Shale Imeson, MD
The saying “May you live in interesting times,” is perhaps especially meaningful for those of us navigating the tumultuous world of today’s health care marketplace. As reimbursement shifts toward value-based payments, the health care industry struggles to find ways to meet new demands for efficiency, including improved outcomes and lower costs.
In particular, hospitals are looking for ways to control costs while also boosting quality. One way to do so is to integrate surgical services with other hospital-based specialties. In theory, this plan will break down walls and foster more collaborative approaches to care.
However, differing schedules, disparate goals and cultural clashes can inhibit integration, frustrating providers and patients, fragmenting care delivery and ultimately leading to poor outcomes. That paradigm must change.
Anesthesiologists should be natural partners for hospitals seeking to improve quality, efficiency and operations. As hospital-based physicians, our fate is tied directly to the success of the facility. Therefore, we have an obligation to demonstrate our ability to improve not only surgical services but the entire spectrum of acute care. We must make the cultural shift from being in our practices to being fully engaged with the leadership of our hospitals.
Expanding the Anesthesiologists’ DNA
While such efforts have not previously been part of our DNA, anesthesiologists are well positioned to lead the development of protocols and processes that streamline operating room (OR) throughput. Because of Centers for Medicare & Medicaid Services (CMS) penalties related to high readmissions associated with elective hip and knee surgeries, hospitals are at risk for millions of dollars in lost compensation.
To meet this latest regulatory burden, anesthesiologists at the hospital where I practice have collaborated with orthopedic surgeons, perioperative nurses and physical therapists to develop a standardized program for total joint replacement.
Consistent techniques for anesthesia and analgesia, for example, allow physical therapists to predict when patients will be ready for their first post-op ambulation. Using this approach, we improved process efficiency, decreased length of stay and boosted overall outcomes. Plus, costs have declined while patient satisfaction rose.
Additionally, our anesthesiologists have engaged with hospitalists, intensivists, OR nurses and the hospital’s ethics committee to refine perioperative modification of DNR orders. We worked together to develop a standardized approach that is consistent with current ethical guidelines to address a delicate and important topic.
Specific options are laid out for the patient and family to consider, and their choices are documented for all perioperative care providers to follow. Having a well-defined and clear process for decision making and documentation helps resolve DNR questions before surgery, while also addressing the concerns of patients and families.
There are other examples of anesthesiologists leading the way in integrated care models.
Under the guidance of anesthesiologists, a regional hospital system developed processes to review patient readiness at least a day before the scheduled surgery. These processes included confirmation of insurance authorization, the surgeon’s admitting paperwork, and any required pre-op labs and consultations. Engaging patients early allows us to review their physiology and pharmacology and understand each patient’s social situation. If an issue is uncovered during the pre-op clinic visit, such as a lack of resources for home support following surgery, a positive drug test or any change in health, we have time to identify solutions or fit another patient into the surgery schedule for that day.
By reducing bottlenecks and no-shows, we make efficient use of the OR and the accompanying resources. Engaging patients in a significant way preoperatively also allows patients to take some ownership of their procedures so that they are more likely to follow pre-op instructions, be on time for surgery and be more engaged in their recovery.
Building an Integrated Approach: The Anesthesiologist’s Role
Programs that create efficiencies in the OR also address one of the most significant challenges hospitals face when developing team approaches to care: getting support from surgeons. Surgeons are not opposed to a collaborative approach to care; however, they are likely to rebel against programs that add additional burdens and complexity to their jobs while doing little to improve patient outcomes. The input and support of surgeons are vital to the success of any change that affects their patients. Their opinions must be actively sought and integrated into the program design from inception. Regular reporting of objective results helps keep them engaged, as their continued involvement leads to further improvements.
While getting support from surgeons is important, it is not the only problem anesthesiologists must address when developing integrated approaches to care. Anesthesiologists and surgical groups are facing serious questions about the future of these professions and their practices. An increase in the number of hospitals that are owned by corporations or funded by venture capitalists also makes the current marketplace for surgical care challenging.
With all the consolidation in health care today, it is tempting for independent anesthesia providers to sell to or partner with corporate-owned firms that can provide financial security and practice management support. At the same time, however, we should be willing to explore other options. Any new arrangement should seek to preserve our independence, continue the concept of “our practice in our community” and maintain a focus on the quality of care we deliver that allows us to take pride in our work.
When anesthesiologists own their groups and are full partners in democratically run practices, they are more likely to take a personal interest in their hospitals’ successes. They also are more likely to develop innovative ways to deliver care and improve reimbursement. In a democratic partnership, for example, anesthesiologists might be willing to accept some form of financial reward that goes beyond being paid by the case, so that we can also be compensated for taking on leadership roles in our hospitals. When we do so, we can enhance the concept of integrated care and contribute to solving problems.
Becoming Comfortable In Our Expanded Roles
Fruitful collaboration allows all parties to share common values, goals and incentives. When we do, the patient is the ultimate beneficiary. Such collaboration is achieved when disparate medical disciplines join around a unifying theme.
For too long, anesthesiologists have operated in a silo. We’ve been like the master concert violinist playing to an empty concert hall. It’s time we all join the orchestra. When we are all core members of a collaborative and integrated team of providers, the result is better for our profession, hospitals and—most importantly—patients.
Shale Imeson, MD, is a medical director for CEP America, a multispecialty physician partnership, and Director of Anesthesia for Lodi Memorial Hospital, in Lodi, Calif. Dr. Imeson is a diplomate of the American Board of Anesthesiology.