surgical directions ©201511. 22 why focus on perioperative services? perioperative services drive...

Surgical Directions ©2015 11

Surviving the Big Squeeze:Transforming Your OR for the Era of Falling Payments and Rising Quality Expectation

Jeff Peters, MBA President & CEO, Surgical Directions

Alecia Torrance, MBA, MSN(c), BSN, RN CNOR SVP Clinical Operations & CNE

9/01/15


Why Focus on Perioperative Services?

0%

20%

40%

60%

80%

68%

% better performers’ revenue from perioperative services

Perioperative Services are key to a hospital/system's success

Perioperative Services drive hospitals’ performance.

• Over 68% of better performing hospitals’ revenue

• 60% of margin is derived from better performing perioperative services.

• Successful system under Value-Based Purchasing/ACO provides both surgeons and payors more value for surgical services. Equation: Outcome/Cost

By helping our clients tackle the complexities and minimize political and cultural barriers, our clients have experienced significant improvements in surgeon, staff, and patient satisfaction, which has resulted in improved access to the OR, sustainable growth in surgical volume, and increased market share.


Healthcare Leaders Role

As healthcare leaders our goal is to improve the value of

Perioperative Services

Value Outcome Cost


The OR of the Future

Successful healthcare system perioperative services

have common characteristics:

Collaborative governance structure Transparent, comprehensive information Engaged involvement of physicians, nursing and administrative leadership Focus on new innovative model to deliver care

Surgical home Bundled payment

Focused processes to enhance OR efficiency Turnover times On-time starts Case time

Lower costs Uncompromised focus on clinical excellence


Situation: Beaumont Royal Oak

Flagship hospital in trouble and struggling:

• Not meeting financial goals:• Merger talks with Henry Ford terminated• Merger discussion with Oakwood• Bond refinancing

• CRNAs employed by hospital meeting to discuss unionization

• Conflict between hospital and system COO risen to board level

• Anesthesiologist had only a marginal role in operational leadership and less than optimal relationship with surgeons, nurses, and CRNAs.


CEO “Wants” of Anesthesia

• Goal: Beaumont Health System is the #1 academic medical center in the United States

• Drive profitability, volume

• Ensure surgeons are happy

• Ensure surgical outcomes exceed those of UHC hospital benchmarks

• Ensure CRNAs do not unionize

• Relieve hospital administration of the burden of managing the perioperative service line

• Ensure hospital leadership meets political and budgetary goals


Royal Oak Has Opportunities for Improvement

Metric Benchmark Royal Oak Rating

Shared Governance

SSEC: Multi-disciplinary approach to operational leadership

Surgeon as Chair

Matrix organization with traditional ‘nurse in charge’ model

Medical Director

Anesthesiologist / CRNA Co-manages OR with nursingRespectedClinically Active

Surgeon and anesthesia chair at each tower

Lack of collaboration and cross coverage

Daily HuddleMulti-disciplinary approach to proactively manage the schedule 1, 3 and 5 days out

M, W, F Scheduling Meeting lacking depth and scope in proactive schedule management

AccountabilityStrong and decisive leadershipMetrics, Dashboards and KPIs to monitor performance and objectives

Culture of Accommodation


Royal Oak Has Opportunities for Improvement

Metric Benchmark Royal Oak Rating

Block Schedule8 hr blocks plus open time;

75%-85% utilization

Current utilization under 50%

Cases per ORMain OR

IP 950 cases x 50% = 475 casesOP 1,400 cases x 50% = 700 casesTotal: 1,175 cases per OR

732 cases per OR

Day of Surgery Cancellations

<1%~1% Staff indicate much higher

Turnover TimeIP: 20-30 minutesOP: 10-20 minutes

Not Tracked

First Case On-Time Starts

90% or greater within 5-7 minutes of start time

Not Tracked

NA

NA

Notation: Excludes 4 CV OR’s and CV Case Volume


Recommendations

Establish a collaborative governance structure

-SSEC

Empower anesthesia to co-manage OR

Reallocate block to balance capacity with demand

Build organization consensus on a perioperative growth strategy

Break down silos and build collaboration

Develop system-wide dashboards and key performance indicators

Accountability through redefined roles and responsibilities

Develop standard operating procedures to remove variability

-Scheduling

-Pre-Admission Testing (PAT)

-Parallel Processing

-Leverage IT capabilities (tracking board, etc.)


TASK FORCES/PERFORMANCE IMPROVEMENT TEAMS

Process Optimization Initiatives


Create a Perioperative governing body to align incentives. An Operations Committee for all aspects of Perioperative Services

Surgical Services Executive Committee (SSEC)

Surgical Leadership

OR Nursing Leadership

AnesthesiaLeadership

Sr. HospitalLeadership

• Chaired by Medical Director(s) of Perioperative Services• Administration-sponsored Surgery Board of Directors• Controls access and operations of OR• Sponsors and directs Perioperative team activity

