It was not unusual for John Natale, MD, to work from early in the morning to late at night at his cardiothoracic and vascular surgery practice in Arlington, IL. A decade ago, the 63-year-old physician might have been at the top of his game. In particular, he was credited with saving five patients' lives through complicated repairs of abdominal aneurysms.
While Natale distinguished himself with one facet of the Hippocratic Oath, he was certainly not as precise in another more mundane code of conduct that touches on every physician's practice: preparing billings and coding.
Natale says he made simple mistakes. The government believes the doctor tried to rip off taxpayers.
Last year, government prosecutors accused Natale of fraud for using CPT (current procedural terminology) codes that allegedly represented more complicated procedures than the surgical ones he performed. By using such codes on operative reports, he would ostensibly collect higher reimbursements as a result.
Natale is now serving the third month of a 10-month prison sentence after being convicted in U.S. district court last November of two counts of making false statements in connection with surgical codes submitted between August 2002 and October 2003. He was acquitted of two counts of Medicare fraud.
Prosecutors and the Association of American Physicians and Surgeons agree that Natale's case should have a profound impact on physicians. They disagree sharply over what that message is.
"The need for deterrence is very strong in a case like this," said U.S. Attorney Amarjeet Singh Bhachu when Natale was sentenced. "A message needs to be sent out to doctors." The sentencing judge, Rebecca Pallmeyer, noted that "accurate coding is of extraordinary importance."
"The message to doctors is not to take Medicare money," Jane Orient, executive director of the AAPS, told me. "If you take it, you must comply perfectly with requirements, and this is impossible. They can't prosecute everyone of course; they could prosecute anyone."
The AAPS has joined in an appeal of Natale's conviction. It said that the criminalization of language used in medical reports would have a profound impact on the practice of medicine.
"The chilling effect caused by this conviction, if upheld, is undeniably profound for many physicians," the AAPS stated in papers filed with the court. "Physicians will now need to practice 'defensive documentation,' taking more time away from patient care in order to double-check and triple-check their operative notes—or say less in their notes—lest a few inevitable errors be used to incarcerate them and destroy their careers."
"This precedent criminalizes false statements in a private setting without any proof of billing fraud and a greater interference with the day to day practice of medicine is difficult to imagine," the AAPS added.
The criminal case stemmed from the surgeries, and coding, that Natale used a decade ago. Natale made "difficult, life-saving operations" and routinely worked extremely long days, but was consistently behind in dictating his operative reports, according to Orient.
Under federal billing requirements, physicians are required to use AMA-copyrighted codes. Natale allegedly incorrectly stated that he had used a bifurcation or Y-graft in repairing an abdominal aortic aneurysm instead of a straight tube graft actually used. Natale made errors in the reports, according to Orient.
For his part, Natale testified that he was instructed to use similar codes if he couldn't pick the right ones.
"These surgeries in question were done 10 years ago, and the doctor was an extremely busy surgeon from 5:30 a.m. until late at night, chronically behind on his operative reports," Orient says.
"When you dictate late, you are more likely to make mistakes, and when you look at the (Natale operative) report, there were mistakes, parts were incorrect. An essential part of the report is difficult to understand, or is easily misunderstood. Doctors aren't all that great at writing. And he just did a lousy job of explaining, but he saved patients' lives. He saved lives and he's in prison."
Orient says Natale made errors in "two of 2,400 operative reports." That, she says, is "apparently now a federal crime, though the doctor's total charges were much less than he could have lawfully billed." She did not reveal the total charges.
The complexity of the coding and the requirements of the physicians didn't seem to be the problem, as far as the sentencing judge was concerned. "It's hard for me to imagine that there was some motivation other than to pad the bill in Dr. Natele's operative notes," said Judge Pallmeyer in her sentencing report.
Since Natale has been imprisoned, Orient hasn't talked to him, but has stayed in touch with his family. Natale is trying to stay busy in prison by teaching GED students, and "reading as many books as he is allowed to have," she says.
Natale has appealed his conviction, but the odds are that "he will probably never practice medicine again," Orient says.
"Who would want to," she asked, "when you can go to prison—for paperwork errors—10 years after you saved patients' lives?"
An acquaintance of mine was diagnosed with throat cancer, and the doctor assured him that, while serious, the road to recovery would be relatively straightforward and uneventful, because it was Stage I, maybe Stage II.
His wife wasn't convinced, and suggested that her husband seek a second opinion. He went to a prestigious hospital for evaluation, and the verdict was Stage IV—much more serious, disruptive, and disheartening, and yes, it was the correct diagnosis.
Indeed, patients are often encouraged to seek second opinions. But how often are the physicians who misdiagnose the patients even aware of their mistakes? More importantly, what can be done to thwart misdiagnoses in the first place?
A surveyreleased by the National Coalition on Health Careshows that physicians may believe that misdiagnosis, in oncology in particular, is far less common than it really is. This illustrates a definite gap in at least the perception needed to overcome such errors.
The survey was conducted by the NCHC, a Washington D.C.-based group of dozens of health care organizations, and Best Doctors, a Boston-based company specializing in physician programs.
Of the 400 physicians who were asked how often they estimate a misdiagnosis or incomplete characterization occurs in oncology, the vast majority, 60.5%, estimated that it happens "zero to 10%" of the time. Yet published research indicates significantly higher rates of misdiagnosis overall, from 15% to 28% of cases, the study showed.
Of the 400 pathologists, medical oncologists and surgical oncologists who participated in the survey, 79 said that lymphoma was the most misdiagnosed or mischaracterized cancer, followed by breast cancer, 53, and sarcomas, 51.
Referring to the findings, Evan Falchuk, vice-chairman of Best Doctors, says that "it's certainly surprising; [it's] a disconnect [between] what scientific surveys show on misdiagnosis and what doctors in the field say."
"We see in our work, [that] patients who are getting an incorrect diagnosis also often are getting an incorrect treatment plan," Falchuk says. "One of the big problems in healthcare is that there is not enough discussion or data evaluation of misdiagnosis after it occurs to help physicians deal with such issues.
As Falchuk sees it, "there's no feedback loop around this issue in medicine."
For instance, while physicians will gather to discuss morbidity issues following a patient's death, or if there's a terrible surgical complication, "the doctors get together as a team and talk about it, what went wrong, what could have been done better," he adds.
For the most part, however, "the actual issues of misdiagnosis are missing." In an alleged misdiagnosis, such as in the case of my acquaintance, "the first doctor may never know, unless it's reported by a patient," he adds. "There's no systematic way to know, unless someone comes back and says, 'Gee, did you hear what happened?' "
Too often, pathology tests related to cancer now are misinterpreted, which is reflected in the difficulties in diagnosing lymphoma. "Lymphoma is so hard to diagnose primarily because the pathologic classification is so challenging," says David Harrison, a physician at Best Doctors. "The classification schemata are quite complex and doing so accurately often requires a good deal of expertise."
While there are many discussions about medical error, in terms of wasted healthcare dollars, the issue of misdiagnosis referring to the stage of an illness, for instance, is not often the focus of reform efforts.
That should change.
