Boulders in the Perioperative Road: Obstacles or Stepping Stones?

Peter Nosé, MD

Peter Nosé , MD

Director of Operations, Anesthesia

Published January 18, 2017

For most hospitals, the operating room is a profit center that helps support all other hospital operations. Income from surgical services is vital to the success of the organization. For this reason, hospital CEOs are sensitive to both the volume of cases that surgeons bring to their ORs and the manner in which those cases are managed.

With ever-tighter margins on net income, CEOs have sharpened their focus on the operational efficiency of ORs. Maximizing resource utilization such as operating room time and surgical staff can allow for higher case load and thereby augment hospital revenue.

With that said, building a thriving, efficient surgical services program is an elusive goal for most facilities. Last-minute cancellations, surgical start time delays, and long turnaround times between surgeries all impact efficiency. These factors are balanced with the reality that production pressure to proceed with surgery, despite inadequate preoperative patient preparation, contributes to postoperative complications, leading to longer lengths of stay and surgical readmissions. These inefficiencies cost hospitals millions of dollars each year and contribute to a suboptimal level of care for our patients.

A Challenging Population

With their mission to care for a traditionally underserved patient population, faith-based hospitals have even greater efficiency challenges. Many of the patients are indigent, with comorbidities, and fewer social, economic and medical resources than most.

It has been our experience that resource-poor patients frequently arrive late for surgery — if they arrive at all. Others must be cancelled or rescheduled due to noncompliance with preoperative instructions such as fasting before surgery or adjusting their usual dosage of medications. These issues lead to a significant loss of revenue and waste of resources for hospitals. In addition, cancellations and rescheduling damage a hospital’s reputation, decrease patient satisfaction, and frustrate surgeons, who may choose to take their cases elsewhere.

Bottom line: An inefficient surgery program is not good for the patient, the surgeon, or the hospital.

Culture Change at a Safety Net Hospital

A faith-based hospital in Washington, DC, committed to serving the underprivileged and underserved, faced many of these challenges with its surgical services program.

Acknowledging the high rate of last-minute cancellations and no-shows, some of the hospital’s surgeons required all of their scheduled patients to arrive for surgery en masse. As many as 12 patients would arrive by 6 a.m., thus assuring the surgeons that there would always be someone in the waiting room ready for his or her case.

While that worked relatively well for the surgeons, it was not at all patient-centric, with many patients waiting hours to undergo surgery. Not surprisingly, some patients whose surgery was clearly not occurring prior to late morning or early afternoon would become so upset that they would cancel their surgery out of frustration.

Last summer, this hospital turned to Vituity to manage and staff its anesthesia department. Hospital administrators were familiar with Vituity’s ability to transform operations in the ED and hoped that Vituity’s anesthesiologists could similarly lead improvements in the operating room and across the entire perioperative continuum.

Recruiting Engaged Anesthesiologists

Historically, patient readiness for surgery often depended on their ability to exceed certain minimum thresholds to tolerate surgery and anesthesia – such as minimum hematocrit and other lab values, EKG findings, and oxygen saturation.

This paradigm remains important today. However, because educational, technical, and pharmacologic advancements now enable us to get almost anyone through surgery, today's question is: how can we prepare a patient to not simply survive surgery, but get on the road to recovery and back to their daily routines as quickly as possible?

One answer is to engage patients well ahead of surgery so that they’re not only ready for surgery but more importantly ready for recovery. This involves things like working with them early to ensure they’ve stopped smoking, are adequately nourished, are taking prescribed medications, and have completed prescribed preoperative therapies.

On the postoperative side, anesthesiologists can play a key role in improving outcomes and providing a better surgical experience. Patients who receive anesthetics that are based upon standardized care protocols and tailored to reflect best practices wake up faster, have shorter hospital stays, and fewer side effects. All that means fewer surgical readmissions.

The first step in reforming the department was to recruit anesthesiologists willing to roll up their sleeves and become integral team members across the entire spectrum of perioperative care. Vituity was fortunate in having an anesthesiologist leader, Jamaal Snell, MD, who possessed the skills and confidence to view problems as opportunities.

For Dr. Snell, delivering outstanding clinical care supported more than his patients. It supported his ability to gain the confidence of all stakeholders — surgeons and administrators alike — to affect improvements in perioperative services.

Charging anesthesiologists with coordination of surgical services is critical in maximizing surgical efficiency. Surgeons see the anesthesiologist not only as representative of the hospital, but also as a peer, placing anesthesiologists in a unique position to represent both administrative and clinical rolls. Furthermore, having the anesthesiologist serve as a point person throughout the surgical continuum improves the patient experience as well.

Anesthesiologists: True Partners

Everyone from surgeons to administrators to anesthesiologists recognized that there were many inefficient systems and processes that needed to change at this hospital. The challenge was to get stakeholders to invest personal time and energy to make those changes.

Therefore, our initial focus was to start with simple things and achieve success with those. Once we established initial success and gained credibility — as well as momentum — it became easier to get stakeholders on board to tackle the bigger issues.

We decided to first take on the high rate of no shows, cancellations, and late arrivals. We began calling patients the day before their scheduled surgery to review pre-op instructions and remind them of their required arrival time. We developed a process to review patient readiness at least a day prior to the scheduled surgery. This included confirmation of insurance authorization, surgeon’s admitting paperwork, and any required pre-op labs and consultations.

The anesthesiology department also plans to develop a pre-op clinic where we see patients well before surgery to run tests and review surgery instructions. Engaging patients early will allow us to review their physiology and pharmacology and better understand their social situation. If an issue is uncovered during the pre-op clinic visit, such as a lack of home support resources following surgery, a positive drug test, or any change in health, we have time to identify solutions or fit another patient into the surgery schedule for that day. By accomplishing this, we are able to make efficient use of the operating room and the resources that accompany it.

Engaging patients in a significant way preoperatively also creates an opportunity to let patients take some ownership so that they’re more likely to follow their pre-op instructions, be on time for surgery, and become active participants in their recovery activities.

Safer, More Efficient Care

Improving the hospital’s perioperative performance won’t happen overnight. It will require buy-in and close collaboration with surgeons, nurses, hospital administration, AND patients. But what initially seems like more work for the care team ultimately results in improved efficiency through reductions in last-minute cancellations, rescheduling, and redundancies.

Through closer coordination throughout the perioperative arena, it is our belief that the quality of care will improve, readmissions will fall, and the OR will be fully booked. That will lead to more satisfied physicians and patients, and position the hospital to succeed in today’s value-based care environment.

Interested in bringing integrated perioperative care to your hospital? Check out our white paper, Revving the Perioperative Engine.

Partnering to improve patient lives

Vituity branding orange wave pattern background