Components of Comprehensive Preoperative Risk Assessment

There is growing recognition that proper preoperative preparation goes well beyond the anesthesiologist’s assessment of anesthetic risk. With the advent of new anesthesia techniques, innovative drugs, enhanced training, pulse oximetry, and capnography, anesthesia-related mortality risk has declined sharply over the past 40 years. Contemporary estimates of mortality solely attributable to anesthesia are quite low (1 in 100,000) [13]. Conversely, all-cause 30-day surgical mortality for elective non–day surgery approaches 1 in 50 [14]. Understanding and identifying the factors that contribute to patient perioperative risks is the first step towards proper preoperative preparation.

Risks associated with surgical hospitalization can be divided into four categories: (1) patient factors; (2) surgical factors; (3) anesthetic management; and (4) care coordination. The overarching goal of preoperative evaluation and management, therefore, is to identify risk factors from within these categories; implement risk mitigation strategies; and communicate information broadly to all members of the healthcare team in a systematized fashion.

Various Models for the Delivery of Preoperative Care

Surgical patients, even those with significant comorbidities, are seldom admitted to the hospital in advance of their procedure for preoperative care. Instead, preoperative assessment and risk management occur in the outpatient setting for the vast majority of patients. Four models for preoperative assessments exist: (1) the patient visits a preoperative clinic days in advance of their procedure; (2) a telephone interview is the sole basis for the evaluation; (3) the patient is seen by the primary care provider; or (4) an evaluation is performed at bedside, day-of-surgery, in the preoperative holding area. Each of these approaches has merit for subsets of patients, but none is appropriate for all patients all of the time given patient heterogeneity.

Value of Early Remote Triage

While there is no consensus on the optimal approach to preoperative assessments, there is widespread acceptance that certain patient populations are more likely than others to benefit from an in-person clinic visit and/or diagnostic testing. Healthy patients with no/low perioperative risk can be safely “fast-tracked” to the day-of-surgery with little hospital staff intervention. Patients with modifiable risk factors should ideally be identified far enough in advance (e.g., proximate to the time of surgical scheduling) to allow ample opportunity to intervene in a meaningful way. The challenge to date has been finding a system that allows for accurate triage of those presurgical patients who require intense preoperative clinical resources – lengthy phone calls, in-person visits, diagnostic testing – and those who do not.

To facilitate presurgical patient triage, many hospitals rely on RN-initiated phone-based interviews. These interviews use static preformulated questionnaires to elicit the patient’s preoperative medical history. Unfortunately, the static nature of these questionnaires makes it difficult for the nurses administering them to capture the breadth and depth of information required for proper triage. Consequently, it is common that important elements of the patient’s medical history are missed by RN phone triage and only identified upon further questioning on the day-of-surgery. Two studies have shown that nurses are better at ‘ruling out’ patients who did not need additional assessment rather than ‘ruling in’ patients who need to be seen [44, 45]. Such omissions leave patients vulnerable to adverse events; result in day-of-surgery delays and cancellations; and do not effectively tailor the intensity of preoperative assessment to each patient’s needs. In turn this leads to suboptimal care, low patient satisfaction, and excess cost.

To overcome some of the shortcomings inherent in the manual capture of patient medical histories by clinicians, Dr. Michael Roizen developed one of the first computer software programs for preoperative assessment, Health Quiz, in the early 1990s [46]. However, the slower-than-anticipated adoption of the electronic health record (EMR) markedly inhibited the success of Health Quiz. Since that time many authors have validated the use of automated techniques to gather health histories and have found a low discrepancy when comparing the outputs generated by an automated questionnaire with those gathered via person-to-person interviews.

Building upon the Health Quiz concept, the Cleveland Clinic created HealthQuest in the late 1990s as a “home grown” solution. HealthQuest is an outpatient preoperative evaluation computer program designed to triage presurgical patients. Patients are administered a computer based questionnaire. Responses to questions are coded to create a HealthQuest Score, using a scale of 1 (healthy) to 4 (multiple complex medical issues). The HealthQuest Score is used to guide the timing and level of required preoperative evaluation. This triage system was tested over a 3-year period in 63,941 outpatient surgical patients. Of these, 22,744 (35.6%) did not require a visit with a healthcare provider prior to the day-of-surgery, as guided by the computer assigned HealthQuest Score and surgical classification scheme. In addition, patient interview time, patient dissatisfaction with the preoperative process, and the average monthly surgical delay rate all decreased during the study period [47]. While The Cleveland Clinic continues to reap enormous benefits from triaging their patients using HealthQuest, most institutions do not have the manpower nor surgical volume to support development and maintenance of such a sophisticated “home grown” software solution.