Over the past several years, there have been efforts to explain the misdiagnosis dilemma, and its possible causes, such as:
Physicians' overconfidence in their diagnostic abilities
Although statistics are not the be-all-and-end-all, doctors certainly want and need more data if they are to deal with proper diagnoses, the survey shows. At least 38.5% of respondents, the largest segment, named "fragmented or missing information across medical information systems" as among the most significant barriers to accurately diagnose cancer.
In addition, 36% called for "new or improved pathology tools or resources" to help improve diagnostic accuracy rates in cancer cases. That may speak to the need for more "cohesive, precise medical records and record-keeping" among physicians, Falchuk says.
The physicians in the study also called for incentives for hospitals to participate in confidential misdiagnosis data gathering and reporting, perhaps to include it in part of the hospital accreditation process.
Others said that they favor a voluntary misdiagnosis reporting system, and that the National Institutes of Health should study the misdiagnosis issue. Moreover, they say, there should be a greater number of national events and conferences devoted to misdiagnosis.
Years ago, lawmakers and healthcare stakeholders took steps to begin addressing medical errors, and improving patient safety, Falchuk says. But now there's a chance to complete the circle, and to look into misdiagnosis, he says.
The survey findings are an "opening to take firm steps to begin formally measuring and addressing misdiagnosis," he says.
Children's National Medical Center in Washington D.C. this month named joint chief medical officers, among the first hospitals to do so, to handle the "complexities of the evolving healthcare landscape."
When Denice Cora-Bramble, MD, MBA, FAAP, answers her phone at the Children's National Medical Center, she says she's chief medical officer.
So does David Wessel, MD.
What gives? This isn't a new version of the old TV show "To Tell the Truth," but reality at the Washington D.C. hospital, where both physicians hold the title of chief medical officers.
Children's National Medical Center believes it is the first pediatric hospital, if not one of the first hospitals in the nation, to employ joint CMOs. The American Hospital Association, for one, says it has not heard of a hospital having dual CMOs.
CNMC officials are convinced having two CMOs may be increasingly suitable as hospitals continue to deal with what the hospital called the "complexity of the evolving healthcare landscape" and population health management.
What's not surprising is that physicians are playing significant leadership role in this. As Kurt Newman, president and CEO of CNMC said in a recent statement announcing the appointments, the dual CMO posts are designed to help the hospital continue on a two-pronged approach.
One is to develop ambulatory and community health programs to help keep patients out of the hospital; the other is to maintain specialty care when patients do need in-hospital treatment.
Previously, Cora-Bramble was senior VP for the hospital's Diana L. and Stephen A. Goldberg Center for community pediatric health, and acting executive VP ambulatory services. She is now executive VP, CMO for ambulatory and community health services.
Wessel is executive VP CMO for hospital and specialty services, where he will lead the focus on providing the inpatient and subspecialty care. Before taking on this position, he was senior VP of the Center for Hospital-Based Specialties, which includes a neonatology team and one of the only dedicated pediatric cardiac intensive care units in the country.
The two new CMOS reflect an alignment with the realities of healthcare reform, which involves a shift toward value-based models, population health and patient-centered medical homes, and the need to develop surgical models. Working to improve relationships with other institutions and broaden specialties, especially in areas where there is demand for physicians, is another way the CMOs' role is inspired by the changing landscape of healthcare.
Nancy Foster, VP of Quality and Patient Safety at the American Hospital Association says she was not aware of two CMOs at a hospital, but she's not surprised by it by the Children's National Medical Center decision to have them.
"I have not previously heard of two people holding that title, but it is consistent with the trends we see in hospital and health system leadership," Foster says. "Hospital boards and CEOS are assessing what the organizational needs are and constructing leadership teams that will enable the organization to achieve them.
With growing ambulatory care programs, particularly, and the "increasing complexity (in) the kinds of care hospitals can providing without admitting patients," Foster adds, "it is not surprising that some hospitals are re-thinking how to best provide appropriate clinical care leadership in the ambulatory as well as the inpatient environment."
Children's National Medical Center has 303 beds and eight regional outpatient centers, focusing on medical needs ranging from cancer to emergency, trauma, critical care, neonatology, orthopedic surgery and neurology. It includes the Children's Research Institute and the Shiek Zayed Institute for Pediatric Surgical Innovation.
The two new CMOS succeed Peter R. Holbrook, MD, who spent 37 years at Children's National Medical Center. When he left last summer, the hospital released a statement saying that Holbrook's tenure "included significant contributions to the development and recognition of intensive care as an essential subspecialty in pediatrics."
Holbrook made lasting impressions on the hospital. His departure, too, represented a changing of the guard in how Children's National Medical Center, and I'm sure others as well, see the pace and complexity of leadership ahead for physicians, and how they respond within the orbit of the hospital and increasingly within its outpatient satellites.
As a hospital spokeswoman told me, during his tenure as CMO Holbrook "was responsible for clinicians—focused on quality and safety."
The two new CMOs see a much-expanded realm of responsibilities—individually and separately.
In his role, Wessel will be focused on clinical issues, but a hospital spokesman clarifies it a bit: "Much more hands-on in the business of running a hospital/clinical practices, and working with employed physicians to address the realities of a changing marketplace."
That changing marketplace? Wessell told me the hospital is contemplating formulating an Accountable Care Organization.
There is a great demand for outpatient programs in pediatric care, much as there is at hospitals involved in adult care. While Children's National is generating more outpatient programs, it still must broaden its inpatient base, Wessel says. There is a need to continue developing and expanding a variety of pediatric services, wrapped within specialties such as orthopedics to cardio to neurosurgery.
"Specialties are hard to find" in pediatric care, he adds. Those service lines will continue to flourish, reflected in the hospital's recent construction of a 26-bed cardio intensive care unit. "There is an opportunity for enormous advances," he says.
Clinically, while the hospital has made great strides in its delivery of pediatric care, there is always more to do. More than a decade ago, there was a mortality rate of 10% among children having cardiac surgery, Wessel noted. Now it's dramatically reduced to 2%.
"We want to not only have their hearts fixed, but have them contributing to society in an optimal way," he says. "We can continue to learn."
As it stresses clinical improvements, the hospital also places focus on "implementing cost reduction strategies and improving physician efficiency," Wessel says. Like adult care hospitals, the children's hospital is examining ways to reduce the use of CT scans and expose its young patients to less radiation. "It's not needed for every head bump," he says.
"You are killing yourself. You're working too hard." Surprisingly, those were the admonishments from patients, advising their doctor. It was the reverse scenario from medicine-as-usual.
Indeed, Jeffrey H. Graf, MD, FACC, a Manhattan cardiologist and internists, had been struggling with the push and pull of his practice over the last few years. Like many doctors, the 57-year-old physician found his reimbursements were going down, and expenses were going up.
Consequently, his hours were extremely long, and the fun of being in practice was disappearing. Still, he loved his patients and wanted to keep helping them.
Graf thought about going into a full concierge model, where patients pay a flat fee per year. His conclusion: "I looked into the faces of people I knew for a long time and thought: 'I can't do this; it isn't right. So many of my patients would have to leave me, especially those who couldn't afford the program. It isn't the way I want to practice; I can't go [concierge] full-time," he says.
