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OR business
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quickly. Scoring an " early win " can
energize a PSH initiative and set the
stage for rapid growth.
It is helpful to understand how pioneering
hospitals have launched a
PSH. Common starting points include
orthopedic surgery (especially for joint
replacement), colorectal surgery, gynecological
surgery, cardiac surgery (especially
for bypass procedures), and
bariatric surgery.
Other PSH programs have begun
with a focus on general surgery, pediatric
surgery, urology, gynecologic oncology,
spine surgery, or neurosurgery.
Recently, we have also seen several
hospitals target elective Caesarian delivery
for their initial foray into the surgical
home model.
Difficulty with designing PSH
protocols
A surgical home initiative might involve
dozens of units and hundreds of individual
stakeholders. It can be challenging
to get everyone on the same page regarding
clinical protocols and pathways.
The best way to overcome this obstacle
is to establish a PSH Steering
Committee (PSHSC) to lead all clinical
decision making. An effective PSHSC
includes clinical stakeholders-surgeons,
anesthesiologists, and nursing
leaders-plus representatives from key
support systems, such as presurgical
testing, pharmacy services, laboratory
services, radiology, central sterile processing,
information technology, human
resources, and social services.
The main job of the PSHSC is to
develop standardized protocols covering
the entire spectrum of perioperative
care for the targeted service line. For
example, clinical protocols for a joint replacement
surgical home might include:
* standard preoperative processes
that cover scheduling, lab testing,
prehabilitation classes, medication
management, and nutrition orders
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OR Manager | April 2020
* intraoperative protocols such as
multimodal pain control, regional anesthesia,
nausea prophylaxis, normothermia
safeguards, and a jointspecific
infection prevention bundle
* optimized postoperative care, including
early ambulation and opioid-sparing
pain management
* a standard postacute pathway that
ensures early discharge, physical
therapy, consistent communication,
and fully integrated joint-specific
home care.
The PSHSC should also establish
metrics for monitoring surgical home
processes and outcomes. A sample
dashboard illustrates how a PSHSC
could use a key indicator report to monitor
PSH performance (sidebar, p 19).
Although it may seem as though
the surgical services executive committee
(SSEC) could take charge of a
PSH, launching a surgical home is a big
enough project that a separate committee
is needed. In addition, a surgical
home requires involvement from stakeholders
who are not part of a traditional
SSEC (eg, pharmacy). Further, we recommend
launching a PSH with just one
service, so putting it under the charge
of a multiservice SSEC can lead to confusion.
In short, the PSHSC can report
to the SSEC, but it should always be a
separate entity.
Uncertainty about how to roll
out the model
In some hospitals, the prevailing
change management culture favors
large-scale rollouts. For a complex surgical
home initiative, however, a largescale
" go live " is not advisable. The
PSH model is a very hands-on approach
to patient care that requires a lot of
flexibility. Initiatives that start small and
scale slowly have the best chance of
success.
We recommend a " rule of one " approach.
After PSH clinical protocols
have been established, test the model
with one surgeon and one patient, and
review the results. Data from even a
single patient will show how the pathway
works in real life and generate insights
on how to improve the model.
Continue to test, review, and iterate
with successive patients. Once the
model is working successfully for one
surgeon's practice, expand it to other
members of the surgeon staff.
Difficulty with getting surgeons'
buy-in
A surgical home initiative will usually
require some changes in clinical practice
and patient time commitment, so
surgeons may resist participating in the
model.
One solution is peer education, especially
from the surgeon champion who
is spearheading the surgical home initiative.
If coaching fails to persuade a
surgeon to adopt a key protocol, consider
escalating the issue to the SSEC.
Ultimately, however, surgeon buy-in will
stand or fall based on clinical results.
As a surgical home begins to deliver
better outcomes and prevent complications,
even skeptical surgeons will willingly
adopt new protocols.
Another solution is to establish a
comanagement agreement. Comanagement
can be complex, but it is essentially
a contract that allows physicians
to be rewarded for improving patient
care and reducing costs.
One component of a comanagement
agreement would be hourly compensation
for taking part in PSH management
activities, such as planning protocols,
reviewing performance, and working on
continuous improvement. (Hourly compensation
is based on independently
determined fair market value for physician
work input.) The other component
would be a performance incentive tied
to improvement on baseline metrics for
quality, outcomes, and costs.
A comanagement agreement is a
flexible way to align physicians with the
PSH model. Performance metrics can
be customized to the particular goals
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