12/23/2013 The Scope of the Perioperative Surgical Home Logical Steps Towards Advancing Health Care and Patient Safety Mark A. Warner, M.D. 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 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 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 • CMS support 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 1 12/23/2013 Perioperative Expense Reduction Opportunities • 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 Steady Progression • • • • 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 The Goal: Cost-Effective, Efficient, and Safe Perioperative Care 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 Creating a Real-World Surgical Home Zeev Kain, MD, MBA Professor and Chair Associate Dean & Acting Chief Medical Officer Department of Anesthesiology & Perioperative Care UC Irvine School of Medicine 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 2 12/23/2013 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. UC Irvine PSH Mission 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 Joint Surgical Home Team • Coordination of care • Reduce cost of care and decrease LOS Ranjan Gupta • Reduce complication rate and re-admissions Alice Issai Zeev Kain Laura Bruzzone • Standardization of practice using evidence based practices & guidelines • Improve overall satisfaction of Surgeons, Anesthesia, Nursing & Patients Ran Schwarzkopf • Provide Quality & Performance Improvement Measures demonstrating success, outcomes based on research (NSQUIP, SCIP) SURGICAL HOME- GOAL Phase A HIGH RELIABILITY ORGANIZATION CONCEPT OF INTEGRATED PERIOPERATIVE CONTINUUM Traditional Decision to Operate •Minimal pre‐ procedure planning Preoperative •Variable pre‐op assessment, testing and medical treatment Intra operative Post operative Post Discharge •Provider choice anesthesia •Lack of standardized protocols •Surgeon managed Post op •Few protocols •Variable support often leading to ER PATIENT Decision to Operate Early Return to Normal Activity Evidence based standardization of practice Achieving key health care metrics Accountability Efficiency and effectiveness Shared Decision Making, Patient Centered Care Seamlessly Integrated, protocolized care at each phase of care Surgical Home 17 3 12/23/2013 SEAMLESSLY INTRGRATED, TEAM BASED CARE Decision to Operate Phase Traditional Surgical Care Preoperative Intra operative •Variable pre‐op assessment, testing and medical treatment •Minimal pre‐ procedure planning Post operative •Provider choice anesthesia •Lack of standardized protocols •Surgeon managed Post op •Few protocols Post Discharge UC Irvine Formed 6 Teams… •Variable support often leading to ER visits PreOp Admissions Research IntraOp PATIENT Surgical Home Leadership Shared Decision Making, Patient Centered Care • • Surgical Home • • 18 • 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 , preoperative 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 of discharge) 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 Protocols: Team A – Preoperative Admission Immediate PostOp QA & PI Post Discharge Measure: Pre-Op Admission Process Map Pre-Admit Process Map • Preoperative Evaluation Assessment • Renal Risk Guidelines • Pulmonary Risk Guidelines • Delirium Risk Guidelines • Cardiology Consult • Dental Evaluation • UA Protocols • MRSA Guidelines Protocols: Team B - Intraoperative E q u ip T ech Pt Bathroom Pt change clothes Call interpreter Vitals Pg Anesth/ Surg Res ID Pt for Block Call Block Team Surg visit IV Labs Comm. w/HA Tech for next case needs Milestones • Efficiency Metrics w/o To PPCU Check Pt checklist Room Ready Check case cart w/o w/o Set up equip Remove excess equip test Clean w/o w/o Clean Back to OR Next Pt. Ready Comm. w/Anesth Case cart To room Removes empty trays & organizes case cart Comm. w/Circulator & Scrub Tech about needs Reorganizes case cart Repage resident for f/u needs Clean – First case start – Turnover times PPCU Pt 1½ hr before sched OR to bed Check for Pt arrival in PPCU Review preference cards Retrieve/Stage equip needed Next case cart staged outside room – SCIP Antibiotics – SCIP Normothermic – SCIP VTE Prophylaxis OR C ir c u la t o r Ask RN for Next case cart • QA protocols S c ru b P e rs o n Process Map Swim Lanes TOC Review preference card • Anesthesia & Nursing protocols for equipment & equipment repair in place 4 12/23/2013 Project Charter Define: Acute Post Operative Project Name: Joint Surgical Home-Acute Post Operation • Manage Patient from transfer from PACU to Discharge, including: 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: Scope: Inpatient stay for elective joint replacement. Single primary knee replacement, not bilateral. Single primary hip replacement, not bilateral. Y = Length of Stay [Add Path-Y’s as necessary] – Acute care – Medical management – Following SCIP measures – Physical Therapy – Discharge planning – Patient Education Benefits: Provide a needed service to the community. Patient satisfaction. Staff satisfaction. Reduce LOS. Reduce hospital cost. Increase bed capacity. 