcare organization seemed to help
with PSH implementation. Essentially what they're saying is that if the staff and leadership are already
on board with being patient centered, the PSH is almost a natural extension of that philosophy.
So it was easy to get people and it was easy to get needed resources together, if you were already
patient-centered to begin with. Another thing, and this is really on a flip side of what we're talking about
with the barriers was the surgeon experience. If the PSH was something that made the surgeon's life
easier, surgeons were generally very supportive and on board with the PSH program because it made
their job better.
One organization talked about how the PSH program optimized pre-op testing, so pre-op testing was
pretty much always done and done correctly by the time the patient got to the operating room. And the
operating room was running more efficiently because of PSH scheduling initiatives. And so surgeons
liked it because they showed up to the surgery, the patient was ready, the OR was ready and everything
went smoothly.
So the surgeons were huge fans of the perioperative surgical home and so it's easier to get other people
on board as well. And again, sort of a flip slide to one of the barriers we talked about, many
organizations talked about how if your IT capabilities are strong and you're able to share patient
information across the phases of surgery, it was very easy to coordinate care, relatively speaking, and
made implementing the PSH easier.
Similarly, critical process capabilities helped organizations implement the PSH as well. This is talking
about clinical resources, equipment, and staff. So if you have a lot of resources to work with, it's easier
to do your job in general, and that's the case for the PSH as well. And then lastly communication of the
PSH benefits, so a lot of organizations had difficulty not only providing evidence that the PSH was but
communicating that to the people they needed to communicate that to and doing that effectively.
So if you're also I guess the enabler side of that is if you're able to communicate what you find that
patients are more satisfied that you are reducing costs or you are improving quality. It's easier to get
organizational support but if you don't have indicate that to the higher ups or to the people, the boots
on the ground that are doing the work, it's difficult to implement, the PSH.
Last one. Organization or care team readiness for change. This is sort of the opposite of what we were
talking about earlier with the resistance to change is a barrier, if the care team is ready for change, if
you're in a sort of change, a prochange organization so to speak it's a little bit easier to implement new
programs like the PSH.
Another enablers that were mentioned were people engagement, the use of a small scale pilot program
or the presence of a payment model. So a lot of the organizations started the PSH with perhaps one
surgery line instead of trying to implement all at once. They just looked at joint surgery of some kind.
They coordinated across joint surgery and that they were able to look at that was finite and small
enough where they could implement it without lots of resources. But they could prove that it works.
And in the premise of a payment model most organizations didn't have this. If the organization that had
sort of making progress and developing a payment model for care coordination mentioned that it was
easier to move forward if that was in place.
Another question that we asked our respondents was what was the strength of your PSH program to
others? We had some common responses, the most common response was the emphasis on care
coordination. Some organizations focused a lot more on coordinating care. They seem to think that they
coordinate care more than others.
A common response connected to some patient satisfaction or surgeon satisfaction, and then indicated
that they were well able to use metrics to demonstrate value. Which was a strength of their particular
program and you can see some of the other strengths listed here. On the flip side of that we asked the
respondents about opportunities for growth in pre, intra, and post operative care.
One common response was the development of care protocols for all three of those phases. Several of
the organizations had started trying to coordinate individual care programs for patients but developing
protocols to do that kinda stream lines that process going forward so that seemed to be something that
most of the organizations mentioned.
Other things mentioned included triaging patients better and to target patient segments that really
need care coordination. In the interim of this stage you see the efficiency and effectiveness initiatives or
supply chain type initiatives. On the postoperative side, again protocols show up, medication
management and expanding pain services on the postoperative side.
One of the final questions that we asked respondents, we asked them to indicate how important they
thought the PSH was to forge their parties. So, first we asked them to indicate how important the PSH
was to them personally and that's the first line on this chart. And as you can see both of them indicated
on a scale of one to 10 the PSH was very important to them.
The mean was something like 9.7 and the median was 10 so most of the anesthesiologists we spoke with
thought the PSH was very important. We also asked them how they thought other anesthesiologist In
practice, we see the importance of the PSH. The results were a little lower, around seven.
Some of the anesthesiologists were that people were not involved with the PSH program, didn't care
and really just wanted to administer anesthesia, do their job and go home. So that's the push back that
we found were reported for other anesthesiologists in their practice. Let me ask how these
anesthesiologists thought the healthcare organization perceived the importance of the PSH.
Most health care organizations they thought perceived the PSH to be pretty important. The medium was
eight for this response largely because I think these health care organization realized the potential to
lower cost and improve quality and so on so they could see the PSH as an important mechanism for
doing that.
And then surgeons, as we mentioned before, some of the anesthesiologists, there was a wide variety of
responses for this one. Some of the anesthesiologists seemed to think surgeons worked with it and it
was a ten. It was very important, and then other anesthesiologists who had trouble with surgeons
indicated that surgeons were, did not think the PSH was important.
So we saw a very wide variety of responses for this first question. Going back to the category, the
anesthesiologists that we asked about on a scale from one to ten. The median score was ten very
important. And the minimum was seven. So no one we spoke to thought it was unimportant.
So most practitioners when asked more about this indicated that perioperative care management to the
future of the specialty, and so this respondent quote kind of sums it up I think. One of the respondents
said, I think it's the nature of what healthcare has to be. I think it's bigger than anesthesia.
I think it is. All physicians, all, have to play a part in the whole system and can't just be working in their
specific, traditional area of expertise. From that regard, it is absolutely critical. And I think that sums up
what a lot of the anesthesiologists were saying as a whole for our interview process.
So, in response to some of these findings and other findings on the PSH, the American Society of
Anesthesiologists have what they're calling the Perioperative Surgical Home Learning Collaborative. And
that's sort of the process on a large scale where they're all working together. So they've pulled together
41 health care organizations that have.
Doctors trying to just get together, make the first meeting about the lifeline, and talk about best
practices and learn from experts. And ideally create a road map for PSH implementation. So if you're
interested in learning more about that there is a link here on the slide from the ASA website.
And also based on these results, we are working on three different publications. The first two relate
more to the literature review that we performed last year. One is an international comparison of pre,
inter, and postop care evidence basically. So we're comparing what US evidence says to what
international evidence says and that is awaiting publication in Quarterly.
It should be released in December, published in December. We've also got a manuscript focusing more
specifically on preoperative testing practices in different countries. We're looking at what the evidence
says from different countries and also what test protocols working on that currently within the health
care management journal. And finally, we're working on a third manuscript focusing on residency board
requirements, and perioperative care.
So we're taking kind of our survey, what we found were the most important elements of perioperative
care, and we're mapping it to residency training curricula, essentially. To see which evidence are coming
out of med school prepared to handle the burden of perioperative care and perioperative care
coordination. Of course no one is really coming out of med school ready to do this the big and what
needs to be.
That's kind of where we're going with that right now. What we're working on currently. And with that,
hat's all I have got so I am ready to open up the floor for questions if anyone has them.
>> Thank you Kayla for the presentation. Does anyone have any questions?
I have none. I'll mute everybody for the Q and A, so if you have any questions just feel free to say so. No
questions? All right, well, if nobody have any questions, we would like to conclude the webinar. But if
you still have any question after the presentation, please feel free to send me or send Kayla or Dr. Kash
your question by email.
So I would like to thank everyone for attending todays webinar. Please feel free to send us any
questions, as I said, and we will see you at our next webinar. Thank you.