Trends in Perioperative Anesthesia Services Management and the Implementation of Accountable Care

Posted on Thu, Sep 10, 2015
Trends in Perioperative Anesthesia Services Management and the Implementation of Accountable Care

By Trevor S. Sutton, MD, MBA, CPE

The current and future healthcare market requires that providers, facilities and integrated healthcare systems implement business strategies that focus on optimization of population health. Evolving regulatory mandates, incentives and guidelines have initiated change in healthcare delivery models as well as change in the management of healthcare services.
In this rapidly changing market, effective anesthesia practice management requires forward-looking design and implementation of strategies that promote alignment between anesthesia providers, non-anesthesia providers and healthcare delivery systems in achieving the often quoted “triple aim”:

  1. High-quality care based on consensus standards, guidelines and performance metrics
  2. Efficient cost management
  3. Achievement of enhanced patient (and client) satisfaction in association with healthcare delivery.1 

An important consideration in population healthcare management is that the delivery of clinical services must be market-driven on multiple levels. Specifically, healthcare management strategies must incorporate evidence-based best practice when there is consensus regarding clinical decision-making and clinical outcomes associated with healthcare delivery. Moreover, healthcare management strategies must be achievable and sustainable in terms of available clinical evidence and local or regionally available healthcare resources. The ladder requirement may create a hurdle to success when loosely coordinated healthcare delivery teams serve sizeable and geographically dispersed populations with a broad array of healthcare service needs. We recognize that a monolithic approach to anesthesia services management and a non-integrated approach to anesthesia care delivery will inevitably face implementation and sustainability challenges when it’s applied to a broad variety of clinical practice settings.
The Perioperative Surgical Home (PSH) is a concept that has been examined and promoted by the American Society of Anesthesiologists in response to the growing mandate for accountable care.2 It’s referred to as a “disruptive innovation” because it recommends enhanced implementation of the full array of anesthesia competencies not only in clinical care, but also in perioperative health system management. The PSH targets achievement of the population health “triple aim” through anesthesia team engagement in developing, supporting and leading coordinated and disciplined healthcare delivery models that promote measureable accountability for the service and outcomes associated with the perioperative care of surgical patients.2

Scope of the Perioperative Care Continuum
As suggested by the PSH model, the spectrum of coordinated anesthesia services must extend throughout the care continuum to enhance both value generation and accountability. This implies the existence, development or acquisition of substantial capabilities by groups and organizations that manage the delivery of anesthesia services. The competencies required include, but are not limited to:
  • Mature and effective clinical and executive healthcare leadership
  • Robust clinical, technological and administrative competencies across the perioperative care continuum
  • A clinical operations culture that prioritizes commitment to patient safety, learning, innovation and continuous improvement 
Because these competencies must be applied in all phases of the care continuum, examination of the scope of the care continuum is an important consideration.
The historical model for delivery of anesthesia services has focused on day-of-surgery patient
care (Figure 1). This model remains prevalent today, with an anesthesia management strategy that is often focused on volume-based and flow-directed management of operating room service. This, in many aspects, reflects a supply chain management approach to the delivery of anesthesia services. In such models, systems for coordinated engagement of patients, medical consultants, laboratory testing and cross-specialty physician follow-up following procedural care often are not fully developed or not fully utilized.

Figure 1
In contrast to the historical model for anesthesia service delivery, current and future models for anesthesia services management will create opportunities for early and extended engagement of both patients and the medical consultants who drive the referral and management of surgical patients. This more sophisticated and disciplined framework for managing service delivery recognizes that the domain expertise of anesthesia providers includes interpretation and implementation of guidelines for preoperative testing, preoperative risk assessment, and preoperative risk modification as well as post-operative critical care and post-operative pain management.
In support of this contemporary framework for anesthesia services management, numerous case studies have demonstrated that anesthesia preoperative assessment programs promote reliable, high-quality, cost-effective care. There also is evidence that anesthesia providers have an important role in preoperative risk modification strategies (“pre-habilitation”).3 Anesthesia providers are integral in evidence-based clinical care pathways such as Enhanced Recovery After Surgery (ERAS)4. Anesthesiologists also deliver high-quality and cost-effective care in the critical care setting through expertise in ventilator management, blood product transfusion protocols, pain management protocols, and sophisticated utilization of monitors and pharmacological agents that accomplish both hemodynamic stabilization and organ protection. Finally, anesthesia providers impact patient experience and length of admission through preoperative consultation, mitigation of morbidities such as pain and nausea, as well as through targeted strategies for glucose management, fluid management and management of other clinical and physiologic parameters in coordination with surgeons and medical specialists. Patient assessment following discharge also may involve teams that include or are led by anesthesiologists, particularly as consultants for outpatient pain management and, in selected instances, to contribute to multispecialty approaches to care that monitor and improve functional status during convalescence from surgery to maximize desirable outcomes and prevent readmission.
In summary, the current and future models for effective delivery of anesthesia care will leverage domain expertise in the management of anesthesia clinical services across the entire surgical care continuum. Broad clinical expertise, expertise in multispecialty care coordination, and expertise associated with data analytics and utilization of technologies that efficiently bring safe care to patients in the most cost-effective settings are the requirements for the new anesthesia service delivery model. Importantly, local solutions may require flexible and selective application of these competencies since an integrated and consensus-driven approach is consistently a requirement of effectiveness and sustainability (Figure 2).

