12/23/2013

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Logical Steps Towards

Advancing Health Care and Patient Safety

Mark A. Warner, M.D.

The Scope of thePerioperative Surgical Home

Why A Surgical Home?

• Patient safety

– Biggest opportunity for a positive impact

• Cost-effectiveness

– Short-term care; major costs

• Efficiency

– Where it is needed most

• Standardization

– Multi-disciplinary; drives common care processes

How Did Anesthesiology Get Here?

• American Board requirements for more:– General medicine exposure in internship

– Preop medicine and expanded critical care

• ACGME requirements for:– Closer tie between internship and core

program

– More out-of-OR clinical experiences

• CMS support

Gaining Momentum

• April - May 2011: Anesthesiologists met with CMS (Berwick) and HHS (Sebelius) leaders

• Anesthesiologists provided input to CMS’s Center for Innovation request for proposals– Currently $64 M+ in related projects

So What Does This All Mean?

• Anesthesiology will change

• New models of care will evolve

• Anesthesiology trainees are increasing gaining experiences that will support this change

• Opportunities to decrease expensive complications and inefficiencies

Why Anesthesiologists?

• No one knows the perioperative practice better

• Can bring efficiencies and improvements that cross multiple provider groups

• Surgical complications represent 7-10% of hospital expenses; proven track record of anesthesiologists in preventing complications

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Perioperative Expense ReductionOpportunities

• Preoperative assessment and management– Improved patient efficiency

– Decreased testing

• Oversight of perioperative processes and patient management– Reduction in expensive complications

– Early recognition of problems (rapid response care)

A Few Important Opportunities

• Blood product oversight– Major opportunities to reduce the direct costs

and the many indirect complications of transfusion

• Allergy testing– Less than 10% of patients with assumed PCN

allergy are reactive

• Predictive medicine (still maturing)– Genetic testing, risk profiling, and

pharmacologic management

A Steady Progression

• Seems logical

• May not work – but studies suggest it will

• Should move forward

• Must study to determine what matters and how much it matters to improving health care finances and outcomes

The Goal: Cost-Effective, Efficient, and Safe Perioperative Care

Professor and ChairAssociate Dean & Acting Chief Medical Officer Department of Anesthesiology & Perioperative CareUC Irvine School of Medicine

Zeev Kain, MD, MBA

Creating a Real-World Surgical Home

A Change in Paradigm

Today Future

Fragmented Care Collaborative Care

Discounted Fee for Service Shared Risk/Reward

Payment for Volume Payment for Value

Isolated Patient Files Integrated Electronic Record

Adversarial Payer‐Provider Relations

Cooperative Payer‐Provider Relations

Focus on procedure Focus on triple aim

“Everyone For Themselves” Joint Contracting

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UC Irvine Health Perioperative Surgical Home

• PSH is a multi-departmental initiative aimed to transform surgical care by improving quality, lowering costs and

increasing patient and provider satisfaction.

Traditional Surgical Model Short Falls

• High perioperative care cost (est. 60% of Hospital Expenses)

• Fragmented continuum of care (btw. Hospital, Clinic, Lab, & Physician services)

• Idiosyncratic that focus on hospital reimbursement

• Order of consults and lab testing variability by medical & surgical services

• Post-operative care is generally disorganized, highly variable, & skilled labor dependent

• Poor accountability system

• Preventable Complications

UC Irvine PSH Mission

• Coordination of care

• Reduce cost of care and decrease LOS

• Reduce complication rate and re-admissions

• Standardization of practice using evidence based practices & guidelines

• Improve overall satisfaction of Surgeons, Anesthesia, Nursing & Patients

• Provide Quality & Performance Improvement Measures demonstrating success, outcomes based on research (NSQUIP, SCIP)