Instead, Graf opted for the middle ground. He is among a growing number of physicians who are dipping into concierge while maintaining a full-time practice, in a scenario that is aptly named "hybrid concierge." A hybrid model allows doctors to merge traditional and concierge programs. This gives them the option to care for patients who rely on Medicare or other government or private insurance programs.
Concierge itself has been growing in popularity, as reflected in a recent Merritt Hawkins' physician recruiters survey. The 2012 findings showed that 6.8% of 13,500 physicians say they will embrace direct pay or concierge medicine within the next three years. A fear of major reimbursement cuts is among the top threats cited by healthcare leaders in the HealthLeaders Media 2013 Industry Survey.
Wayne Lipton, founder and managing partner for Concierge Choice Physicians in Rockville Center, NY, which uses the hybrid model, says the field is growing, but he has no precise numbers. The hybrid model provides services not covered by the patients' traditional insurance by offering comprehensive preventative care and wellness visits, while also ensuring patients can continue to receive care from their chosen physician, Lipton says.
Graf, who has been in practice for 26 years, says he embraced the hybrid model so he could continue serving his longtime, insured patients, some of whom rely on Medicare and Medicaid. At the same time, he could offer specialized service for patients who pay a fee for concierge care, which entails more individualized attention such as longer office visits and more phone calls.
"I am very comfortable with the model," he explains. "I didn't feel like I was putting anybody against a wall, saying: 'You join my program, or you have to leave.'"
"People," he says, "are very happy I'm taking care of them and they are delighted with the options." At the same time, he's feeling the stress dissipate, as his workdays are getting shorter.
Like Graf, the "vast majority of physicians who choose the hybrid [do so] because they don't want to say goodbye to their patients," Lipton says. "Most physicians with us opting for the full model do so because it's a way to prolong retirement. They can slow down, yet still see patients. Or, [they choose it] because they have younger families or other personal needs, and a full model gives them the time they need."
Another compelling reason physicians are seeking concierge is because they are "worried about changes in the market, and they are looking to options such as cash-only models."
Because they don't exclude patients, the hybrid models may offer more options for physicians as well as patients, he adds. It would be up to patients themselves if they want to have the concierge fee plan, or continue regular services.
As doctors divvy up their days, the concierge generally takes more time for each patient, and offers physicians a chance to see fewer patients, and have a thus less stressful practice, Lipton says. That's what Graf is starting to see. Besides offering more comprehensive care, the concierge model has convenient scheduling and shorter wait times, as well as more immediate phone access to physicians, Lipton says.
But hybrid isn't for all doctors, says Lipton. "For a hybrid to be successful, you have to be a great doctor—the kind that patients like and respect so much that they are willing to pay an additional fee in order to access your services," Lipton says.
For Graf, it was, oddly enough, his patients who first came to him and suggested he change his practice model to consider concierge a few years ago. "The thing that got me was about 10 patients over a course of a couple of years who said to me, 'you are killing yourself. You are working so hard. You should think about doing this," Graf recalls.
"When I started in solo practice [in 1987,] it was very different then. Patients were satisfied and doctors were very happy," Graf says. "Reimbursements were reasonable and things went along very nicely. But that evolved over the years, in terms of lesser reimbursements, more and more overhead, less time, more stress. I was looking around and seeing at this point, every single one of my colleagues in solo practice, or at least most of them, either had sold their practices to a hospital, or joined a big group or had given up."
Despite the complications of a physician's practice, he wasn't entirely ready to walk away from it. Besides, he has raised four children. Graf kept talking to patients about the full-time concierge model, and he got differing opinions. Some patients wanted to remain with him, and others didn't.
"I have had a very long relationship with many of these patients," he says. "Offering the hybrid program was the best way to continue to care for all my patients and also ensure my autonomy, while providing my patients with real choices. I have a long way to go in medicine."
While many internal medicine physicians are exploring the hybrid model, specialists are only beginning to embrace the concept, he says.
Graf didn't reveal the number of his patients in concierge or hybrid models. "The number of patients in the Concierge plan is increasing slowly but surely," Graf says. "The hybrid model is working out well. I still have a greater number of patients in my traditional practice."
Graf anticipates that more patients may choose concierge and like the hybrid approach since healthcare reform may mean "many millions more patients and a major shortage of primary care MDs," as well as far fewer medical students choosing primary care as their career path.
"I'm not looking to work harder," Graf says with a laugh. "I want to work better for people. I feel I'm practicing good, old-fashioned medicine and that fits right with everybody."
Physicians are perpetually rushed. They have to see patients, learn how to use electronic medical records systems, and figure out the political vagaries of their own healthcare establishments. And that's all before lunch.
In the back of their minds or, in the worst case, the forefront, there's another nagging day-to-day concern: malpractice. Physicians spend a lot of time dealing with malpractice cases. And I mean a lot.
A Health Affairs report this month offers a startling stat: Doctors spend on average, nearly 11% of their time over a typical 40-year career with an "unresolved, open malpractice claim."
Wow.
"You hear horror stories about the court system and how long it might take to resolve cases," the lead study author, Seth Seabury, a senior economist at RAND Corp told me. "One of the things that surprised us was, over the course of an entire career, how much [of a doctor's time] was spent on unresolved claims. Having a claim outstanding and unresolved, that hangs over someone's head."
Specifically, the RAND researchers analyzed data from 40,916 physicians covered by a nationwide insurer. They found that, over a presumed 40-year career, the average doc spends more than 4 years, or about 50 months of his or her time, with an unresolved malpractice claim.
Seabury, who is also associate director of the RAND center for health and safety in the workplace, and his colleagues analyzed the time physicians spent with open claims, and its impact on specialties, the severity of injuries, and whether malpractice was eventually found. The claims analyzed were from between 1995 and 2005.
Adding to the malpractice delays was the fact that a claim wasn't usually filed until 28 months after the incident in question. And the case wasn't resolved until 43 months after the incidents, often leaving a nagging shadow of the case over doctors and patients alike.
"Claims involving high-risk specialties can take an extremely long time to resolve, and some don't even result in actual compensation for the patient," Seabury says.
The report shows that pediatrics and obstetrics cases took the longest to resolve. Birth-related neurological damage cases often take a lengthy period of time to finalize. Neurosurgeons generally spend the most time with open malpractice claims, 27% of a 40-year career, the report shows. Yet, more than 102 months—or 21.13% of careers—were spent with an open claim in which no payment was made.
For physicians generally, claims that did not result in payments amounted to 7% of a four-decade career.
While RAND focused much on the four-decade career, there was some good news. The claims were resolved more quickly for younger physicians, but it was still a time-consuming process. The time to resolve a case was an average 16 months for doctors 30 to 39 years old, compared to more than 20 months for physicians 40 to 49; and 21 months for physicians 50 or older.
Probably to no one's surprise, the report found that malpractice claims involving death or permanent disability took the longest to resolve, about 18 months.
