At the Margins

Poor surgical planning is costing you—and your patients

by John Johnston, CPA, MHA and Sharon Ward, RN, MS, CEN

With competition for surgical referrals intensifying, many hospitals have streamlined the process of getting patients from the surgeon’s office into the operating room (OR). A reduced lead time may be advantageous for a healthy 25-year-old who schedules elective knee surgery, but not all patients benefit from such a compressed timeframe: An unintended consequence of the well-oiled scheduling system is that it leaves the most complex patients—the elderly or those with chronic conditions—unprepared for surgery and at greater risk for complications, a longer inpatient stay, costly readmissions, and a higher-cost surgical episode.

With rising performance penalties and more payment tied to risk, some hospitals are recognizing the need to create a separate, more involved pathway for those high-needs surgical patients. This model—the perioperative surgical home—is capturing the attention of hospital leaders who are struggling with surgical costs and outcomes and are looking for an innovative approach.

Explaining the surgical home model

Typical OR efficiency initiatives focus on identifying the most effective clinical and operational processes for the day of surgery. Although the most expensive part of a surgical episode is usually the procedure itself, the variability in cost and outcomes is mainly driven by what happens after surgery—length of stay, complications, 30-day readmissions, and discharge disposition, for example. This is because most patients are scheduled with very little pre-operative optimization, so characteristics associated with poor outcomes (such as anemia or diabetes) aren’t managed, so the surgery may go as planned but still result in avoidable complications.

The surgical home addresses not only the procedure but also the entire process, from well before the surgery to recovery and discharge.

The implications for patients and their physicians are very real. For example, we recently spoke with an anesthesiologist at a health system in the south who told us he could predict which patients would need a post-op blood transfusion, all because they were not optimized in advance. Those patients, he said, were at risk for serious and avoidable complications. This health system is now in the planning stages of a surgical home, and one of its many goals is to cut blood transfusions in orthopedic elective cases by 50%.

What it looks like in practice

There are many ways to design the pathway for high-risk patients. But in all cases, the new model should begin at the moment a surgeon decides to schedule a procedure. This approach is referred to as a “prehabilitation” process, and it varies based on the type of surgery and the comorbidities that a patient presents.

Here’s an example of what this process might look like for an elderly patient who is scheduled to receive a knee replacement.

  • Scheduling: The surgeon’s office staff schedules the procedure two to four weeks in advance, captures patient’s known condition and risk areas on the scheduling form, with ample time for the patient and medical staff to prepare.

  • Medical preparation: The primary care physician prescribes medications and therapies to ensure the patient is in best possible health before the procedure. If the patient requires special equipment (such as a cane or walker) after surgery, the orthopedic surgeon writes a prescription for the equipment, and a physical therapist helps the patient learn how to use it.

  • Patient education: The patient navigator and joint coordinator help the patient prepare for recovery, including setting up home health services and making preparations in the patient’s house (e.g., setting up a bed downstairs). A financial screener explains the patient’s financial obligations.

Under this scenario, the patient already has the necessary equipment, a discharge plan, and an understanding of financial liability well in advance of the surgery date. This planning creates a more predictable experience for both the patient and the medical staff involved in the procedure.

How hospitals can get started

Hospitals should focus their initial efforts on one diagnosis-related group that is high volume, has a relatively high proportion of complex patients, or is prone to variation—and become skilled at screening and optimizing elective patients within that group. Joint replacement is often a good place to start.

After this subset of patients is selected, the surgical home takes several weeks or even months to coordinate. Hospital and health system leaders should spend the early days educating the health care professionals involved and forming a unified vision.

Physicians often are the biggest champions. A recent survey from the American Association of Hip and Knee Surgeons found that 94% of physicians view high-risk surgical patients as a threat to alternative payment models. More than ever, surgeons need hospital partners who can help them manage these complex cases and improve their outcomes. Getting control of the surgical episode can be a strong step in that direction.

This article previously appeared on the hfm Healthcare Finance Blog.

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