Joint Surgical Home Team

Ran  Schwarzkopf

Laura Bruzzone

Alice IssaiRanjan Gupta Zeev Kain

SURGICAL HOME- GOAL

A HIGH RELIABILITY ORGANIZATION CONCEPT OF INTEGRATED PERIOPERATIVE CONTINUUM

Decision to Operate Early Return to Normal Activity

Evidence based standardization of practiceAchieving key health care metrics

AccountabilityEfficiency and effectiveness

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PATIENT

Phase Preoperative Intra operative Post operative Post Discharge

•Variable support often leading to ER 

•Minimal pre‐procedure planning

Decision to Operate

•Variable pre‐op assessment, testing  and medical treatment

•Surgeon managed Post op•Few protocols

•Provider choice anesthesia•Lack of standardized protocols

SurgicalHome

Shared Decision Making, Patient Centered Care

Seamlessly Integrated, protocolized care at each phase of care

Traditional

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PATIENT

Phase Preoperative Intra operative Post operative Post Discharge

•Variable support often leading to ER visits

•Minimal pre‐procedure planning

Decision to Operate

•Variable pre‐op assessment, testing  and medical treatment

•Surgeon managed Post op•Few protocols

•Provider choice anesthesia•Lack of standardized protocols

SurgicalHome

Shared Decision Making, Patient Centered Care

Traditional Surgical Care

• Shared decision making to outline the best course of treatment

• Patient education and expectation management

• Discharge planning (expected date of discharge)

• Referral to classes for optimal healing strategies

• Early Anesthesia intervention , pre-operative health and risk assessment

• Tailored optimization health/medical condition (hemoglobin, statin, beta blocker, VTE, nutrition management)

• Patient education and expectation management

• Discharge planning(Expected date ofdischarge)

• Pre-operative therapy prescriptions and

• Standardized protocols for tailored anesthesia care

• Standardized equipment and nursing protocols

• Infection prevention strategies

• Optimize fluid management technologies (goal directed fluid therapy)

• Multimodal

• Targeted recovery plan

• Early Ambulation, PT/OT

• Multimodal analgesia minimal systemic

• Early removal of drains and catheter

• Nutrition management

• Early intervention protocols for deviation from recovery goals or medical problems

• Discharge readiness

• Personal recovery pathway

• Early remote follow up (telephone or telemedicine)

• Home health, (if discharged home) wound management, ostomy management

• Physical activity/ PT

SEAMLESSLY INTRGRATED, TEAM BASED CARE

UC Irvine Formed 6 Teams…

Surgical Home 

Leadership

PreOpAdmissions

IntraOp

Immediate PostOp

Post Discharge

QA & PI

Research

Protocols: Team A – Preoperative Admission

• Preoperative Evaluation Assessment

• Renal Risk Guidelines

• Pulmonary Risk Guidelines

• Delirium Risk Guidelines

• Cardiology Consult

• Dental Evaluation

• UA Protocols

• MRSA Guidelines

Measure: Pre-Admit Process Map

Pre-Op Admission Process Map

Protocols: Team B - Intraoperative

• Anesthesia & Nursing protocols for equipment & equipment repair in place

• QA protocols

– SCIP Antibiotics

– SCIP Normothermic

– SCIP VTE Prophylaxis

• Efficiency Metrics

– First case start

– Turnover times

Process Map Swim Lanes

T O C O R C i r c u l a t o r

S c r u b P e r s o n

E q u i p T e c h P P C U

Pt 1½ hr before

sched OR to bed

Pt Bathroom

Pt change clothes

Call interpreter

VitalsPg Anesth/Surg Res

ID Pt for BlockCall Block

Team

Surg visitIV

LabsMilestones

Check for Pt arrival in PPCU

w/o

To PPCUCheck Pt checklist

Repage resident for f/u needs

Comm.w/Anesth

Back to OR

Clean

Ask RN for Next case cart

Check case cart

Case cart

To room

Review preference card

Retrieve/Stage equip needed

Clean

Set up equip Remove excess

equiptest

Comm. w/Circulator & Scrub Tech about

needs

Reorganizes case cart

Next case cart staged

outside room

Review preference

cards

Comm. w/HA Tech for next case needs

Clean

Removes empty trays & organizes

case cart

Room ReadyNext Pt. Ready

w/o

w/o

w/o

w/o

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Define: Acute Post Operative

