Framing the Issue:
• An estimated 40 million anesthetics are administered each year in the United States.
• In 1985, the Anesthesia Patient Safety Foundation was created to raise consciousness and knowledge of patient safety issues.
• In early 1986, the American Society of Anesthesiologists was the first medical specialty to adopt standards of care for its members.
• Today more than 30 ASA standards, guidelines and statements address care standards for patients before, during and after surgery.
• The ASA created the Anesthesia Quality Institute in 2008. Today, the institute’s National Anesthesia Clinical Outcomes Registry is approaching 20 million cases.
• 2,000 facilities and more than 15,000 anesthesiologists, almost one-third of ASA membership, participate in the NACOR registry.
Anesthesiology was long thought of as a specialty limited to the operating room. But a revolution is underway as the industrywide push to provide higher quality care at lower costs forces anesthesiologists to expand their role.
“Anesthesiologists are very quickly realizing that, although they may be very proud of the anesthesia they provide, if the hospital doesn’t do well, it doesn’t really matter,” says John F. Di Capua, M.D., chief executive officer of North American Partners in Anesthesia, a large anesthesia management company headquartered in Melville, N.Y. At the same time, medical advances combined with consumer and payer demand are shifting many procedures out of the OR.
As a result, smart anesthesiology groups are becoming more involved in what happens outside of the OR. “It’s a soup-to-nuts change in what anesthesiologists think of as their responsibility,” Di Capua says.
Advanced anesthesiology groups are improving care quality inside and outside the OR, using their skills to bolster their hospitals’ interventional procedure programs and testing care models that support new types of payment, such as bundled services and accountable care.
Anesthesiologists increasingly are turning to data to improve patient safety, which, in turn, helps hospitals’ bottom lines. “As you make your complications go away, you improve your patient outcomes, and you make your system more cost-effective,” says Richard P. Dutton, M.D., executive director of the Anesthesia Quality Institute, Schaumburg, Ill.
To collect and provide that data, the American Society of Anesthesiologists established the AQI in 2008. “The leaders of the society recognized that pay for performance was here to stay and that we needed the ability to measure and demonstrate the value of our work,” Dutton says.
Today, 370 anesthesia groups, representing 2,600 hospitals and surgery centers, participate in AQI reporting. The organization, which began operations in 2009, collects data from electronic health records in practices that use them and from billing systems. It puts the information in a usable form that the practices can access at any time to compare their performance with national benchmarks, down to the individual physician level.
“The value we bring is by simply holding up a mirror to the practice,” Dutton says. “Physicians are very competitive people. If you give them a measuring stick, they will improve. Nobody wants to be the guy on the left side of the curve.”
The metrics include clinical measures, ranging from post-operative nausea to intraoperative cardiac arrest; efficiency measures, such as unexpected surgery cancellations; and metrics that are both, such as hospital readmissions. Anesthesiology groups that use EHRs are able to assess their performance on more robust measures than those that use paper records because less information can be gleaned from billing systems. However, only about 25 percent of participating anesthesia practices use EHRs, Dutton says.
In general, project participants have shown steady performance improvement, although no formal data have been published yet. Whether independent anesthesia practices share their performance data with their hospitals depends on their relationship with the institution, Dutton says. But, it’s beneficial when they do.
“Really understanding their own data has a huge advantage in selling their services to a hospital,” he says. “Just having the data so you can say to the hospital, ‘we know how good we are,’ is a huge first step, because many anesthesia groups can’t tell you about their performance. They wouldn’t know if they’re good or bad,” Dutton adds.
That’s not the case at North American Partners in Anesthesia. The organization collects data on 121 outcome points on each of its 1,400 practitioners on every patient case. Its database is 4 million patients strong. Through a Web-based tool, anesthesia department chiefs at its 58 hospitals and more than 100 ambulatory surgery centers have continuous access to their anesthesiologists’ performance data.
“We don’t just collect quality data, we collect efficiency data: What’s the turnover time in that hospital? Did we improve it?” Di Capua says. “We analyze these data and meet quarterly with our hospitals to discuss what’s working, what isn’t and devise ways to ensure that we are continuously improving operationally.”
Rather than taking a punitive approach when physicians don’t perform up to par, the organization helps them through education or mentoring.
In a new quality project, the NAPA has piloted OR remote video monitoring at New York’s North Shore-LIJ Health System’s Forest Hills Hospital and Long Island Jewish Medical Center. Trained auditors look into each OR to check whether physicians and staff are following select protocols. Individual faces are blurred to overcome worker anxiety and meet privacy law standards.
When the project started, presurgery huddles and overnight terminal cleaning rates were below where they had been expected to be, Di Capua says. To change the culture, anesthesia department leaders get a direct text from the auditors when protocols aren’t followed, so that they can respond in real time. For example, if the OR staff doesn’t do their preoperative timeout correctly, the anesthesia leader can walk into the room, go over the process and ask the team to do it again, Di Capua explains.
