When Kelly McQueen, MD, MPH, FASA, joined the staff of the University of Wisconsin (UW) School of Medicine and Public Health, she knew the Department of Anesthesiology was ready to take the next step in providing world-class care. As historically the first academic anesthesiology department in the United States, innovation and expansion are not unfamiliar to UW. From her position as the tenth Ralph M. Waters Distinguished Chair in the department’s history, Dr. McQueen helped to design and execute the launch of their new preanesthesia clinic, which first opened its doors on October 3, 2023. The clinic presents a new opportunity for UW to improve their patients’ experiences and outcomes, as well as to take a proactive position against the threats of burnout in an increasingly demanding health care field.

“This has been very important for provider burnout, as it decreases the workload of each individual anesthesiologist. The preanesthesia clinic work that used to be done by the anesthesiologist of the day was a source of additional work and time within the medical record.”

“When I joined the team here at the University of Wisconsin, it was obvious to me that we needed a more robust, comprehensive preanesthesia clinic rather than just a preanesthesia process,” says Dr. McQueen. Before the establishment of the clinic, preanesthesia evaluations were handled by nurses and individual faculty members. The lack of standardization in the preanesthesia evaluation left pain points in the system. Utilizing the UW Health Perioperative Value Stream Project, Dr. McQueen and her team first analyzed how these pain points translated to a loss of value in their operations. Variations in the patient preparation for surgery occasionally led to insufficient coordination and communication between care teams, as well as between patients and their providers. These inefficiencies ultimately resulted in a higher frequency of cancellations and delays, and a longer inpatient length-of-stay post-surgery. Dr. McQueen’s department recognized the urgency in addressing these inefficiencies: “We know there’s an inevitability of growth in our system of care, and with or without a preanesthesia clinic, our surgical volume will increase. We hope the clinic will allow us to decrease the burden on the system of patients having to be admitted with complications or unexpected poor outcomes.”

The planning team evaluated what lost value could be recovered through the services provided by a preanesthesia clinic. The clinic’s designated faculty and a consistent practice plan allow the department to better prepare patients for surgery and the postoperative period. Streamlining the patient’s preparation and solidifying a preanesthetic workflow could also improve their department’s communication. With these goals established, the project team began ironing out the logistics. “When we were talking initially about the clinic, we completed a business plan that outlined how many people we would need to work in the clinic, how much space we would need, how much it would cost to start a new clinic, and then what the return on investment would be based on the anticipated billing,” says Dr. McQueen. Billing and coding were particularly challenging to assess during the establishment of an entirely new clinic type for their system of care. A value stream analysis showed that if an evaluation and management visit was executed on a day other than the day before surgery or day of surgery, the surgeon or the clinic’s advanced practice provider could bill and code for that service. A nonsurgical specialist could also code a preoperative visit as a consultation depending on who requested the consultation, the specific comorbid conditions of the patients who were evaluated prior to surgery, and the recommendations made to the surgical team. Dr. McQueen says the value stream analysis business plan also considered “the unique components of the preanesthesia clinic and made sure that there was an ability within our system and our electronic medical record to complete the necessary communication to make everybody aware of where the patient is in the process.”

UW’s preanesthesia clinic is run by Medical Director and fellow anesthesiologist William Hartman, MD. Dr. Hartman’s staff of 14 preanesthesia clinic faculty work in the facility on a regular basis alongside advanced practice providers. Having a designated staff in the clinic alleviates some of the burden of care for the department’s anesthesiologists. “Rather than just the anesthesiologist of the day reviewing their cases a few days before or the day before and trying to figure out if everything’s been done, the clinic does that work,” says Dr. McQueen. “This has been very important for provider burnout, as it decreases the workload of each individual anesthesiologist. The preanesthesia clinic work that used to be done by the anesthesiologist of the day was a source of additional work and time within the medical record.”

The PAC team designed an algorithm and questionnaire to establish patient comorbidities and the risks of surgery. With those tools, patients are scheduled for surgery and referred appropriately to the preanesthesia clinic. If any additional testing or lab work is required, patients can complete those steps in the clinic, and staff communicates the completion and results of these tests directly back to the surgery clinic. While it is a physical location, the preanesthesia clinic also offers virtual visits for patients travelling long distances for surgery.

The streamlined, standardized preanesthesia workflow has already made an impact on the department’s financial and clinical performance. While the clinic started with a few initial hiccups, like patients who arrived at the clinic who did not really need to be seen, early successes are occurring. “We got up to speed faster than expected,” notes Dr. McQueen, “and most days the clinic is full and very busy. We’ve had fewer case cancellations and fewer delays because patients are better prepared on the day of surgery. We’re not having that ‘aha’ moment on the morning of surgery where we realize a patient is missing an EKG, and the scheduling of that then delays the surgery start.” In the months to come, the clinic will continue to gather information on patient outcomes and satisfaction, as well as the long-term effects of the clinic on physician burnout.