For claims with only emotional injuries, 51% took six months or more to resolve, 35% lasted at least one year, and 7% weren't resolved for at least three years. Meanwhile, for cases involving a temporary physical injury, 49% took at least one year to resolve, and 10% lasted three years or more.
The time of adjudication may be more distressing for doctors than even the potential damages. "Lengthier time to resolution affects physicians through added stress, work, and reputation damage as well as loss of time dealing with the claim instead of practicing medicine," Seabury and other co-authors write.
But there's more to it: if medical errors were truly involved, and yet it takes so long to resolve these cases, physicians may not really learn from any possible errors. They would delay implementing safety and quality measures to prevent similar adverse events, Seabury says. As for the financial issues, "the time it takes may be more stressful than the actual finances," Seabury adds.
There has been widespread recognition among political leaders that malpractice reform needs to be addressed, with a range of calls for tort reform, such as restricting punitive damage awards.
Seabury says the RAND study shows that the effort to address meritless, time-consuming claims needs to be among the top priorities. "There is a movement that recognizes inefficiencies in the system, that it does take a long time to address and imposes more costs on the healthcare system," he adds. Physicians aren't the only ones who suffer in delayed cases. As the researchers note in the report, patients and their families "faced with a lengthy malpractice process also suffer."
Suggestions for reducing malpractice litigation include proposals for special malpractice courts and a push for physicians to make apologies to derail litigation in the first place, if they are possibly liable, Seabury says.
"If the psychic costs of fear and uncertainty are a sizeable portion of the costs of malpractice to physicians, then the portion of physicians' time spent with an outstanding claim helps explain physicians' negative attitude toward the system, beyond the financial costs," the researchers write.
"The psychic burden that physicians in these circumstances bear also suggests that making the system resolve cases faster without sacrificing compensation to patients injured by the negligent care could have important benefits to physicians and patients."
While neurosurgeons spend the most time with open malpractice cases, those involving psychiatrists are over the quickest. Psychiatrists spend the least amount of time with open malpractice claims—a total of nearly 16 months or just over 3% of their careers. No explanation was offered.
Maybe politicians should spend more time on the couch to figure out the malpractice mess, and how they feel about it.
At last count, 12 hospitals have received the coveted designation as "Comprehensive Stroke Centers," a new level of certification for advanced stroke care by the Joint Commission.
The Joint Commission examination process isn't exactly easy, neither on the heart, nor the brain of the physicians and other healthcare leaders being evaluated.
In formal announcements of their accomplishment, nearly all hospitals describe the Joint Commission review using one word: "rigorous."
"They were tough on us," neurologist Bob Carter, MD, PhD, chief of neurosurgery at the UC San Diego Medical Center in California told me in a recent interview, sharing some behind-the-scenes insights about the Joint Commission's in-depth analysis.
"They asked us a lot of hard questions, and pored over records in detail. It was probably the most rigorous [review] I had in 35 years as a neurosurgeon. This was one of the toughest exams we had."
UC San Diego Medical Center is among the most recent recipients of the Comprehensive Stroke Center designation established by the Joint Commission and the American Heart Association/American Stroke Association.
The designation recognizes significant effort in everything from training to infrastructure to providing state-of-the-art complex stroke care. As HealthLeaders Mediareported in November, the comprehensive review process is much more extensive and lengthy than what is required for lesser designations, such as that of a Primary Stroke Center.
Gregory Albers, MD, director of the Stanford Stroke Center at Stanford Hospital and Clinics in Palo, Alto, CA, calls it a tough process. The stroke team leader recalled that the Joint Commission asked how long it took for neurosurgeons to get to the operating room. Albers told them. Then they asked to see the data that proved it.
As Carter told me, the Joint Commission not only evaluates records and outcomes, but also the necessity for "team-based" approaches, as well as proof of the roles that practitioners and nurses play in providing care. In addition, the commission focused on patient safety and patients' understanding of procedures following discharge, Carter says.
What's more, some of the Joint Commission's insightful questions prompted the UC San Diego Medical Center to re-examine their procedures in stroke care, Carter said. In fact, that response reflects how they made their journey toward the Comprehensive Stroke Center designation in the first place.
Several years ago, as they examined their primary stroke care program, officials of the UC San Diego Medical Center found there were gaps in stroke care for the city's aging population.
While primary stroke centers can handle many patients, certain other patients with severe conditions required a higher level of care, which the hospital believed it wasn't providing.
San Diego then took steps to target patients who too often fall through the cracks in stroke care, according to Thomas Hemmen, MD, PhD, director of the stroke program at UC San Diego Medical Center.
"There's a significant proportion of stroke patients who have a really large blood clot in the brain, or they have a brain bleed or a stroke that is so severe that it either [triggers] a coma or seizure," Hemmen explains.
"They need to come to a place where, at the door, all options are on the table. If you need to go to a surgery right away; if you need to go to the cath lab to remove the large blood clot right away or you go to the intensive care unit where a specialized physician who is trained in the neurology of intensive care looks after your brain function."
The UC San Diego Medical Center team's multidisciplinary programs often target the elderly. Four in 10 of its stroke patients are over the age of 80, Hemmen says. An estimated 7 million Americans have had some form of stroke, the fourth-leading cause of death in the U.S.
Treating patients is one thing. Awaiting the Joint Commission's decision on certification is something else. And, Carter admits, that's a little scary. When his organization went through the process, he wondered if it would work out. "They put us through the wringer and made me respect the process more. I think we were confident, but yeah, we were a little nervous."
The Joint Commission, for instance, examined each record of patients with a hemorrhagic stroke. Carter says. "They pored through the charts very carefully and made sure our reports matched up with what their reviews had," Carter says. "That's a level of rigor and detail that you typically would not necessarily get. I thought it was pretty impressive."
The Joint Commission didn't stop strictly at the end result of clinical aspects of care, but it delved into how they got to those outcomes—through the "emphases on team work and process," he adds. The commission made it clear that, for comprehensive care, a successful hospitalization is not the only endgame, Carter says.
"They very much wanted to understand that we educated the patient for discharge, and made sure that patients understood the implications of their strokes and the implication of downstream medical care and the monitoring they would need. They were rigorous and made us prove what we said we were going to do."
There is much talk about alignment in healthcare, not only with physicians, but with nurse practitioners in coordinating care. That was evident in the Joint Commission's review, Carter says. "It wasn't good enough to say, ‘We have a nurse educator.' We had to show what the practitioner did, and they made us prove we did what we said we were doing."
The Joint Commission review also showed that despite the hospital's progress, there were still lessons to be learned, with specific details of stroke care that will continue to be reviewed and evaluated. "They made us look at every process," Carter says. "Is this a necessary process? Or, is this just a historical process that we've done?"
As a result of the Joint Commission's detailed review, the San Diego hospital, for instance, evaluated its use of CAT scans. "We found small things contributing to delays (in care), such as the way the CAT scans were ordered," he says. Eventually, the hospital adjusted its electronic medical record [system] to improve "time and efficiency" in using CAT scans as well as other procedures, Carter adds.
While there are now 12 comprehensive stroke centers, Carter anticipates that there may eventually be dozens more, as well as more than 1,000 primary care stroke centers "when this all shakes out with the Joint Commission."
