On September 3, 2014, the Anesthesia Patient Safety Foundation (APSF) convened a multidisciplinary conference to examine the patient safety opportunities that might be associated with any number of perioperative surgical home models. The conference co-moderators were Drs. Mark A. Warner and Robert K. Stoelting.
Dr. Stoelting opened the conference by noting that 16 outstanding representatives of multiple medical specialties and health care organizations (Table 1) would provide their views and summarize their experiences related to coordinating care of surgical patients and the impact of that coordination on their safety. In essence, they would be discussing their perception of the perioperative surgical home concept and describing how they believed it may impact patient safety.
The room was packed with 114 attendees from a broad spectrum of health care providers, administrators, and representatives from various medical equipment and technology companies. Nearly three-quarters of the attendees were anesthesia providers, with one-third of those working in private practice settings.
Why Choose the Perioperative Surgical Home as a Topic?
This conference, focused on linking opportunities to improve patient safety across the perioperative continuum, was particularly appropriate given the origin of the perioperative surgical home concept. In 2000, leaders from the APSF, American Society of Anesthesiologists (ASA), and the American Board of Anesthesiology (ABA) met in San Francisco to discuss opportunities to improve patient safety through expansion of anesthesia practices in collaboration with surgical and medical specialties, nursing, and other health care providers. A basic tenet of the meeting was the recognition that the dramatic improvements in patient safety from the previous 2 decades had primarily involved important changes to intraoperative care and management of anesthetized patients. The nearly exponential rate of decrease in intraoperative catastrophic problems during the preceding period had slowed. There was growing recognition that further major advances in patient safety would require multidisciplinary teams working together across the full perioperative period.
Table 1: Speakers at the 2014 APSF Conference on Patient Safety Opportunities and the Perioperative Surgical Home
|George T. Blike, MD||Chief Quality and Value Officer, Dartmouth-Hitchcock Clinic, Professor of Anesthesiology, Geisel School of Medicine|
|Brian J. Cammarata, MD||ASA Representative to the Council on Surgical and Perioperative Safety|
|Claire L. Chandler, AA-C||Clinical Anesthetist, Emory University Hospitals; Past President, American Academy of Anesthesiologist Assistants|
|Teo Forscht Dagi, MD||Professor, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast and Harvard Medical School; American College of Surgeons|
|Franklin Dexter, MD, PhD||Director, Division of Management Consulting; Professor, Department of Anesthesia, University of Iowa|
|Richard P. Dutton, MD||Executive Director, Anesthesia Quality Institute; Chief Quality Officer, American Society of Anesthesiologists; Clinical Associate, Department of Anesthesia and Critical Care, University of Chicago|
|Nancy Foster||Vice President for Quality and Patient Safety Policy, American Hospital Association|
|Linda Groah, RN||Executive Director/CEO, Association of Perioperative Registered Nurses; APSF Board of Directors|
|David W. Larson, MD||Chair of Colorectal Surgery and Chair of Enterprise Practice Redesign, Professor of Surgery, and Director of Quality Cancer Care, Mayo Clinic|
|Ana Pujols McKee, MD||Executive Vice President and Chief Medical Officer, The Joint Commission|
|Bradly J. Narr, MD||Chair, Department of Anesthesiology, Mayo Clinic|
|Lynn J. Reede, CRNA, DNP, MBA||Senior Director, Professional Practice, American Association of Nurse Anesthetists|
|Warren S. Sandberg, MD, PhD||Professor and Chair, Department of Anesthesiology, Vanderbilt University School of Medicine|
|Michael P. Schweitzer, MD||Chair, American Society of Anesthesiologists, Committee on Future Models of Anesthesia Practice|
|Matthew B. Weinger, MD||Professor of Anesthesiology, Biomedical Informatics and Medical Education, Center for Research and Innovations in Systems Safety, Vanderbilt University School of Medicine|
That remarkable meeting triggered changes over the next decade that ultimately resulted in 1) a new definition of the expectations of ABA-certified anesthesiologists; 2) modified anesthesia training requirements for residents that expanded their experiences in general medical and pediatric care, preoperative medicine, critical care, and pain management; and 3) support for the perioperative surgical home concept by the ASA, government agencies, and others.
The APSF reasoned that it is now time to explore how the perioperative surgical home and its various models may assist anesthesia providers in their quests to further improve safety of surgical and procedural patients. For the purposes of this report, the term “surgical” will be used to refer to patients undergoing any surgery or diagnostic/therapeutic procedure.
What Is the Perioperative Surgical Home?
