The UC Irvine Perioperative Surgical Home (PSH) Update 2016 Scott Engwall MD, MBA Interim Chair Department of Anesthesiology & Perioperative Care

What is PSH? • “Perioperative Surgical Home” or PSH is a new way of providing Perioperative Care to patients during the entire episode of surgical care • Endorsed by the American Society of Anesthesiologists and embraced by many surgical specialties • It begins from the point where the Decision for Surgery is made to 30 days post discharge of the patient from the hospital • Is a response to innovative care within the framework of Health Care Reform 2

Why is PSH Important? • Decreases Variability of Care through Evidence Based Standardized Practices • Decreases Cost of Care • Decreases Complications • Decreases Length of Stay • Increases Overall Efficiency • Improves Quality of Care and Overall Outcomes • Improves the Transitions of Care • Improves Surgeon Satisfaction • Improves Patient Experience 3

Perioperative Surgical Home PCMH

Preoperative • Patient centric • Optimization (not cleared and high risk ID)

• Evidence based standard protocols • Patient education

Intraoperative • Evidence based protocols

• Evidence based protocols

• Operations management

• Team management • Right level of care (NNTV)

• Reduced variation • GDT

• Transition to appropriate level of care • Education of patients and caregivers • Rehabilitation and return to function • Reduced variation

• Prevention of complications

• ERAS

• Care plan

Post-Discharge

Postoperative

• Reduced variation

Big ROI

Big ROI

Quality Improvement

Database

Supporting Microsystems • IT • Decision support • Case management

• Pharmacy • Blood bank • Dietary

• Human resources • Patient education • Physical Therapy

Phase

Decision to Operate

Traditional Surgical Care

•Minimal preprocedure planning

Preoperative

•Variable pre-op assessment, testing and medical treatment

Intra operative

•Provider choice anesthesia •Lack of standardized protocols

Post operative

•Surgeon managed Post op •Few protocols

Post Discharge

•Variable support often leading to ER

PATIENT Shared Decision Making, Patient Centered Care

Seamlessly Integrated, protocolized care at each phase of care Surgical Home

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Working as a TEAM

UC Irvine PSH Clinical Pathway

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PSH Launch Service Timelines Schedule / Go Live Dates April 2012

Orthopedic • Elective • Total joint replacement

February 2014

September 2014

Urology

Orthopedic

• Elective • Cystectomy, nephrectomy

November 2014

Orthopedic

• Outpatient services

• Inpatient Services

PHS Winning Formula • • • •

Patient centered Surgical phase accountability Collaborative data driven process approach Standardized clinical pathways -

Early patient education/management Process and detailed oriented Evidence nased Continually updated with base practice

• Lean Six Sigma (continuous improvement) • FMEA introduction (continuous improvement)

Target November 2015

Neurosurgery • Service line

PHS Surgical Targeted Outcomes • • • • • •

Cumulative decrease in Cost per case Cumulative decrease in 30 readmission rate Cumulative decrease in Length of stay Decrease in pain management Sensitivity Predictable and decrease in complications Cumulative Increase in customer satisfaction

What Has Changed for 2016 • Split of the Combined In-Patient Team that covered both Acute Pain Patients and PSH Patients on April 11, 2016 • Resident Curriculum providing a Continuity of Care Model • PSH Playbook and Formula for Success • Development of a PSH Scheduled C-Section Service Line 9