EmCare’s Approach to Perioperative Anesthesia Management
EmCare delivers quality and value in perioperative anesthesia management through maintaining focus on clinical care, clinical service, operations management and cost management.5 Our foundation for excellence in clinical quality is supported by collection of data from every patient encounter that is subsequently embedded in analysis that is indexed against national and internal practice performance benchmarks. This enables us to identify outcomes variation as well as opportunities for practice improvement. Our clinical quality reporting is transparently shared with partner facilities, and this supports alignment of our clinical providers with the performance priorities of our clients and partners.
Our approach for accountability in providing reliable service is supported by the data-driven outcomes program referenced above, as well as by performance metrics/incentives and data garnered through process outcomes analytics created, in part, through utilization of anesthesia information management systems (AIMS) and real-time client satisfaction survey instruments.
EmCare Anesthesia Services also utilizes a variety of provider engagement, risk-sharing and partnership models.5 Accountability for perioperative care is achieved by leveraging internal resources to support high-quality, reliable, cost-effective care delivery. Specifically, EmCare Anesthesia Services focuses on innovation in care transitions and integrated coordination of care between anesthesia, emergency medicine and hospitalist service lines supported by mobile and remote healthcare delivery solutions. We bring telemedicine and mobile healthcare capabilities to the perioperative continuum that extend from sister companies (Evolution Health  and American Medical Response). These resources enhance our capability to generate value through an integrated, multispecialty approach to care coordination. Our focus is to support safety, improve quality, improve satisfaction, and reduce costs through a broad array of anesthesia competencies coupled with locally customized approaches to integrated care delivery that provide innovative solutions across the perioperative continuum.

The Impact of EmCare’s Pre-Anesthesia Testing Clinics
EmCare Anesthesia Service’s pre-anesthesia testing (PAT) clinics have reduced operating room cancellation rates, decreased the incidence of preventable delays in the operating room, reduced operational costs, and increased growth opportunities. The table below (Figure 3) demonstrates baseline performance and performance one year following implementation of an anesthesia-directed pre-admission testing clinic at two EmCare client facilities. Hospital #1 is a regional medical center initially performing approximately 6,500 operating room procedures per year. Hospital #2 is a large tertiary care, sub-specialty referral and trauma center.6

EmCare Anesthesia’s Value Proposition in Perioperative Management
As a leader in anesthesia practice management services, EmCare Anesthesia Services has focused on continuous improvement and versatile expansion of integrated healthcare delivery capabilities coupled with innovative design and implementation of solutions for the current and future priorities in healthcare. Our flexible, yet comprehensive approach to patient-centered care focuses on high reliability, patient safety, quality outcomes and cost efficiency. Through embracing and using the tools of process engineering science, continuous quality management and disruptive innovation, we create an environment for learning and professional development that enables us to attract and retain talented healthcare providers and leaders. This commitment to leading-edge market strategies that promote safety, quality and excellence in clinical performance will enable us to evolve with the changing trends in anesthesia services management, while also allowing us to generate value for the patients, providers and clients we serve.     

Learn more about how EmCare ensures patients are adequately prepped for surgery during our Webinar with Becker’s Hospital Review - Practical Approaches to Improving Patient Pre-Op Preparation - Thursday, September 17 from 1 to 2 p.m. CDT.  >>Click for more information and to register

Dr. Trevor Sutton
Trevor Sutton, M.D., MBA, CPE, is Regional Medical Director of EmCare Anesthesia Services, North Division. He holds a bachelor’s degree in biochemistry from Harvard University, a medical degree with honors from the University of California's San Francisco School of Medicine, and a master's degree in business administration from the Isenberg School of Management at University of Massachusetts, Amherst. He completed his internship, residency in anesthesia and critical care, and fellowship in cardiothoracic and vascular anesthesia at Massachusetts General Hospital, Boston.
1. Berwick DH, Nolan TW, Whittington J (2008). The Triple Aim: Care, Health, and Cost. Health Aff Vol 27, No. 3 759-769
2. Kash B, Clinw K, Menser T, Zhang Y (2014). The Perioperative Surgical Home (PSH): A Comprehensive Literature Review for the American Society of Anesthesiologists
3. Gillis C (2014). Prehabilitation versus Rehabilitation: A Randomized Control trial in Patients Undergoing Colorectal Resection for Cancer. Anesthesiology Vol 121, 937-947
4. Cannesson M, Kain Z (2014). Enhanced recovery after Surgery Versus perioperative Surgical Home: Is It All in the Name? Anesthesia and analgesia Vol 118 (5), 901-902
5. Hicks, M (2014). EmCare’s Approach to Perioperative Management (Presentation) EmCare North Division Leadership Conference Philadelphia, PA
6. EmCare Anesthesia Case Studies (2014). The Impact of the Pre-Anesthesia Testing Clinic Sparks Regional Medical Center (Fort Smith, AR), Baylor University

Sheila McDermott
Probably the only article I have read that is right in the mark with the growing Trends in Peri-Operative Anesthesia Management. This article should be use as the frame work for the new trends in Anesthesia. Kudos to Dr. Sutton for his insightfulness and brilliance as a leader in anesthesia management. You should be the leading force in EmCare's Anesthesia
Accountable Care Implementation.
9/10/2015 1:36:33 PM