• Manage Patient from transfer from PACU to Discharge, including:

– Acute care

– Medical management

– Following SCIP measures

– Physical Therapy

– Discharge planning

– Patient Education

Project CharterProject Name: Joint Surgical Home-Acute Post Operation

Champion: Dr. Kain

Belt: Dr. Kain Master Black Belt: Dr. Kain, Henry Alvarez

Problem Statement:

Average length of stay (ALOS) for Total Knee Replacement (TKR) has been 3-4 days.

Average length of stay (ALOS) for Total Hip Replacement(THR) has been 4 days.

Project Goal:

To decrease ALOS for TKR patients to 2-3 days within 6 months of joint program implementation.

To decrease ALOS for THR patients to 3 days within 6 months of joint program implementation.

Project Y / Path-Y:

Y = Length of Stay

[Add Path-Y’s as necessary]

Scope:

Inpatient stay for elective joint replacement.

Single primary knee replacement, not bilateral.

Single primary hip replacement, not bilateral.

Team Members:Dr. Kyle Ahn, Anesthesia - Co Leader

Victoria Malonzo,RN - Ortho Inpatient Nurse Manager/Co Leader

Benjamin Reymer, Physical Therapy - Co Leader

Dr. Ran Schwarzkopf - Joint Replacement Surgeon

Tina Moeller - Case Management

Goli Shayboni, RN - Ortho Staff RN

Steven Bereta, RN, - Med/Surg Educator

Hiep Nguyen, RPh - Phamarcist

Tania Bridgeman, Administrator or Disease Management

Marianne Lovejoy – Patient Care Performance Improvement Advisor

Dr. Justin Hata

Dr Trung Vu

Steven Bereta – Med/Surg Educator

Benefits:

Provide a needed service to the community.

Patient satisfaction.

Staff satisfaction.

Reduce LOS.

Reduce hospital cost.

Increase bed capacity.

Timeline:Define/Measure [Completed 3/14/12]

Analyze [June 2012]

Improve/Control [July 2012]

Define: Post Discharge

• Manage patient 30 day post discharge from hospital

– Discharge order & instruction• Ortho scheduler/nurse navigator/case manager

• Home vs acute rehab vs skilled nursing facility

– Pain prescription

– Rehab and DME

– Wound care

– Prevent readmission– Telemedicine Initiative

– QA27

Team E: QA Measures & PI

• NSQIP‐Projected

Return to OR

Pulmonary Embolism

VTE Requiring Therapy

Renal Failure

Respiratory Failure

Unplanned Re‐admission

• AAHKS

• Quality, accountability and process measures 

• PI Resource will be necessary to accomplish data collection

• SCIP-Current

SCIP 1- antibiotics given within 1 hour/Vancomycin over 120 m

SCIP 2- recommended antibiotics

SCIP 3-antibiotics d/c/24 hrs

SCIP 9 – urinary catheter removed POD1 or POD 2

SCIP 10- surgery pts with temp management

SCIP - cardiovascular-pts on beta blockers-give peri-op

SCIP VTE 1 & 2- VTE ordered and received

Orthopedics: Total Knee Replacement Clinical Pathway

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• Orthopedic Surgical Home Clinical Path

• Financial / Clinical Update 

• One Year later

Clinical Path Dashboard: Joint Replacement (Primaries)

Metrics Metrics

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Urological Surgical Home

Nephrectomy/Nephroureterectomy Patient Care Pathway

Cystectomy Patient Care Pathway

UROLOGY SURGICAL HOME

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TEAMS

Quality Assurance

Shermeen Vakharia, MDYasameen Faizy, MHA

Tania Bridgeman, PhD, RN

Urology Clinical Lead

Atreya Dash, MDPre Op TeamLes Garson, MD

Debra Morrison, MDAnna Harris, MD (Ad hoc)