Collaborative Governance

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=8eYcgabc9Ye_PM&tbnid=pxbg2gS39u20lM:&ved=0CAUQjRw&url=http://www.berylhealth.com/patient-care/from-the-bedside-to-the-boardroom-the-new-role-of-the-cno/attachment/doctors-collaborating-with-a-business-team/&ei=rF91UZD6J87QqwGihIHgCg&bvm=bv.45512109,d.aWM&psig=AFQjCNE6S7cuH-HWCm6NzcL-VJy8Rb-9LA&ust=1366733058250943


Case Study:Full or Partial Blocks

Full Day Block Partial Day Block

Hospital Revenue ↑ ↓

Anesthesia Revenue↑ ↓

Nursing Costs Per OR Minute

↓ ↑

Case Volume↑ ↑

Payor Mix ↑ Commercial ↑ Government Pay

Profit Per Case ↑ ↓


Case Study:Block Time Ratings

Metric Benchmark- Current Memorial Previous

Length 8 hour + Variable

Utilization to maintain 75% 50%

Release time Variable by specialty 24 hour

Open rooms 20% 0


What is the Huddle?

H - HEALTHCARE

U - UNITED

D - DAILY (TO MAKE)

D - DECISIONS

L - LEADING TO

E - EXCELLENCE

PROBLEM/OPPORTUNITY LIST:

1) Recap of previous day

2) Total cases for next day and 5 days

out; PAT and scheduling completion

3) Review of schedule

4) Total number of anesthesia providers

to start day

5) PAT problem review

6) Antibiotics review

7) Review Pending Action items


Case Study: Pre-Anesthesia Testing

Effective PAT

Medical Director

Telephone Questionnaire

Single Pathway Scheduling

Risk Management Strategies

Testing ProtocolsSystems to treat patients with co-

morbid conditions


PAT at Beaumont Hospital

Pre-intervention

• Patients screened - 66%– Inadequate nursing staff to do the calls

or visits– No inpatients screened

• Very limited real time screening of lab data (done 3 days out)

• No midlevel support in PAT• Remote from hospital

Post-intervention

• Patients screened - close to 100%– Adequate staffing levels to complete

calls and visits– All inpatients screened

• Real time lab review– Using SD Abby process

• Midlevel support coming on board• Developing hospital based PAT and remote

call center


PAT Pre-op Clinic Advantage

• Patients arrive 72 hours prior to procedure for lab work, if required

• Reduce or eliminate lab delays on day of surgery

• Allow the hospital to capture the revenue associated pre-op visit

• Introduction of the Preoperative Surgical Home concept


Key Drivers:Non-Labor Costs

Metric Best Practice Norm

Inventory Turns•PAR, Min/Max levels•Single sourcing 10-12 2

Returned items from case <10% 30%

High dollar implants/costs (knees)•Optimize GPO contracts•Create capitated rates•Leverage consignment

$3,200 $4,800

Reprocessing 30% 5%

Non-Labor costs 60% of OR budget


ANESTHESIADriving Perioperative Performance


Anesthesia’s Role is to DrivePerioperative Performance

Driving Perioperative Performance

Effective Medical Director

Strong leader

Stipend based on service

standards

Incentives aligned

Available effective regional blocks

PAT

Protocol driven and

evidenced-based

Surgical Home & Bundled

Payments

Participate in Daily Huddle

On-time starts

Quick procedural turnover

time

Well-positioned

for the future

Respected clinically

Growth in Case Volume & Improved Bottom Line


Key Performance Indicators


SURGEON-SPECIFIC SCORECARD & ACCESS

Data-Driven Decision Making Initiatives


Physician Scorecard


Physician Scorecard (cont’d)


Surgeon Dashboard


Case Time Task Force


Results

Case volume increased by 9%

Anesthesia units increased 9%

Government pay decreased 2.5%

Hospital administration very satisfied

Relationship between anesthesia, surgeons, and hospital improved


Outcome

Impact: 9% increase in case volume over prior year in HJD

National recognition:

Increase in US News and World Report ranking for HJD

from 4 to 8 in two years


Surgical Home Provides

Surgical Home ensures your hospital provides high-value care to patient and payors

Value

Quality

Cost


Surgical Home Manages the Patient Experience


Who Participates?

All disciplines:

Surgeons, nurses, anesthesiologists and discharge planners work collaboratively to optimize the patient experience


Critical Components

• Pain Management Expertise– Ambulation

• Post-Discharge– PCP visit within 24 hours to manage cormorbidity– Home health meets patient upon arrival home– Daily rounding (SNF and homebound patients)


The Impact of a Surgical Home

Surgical homes are impacting outcomes, costs and patient satisfaction

Note: The University of California Irvine is now leading superior performance to grow market share

University of California Irvine Joint Replacement

UCI Benchmark

LOS 2.7 days 3 days

30-day readmissions

.05% 4.4%

Cancellation Rate .05% 1.5%

Patient Satisfaction Rate

99% 95%


How to Get Started

Gather everyone around the table Build organization consensus on the benefit of a surgical home Identify key surgical line procedures:

• Orthopedic

• Hip

• Knee

• Cardiac Identify CHAMPION Organize team Develop opportunity for evidence-based practice/coordination of care Manager Care

• Pre-Surgical

• Acute

• Post Discharge Measure process and outcomes through dashboards


Questions

surgical directions ©201511. 22 why focus on perioperative services? perioperative services drive...

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