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Episode Overview
LISTEN TO THE EPISODE:
Host:
Daniel J. Marino
Managing Partner, Lumina Health Partners
Guests:
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Alex Hannenberg, MD
Senior Research Scientist, Ariadne Labs; Principal Consultant, ORDx&Rx Surgical Safety Solutions
Arthur Boudreaux, MD
Former Chief of Staff, UAB Medicine at University of Alabama at Birmingham
Daniel Marino:
Welcome to value based care insights. I'm your host, Daniel Marino. As I've mentioned time and time again on the program, I spend quite a bit of time in our consulting practice networking with a lot of hospital leaders around the country. And there continues to be a theme with many hospital leaders, particularly CFOs, where they recognize that there's opportunities to improve their overall efficiencies within their OR within their operating rooms, improve overall surgical services. But many of them struggle with understanding where some of that improvement would really need to come from. And, a lot of times, they're not even sure what the opportunity is. What they do here is that there's challenges from the medical staff related to perioperative services. They may have a maybe the chief of surgery coming into their office or to the CEO's office, and complaining about how inefficient the or is, or maybe we're late on our 1st time start, which is backing up the whole day, and it has such economic impact to the organization. And as I'm talking with folks around the country, oftentimes they're not really sure where to even start in in improving perioperative services.
Well, I I'm really excited today to have 2 wonderful gentlemen join us on the program. With a tremendous amount of knowledge and expertise in this area. The 1st is Dr. Alex. Hannenberg. Dr. Hannenberg was a 2,010 president of the American Society of Anesthesiologists. He served as the chief quality officer and oversaw the Perioperative Surgical Home Initiative. He's also the adjunct Clinical Professor of Anesthesiology at Tufts University Medical School, or Tufts University School of Medicine. As well, we have Dr. Art Boudreaux. Dr. Boudreaux is Professor of Anesthesiology and Perioperative Medicine at UAB Health Services Foundation. He's also an anesthesiologist and a physician executive, and has served previously served as the system chief of staff at UAB Medicine. Gentlemen, welcome to the program.
Dr Alexander Hannenberg:
Glad to be with you, Dan.
Daniel Marino:
So, Dr. Hannenberg, maybe we could start with you as you work as you work with hospitals and health system leaders and physician executives around the country. As I mentioned many of them. You know they're struggling with their perioperative services. Where do you see some of the biggest challenges occurring within the or within perioperative care?
Dr Alexander Hannenberg:
Yes, I would park most of the issues we confront under the heading, Unwarranted Variation. And that is meant to say that you have multiple surgeons and proceduralists and multiple anesthesiologists. In many instances, everybody doing their own thing. And it is an inescapable truth that in that situation not everybody is doing it the best way, and not from the point of view of patient outcomes or institutional efficiency. So therein lies the opportunity to try to get all of the above-mentioned players aligned, and deciding how we are going to do that. And the we can cross, you know, different private practices, different departments, and so forth.
Daniel Marino:
Yeah. So you know. And that makes a lot of sense to me. You know, I used to manage a number of physician practices years back, and one of the things that you know, I learned early on in my career was, physicians have different practice styles, right? So they have different ways of being able to practice, that's important to them. But it does create some clinical variation, and it does create a lot of inefficiencies, and especially when you think of perioperative care that inefficiency really does drive up costs and really does have a negative impact on patients. So, Dr. Boudreaux, when you're when you're working with organizations. What are some of the metrics that are important as we start to think about identifying these inefficiencies? Obviously some of these metrics are leading into a lot of increased costs. But what are some of the things that you look at?
Dr. Boudreaux :
When we look at metrics of inefficiencies, such as the number of cases that are cancelled on the morning of surgery or delayed, because, an anesthesiologist or a surgeon doesn't believe that the patient has had an appropriate workup before the operation. Length of stay, readmission to the hospital because of surgical complications. Those are kind of metrics that we look at.
Dr Alexander Hannenberg:
And those, and those obviously are the things, because, as you say, Dan, there are huge costs associated with them, that handicap performance and value based purchasing arrangements also because everybody's doing something different. The surgeon doesn't know what the anesthesiologist wants to do and vice versa. And there's a potential for conflict there. And to the extent that everybody knows what's meant to happen. Conflict is reduced, and culture is improved.