Jaime Billingsley, RN Diane Rigger, RN

Young Kim, RN Jaime Pizziferri, RN (Ad hoc)

Jackie Stromberg (Ad hoc)Bernice Martinez

Ly DaoDavid Keymel, RN

Post Op TeamKyle Ahn, MD

Trung Vu, MDSusan Christensen, RNJaime Billingsley, RN

Heribert Bacareza, RNHiep Nguyen, Pharm D

Calvin Chang, PTDavid Keymel, RN

Post Discharge TeamAngela Parkin, MD

Jackie StrombergJaime Billingsley, RN

Susan Christensen, RNDavid Keymel, RN

Intra Op TeamDebra Morrison, MD

Susan Welbourne, BSN RNLaura Bruzzone, RN, MSN

Eenar Lee, MHANoreen Borromeo-Manalo, RN

Teri Houghtaling, RNDiane Rigger, RN (Ad hoc)

David Keymel, RN

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Communication to the Organization UROLOGY SURGICAL HOME

GO-LIVE

PSH Data Driven Process

• 1 Business Plan Metric

• 2 Process Metrics

• LSS Projects (1)Pre‐Operative

• 7 Business Plan Metrics

• 12 Process Metrics

• LSS Projects (4)Intra‐Operative

• 8 Business Plan Metrics

• 17 Process Metrics

• LSS Projects (1)Post‐Operative

• 4 Business Plan Metrics

• 1 Process MetricsPost‐Discharge

• 6 Business Plan Metrics

• 1 Process MetricAdministrative

•25 Business Plan Metrics

•58 Process Metrics

•101 Secondary Process Metrics

Total Collaborative Data Points

Target On-Line March 2014

Data  Integration

Data  Integration

Collaborative Data Driven Process

Collaborative Data Driven Process

Focus on x’s and not the Y’sPredictor Focus!

PSH Service Line Timelines

Orthopedic‐ Elective

‐ Total Joint Replacments

Orthopedic‐ Outpatient Services

Urology‐ Elective

‐ Cystectomy, Nephrectomy

LiveSeptember 2012 Live

November 2013 TargetApril 2014

Launch ScheduleLaunch Schedule

PHS Surgical Targeted Outcomes:• Cumulative decrease in Cost per Case• Cumulative decrease in 30 Readmission Rate• Cumulative decrease in Length of Stay• Decrease in Pain Management  Sensitivity• Predictable & decrease in Complications• Cumulative  Increase in Customer Satisfaction

PHS Winning Formula:• Patient Centered• Surgical Phase Accountability• Collaborative Data Driven Process Approach• Standardized Clinical Pathways

Early Patient Education / Management Process & Detailed Oriented Evidence Based Continually updated with base practice

• Lean Six Sigma (continuous improvement)

• FMEA introduction (continuous improvement)

Orthopedic‐ InpatientServices

TargetAugust 2014

Neurosurgery‐ Service line

TargetDecember 2014

46

It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change

- Charles Darwin

PSH Learning Collaborative

• ASA is pleased to announce the formation of a learning collaborative of health care organizations (HCOs) to improve the care of surgical patients through the implementation of the Perioperative Surgical Home (PSH).

• This PSH collaborative is targeted to begin the

second quarter of 2014.

• HCOs interested in participating in the PSH learning collaborative are invited to contact:

Celeste Kirschner, Perioperative Surgical Home Project Executive c.kirschner@asahq.org

12/17/201347 Perioperative Surgical Home

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Perioperative Surgical Home Summit

June 7 & June 8, 2014

Presented by

Department of Anesthesiology & Perioperative CareUC Irvine Health School of Medicine

The Balboa Bay Club & Resort | Newport Beach, California

anesthesiology.uci.edu