Combined PSH/In-Patient Pain Services Model for Clinical Coverage

Core Team

Daytime Available Support Staff

Week 1

Week 2

Week 3

Week 4

Pain Attending 1

Pain Attending 2

Pain Attending 3

Pain Attending 4

Acute Pain/Regional Fellow 1

PSH Fellow 1

Acute Pain/Regional Fellow 2

PSH Fellow 2

Combined NP

Combined NP

Combined NP

Combined NP

PSH Resident X2

PSH Resident X2

PSH Resident X2

PSH Resident X2

PSH Fellow 2

Acute Pain/Regional Fellow 1

PSH Fellow 1

Acute Pain/Regional Fellow 2

PSH Inpatient Services Model for Clinical Coverage

Core Team

Daytime Available Support Staff

Week 1

Week 2

Week 3

Week 4

PSH Attending 1

PSH Attending 2

PSH Attending 3

PSH Attending 4

PSH Fellow 1

PSH 3 Resident

PSH 2 Resident

PSH Fellow 2

PSH NP

PSH NP

PSH NP

PSH NP

PSH Resident X2

PSH Resident

PSH Resident

PSH ResidentX2

PSH Fellow 2

PSH Fellow 1

PSH Fellow 2

PSH Fellow 1

General Philosophy of New Team • Assume the care of all PSH Patients – Preoperative work up and Optimization – Day of Surgery Involvement – Post Op Care and Management – Post Discharge Coordination and Connection

Daily Work Flow • 7am – NP or Resident greets first cases in Preop Holding and presents contact card • 7:30-8:30 Team Table Rounds • 8:30-9:30 Multidisciplinary Conference with Surgery Interns, Case Managers and Nursing • 9:30-11:00 Structured Rounds on Patients • 10:00-13:00 a member of the team will split away and do phone preops on new PSH patients

Daily Work Flow • 13:30-14:00 Didactics for Residents and Fellows • Though out the day visit PACU as new patients arrive and write PSH orders – Automatic notification from AIMS system of case end – Telephone hand off from intraoperative team to the PSH team

Daily Work Flow • 14:00-16:00 – Afternoon rounds to tie up issues – Post Discharge Calls to patients • 48 hours post discharge and document • 30 days post discharge and document

• Overnight coverage by phone with Fellow or Resident on for the week as needed for issues

Structured Rounds • Focused on Milestones, Expectations, Normalization and Goals – Pertinent Labs (hemoglobin and glucose control) – Pain Control – Advance of Diet – PT and mobility – VTE – Tubes out – Case management and placement

Goal Board

Patient Engagement • Expectation Management – Starts with first contact – Reinforced Day of Surgery – Reinforced Daily in Hospital

• Marketing of who we are – Starts with first contact – Reinforced Day of Surgery – Reinforced Daily in Hospital

PSH Resident Curriculum • PSH 0 – The interns – Preop 2 weeks – Point of Care Ultrasound 2 weeks

• PSH 1 – CA-1’s – Preop 2 weeks – PACU 2 weeks – Patient Education – ECG Modules

PSH Resident Curriculum • PSH 2 – CA-2’s – On in-patient service 4 weeks • Works with Inpatient Team • One week on call

– Continue Point of Care Ultrasound – Other Experiences • Case Management • Rehabilitation Experience with PT and OT

PSH Resident Curriculum • PSH 3 – CA-3’s – On in-patient service 4 weeks • Works with InPatient team • One week on call

– Other Experiences • • • • •

Blood Bank Pharmacy Billing OR Management Ethics Committee

Resident Continuity Model • PSH 2 and 3 Experience – Required to pick a minimum of 2 patients when on service to take through entire process • • • • •

Preop and Optimization Day of Surgery will provide anesthesia care Provide immediate post op care Provide in hospital post op care Provide post discharge follow up/transitional care

PSH Playbook • Phase 1 – Service Line Feasibility – Leadership Buy-In • Organizational • Service Line

– Pre-Metrics – ROI calculations – Select Leads and Champions – Kick Off Retreat • Map Current and Future States

PSH Playbook • Phase 2 – Development – Continue to Map Current and Future States • • • •

Preop Day of Surgery/Intraop Post-op Post Discharge

– Create the Standardized Clinical Pathway – Create the Standardized Order Sets – Create the Patient Education Elements

PSH Playbook • Phase 3 – Pre-Implementation – Test – Educate

• Phase 4 – Implementation – Go Live – Collect Data – Tweek

• Phase 5 – Maintenance – Continue to Collect Data – Constantly Examine and Tweek

PSH for Scheduled C-Sections • Now in Phase 1 – Feasibility – Have met with stakeholders – Doing Pre-Metrics – Focus • Patient Experience – Increase Survey Scores – On Time Starts for scheduled cases

• Pain Management • Length of Stay • Decrease Variability of Care

QUESTIONS?