Daniel Marino:
So when you, when you bring when you think about some of those metrics, and you think about some of the inefficiencies. Yeah, and not that we want to point fingers. But is it more? Is it more influential to have the surgeons being very aware of some of these metrics? Or is it more influential to have the anesthesiologists be aware of these metrics? Or maybe it's both bringing them both or both groups together, to say, Hey, look! The only way we're going to become efficient is to really begin to begin to collaborate on what a what we would consider a best practice approach.
Dr. Boudreaux:
If everybody believes that they're if everybody believes that they're on the same page and the patient gets a standardized best practice type of care we will eliminate, eliminate a lot of the delays and the problems that happen on the morning of surgery.
Dr Alexander Hannenberg:
And to your point, Dan. Both the anesthesiologists and the surgeons hate those delays and cancel a cancellations, and to the extent that they have a shared financial interest in value based performance. They also hate it for that reason.
Daniel Marino:
Yeah, absolutely. I mean, you know, if you have the anesthesiologist there, and the surgeon comes in late to a case right? Then, you know, that's excess time that they're not able to perform, or to bill around it, and vice versa. Right? So I agree with you. I think it really does come down to creating the efficiencies of the overall process. So when you think about that, and you think about kind of bringing these groups together. What are some of the guiding principles that are important to creating some of these efficiencies? Dr. Handenberg? Any thoughts.
Dr Alexander Hannenberg:
Yeah. Well, I think to the extent possible of sharing the evidence. To inform best practices is an important key to getting people on board, and it is not always possible to pull out a published practice guideline on every question but even locally vetting ideas about how we want to do something is a critical part of getting the adherence to a standardized protocol. And you know, let's not forget that most of these protocols and everything we're really talking about has a lot to do with avoiding preventable harm to patients and improving outcomes. And that's why we all chose the careers we chose.
Daniel Marino:
Right. Well, at the end of the day it's patient outcomes and patient safety, right? And I mean, that's really what's driving it. So when you when you talk about these guidelines, how important is the data, right? How important is the data to really understand where some of our inefficiencies are? Or does it really just come down to understanding process and trying to hear to the guidelines to support the process? Dr. Boudreaux, any thoughts.
Dr. Boudreaux :
Well, I think like in our institution. When we develop a protocol or a process for care, let's say if a patient is having surgery, and they take a diuretic in their serum potassium is within a certain range. We, as a as a faculty, agree that we will do the or proceed with the anesthetic. If the theorem potassium is within a certain range, and all of us have agreed to that, and we looked at literature to support whether that is a good idea, or that improves the care of a patient. So we have we have all gotten together on a numerous things like that, and agreed what we will do going forward.
Daniel Marino:
So you have your clinical outcomes. You have your clinical measures right that are supporting good, patient care, which is absolutely key. How about some of the operational measures are there operational key performance measures that you look at that really drive some of the performance or identify the inefficiencies.
Dr Alexander Hannenberg:
Well, I think the frequency of complications we've already mentioned. Things like same day cancellations, utilization of post acute care, optimize a patient meaning, identify problems and address them before surgery reduces complications, improves recovery. And one of the big financial outcomes of that is reduction in the utilization of post acute care. So those and readmission for sure, avoiding never events. There are lots of metrics to use, most of most of which, really come back to having the patient to the best possible condition they can be in before you take them into that operating room. So it's 2 parts. Let's make sure we identify problems early in the process at the moment surgery is contemplated and then go beyond that to say, Okay, we've identified, you know, poor diabetic control or anemia, or what have what have you? And there's quite a list, and we have a lubricated process for getting that addressed and fixed to the extent possible, so that the surgery can proceed in a timely fashion.
Daniel Marino:
If you're just turning in today, I'm Daniel Marino you're listening to value based care insights. I'm having a great discussion with Dr. Alex Hannenberg, Dr. Arthur Boudreaux, and we're talking about opportunities to enhance perioperative services within the hospital ORs. And Hannenberg, let's just build on that for a second. So when you start to identify some of these clinical outcomes, some of these opportunities and even some of the inefficiency outcomes there. What are some of the solutions or the steps you want to put in place to create the right solution around the efficiencies? Are there models that are out there? We had mentioned best practice. What are some of the things that you look at to kind of drive this level of improvement in perioperative care?
Dr Alexander Hannenberg:
The optimal arrangement is a predictable and agreed upon model for flagging and identifying problems. For knowing what to do about the about them and delivering on that in a reliable fashion. One thing I want to emphasize is, as I said before, you can think about anemia diabetic control respiratory, respiratory capacity and reserve. There's a long, long list, and there's a lot. A great variety of surgical procedures. One thing that I see as a successful approach is not a biting off more than you can chew. To say. We can choose in the total joint population to launch this kind of initiative around diabetic care.
