[This content is sponsored by Surgical Directions.]
The operating room, as well as the entire perioperative service line, is an essential area in which executives should focus their attention if they want to boost clinical outcomes and financial results and, ultimately, maximize value.
In the surgery sector, the focus on value is causing the movement toward bundled payments, according to Jeff Peters, CEO of the specialty healthcare consulting firm Surgical Directions.
One such bundle, the Comprehensive Care for Joint Replacement Model, demonstrates CMS’ commitment to emphasize value, as it is the first bundle of its kind to be mandatory in the roughly 800 hospitals across 67 markets in which it applies.
“Under the [Comprehensive Care for Joint Replacement Model], joint procedures are going to be paid by bundled payments in multiple markets. Clearly, the CCJR is a test for how surgery is going to be paid,” said Mr. Peters.
The CCJR bundled payment covers all the patients’ testing for 72 hours prior to surgery; the surgical episode, including the hospital costs, surgeon costs and anesthesia; and the costs following discharge for 90 days.
According to Mr. Peters, hospital leaders need to make several changes in the OR to reflect shifting payment models. There are several major aspects involved in transforming the OR that executives must tackle to improve value.
Here, Mr. Peters explains in his own words the five areas of the OR healthcare leaders should transform.
Education and Quantification
For long-lasting transformation, physicians need to understand why change is necessary. The physician champion or department chairman leading the OR transformation effort must impress upon clinicians that change is not an option — not only is the hospital’s reimbursement dependent on change, the surgeons’ compensation will also be affected. Hospitals’ new job is to prove their value to patients and payers.
Educational opportunities should be made on a monthly basis and include both town hall-style meetings with all the hospital’s surgeons, as well as individual sit downs with each physician. During these one-on-one meetings, those overseeing the transformation efforts should quantify and compare surgeon performance.
Some individual, regional and national metrics to quantify for surgeons include cost per procedure, patient satisfaction and clinical outcomes such as 30-day readmission rates, surgical site infections and discharges to a rehabilitation hospital or skilled nursing facility.
Physician Leadership
A huge part of building physician commitment to an OR transformation, and eventually picking a physician leader, is assessing the opportunities to improve clinical outcomes, patient satisfaction and financial profitability.
One of the easiest ways to foster support among surgeons is to quantify these outcomes. This is because physicians are competitive by nature — no one likes to be seen as a weak link. If a physician’s clinical outcomes are lower than his or her peers or external benchmarks, the physician will be motivated to improve. Additionally, physicians whose outcomes are higher than their peers may be chosen by executives to champion transformation efforts.
Getting surgeons on-board with initiatives regarding the OR may become easier as their compensation is increasingly based on clinical outcomes. Once a hospital engages its surgeons, leaders will quickly realize how suited these physicians are to help lead their process improvement teams.
Tension between business-minded hospital administrators and the physicians who treat patients on the front lines commonly prevents the two sides from seeing eye to eye when it comes to making changes to the clinical workflow. However, as the imperative to transition to a value-based care delivery system grows, hospital leaders and physicians will need to find ways to work together effectively. Identifying, developing and training physician leaders — who are already respected and deemed credible by their clinical peers — will help mitigate resistance and cultivate the buy-in necessary to make these changes as swiftly and successfully as possible.
Anesthesia’s role will also change during an OR transformation. Anesthesiologists should take on more of a leadership role by leading the pre-anesthesia testing process and helping identify and remedy issues that contribute to surgeon outliers who have longer-than-average case times.
Governance
As with any initiative, governance is critical to the continued success of an OR transformation.
The governing body’s overall goal should be to oversee and manage the perioperative service line. Representatives should include medical directors of the OR, surgeons in key specialties, anesthesia, nursing leadership and hospital leadership.
Typically, the highest volume surgical specialties of a hospital are general and orthopedic surgery. That said, surgeons specializing in these areas should be involved in the governing body. Hospitals should also engage surgeons from other major specialties offered at the hospital.
Beyond creating a governing body, executives should re-evaluate how the OR is managed. Traditionally, the OR director led the OR. The individual in this role was responsible for pre-admission testing, the OR and the post-anesthesia care unit. This person was not, however, responsible for the OR floor.
Because hospitals are now measured on the overall care experience, it is imperative for the OR director to feel a sense of ownership and responsibility for patients’ entire episode of care. The title of the position is evolving to reflect these changes — vice president of perioperative services.
If value is going to be measured along the continuum of care, hospitals need a management structure that follows the continuum of care as well.
Process Redesign and Improvement
In addition to a strong governing infrastructure, hospital leaders should establish process improvement teams to assess clinical pathways, pre-admission testing, anesthesia and information technology.
Executives should consider redesigning or improving upon the following three areas.
Clinical processes. Protocols differ for each procedure. For instance, in joint surgeries, the key to driving value is getting patients to ambulate before they are discharged from the PACU. The key to ambulating quickly is being pain free, so the role of the anesthesiologist extends beyond just putting the patient to sleep and waking them up; it includes controlling patients’ pain, allowing them to walk.
Care redesign. A large share of orthopedic and joint patients have, historically, been discharged to skilled nursing facilities or rehabilitation hospitals, which may or may not have the same quality and infection control standards as acute care hospitals. The last thing a hospital leader wants is for a patient to develop complications at a post-acute facility and end up being readmitted to the hospital. Not only is this bad for the patient, it’s bad for the hospital’s bottom line. Instead, the goal should be to discharge patients directly to their home or place of residence.
Case time. ORs cost between $40 and $60 per minute, so reducing case time also reduces the cost of a surgery and improves patient satisfaction. One of the most efficient ways to reduce case times is to show surgeons their case time data and how it compares to peers. Armed with that data, the outliers will typically identify ways to improve. Enhancing pre-anesthesia testing is another way to knock case times down.
Metrics
Surgeons are less inclined to respond to maximizing the hospital’s opportunities as they are to respond to how reinventing the OR and the perioperative service line can benefit them and their patients.
Based on this observation, metrics that are presented to surgeons should be personalized — feeding their sense of competition — rather than focusing on the organization as a whole.
There are three types of metrics that drive value improvement among surgeons: clinical outcomes (including surgical site infections, deep vein thrombosis rates, length of stay, discharges home and readmission rates), financial outcomes (including cost of care per surgeon, joint implant costs, supply costs and lab/imaging studies) and patient satisfaction measures regarding the surgical episode and functionality after the procedure.
Chicago-based Illinois Bone and Joint Institute is one example of a healthcare facility using metrics to drive value. As an ambulatory surgical center, the Institute is able to perform joint replacements and has used metrics to help send patients home one hour after their surgery. Doing so has dramatically reduced costs and improved outcomes.
The way ASCs operate is the way hospitals are going to need to operate their ORs in the future. In this regard, trying to stick with tradition won’t help a hospital survive.