Unfortunately, not all stroke centers, despite their designation, work together as a team to provide stroke care. That should change, Carter says. All stroke centers need to better coordinate care for stroke patients, especially under emergency conditions. Carter equates such an effort as similar to trauma centers.
"When there's an auto accident, it's immediately known where to send the patient," Carter says, noting that EMS crews immediately decide what's necessary for an injured motorist, and what hospital is equipped to provide best treatment. That's been successful," Carter says. "The same should be done for a stroke patient."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Gerilynn Sevenikar.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"We're getting more cash back from our patients, but the better news we're getting letters from our patients saying how much they appreciate this."
Gerilynn Sevenikar, vice president of patient financial services for the 2,092-licensed-bed Sharp HealthCare System in San Diego sees herself as upbeat, but her optimism was surely tested in 2009. The balance sheets weren't looking good: Collections from the uninsured population were decreasing, while unemployment was increasing in San Diego County. There was so much uncertainty it would not have been surprising if Sevenikar may have wondered if should have chased her early dreams of becoming an airline pilot. Instead, she was juggling so many things as a financial leader at Sharp it was not unlike being an air traffic controller.
Indeed, back in the 1970s, when she started her career at Sharp, she had been thinking of becoming an airline pilot, and in fact, has a pilot's license. Those vocational plans changed, however, as work at Sharp became more fulfilling, and certainly challenging.
When the fiscal climate appeared dire a few years ago, Sevenikar found ways to help the uninsured, or self-pay patient population gain federal or state funding, and also opened the door for Sharp to obtain millions of dollars in payments it would not otherwise obtain. She also has tried to make the bureaucratic process more manageable for patients and more efficient for providers.
One of the key actions that Sevenikar took was helping Sharp team up with Foundation for Health Coverage Education, a San Jose, Calif.–based nonprofit that assists in helping people understand their healthcare eligibility status. Under the collaboration, Sharp initiated the FHCE's eligibility quiz (www.CoverageForAll.org) into the emergency department registration process to reduce the numbers of self-pay patients by finding public and private health insurance eligibility information to help them access to coverage. The effort has resulted in helping more than 32,000 self-pay patients "navigate through a maze" of government health coverage programs, Sevenikar says. Over three years that Sharp has partnered with FHCE and through other internal initiatives, it's recovered $4.7 million in revenue, according to Sevenikar.
As she wades through paperwork and balances the needs of patients and demands of the hospital system, Sevenikar says she understands providers must be tough yet sensitive while seeking payments. Along the way, patients have sent her heart-felt emails expressing "thanks," and some surprised her.
Sevenikar recounted the story of a patient lacking insurance who wondered the kind of reception she would receive at the hospital. Sevenikar and her staff made her feel comfortable. "Upon arrival I was so afraid I would not be seen because I was uninsured; not only was I not turned away, I wasn't treated differently than anyone else," the woman wrote to Sevenikar. "Everyone in the department was very nice, and skilled at their profession."
Such comments make her feel terrific, says Sevenikar. "It means we're making a difference!" she exclaims.
Not every patient is happy, of course, nor would Sevenikar expect that. "There's not going to be a 'thank you, Sharp, for sending me the bill,'" Sevenikar says. "That's not happening. There's always going to be some dissatisfaction."
Still, she takes the lessons from 2009, and is carrying them forward. That year, during the economic downturn, Sharp was tested, like many healthcare organizations. Sevenikar says she started seeing steep declines in self-payments, about $3.4 million in one year. At the same time, there was an increase in self-pay volume, about 7%. That coincided, not surprisingly, with a significant rise in San Diego's unemployment from around 8.7% to 12%.
"I did the analysis and it was truly a reflection of the economy," Sevenikar recalls. "People were just feeling the pain. We looked at how we were handling the process with our patients. We wanted to be sensitive to what they were going through. How were we going to bridge the gap for them? What's the right thing to do? What's the reasonable thing to do." Eventually, she says, "We're partners in this process."
One of the ways that Sevenikar believed Sharp could improve payments was to help patients navigate the system better. She began working with Foundation for Health Coverage Education to help patients consider their coverage options. After reviewing data, Sevenikar says that more than 80% of Sharp's uninsured patients are eligible for some assistance.
"We did the research for patients and we asked what sort of funding programs they could be eligible for," Sevenikar says. "When they came into our emergency rooms, we gave them the information and application and everything they needed to apply for funding, so they can move forward with some kind of assistance."
That focus paid off, Sevenikar says. Within the first two years, payment collections increased 6.5% and 4.4%, Sevenikar says. "We're getting more cash back from our patients, but the better news is that we're getting letters from our patients saying how much they appreciate this," she says.
While Sevenikar already has faced some tough economic hurdles, more financial cutbacks loom. Healthcare reform offers more challenges, including anticipated increases in the uninsured population, Sevenikar adds. For the most part, Sevenikar says, technology will be of overwhelming importance as hospitals confront any potential problems.
"We are moving toward stronger automation, that's what I tell my employees," Sevenikar says. "I tell them embrace technology, become an expert at it, and become invaluable to the organization."
More and more, though, she's knows that patient satisfaction is a crucial element of what she does. "When you are thinking about patient billing and collections, the bottom line is, 'Are you doing the right thing?' "
It may sound like a bus or train depot, but for America's beleaguered emergency departments, the "transfer center" is becoming more popular as potential relief to physicians and health facilities. And it's a just-in-time concept, since finding an Rx for overcrowded EDs is one of the top hospital issues for the upcoming year.
In many cases, physicians in rural areas are using transfer facilities to ensure adequate care for patients who may have otherwise gone to an ED at a hospital that may not have, for instance, adequate ED, neuro, cardio, or orthopedic services to treat severe cuts or head injuries.
So instead of waiting for a long time and clogging up the EDs, patients are diverted to other facilities and where they can readily be treated.
Transfer centers—which are seen as a time- and resource- saver for EDs—may make a dent in patient waiting times, too. The centers channel patients from primary care offices, or clinics and community hospitals, to acute-care settings. In some cases, by calling their physicians, patients bypass the ED altogether and are sent for specialized care by contacting the transfer centers.
Throughout the country, among the greatest challenges in the ED is improving patient flow, as reflected in a HealthLeaders Media Intelligence Report last year. Top healthcare executives said they worried about worsening ED revenue margins and increasing volumes of uninsured patients for the upcoming year.
The transfer center process reduces extraneous calls and time for ED physicians for care, says Rick Newman, director of the Mountain States Health Alliance's medical transfer center. The MSHA includes hospitals, 21 primary and preventive care centers, and numerous outpatient sites operating in 29 counties in Tennessee, Virginia, Kentucky, and North Carolina.
After the health system began a call-center and tentatively started its transfer center in the 1990s, the health system transferred about 850 patients a year. Now it transfers about 1,100 a month, with 10% of admissions impacted by the call center. ED physicians "were begging us to assist them," says Newman, a longtime engineer. "The ED physicians have an easy way to set up the transfers to move patients in and out the door to a higher level of care," he says.