In describing the perioperative surgical home concept, the speakers noted that it is essentially a patient-centered, systematically-designed care pathway of the entire perioperative continuum. Inherent within the concept are several key attributes: 1) although focused on patients, it also must be user-centric to ensure that teams will be engaged and participate; 2) teamwork consisting of collaboration between multiple disciplines is essential; 3) standardization of clinical processes and patient expectations must be integrated; and 4) data collection processes and metrics must be established to document improvements in patient safety, satisfaction, and outcomes as well as cost-effectiveness and efficiency (value) of care.
A number of the speakers gave useful examples of how the perioperative surgical home concept has been successfully piloted in their institutions and described the lessons that they had learned:
- There must be a deliberate, multidisciplinary perioperative system design, “Decision (to operate) to discharge.”
- The design must be applicable to small as well as large hospitals.
- Nurses and pharmacists, in their roles as the primary implementors of clinical pathways and protocols, are vital team members and must be fully engaged in planning, executing, and assessing the care model. Specific focus on the sickest patients is crucial as they often are the patients who fall outside of standardized care pathways.
The speakers also provided attendees with a few unique pearls of wisdom:
- Preoperative patient assessment and optimization is important, especially regarding setting patient expectations for what they will experience: “If they know what to expect, there is a greater chance that patients will be satisfied.”
- Since a major expense in perioperative care includes re-admissions, “Ensure efficient, safe, and durable discharges.”
- When starting out, “Engage (your colleagues), communicate, standardize, communicate, coordinate, communicate, and then communicate some more.”
- Ensure that the hospital or health system engages in the perioperative surgical home, then “Either lead the effort or contribute and add value.”
- And finally, paraphrasing Woody Allen, “Remember, 80% of success is showing up—be involved; be a leader.”
Interesting Attendee Responses
An audience response system was used to pose questions to the attendees during the conference. Their responses suggest that while most believe that the perioperative surgical home concept will be able to improve patient safety, especially reduction of perioperative complications (e.g., deep venous thromboembolism, surgical site infections, and pneumonias), there is still confusion, concern, and some degree of skepticism about the acceptance and sustainability of the concept.
Improved Patient Safety
- Nearly 9 in 10 attendees believed that “the perioperative surgical home concept can improve patient safety and outcomes through better coordination of care.”
- More than 9 in 10 attendees agreed that “the perioperative surgical home concept will contribute to patient safety by promoting improved multidisciplinary communication, teamwork, and attention to patient-centered care.”
- Three-quarters of attendees felt strongly that “the ‘main driver’ of the perioperative surgical home concept is to deliver a better patient experience and outcome at a lower cost.”
Acceptance and Sustainability
- Two-thirds of attendees did not believe that “the perioperative surgical home concept will gain widespread acceptance.”
- Two-thirds of attendees expressed concern that “surgeons will not be full participants in the perioperative surgical home model.”
- One-third doubted that “hospital facility leaders will recognize the value of the perioperative surgical home concept for improving patient safety.”
- Nearly all attendees agreed “that the perioperative surgical home concept will require creation of alternatives to traditional fee-for-service finances” if it is to be successful.
- And sadly, nearly 8 in 10 attendees worried that “demand for efficiency and production by hospital facility leaders may overwhelm patient safety concerns.”
Role and Training of Anesthesia Professionals
- Two-thirds of attendees believed that “anesthesia professionals are best positioned to lead the perioperative surgical home concept so as to facilitate standardized care in partnership with surgical and nursing colleagues.”
- All attendees agreed that if the perioperative surgical home concept gains acceptance, “training programs will have to change.”
Clearly attendees believed that perioperative patient safety can be—and should be—enhanced by deliberately and systematically designing care pathways that optimize patients preoperatively, manage them perioperatively with teams of health care professionals who work collaboratively, and reduce complications and re-admissions. The impact of the perioperative surgical home concept will need to be tracked with excellent data systems and analyzed carefully to ensure that patient safety, outcomes, and satisfaction are consistently improving.
A looming, occasionally overwhelming message from speakers and attendees was that the perioperative surgical home concept remains to be proven effective at improving patient safety, reducing expenses, and increasing patient satisfaction. Thus, the acceptance and sustainability of this concept remains suspect. The ASA’s learning collaborative of the perioperative surgical home may provide information on the value of various models as well as examples of best—and ineffective—practices. Proponents will need to show how the perioperative surgical home concept can be monetized to support interest in the changes that will be necessary to sustain it long-term.
Should various models of the perioperative surgical home concept prove effective at reducing expenses and improving patient safety, a key question will then be, “Which patient safety issues are most effectively improved and have the greatest impact on patient outcomes and satisfaction?” That question and subsequent discussions, debates, and trials that study the best approaches to improving patient safety across the broad continuum of perioperative care will undoubtedly be the focus of future APSF efforts.
Dr. Warner is Professor of Anesthesiology at the Mayo Clinic in Rochester, MN. Dr. Stoelting is the President of the APSF.