Daniel Marino:
Right? Well, and there's many organizations around the country who have I think, have started to really become quite proficient in implementing a lot of these best practices. I don't think they have to reinvent the wheel right? So there's standardized best practices that are out there that I think organizations can turn to. Dr. Boudreaux, when you're when you're having conversations with folks. You know. We've heard some pithy names around, for instance, like the Surgical home, or you know, other types of ways of being able to characterize some of these best practice approaches. What are some of the things that you've seen as organizations are turning to looking at some of these standardized best practices?
Dr. Boudreaux:
Well, we look at the concept of the perioperative surgical home, or enhanced recovery after surgery is pretty popular around the country nowadays, and both surgeons and anesthesiologists realize that if we implement these standardized best practices for each patient that is, having a particular procedure, their outcomes would be better, and their efficiencies in the operating room will be better. As an example, let's say, a patient comes to have surgery for a total joint replacement, a hip replacement, and we recognize in the preoperative evaluation that they have out of control diabetes. Well, we know from the literature that those patients have a higher incidence of post-operative infection, reoperation or joint failure, and the like. So we can recognize that we can do something about it, gain better control of their diabetes, or, you know, postpone the operation for that to happen. And the surgeons are now all coming on board with that concept. We're all trying to work together to get the best outcome.
Daniel Marino:
So, Dr. Boudreaux, when you, when you're talking through that, how important is the governance structure that you put in place to? I guess both align the surgency anesthesiologists around what that best practice is, but I would assume then to monitor it ongoing so you continue to improve?
Dr. Boudreaux:
Well, governance is really important, and one of the ways that you can do that you can get a group of physicians together. A group of surgeons, a group of anesthesiologists, a small group. And have them get together and agree and look at the literature, agree on what they think a best practice would be for a particular operation, and everybody gets on board with that best practice and starts to implement. And what has happened? What has happened in our institution? At least the patients that go through this standardized process their outcomes are better.
Daniel Marino:
Yeah.
Dr. Boudreaux:
And their cancellations for fewer, and all the other surgical colleagues start noticing that. Hey, those guy, those patients are doing better than mine.
Daniel Marino:
Right, yeah.
Dr. Boudreaux:
And everybody now wants to get on board with that.
Daniel Marino:
So there's really a culture change that that you need to really integrate as well as then the monitoring component right. And all of that really needs to be built into the overall governance structure. I would assume.
Dr Alexander Hannenberg:
Yeah, it's governance structure. And it's what I would call clinical leadership that is influential thought leaders in a surgical domain need to be the champions, and that goes a long way to launching this in the right way and promoting adherence.
Dr. Boudreaux:
And the hospitals have to. The hospital administrator has to recognize the benefit of this and to be willing to help fund it.
Daniel Marino:
And help support it. You are absolutely right. And in a lot of my conversations that I'm having many of the hospital leaders, whether it's the CEO, or it's the CFO, you know, even the COO right that's in charge of operations. They're all willing to support it. But a lot of times either the medical staff politics get in the way, or they're not sure where to start. Having them part of that process. I think it needs to be physician, or, you know, certainly, physician led, but administratively supported. I think, as you as you pull that model together, that's what's going to drive a lot of the change.
Dr. Boudreaux:
I hear him.
Dr Alexander Hannenberg:
Have having a hospital administration understand the downstream benefits that come from a legitimate investment in putting this together is absolutely critical. You're a thousand percent right.
Daniel Marino:
Dr. Hanneberg, you know, as you're you know, you were past president of the American Society of Anesthesiologists. You've seen the role of the anesthesiologist sort of evolve over time. What should their role be in this level of governance? In in some cases, what I've heard in talking with some of our anesthesia colleagues around the country. I mean, some of them feel strongly that you know they should be the ones that are really influencing some of these governance structures and perioperative care, or even running the board, if you will. Any thoughts there on where anesthesiologists, the role that they should take in moving this forward?
Dr Alexander Hannenberg:
Well, the bi the bias will be obvious, but what I would say is that the training of an anesthesiologist focuses a great deal on the medical management of surgical patients, number one. And number 2. Anesthesiology is the single common pathway for all surgical or increasingly procedural care patients, that that is that the anesthesiologists take care of the cardiac patients and the orthopedic patients, etc, etc. And so that alone, I think, suggests that there's a logical role for the anesthesiologist at the core of this work.
