If your hospital is like many hospitals in the US, a large number of your elective surgical patients are being added to the schedule with very short lead times, often less than 72 hours. Patient preparation, which should include a completed chart, pre-authorization, and patient counselling activities, is nearly always a last-minute affair.
Traditionally, this ‘nick-of-time’ system has resulted in an excessive number of patient cancellations and delays, inconsistency in patient care, lost revenue, and most importantly patient dissatisfaction. Indeed, hospitals badly lag most industries in creating a customer friendly, high-quality environment. This has led to the continued out-migration of procedural care to ambulatory and office settings.
Why have hospitals permitted a system that produces these serious problems to continue? The answer lies in a century-old hospital-physician relationship. Because they bring in the majority of revenues, hospitals have traditionally viewed the surgeon as the customer. To maintain surgeon loyalty and their procedural volume, the conventional refrain of a hospital administrator was, “any patient, any time!” In this environment, hospitals have allowed surgeons and their offices to dictate patient preparation practices, with the hospital left scrambling to deal with last minute problems.
With its dramatic effect on both hospital and surgeon revenue, the COVID pandemic has dramatically accelerated the movement towards a new hospital-surgeon-patient relationship. The need to rebuild procedural volume while allaying patient concerns has shifted the focus onto patients and payers as the primary “customers” of surgical services. In this new environment, high-value patient care, along with high patient satisfaction, is now a mandate for successful hospital emergence from the pandemic.
A major element of this realignment is developing an elective patient scheduling and preparation system that is timely, consistent, measurable, and customer friendly. Working with our clients and using guidance from the American College of Surgeons[i], Surgical Directions is now implementing a “72-hour rule” for elective surgical patients. This rule states that the elective surgical patients will have all elements of their preparation complete at least three business days prior to the day of surgery.
Adapting to this system requires close oversight and, as appropriate, intervention to address compliance issues. Components and expectations of this system should include:
- Improved surgeon/office communication and cooperation. This is essential for creating a more centralized and consistent process.
- Enhanced coordination via a daily operations huddle. The huddle proactively reviews patient preparation 3-5 days in advance. This multi-disciplinary group, working closely with surgeons and their offices, ensures that all elements of patient preparation are addressed.
- Completed pre-anesthesia testing (PAT) at least 72 hours prior to surgery. This necessitates a system that has the mandate and resources to do the work, including a completed chart with signed consent, patient history and physical, lab work, consent, and physician orders.
- Implemented testing guidelines for patients having surgery. Hospitals are requiring patients to be COVID tested prior to surgery. This is a challenge for patients who must make a trip to the hospital to be tested 3-5 days prior to surgery. It remains unclear how long this guideline will be in place, but for today it is another requirement that hospitals have mandated.
- Dedicated resources for a hospital financial unit. The unit will complete both hospital and surgeon preauthorization (when appropriate), patient financial counselling, as well as deductible and co-pay negotiations at least 72-hours prior to surgery.
- A well-designed patient engagement technology. Using either the hospitals EHR, or a third-party solution (e.g., Twistle, etc.), this technology has become an essential part of communicating and managing all aspects patient preparation and education. Patients need to be encouraged to register with the solution as this will help patients be better participants in their care. The engagement solutions provide a mechanism for both patent preparation and contact.
- Provisioned data and analytics to monitor operations. Effective tracking of the quality, efficiency, and productivity of procedural services requires the IT department, working with the front-line teams, to develop data and analytics that provide all parties with monthly updates on progress and performance.
- An educated physician office staff. The office staff will need to modify their processes to comply with timely report submission to the surgical site and for patient instruction via communication tools. The patient PAT nursing assessment and preop instruction call should be scheduled in the same way patient onsite PAT visits were done. Patients can drive the time by scheduling the call just like a face to face appointment except it is either via phone or virtual. Traditional PAT department hours may need to be expanded to meet the needs of their patient population. This could include working early evenings and Saturdays.
- An active Surgical Services Executive Committee (SSEC). Managing timely elective patient preparation requires a multidisciplinary leadership team that includes senior administration, surgeons, anesthesia and nursing leadership. This committee, using data and analytics, provides oversight, accountability and guidance for the elective preparation process.
With a culture that has been habitually resistant to significant change, the economic stress of the COVID pandemic, combined with an emerging payer insistence on both high value and customer friendly care, requires timelier patient preparation that is not only possible, but imperative.
Surgical Directions is working with hospitals and surgeons to redesign, centralize and improve perioperative processes. We have found that implementing a “72-hour” rule for completing elective patient preparation is being accepted by surgeons. Their desire to maximize elective patient satisfaction and care, driven by both patients and payers, is driving this new more cooperative approach.
In summary, timely elective patient preparation is a must for the future success of the US hospital. The cost of implementing this new patient-centric system is far cheaper than the cost of maintaining the traditional surgeon-centric approach. In this scenario, everyone wins.
[i] M. Mohamed et al., Non-Elective Surgery Triage (NEST) Classification: Validation on an Acute Care Surgery Service, American College of Surgeons, Reference No.: 107304, Session 22, 2015