Anatomy of a High Performing Surgery Center
Part 1: No Cowboys Allowed
The cowboy spirit including features such as independence, strength, and resourcefulness is part of American lore. Today, as a physician executive, my admiration of the cowboy role is more nuanced – especially when it comes to helping hospital and Ambulatory Surgery Centers operate at the highest levels of quality, safety, efficiency and profitability. To be honest, there’s not much room in a surgical environment for acting independently.
Surgical care requires seamless integration of the services of multiple physicians, nurses and surgical staff. Collaboration across these disciplines in crucial to implementing the principles of evidence based medicine and standardization of care. Care should be varied only to accommodate a patient’s unique medical needs, rather than to oblige a physician’s “cowboy spirit.”
For example, failure to gather patient information from all available sources (patient, family, surgeon, primary care physician and previous records) in formulating a plan for care can lead to waste (unnecessarily repeating lab work or diagnostic tests), inconvenience (cancellation of surgery), unsafe conditions (missing an important medicine preoperatively), or a discharge process that provides no meaningful postoperative support. This is just the “tip of the iceberg” of things can get off track when any member of the surgery team fails to recognize their essential role as a member of a highly collaborative and interdependent enterprise.
Surgery is one of the most complex undertakings in all of healthcare. Complexity requires collaboration and close coordination of expert teams. It requires the surgeon, anesthesiologist and nurses to pay uncompromising attention to every detail as a cohesive care team. Every care plan, process and workflow associated with patient throughput, from scheduling of surgery through pre-op and discharge, to attainment of goals must be optimized for quality and patient outcomes while balancing operational efficiency. Although finding the right balance can be challenging, careful preparation and collaboration with aligned anesthesia teams can enable surgical teams to succeed in the race toward achieving the best outcomes for their patients.
In our practice, we’ve developed four strategies that stand out as drivers of quality and performance.
1.) Establish front-end processes to mitigate risk and expedite throughput: Surgical teams can take several steps to ensure convenience, comfort and efficiency before the patient ever enters the facility. Patient selection, for instance, is especially important. Spending extra time to ensure that patients are good candidates for outpatient surgery in an ASC environment can facilitate throughput, conserve resources and mitigate risk. Comprehensive preoperative evaluation that includes standardized risk stratification can clearly articulate the types of patients that can safely undergo procedures at an outpatient facility, and goes a long way towards making sure the patient’s expectations are aligned.
2.) Deploy an electronic health record (EHR): An EHR offers many benefits for surgical environments, including improved pharmacy reconciliation, legibility, compliance and quality data capture. In addition, an EHR provides a platform for standardization of preoperative evaluation, risk stratification, clinical guidelines and processes to drive outcomes and patient safety. Leadership can push out changes via the EHR, thus allowing all clinicians across multiple locations to enact these changes immediately. Similarly, principles of evidenced based medicine, enhanced recovery and a patient-centered medical home are concepts we implement in collaboration with our ASC partners. Ray Grundman, senior director of external relations and a surveyor with the Accreditation Association for Ambulatory Health Care, is also seeing these ideas translated to anesthesia homes and surgical homes. “ASCs (and other surgical settings) could benefit from the concepts epitomized in PCMHs in terms of developing a relationship with patients, providing continuity and quality of care, and driving patient satisfaction."
3.) Employ data analytics: In an environment where even the smallest detail can help improve performance, data analytics is particularly useful. Capturing and analyzing these details gives leadership greater insight for making decisions. In addition, data analytics can reveal variation by facility, operating room (OR) and clinician. If certain physicians or teams consistently have lower throughput, discussing their individual or collective data can help drive improvements such as proactive anesthesia techniques to minimize discharge delays. On the other hand, if one OR has exemplary throughput, there may be data to explain why the team’s performance is better and replicate that elsewhere.
4.) Utilize anesthesia leadership to review current protocols: Because anesthesiologists are experts in perioperative care, they’re able to observe the entire care continuum with an eye toward improving quality and reducing costs. For example, periodic review and updating of preoperative testing guidelines can reduce unnecessary laboratory testing and increase patient satisfaction and throughput while decreasing costs. Anesthesiologists can employ regional anesthesia options such as nerve blocks for surgery and/or postoperative pain control, thereby reducing the use of general anesthesia and narcotics, and the associated side effects of nausea, vomiting, potential for over sedation, and delayed discharge.
These four initiatives promise significant improvements in value, efficiency and patient satisfaction. However, implementation requires a change of culture, continuous education of staff and a data driven process improvement cycle. Even if you have already adopted some of these strategies, we can help with the “heavy lifting” of implementation. Together, we can win in the race to improve quality and deliver value in surgical care.