A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
The health care landscape has never been more complex. A deadly and enduring pandemic; health care delivery challenges that leave some communities at higher risk for adverse outcomes; an opioid crisis that takes nearly 200 American lives per day; and an ever-evolving regulatory climate. In the midst of these challenges, health care organizations are pressured to decrease costs and transition to value-based care.
With so many difficulties to confront, hard work and good intentions aren’t enough. We need new approaches to delivering care. Health care organizations need an accessible, inclusive, and scalable organizational model that breaks down silos, empowers clinicians to coordinate care team workflow, and embraces specialists from across the full spectrum of a patient’s surgical journey. A fiercely patient-centered model that facilitates standardization, customization, and coordination can give health care organizations a platform to help them thrive in this harsh climate.
What is the perioperative surgical home?
The American Society of Anesthesiologists (ASA) first introduced the Perioperative Surgical Home (PSH) in 2012 to address the wide range of surgical care delivery challenges impacting quality and patient safety. PSH was systemically designed and has been finely tuned to advance the Quadruple Aim: improving population health, enhancing patient care and outcomes, reducing the cost of care, and improving provider and team satisfaction. A physician-led, patient-centered coordinated model of care, PSH is a modular whole-health model adaptable to all settings, service lines, and institution sizes. It has been successfully employed to focus on isolated problems and broad, deep systemic issues alike.
A history of proven outcomes
From the beginning, the PSH would be under intense scrutiny to deliver on its promise of addressing widely variable delivery models, skyrocketing costs, fragmented care, and more.
In 2014, the first PSH Learning Collaborative brought leading U.S. health care organizations and diverse service lines together from every corner of the country to develop, pilot, and evaluate the PSH model. Two additional Learning Collaboratives followed, testing PSH’s ability to drive meaningful and lasting change.
Indeed, the Learning Collaboratives proved PSH could successfully move the needle for health care organizations. Learning Collaborative participants reported reducing length of stays by up to 50 percent, pain scores by up to 75 percent, hospital-acquired conditions by up to 30 percent, readmissions by up to 75 percent, and episode of care costs by up to $4,000 to 10,000 per patient. Participants improved patient outcomes by combining time-tested and innovative tactics such as designing preoperative optimization clinics, risk assessment and stratification tools, and optimization pathways. They decreased costs by creating pro forma financial statements to forecast expenses and revenue and by reducing case cancellations, surgery-related complications, and readmission rates. Increased provider satisfaction was accomplished by establishing regular meetings, data dashboards, collaborative practice agreements, and new pathways in electronic health records. Additionally, participants improved the patient experience by developing educational tools and materials, patient navigators, and processes for the patient’s pathway from the surgeon’s office to PSH preoperative clinics.
The Learning Collaboratives spread protocols, lessons, and outcomes across the country. Over 100 hospitals and health care organizations have adapted, customized, and scaled PSH in their institutions. The model is modular, which means PSH practitioners can adapt it to positively impact a wide range of discrete and systemic challenges.
The PSH saves a hospital $12 million and increases patient satisfaction.
New Hanover Regional Hospital in rural North Carolina used PSH to address increased complications and readmissions, as well as operating room inefficiencies, case delays, and cancellations, which had led to millions of dollars in Centers for Medicare & Medicaid Services (CMS) penalties. The hospital implemented PSH to examine and identify variables to overhaul and adapt to evidence-based practice improvement pathways. As a result, New Hanover improved care delivery processes, increased patient satisfaction, and transformed their care team culture, by breaking down silos among clinicians and staff. Since implementing the PSH model, they have not paid a CMS readmission penalty. In addition, using multimodal pain management processes, they have reduced oxycodone tablet prescriptions by over a million tablets. They were so successful at streamlining the perioperative optimization process with hospitalists colleagues, surgeons saw the results and brought more procedures to the group for standardization. By 2018, with eight service lines, they saved $12 million and created 2,268 hospital bed days, allowing them to provide care for an additional 768 patients.
And they’re not alone. New Hanover is a good example of the difference PSH can make, but it’s only one of many.
Leveraging PSH to meet today’s needs
PSH’s success is due, in part, to its adaptability. The model enables rapid response to the ever-changing needs of today’s health care environment. For example, a health care team can leverage their existing PSH infrastructure to address the opioid epidemic, respond to the COVID-19 pandemic, engage stakeholders from patients to the c-suite, and more. Once PSH is established, value multiplies from scaling new processes and workflows across diverse service lines and episodes of care. Additionally, right now, the health care landscape is littered with organizations that have one foot in fee for service and the other in value-based care. A framework like PSH that fits snuggly around each payment model and aids the inevitable transition toward value-based care meets the complex environment of the health care industry.
The guide for implementing PSH to drive lasting change
In the decade since launching, PSH has become more nimble, more effective, and more resolute to deliver meaningful impact on pressing and outstanding health care issues. The demand to provide value through cost reductions, improve outcomes, deliver more for less, and participate in bundled care and risk payment arrangements means health care institutions must remain flexible, agile, and financially viable.
PSH gives care teams the framework and guidelines to advance best practices that reduce variations in care, provide continuous quality improvements, optimize value for patients and health care organizations at every stage of the journey, then measure success and adjust to improve. That’s why, earlier this year, ASA introduced a PSH Implementation Guide, a “how to” manual with tips, instructions, and best practices to help health care professionals adapt, customize, and scale any or all of the diverse solutions PSH offers. By bringing the PSH model—along with information on how to customize it—to health care teams everywhere, it will help to assist health care organizations with achieving better care, decreasing costs, and improving outcomes in every community in the country.
Randall M. Clark and Robert Shakar are anesthesiologists.
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research, and scientific society with more than 60,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during, and after surgery. ASA members also lead the care of critically ill patients in intensive care units, as well as treat pain in both acute and chronic settings.
For more information on the field of anesthesiology, visit ASA online at asahq.org. To learn more about how anesthesiologists help ensure patient safety, visit asahq.org/madeforthismoment. ASA publishes Anesthesiology, Anesthesiology Open, and ASA Monitor, and stays connected with members and the public on Facebook, X, Instagram, Bluesky, and LinkedIn.
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