"If anybody presents at the ED in any of these disease states, or in critical condition, the ED physician is going to have to transfer them to another facility," Newman says. "At the ED, there may be a roomful of patients, and some hospitals may not be able to admit them because of their condition, and need to move them out quickly."
Newman says the transfer centers are particularly important in rural areas. In some cases, patients may have "gone to their local ED and they've been seen by a physician and essentially a determination is made they cannot meet the patients' needs," Newman says.
"In Northeast Tennessee, it's very rural, so hospitals in the network may not have orthopedic services available, or they may have no neurological surgeons," he explains. About 60% of transfers are from the ED, he says.
Under the transfer system, usually one call is made, typically to an 800 number, and within an average 30 minutes, the patient is in an ambulance or in a helicopter to another facility, Newman says.
Nurses or physicians help coordinate the transfer center. "The impact on the ED is getting the critical care patient on the way to the other hospital in the quickest way possible," Newman says. "By doing the transfer, we're not tying up the ED physician."
At a receiving hospital, a hospitalist plays a key role in coordinating care. "It involves bringing in a specialist who may be required," he says.
Newman says the MSHA manages the patient transfers and personnel-on call schedules under its program MD Link. Newman says the hospital uses software that allows referring clinics, admitting staff, inpatient nurses, physicians and case managers to be connected.
Some hospitals still operate manually, with phone calling and written forms, and that could spell delays, Newman says.
"It used to take 20, 30, multiple calls to try different hospitals and develop relationships with physicians over the years—a lot of work for the ED physician to line up a transfer. Now they call one number," Newman says. "Before all the transfers went from ED to ED, now we have accepting physicians who don't tie up the ED," he adds.
And that, he says, is a step toward easing the bottlenecks at the ED.
Heading into 2013, the Sustainable Growth Formula issue remains unresolved. Despite the enormity of the SGR, which proposes reduced payments to doctors, it isn't even foremost in the minds of some physicians because of so many other complicated dilemmas.
A few weeks ago, when top officials of The Physicians Foundation went to Washington, D.C., to visit Congressional offices, they were greeted with: "We know what you're going to be talking about," recalls Lou Goodman, PhD, the foundation president, in a recent conversation with HealthLeaders Media. Sure, it was going to be the SGR. If Congress doesn't impose a "doc fix" to avoid significant cuts, the shortfall is pegged at 27% beginning January 1.
Not so. "No, I'm not going to talk about the S-word," Goodman said, shocking them into listening.
Instead, Goodman wanted to talk about the foundation's annual Watch List, covering major issues confronting physicians. The list is based on a compilation of Physicians Foundation reports over the previous year. For 2013, much of the Watch List is focused on ramifications of the Patient Protection and Affordable Care Act, questions about physician autonomy, hospital consolidation, physician administrative burdens, and the impending 32 million more uninsured into the healthcare system, as well as the overall "despondency" and "unhappiness" of doctors.
The SGR didn't make the list because, Goodman says, it is "a symptom of other issues. It is something we have to figure out, and roll into what we do as we go forward." As more doctors become part of hospital systems and payment models such as bundling or gainsharing are evaluated, the "issue of SGR loses its significance, [and] really [becomes] a focus of individuals and private practice," he says.
As Goodman sees it, 2013 will be a "watershed" year. "So many doctors are unhappy and concerned what the future is bringing," he says.
Let's start with what The Physicians Foundation sees as the top five issues facing its members in the upcoming year. And I'm throwing in four concerns of my own, related to quality and clinical achievements.
The "nebulous" PPACA. The foundation sees a swirl of uncertainty around a host of issues that contribute to widespread physician pessimism: accountable care organizations, health insurance exchanges, the Independent Payment Advisory Board, Medicare physician fee schedules.
The consolidation movement. The foundation is worried that while large hospital systems and medical groups continue to acquire smaller/solo practices at a high rate, "increased consolidation may potentially lead to monopolistic concerns, raise cost of care, and reduce the viability and competiveness of solo/private practice," Goodman says. With everything from ACOs to hospital consolidation with practices, "We believe there's a mad rush toward getting bigger," he adds.
The uninsured. As the PPACA expands eligibility for Medicaid and provides tax credits that make insurance more affordable, the Congressional Budget Office projects that 32 million people will have more insurance by 2019. By 2014, companies with 50 or more full-time workers must provide health insurance that the government deems affordable and fair. "As the 12-month countdown to 30 million continues across 2013, physicians and policy-makers will need to identify measures to help ensure [that] a sufficient number of doctors are available to treat these millions of new patients—while also ensuring the quality of care provided to all patients is in no way compromised," the foundation notes.
Physician autonomy. The Physicians Foundation believes that physician autonomy—particularly related to a doctor's ability to "exercise independent medical judgments without non-clinical personnel interfering with these decisions"—is deteriorating. Add to that decreasing reimbursements and liability/defensive medicine pressures. In 2013, "physicians will need to identify ways to streamline these processes and challenges, to help maintain the autonomy required to make the clinical decisions that are best for their patients," the foundation says. Of all the issues facing doctors this coming year, "the erosion of physician autonomy concerns me the most," Goodman says.
Administrative burdens. Increasing administrative and government regulations were cited as one of the chief factors contributing to pervasive physician discontentment, according to the foundation's 2012 Biennial Physician Survey. "We're not making widgets, but providing care and making life and death decisions," Goodman says. "We don't need to be involved in wearing green eye shades, but financial decisions need to be reviewed by doctors. Doctors have to be involved in the conversation."
Overutilization. Whether it's stents, angioplasty, or spine and cardiovascular surgeries, excessive and unnecessary clinical procedures are creating a growing uproar among doctors themselves, as well as academics, and in some cases, government investigators. In a recent speech, Don Berwick, MD, former administrator for the Centers for Medicare & Medicaid Services, said 50% of stenting and coronary bypass surgeries performed today don't resolve symptoms and don't extend life or prevent heart attacks. Stents are under the microscope now more than ever, especially with the recent focus on the for-profit hospital chain HCA in the wake of a New York Times report. Then there's the tendency for physicians to fall in love with expensive medical devices, particularly implantable ones used in cardiology and orthopedic procedures, and the companies that make them. A General Accountability Office report points out potential problems of the physician–device maker connection.
Embrace the data. More than 69% of primary care physicians reported using electronic medical records in 2012, up from fewer than 46% in 2009, according to a Commonwealth Fund report published in Health Affairs. Yet the presence of this technology is among the reasons U.S. doctors are moving out of their existing private practices and toward hospital employment, according to a report from Accenture. For physicians to fully embrace EMRs, health systems must improve record-keeping and quality controls, Goodman says. "From a doctor's perspective, they are being bogged down in collecting information as well as compliance issues," hesays.