Daniel Marino:
Yeah. Well, my question was definitely meant to be a little biased there. But I love the answer nonetheless. But how important, then, is aligned incentives between the anesthesiologists and the surgeons.
Dr. Boudreaux:
Aligned to incentives are always important. I think all of us want to take the best care of patients that we can. We want to do it in the most efficient way possible, and we want to all have great outcomes. And I think if we all agree to that. And we work toward that goal We'll accomplish that outcome.
Dr Alexander Hannenberg:
And so they're those are one type of aligned incentives. But you know, if you are living in a value-based purchase purchasing or capitated ma model. It is, you know, natural extension to build financial performance measures around some of the things we've been talking about.
Daniel Marino:
Yeah. And that's really what my thoughts are. As well, too. I think you need to have some aligned financial incentives there, right? And there's different models that you can structure. But you know, form follows function. So if we have an idea of where we want to go, we're able to measure it. The incentives help us to get there, and they could be multi level of incentives.
Dr Alexander Hannenberg:
So I mean, the only thing I'd say I'd say I'd say is, I don't need to remind you that time is money. A lot of what we're talking about is waste, you know, avoiding wasted time. There is just under the surface a financial incentive, even without a, you know, a capitated environment.
Daniel Marino:
Well, and there is. I mean there's that financial incentives for the surgeons, but also for the hospitals. Right? So if you do this the right way.
Dr. Boudreaux:
Right.
Daniel Marino:
It would be a just, a natural collaboration around that level of incentives. Well, gentlemen, this has been fantastic. Last quick question for both of you, and maybe we could start with you Dr. Boudreaux. As organizations, as hospitals are thinking about taking a look and improving their perioperative care. Perioperative services, in your opinion, where should they start.
Dr. Boudreaux:
They should pick a procedure, for instance, that they do the most of.
Daniel Marino:
Yeah.
Dr. Boudreaux:
Or a procedure, a procedural area where they're having problem the most problems. And they could, they should focus on that area 1st and get physician leaders involved in in this standardization process and try to fix those areas first. And once you succeed in fixing a specific area, it becomes contagious.
Daniel Marino:
That really will drive the change.
Dr. Boudreaux:
Right.
Daniel Marino:
Yeah, so. And from your perspective down, Dr. Hannenberg, how about from the from the physicians? Where do we start on being able to bring the anesthesiologists, the surgeons together to really drive this change?
Dr Alexander Hannenberg:
It is leadership and persuasion. The problems that drives you nutty every day understanding that what we're talking about is the solution to those problems.
Daniel Marino:
Yeah.
Dr Alexander Hannenberg:
And if that doesn't motivate the physicians and everybody who works with them frankly, the administrators, the nurses, and so forth. I don't know what will. But connecting those dots, the delays, the cancellations, the unplanned admissions, etc, and connecting that dot to why is that happening? Because we didn't do anything about the anemia or the diabetes, or whatever, because we didn't recognize it. And we didn't have a organized system to address it. I think that's the key to putting this together. We suffer problems every day, and our patients do as well.
Daniel Marino:
You need to connect those dots right, and bring the folks together to look at where the challenges are, and then be very forthcoming in addressing them. Well, gentlemen, this has been fantastic. I really appreciate your time. And if anybody wants to connect with you. You know your organization that that you work with is ORDX. It's a perioperative consulting firm and should they go to your website, maybe you can give the website, address, or something in that regard.
Dr Alexander Hannenberg:
That's an efficient way. Because art and I work with ordxrx.com is the website. And it is a multi professional surgical nursing, anesthesia collaboration to address problems such as the ones we've talked about today.
Daniel Marino:
Yeah, well, it's a definitely a great organization. And I've enjoyed the number of conversations that you and I have had, and all of us have had, and certainly with your colleagues. I want to thank you for joining us today, and if anybody, any of our listeners specifically want to connect with either Dr. Hannenberg or Dr. Boudreaux. Please reach out to me directly at Dmarino@Luminahp.com, and I'll be happy to direct you. But, gentlemen, thanks again for your time. I really appreciate it.
Dr Alexander Hannenberg:
A pleasure. Thanks for your interest.
Dr. Boudreaux:
Thank you.
Daniel Marino:
And I want to thank you, our listeners, for tuning in until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.
About Value-Based Care Insights Podcast
Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners
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