The status of each OR is posted on LED boards in the operating room, recovery room, surgeon’s lounge and executive director’s suite. The tool is Web-based so that everyone with authorization can check OR status at any time. An app allows smartphone access. “If I’m in my Melville office, I can look at what’s happening at LIJ and tell you exactly which rooms did their timeout right and which ones didn’t,” Di Capua says.
Big payoffs for video monitoring
The two hospitals also use video auditors to eliminate wasted time in the OR. For example, before the project began, nurses called the cleaning staff to let them know when an operation was over. Now the video auditors notify the cleaning crew when a room is about to turn over, so that they can be there and step in right after the patient leaves.
“You don’t need a registered nurse degree to know when they’re about to finish a room,” Di Capua says. “The nurses get relieved of a lot of busy work and can practice to their license.”
The OR is a hospital’s most important revenue stream, he says. “It has to be very carefully managed so that you’re not spending money unnecessarily and you’re utilizing this very expensive space to its fullest.”
The video auditing project has a customer service angle, too, he says. If the patient’s family members want to be updated on the progress of surgery, the auditors can text them when surgery is wrapping up.
Although the project is labor-intensive, it pays off, Di Capua says. The nine-month LIJ Medical Center pilot, which included 15,000 cases, recently wrapped up. Video monitoring not only dramatically improved compliance with the surgical safety checklist, but also improved OR throughput by more than 20 percent.
Improved compliance with the checklist, and with OR cleaning and other protocols not only makes patients safer, but also saves the hospital money with every avoided wrong-site surgery and prevented complication that could increase length of stay or lead to readmission, Di Capua says.
Beyond the OR
A growing percentage of anesthesia care is being delivered in non-operating room settings because of the rise of complex minimally invasive procedures, often on extremely sick patients, in cardiology, radiology and gastroenterology interventional suites.
“The entire world of where we practice is changing,” says Di Capua, who is senior vice president of anesthesiology services for the North Shore-LIJ Health System. Ten years ago, only 10 percent of the volume in his anesthesia departments was outside the OR. Now it’s more than 50 percent.
“Anesthesia is having to really create the equivalent of an OR experience in new territories,” Di Capua says.
An important part of the OR experience is patient safety practices, such as surgical care improvement measures and use of a safe surgery checklist, to which many anesthesiologists are accustomed. “As anesthesiology moves into these other areas, we are bringing our safety culture and processes to these environments that really didn’t have them before,” Dutton says.
Anesthesiologists’ presence in interventional suites also allows hospitals to bring in new business. For example, if high-end radiologists want to do more complicated procedures, such as repairing aortic aneurisms, they need anesthesiology support, Dutton notes.
Strong anesthesia groups also bring their focus on improving efficiency to interventional suites. “A department that was able to do five procedures in a day might be able to do eight, because now you start to take the history and culture of an OR, which is very regimented, and you put that into the non-OR environments,” Di Capua says. “We create revenue through that by helping our hospital partners grow in their markets.”
Some anesthesia practices are using their expertise in quality and efficiency to help hospitals create service bundles. Dutton uses total knee replacement as an example. The hospital and the physicians together can offer insurers a flat rate for everything included in a knee replacement package.
“The insurance company loves this because it makes their business very predictable,” he says. The price is typically lower because the fixed rate means providers are working to prevent complications, to get patients up and out of the hospital quickly and safely, and to avoid readmissions.
“The other side of that coin has to be publicly transparent quality measures,” Dutton adds. “The public is happy to have us sell a total knee at a fixed price. They understand why that’s good for the insurers, the hospital and the doctors, but they need to know that they’re going to get the best care out of that. We have to be public and transparent about our outcomes, and that’s very much why our registry was created and where we’re headed.”
A ‘surgical home’
A new model of care the American Society of Anesthesiologists has created lends itself to new payment models, such as bundled payment and accountable care. Anesthesiology has continued to evolve to the point where anesthesiologists have a role in care along the entire operative continuum, from the preoperative assessment to post-discharge care, says Jane C.K. Fitch, M.D., president of the organization. Anesthesia subspecialties in pain management, critical care medicine, and palliative and hospice care reflect that transformation.
Their involvement in the continuum of operative care puts anesthesiologists in a good position to test the new care model, called the perioperative surgical home, Fitch says. The concept behind the surgical home, somewhat analogous to the primary care medical home, is to provide patient-centered, coordinated care throughout the patient’s entire surgical experience and beyond without the fragmentation and duplication that often mark the surgical care episode today.