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 Timeline: Define/Measure [Completed 3/14/12] Analyze [June 2012] Improve/Control [July 2012] Define: Post Discharge Team E: QA Measures & PI • Manage patient 30 day post discharge from hospital • SCIP-Current – 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 – QA • NSQIP‐Projected  SCIP 1- antibiotics given within  Return to OR 1 hour/Vancomycin over 120 m  Pulmonary Embolism  SCIP 2- recommended  VTE Requiring Therapy antibiotics  SCIP 3-antibiotics d/c/24 hrs  Renal Failure  SCIP 9 – urinary catheter removed POD1 or POD 2  Respiratory Failure  SCIP 10- surgery pts with temp management  SCIP - cardiovascular-pts on beta blockers-give peri-op  SCIP VTE 1 & 2- VTE ordered and received  Unplanned Re‐admission • • • AAHKS Quality, accountability and process measures PI Resource will be necessary to accomplish data collection 27 Orthopedics: Total Knee Replacement Clinical Pathway 5 12/23/2013 Clinical Path Dashboard: Joint Replacement (Primaries) • Orthopedic Surgical Home Clinical Path • Financial / Clinical Update • One Year later 30 Metrics Metrics 35 6 12/23/2013 Urological Surgical Home UROLOGY SURGICAL HOME Cystectomy Patient Care Pathway Nephrectomy/Nephroureterectomy Patient Care Pathway TEAMS Pre Op Team 38 Urology Clinical Lead Atreya Dash, MD Les Garson, MD Debra Morrison, MD Anna 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 Dao David Keymel, RN Quality Assurance Post Op Team Shermeen Vakharia, MD Yasameen Faizy, MHA Tania Bridgeman, PhD, RN Kyle Ahn, MD Trung Vu, MD Susan Christensen, RN Jaime Billingsley, RN Heribert Bacareza, RN Hiep Nguyen, Pharm D Calvin Chang, PT David Keymel, RN Intra Op Team Debra Morrison, MD Susan Welbourne, BSN RN Laura Bruzzone, RN, MSN Eenar Lee, MHA Noreen Borromeo-Manalo, RN Teri Houghtaling, RN Diane Rigger, RN (Ad hoc) David Keymel, RN Post Discharge Team Angela Parkin, MD Jackie Stromberg Jaime Billingsley, RN Susan Christensen, RN David Keymel, RN 7 12/23/2013 Communication to the Organization UROLOGY SURGICAL HOME GO-LIVE PSH Service Line Timelines Pre‐Operative • 1 Business Plan Metric • 2 Process Metrics • LSS Projects (1) Intra‐Operative • 7 Business Plan Metrics • 12 Process Metrics • LSS Projects (4) Post‐Operative • 8 Business Plan Metrics • 17 Process Metrics • LSS Projects (1) Post‐Discharge • 4 Business Plan Metrics • 1 Process Metrics Administrative Total Collaborative Data Points • 6 Business Plan Metrics • 1 Process Metric •25 Business Plan Metrics •58 Process Metrics •101 Secondary Process Metrics Live September 2012 Live November 2013 Target April 2014 Target August 2014 Target December 2014 Orthopedic ‐ ‐ Elective Total Joint Replacments Urology ‐ ‐ Elective Cystectomy, Nephrectomy Orthopedic ‐ Outpatient Services Orthopedic ‐ InpatientServices Neurosurgery PHS Winning Formula: • • • • Predictor Focus! • • ‐ Patient Centered Surgical Phase Accountability Collaborative Data Driven Process Approach Standardized Clinical Pathways     Focus on x’s and not the Y’s 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 46 Launch Schedule Target On-Line March 2014 Collaborative Data Driven Process Data Integration PSH Data Driven Process Early Patient Education / Management Process & Detailed Oriented Evidence Based Continually updated with base practice Lean Six Sigma (continuous improvement) FMEA introduction (continuous improvement) Service line 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 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 [email protected] 47 12/17/2013 Perioperative Surgical Home 8 12/23/2013 Presented by Department of Anesthesiology & Perioperative Care UC Irvine Health School of Medicine anesthesiology.uci.edu Perioperative Surgical Home Summit June 7 & June 8, 2014 The Balboa Bay Club & Resort | Newport Beach, California 9