Malpractice malady. The HealthLeaders Media 2012 Industry Survey shows that a whopping 58% of physician leaders said they ordered a test for a procedure primarily for defensive medicine reasons in the past year. But their worries may make things worse, keeping mistakes under wraps or encouraging too many tests or procedures
Teamwork. Team-based protocols and efficiency approaches are more and more important today. "One of the problems of medicine is that a lot of people are very stuck in their preconceived notions of what is right and wrong, and things are not as well understood as one would hope," neurologist Thomas Hemmen, MD, PhD, director of the stroke program at UC San Diego Medical Center, recently told me. Another physician leader, Michael J. Dacey, MD, FACP, senior VP for medical affairs and CMO for Kent Hospital in Warwick, RI. told me earlier this year that doctors "must be more collaborative, work as a team. There's a different-mindset."
For physicians looking ahead to the New Year, that about says it all.
Maybe politicians should take a page from this playbook, too?
This article appears in the December 2012 issue of HealthLeaders magazine.
Anesthesiology may be a sleeper in healthcare, in a manner of speaking. While not traditionally regarded among the top service lines, anesthesiology programs are a direct link to a hospital's biggest moneymaker: surgery in the operating rooms.
As much as 60% to 70% of hospital revenues are tied to the operating room, and anesthesia administered in the OR or other parts of the hospital are critical because of their widespread impact, according to Sabrina Bent, MD, MS, clinical associate professor of anesthesiology and director of research at Tulane University in New Orleans.
Yet throughout the United States, when surgeries are canceled at the last minute—often because patients decide to delay or forego the procedure, and sometimes because of scheduling problems in hospitals—it can cost healthcare facilities millions of dollars in lost revenue.
Hospitals are homing in on anesthesia programs to buttress their ORs and improve coordination with patients to reduce delays. They are also initiating changes to improve scheduling and staffing, and overcome bottlenecks in patient flow, which are the result of inefficient and unpredictable OR scheduling.
"Anesthesiologists are the traffic cops" in the OR, says Martin De Ruyter, MD, associate professor in the department of anesthesiology at the 606-bed Kansas University Medical Center in Kansas City, Kan. De Ruyter says effective partnerships with the anesthesia department help improve physician communication and accountability, which directly impacts perioperative care.
That coordination is essential to reducing inefficiencies in care caused by the cancellations of procedures, which cost $1 million in 2009 at the 235-bed Tulane Medical Center, according to Bent. This financial fallout prompted Tulane to take steps to revise its scheduling programs, with anesthesia service a key element for improved preoperative procedures, she says.
For several years, the 866-bed St. John's Regional Health Center in Springfield, Mo., organized programs to improve flow in surgical cases for its 39 surgical suites. Anesthesiology was a major focus of a physician-led committee exploring patient flow, says Jeff Hawkins, RN, MHA, OR administrative director for Mercy Health, which runs St. John's. "There is an oversight coordinator who works hand-in-hand with anesthesia, looking at the rooms, what's open, what's not, where we can put people in," Hawkins says. "There's a lot of communication going back and forth. There is a long list: What did we capture, what did we miss?"
By focusing on OR efficiency and service, the scheduling changes are often coordinated by anesthesiology leaders, says John Herring, MD, the anesthesia medical director at the 280-staffed-bed St. Luke's Hospital, in Cedar Rapids, Iowa, who also practices with Linn County Anesthesiologists. One of the areas that the hospital focuses on is block scheduling, a procedure in which anesthesiologists have flexibility in scheduling to ensure that different ORs are utilized and reducing the number of empty suites on some days and overcrowded ones on others.
"It's beneficial for everyone to improve scheduling processes and define block scheduling," says Herring, noting that there should be efforts to "reduce the unintended but frustrating competition for resources."
Success key No. 1: Avoiding cancellations
Patients forget they have a surgery appointment. They get lost going to the hospital. For whatever reason—or excuse—they may fail to show up for a scheduled operation.
Sometimes hospitals themselves mess up the OR schedules because of lack of bed space or equipment.
The missed appointments and scheduling miscues can have a huge dollar impact on hospitals, with surgeries canceled on short notice. But meticulous preoperative coordination can improve care and reduce the possibility of cancellations, ensuring that patients are medically ready for surgery and have received the proper preoperative instructions for the day of the procedure, says Bent.
In a 2009 study at Tulane University Medical Center, Bent and her colleagues found that cancellations occurred in 487, or 6.7%, of scheduled surgeries at the hospital. That amounted to a $1 million financial loss in one year, she says. The losses showed that there was a need for preoperative clinic visits by patients, which are now mandatory, she says.
Last-minute cancellations may stem from various reasons. More than 30% of patients in Bent's study failed to show up at the time of surgery because of transportation problems, confusion over the date of the procedure, forgetting about the appointment, or for other reasons, she said. Another one-third of the procedures were canceled because of issues at the hospital itself, such as a lack of beds or equipment. "There are multifactorial reasons for cancellations," says Bent.
Scheduling errors also can occur when one piece of expensive equipment is needed in two ORs at once, other equipment fails, or the intensive care units happen to be full, leaving no place for patients to recover following procedures.
The cancellations were more likely among patients who did not have a preoperative clinic visit with the anesthesiologist; nearly 11% of the surgeries were ultimately canceled compared with less than 4% of those that were preceded by a clinic visit.
The canceled cases show the need for preoperative evaluation. Of the canceled cases, 19% had undergone preoperative evaluation and 76% had no preoperative assessment at all, says Bent.
A new scheduling paradigm was established, with a focus on mandatory preoperative clinic visits and stopping cancellations, she says. There was a "concerted effort" among administrators, providers, and fiscal analysts at the hospital to carry out the program, she says.
The hospital initiated a mandatory preoperative clinic visit by patients to ensure proper fasting prior to surgery, for instance, and having their blood pressure monitored or EKG performed. Online educational programs are also available for patients, who are considered otherwise healthy without comorbidities.
While many hospitals and surgery centers have some form of preoperative clinic or evaluation, many aren't mandatory and the compliance of patients being evaluated "is not 100% and frequently a lot less," Bent says. "Surgical referral to an anesthesiologist for a preoperative clinic or to a preoperative online is not consistent." Since Tulane adopted the mandatory program, compliance has been estimated at near 100% among patients and staff, and follow-up studies are continuing, Bent says.
Hospitals also have been historically at fault for needless surgery cancellations and failure to adhere to preoperative clinic programs, Bent says. Surgeons, for instance, have been reluctant to tell patients they should attend such programs. "The whole point is to be able to recognize and treat or otherwise optimize the patient for surgery before the day of surgery," she says.
One of the most important elements in dealing with postoperative care is the variability among specialties. Some surgeries simply have more cancellations or delays, depending on the patients and kinds of care.
"The cost of cancellation varies by specialty, so you might concentrate on the cost of canceled cases," Bent adds. "For those implementing processes, specialties stand to be the greatest in lost revenue."
According to Bent's 2009 study on revenue loss by specialty, general surgery had an average loss per case of $2,000 and a total revenue loss of $200,478; neurosurgery had an average loss per case of $5,962 and a total revenue loss of $41,735; ophthalmology, $2,927 per case and a total of $46,828 lost; and orthopedics, $2,779 and a total of $71,807 lost.
Success key No. 2: Block time scheduling
When anesthesiologists and physicians at St. Luke's Hospital began to look at OR inefficiencies, they didn't have to look far: Surgeons were competing with each other for time and space in the OR. And they experienced a shortage of available anesthesiologists.