The model uses a multidisciplinary team approach with one physician taking the lead, Fitch explains. Depending on how the concept is implemented at a given hospital, the team leader could be an anesthesiologist, surgeon or other specialist. “The most important construct is that it is coordinated care, that it is multidisciplinary, and that it is going to take one individual to help lead, guide, orchestrate and set it up,” adds Fitch.
Under bundled payment, the various providers involved in the care episode worry whether their share of the flat rate would be enough. The perioperative surgical home model could help to alleviate those concerns, Dutton says.
The Institute of Medicine estimates that about 30 percent of health spending is lost to inefficiencies. “If you coordinate the care better and recover the money that we’re wasting, you then have a really big pot that you can spread around,” he says. “We can sell total knee replacement to the insurance company at a better price, and we can all still make money.”
Looking for validation
The ASA is working with several payers, public and private, to educate them about the perioperative surgical home concept and determine how payment could be handled. “Whether we end up with specific grants that let us do pilots or whether they just simply considered this as an experiment in a bundled system remains to be seen,” Fitch says.
Because the perioperative surgical home model is so new, the ASA is working to get the word out, Fitch says. In July 2015, the society held its first learning collaborative on the concept, and it is reaching out to hospital, surgical, surgical subspecialty and interventional medicine associations. “We certainly understand that it’s a partnership because the patients are picking their surgeon for the procedure or they’re picking their cardiologist or gastroenterologist,” Fitch says.
Only a handful of hospitals have established perioperative surgical homes, and more than 40 institutions are at various stages of implementation, she adds. So far, little published evidence exists on its effectiveness.
However, a study of the first year of a perioperative surgical home for total joint replacement at University of California Irvine showed positive results. None of the 146 patients studied had a major complication, in-hospital mortality was zero, and the 30-day readmission rate was 0.7 percent, according to the study, published in the May 2014 issue of Anesthesia & Analgesia. The mean length of stay for both hip and knee [replacements] was three days, 97 percent of patients reported no nausea or vomiting during their hospital stay, and all patients received two physical therapy sessions within 24 hours of surgery.”
Researchers were unable to compare these results with previous outcomes at the institution because the joint replacement program was new. “However, we believe that our experience with the total joint perioperative surgical home program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve higher patient satisfaction,” the authors wrote.
Although most anesthesiology practices are still small, independent groups, the major changes in health care are forcing more anesthesia practices to grow in size. That’s because bigger groups are better able to afford to put resources into quality management and hire staff to work on compliance and new payment models.
This type of investment gives bigger groups a leg up with hospitals. Dutton says, “They go to a hospital and ask: ‘Do you want to contract with us for anesthesia services, because we’ll show you these data. We can tell you how efficient or inefficient your operating room is, and we’ll help you to be more efficient.’ The information they have is one of the big bargaining chips that helps them to get business.”
Now more hospitals are starting to expect that kind of service from anesthesiology groups. “Hospitals used to be fine with anesthesia just running the OR well,” Di Capua says. “It’s amazing to me how quickly hospitals are saying, ‘I expect more from my relationship with my anesthesia department.’ Anesthesiologists touch the intensive care unit, emergency department, OR, the labor and delivery suite, the floors. So they’re in a fairly unique position to help the institution.”
— Geri Aston is a contributing writer to H&HN.
Patients don’t decide where to have surgery based on who will provide their anesthesia. In a world in which providers of all types are pressed to show their value, that reality is forcing forward-thinking anesthesiology practices to contribute in other ways. Here are some approaches they’re taking.
The anesthesiology group adopts patient safety practices, such as following Surgical Care Improvement Project measures; tracks its compliance; and uses the findings to improve performance. The practice also tracks patient outcomes on a variety of measures and uses that data to improve care, and prevent costly complications and readmissions.
Boosting OR efficiency
The group works to improve operating room efficiency, for example, by tracking unexpected case cancellations and OR turnaround time, and using the results to improve practices. For example, many academic medical centers and some non-academic institutions have preoperative assessment clinics where anesthesiologists evaluate patients days to weeks before surgery to determine if they have conditions that could interfere with or even prevent surgery and to help get them into optimal shape before their procedures, notes Jane C.K. Fitch, M.D., president of the American Society of Anesthesiologists.
The practice looks for ways to trim expenses through standardization of equipment, medication or medication use. For example, the group could develop standards for the use of expensive medications, such as the long-acting local anesthetic bupivacaine or intravenous acetaminophen, so it’s prescribed when the patient would benefit, notes John F. Di Capua, M.D., chief executive of North American Partners in Anesthesia.
Going beyond the OR
Subspecialties in critical care, pain medicine, sleep medicine, and palliative and hospice care are moving anesthesiology outside the traditional realm of the OR. As the population ages and the rates of chronic, sometimes painful, conditions increase, the demand for critical care, pain management, palliative and hospice services by anesthesiologists likewise will grow, Fitch says.