As St. Luke's and another hospital tapped into an anesthesiology group, they found that they sometimes had to "take a number" to get a doctor. The anesthesiologists were sent from hospital to hospital as needs arose. Sometimes, one surgeon's need conflicted with another's. Sometimes, there were too many physicians and anesthesiologists available for surgery; at other times, too few. St. Luke's officials knew they were in the midst of a money-losing proposition. The problem, as they saw it, was limited resources and an inefficient scheduling system.
The various demands, particularly on the anesthesiology group, "shot holes in the schedule for the operating rooms at each institution," Herring says. "There was a huge variability for surgical loads at each place. You would have peak times that were difficult to staff and cause the hospital to spend overtime, yet there were low periods, too. Surgeons would compete with each other for personnel and equipment, and there was a need for anesthesiologists as well. For the hospital, it was a costly and very significant dissatisfaction. The anesthesiologists were trying to satisfy the surgeons' needs, not realizing it was creating a disadvantageous position for the hospital. The hospital made it apparent this was a problem and needed the resources to be more stable."
Block time was the solution. With this technique, it is important to coordinate all the surgical equipment needed for a specific surgery but also to involve anesthesiologists. By establishing the block times, office space and surgery space is coordinated for the different physicians, nurses, and anesthesiologists involved in the process, he says.
By utilizing the block schedule, the hospital has reduced conflicts in using the OR and avoided delays in the start of surgery, says Herring. Over the past two years, available block hours—reserved time for specific surgeons and procedures—have increased from 300 to 1,000 per month. The hospital estimates that it has improved overall utilization of the OR, without empty spaces, from 50% to 77% over that time, Herring adds. The hospital also anticipates it can reduce staff attrition by improving the OR efficiency, with an ultimate savings of $2 million in direct cost and the potential for $2 million of savings in indirect costs, Herring adds.
The New Milford (Conn.) Hospital also has used block scheduling to avoid delays and eliminate competing schedules, says Edward A. Zane, MD, chief of the department of anesthesiology and medical director for the OR. Surgeons are held accountable for their schedules and may lose their scheduled surgeries if there are conflicts. But if they are efficient in their scheduling, are high utilizers, and have a high volume of low-acuity cases, they are allotted additional block time, Zane says.
On each scheduled shift, anesthesiologists play a key role, Zane adds. For surgeons, it's important that each day they book their schedules early and coordinate with anesthesiologists. "We work with the surgeons and assign an anesthesiologist to a room each day," Zane says.
Success key No. 3: Alignment
To improve the flow of patient utilization in the OR, St. Luke's Hospital created a perioperative governing council, says Herring, the anesthesia medical director. The key word in the council, he says, is "governing." This group is empowered to dictate OR improvements, so it has clout. That wasn't always the case. Previously, the hospital had an advisory council that made recommendations, but their suggestions for improvement weren't always addressed—and that, Herring says, wasn't good enough.
The perioperative governing council is composed of hospital administration officials, surgeons, and anesthesiologists. Physician involvement and leadership are essential, Herring says. As a result, physician membership originally was assigned and approved by the St. Luke's C-suite and now the committee itself decides its membership. The governing council's decisions are forwarded to responsible hospital personnel and medical staff committees as appropriate.
The council is responsible for scheduling surgery start times, anesthesia schedule management, and block times prior to surgery, with an effort to ease caseloads, Herring says. The 16-member council includes five members from anesthesia, seven members from surgery, and four members from administration as a way to give balance in efforts to improve efficiency, according to Herring. The council also works with a surgery executive committee, which includes the director of surgery, the anesthesia director, the COO, and director of surgical services to focus on start times and set the agenda for the council.
The hospital changed from an advisory to a governing council with physicians to give the group enough power to go forward, he adds. The system was used to complete a block scheduling arrangement in which anesthesiologists, who work for their own groups, sign contracts about their availability with the hospital, Herring says. He characterizes the contracting process as the result of a collaborative effort that defines scheduling and block times.
Although there was initial resistance to the coordinated effort, "we gained a lot of political support as the doctors came to understand what we were trying to do," Herring says. "It began to make sense, to have a focus."
Coordinating care and improving patient flow are often the responsibility of the medical director of the OR. At New Milford, that role is assigned to Zane, chief of the department
of anesthesiology.
As head of the OR, Zane coordinates staff as well as anesthesiologists. He belongs to a physician network, the Western Connecticut Medical Group, which provides anesthesiologists to New Milford Hospital and two other healthcare facilities. Many of the anesthesiologists interchange their role based on the needs of the particular hospital, "matching the supply with the demand," Zane says. "It's very flexible and very good for staffing," he explains. "When it is busy in one place, we can shift staff to another place, if one staff is slow."
Along the way, they built a multidisciplinary team, with anesthesiologists having a key role. As anesthesiology chief and medical director of the operating room, he coordinates staff. "It's an OR team, and that's an important factor," Zane says. "We're a team."
Success key No. 4: Pain management
In many surgeries, postoperative pain is a particular concern for patients, physicians, and hospitals. Severe pain can result in readmissions, which is undesirable for the patients and costly for healthcare facilities. To help eliminate postoperative pain, anesthesiologists are using peripheral nerve blocks that can enable patients to move quickly into physical therapy, with less need for to take narcotics and opioids, says De Ruyter of Kansas University Medical Center.
The process involves using peripheral nerve catheters to ease postoperative pain for patients following orthopedic surgery. The catheter is a threadlike tube that provides a continuous infusion of anesthesia for pain relief that lasts up to three days after procedures. Nerve-block anesthesia has been used to alleviate pain in breast cancer surgery as well as kidney stone and hernia removals.
In a study of 510 patients treated over a three-year period, De Ruyter says he found that a peripheral nerve block can provide satisfactory analgesia for several days after orthopedic procedures, particularly in outpatient settings. Of the outpatients studied, the average duration of the catheter infusion was 2.3 days, and "no patients reported falls or difficulty in removing their catheters at home," De Ruyter says. In addition, "they actually participate in physical therapy more quickly, and we have less [use of] narcotics and opioids," he notes. "There's a high degree of patient satisfaction: ‘Hey my leg doesn't hurt. This is great! Let's do it again.' And then they want the other leg [operated on]," De Ruyter explains.
While some hospitals have reported success with peripheral nerve blocks, they are less commonly used for outpatient surgical procedures because of potential catheter-related complications and patient difficulty in having access to a physician outside the hospital after being sent home.
Communication via the phone appeared to be enough to monitor the patients in De Ruyter's research. He studied patients who had undergone foot and ankle surgery between 2008 and 2009 who were offered at-home analgesic therapy. The anesthesiologist contacted each patient daily while the analgesic was in place to "assess the efficacy and safety of the block," De Ruyter says.
"The once-daily telephone contact with patients was adequate. There was minimal impact on the anesthesiology care team, and patients or caregivers were able to reliably remove their catheters at home," he says.
Reprint HLR1212-7
This article appears in the December 2012 issue of HealthLeaders magazine.