Perhaps the two most important elements of a preoperative health history are a current medication list and a current review of systems. Data within EMRs, however, are highly perishable and therefore cannot be relied upon for making perioperative management decisions. Eliciting up-to-date information directly from the patient can be quite time consuming. While it is widely recognized that using mid-level providers as scribes is not an effective use of healthcare resources, little emphasis has been placed on finding ways to directly engage patients in the process of clerical data entry. In fact, none of the commercially available hospital-wide EMRs has developed a patient portal capable of eliciting a comprehensive health history directly from the patient.

Unlike many other industries that have been revolutionized by the wave of self-service the Internet provides, medicine has lagged behind in its acceptance of the Web as a means for communication and, therefore, has been reluctant to enter the arena of web-based applications. However, the internet can be utilized as a telemedicine portal and there are a handful of commercially available web-based preoperative assessment tools. Many of these products are offered either on a per-click basis or for a nominal annual licensing fee, thus eliminating the large upfront and ongoing maintenance costs typical of traditional hardware and software based information technology products [48–50]. That notwithstanding, web-based assessment tools have yet to be widely accepted and adopted.

In the meantime, organizations can use paper-based questionnaires that can be self-administered at the time of the surgical visit to determine the nature and timing of the preoperative assessment (in-person versus phone consultation). See Figure 18.1.

Figure 18.1 A stepwise approach to determining the timing and nature of the preoperative assessment for elective noncardiac surgery.

Nuts and Bolts for Starting a Physician-Directed Preoperative Clinic

The first step in planning a preoperative clinic is to define the clinic’s mission. In its most robust form, a preoperative clinic should be designed to identify and mitigate all risk factors that impact a patient’s surgical hospitalization. In essence, a well-functioning preoperative clinic serves as the epicenter for the surgical episode of care. For this to occur, however, representatives from hospital administration, surgery, anesthesia, and nursing must explicitly define and agree to the operational goals (Box 18.1) of the clinic and implement a standardized system for communicating information between any and all providers who will interact with patients during the surgical continuum of care.

Once the goals of the clinic have been defined, the clinic structure can be developed and individual roles delineated. A medical director should be appointed. Ideally this person will have a background in both anesthesia and internal medicine. Hospitalists are well suited for this position as well. In situations where hospitalists are used to staff a preoperative clinic, however, there should be a plan in place for immediate access to an anesthesia consultant should questions arise regarding anesthetic options, appropriateness of anesthetizing location, and/or airway management.

The clinic medical director is responsible for developing protocols, guidelines, and care pathways in conjunction with their surgical, medicine, and anesthesia colleagues. The medical director should also educate the residents and mid-level providers who staff the clinic day-to-day. In addition, a clinic manager (typically a RN) should be appointed to ensure there is adequate infrastructure and support for the administrative and nursing staff. Preregistration, laboratory work, and EKGs can either be performed within the clinic (one-stop shop) or patients can be directed to other parts of the hospital for these services.

Appointments should be scheduled only after the patient has been triaged. This triage should occur proximate to the patient’s initial visit in the surgeon’s office, thereby allowing ample time for medical optimization, required testing, and/or subspecialty consultation. Triage should be performed by a highly experienced nurse practitioner or physician assistant who can determine if additional information is required prior to formal perioperative risk assessment. Failure to make the correct triage decision or to secure relevant health records prior to formal evaluation has potentially negative consequences downstream – adverse outcomes, low clinic throughput, high cost, low patient satisfaction. Thus it is imperative that a robust triage system be in place and that triage is conducted by a highly experienced member of the preoperative assessment team. Once triaged, patients can be scheduled for either a phone consultation or in-person visit (where appointment duration is consistent with the complexity of the patient’s care). When possible, patients should be evaluated a minimum of 7 days prior to their surgical date to ensure ample time for medication management.

At the time of formal evaluation, the health history and all pertinent medical records are reviewed. Additional tests or subspecialty consultation can be arranged and a formal risk assessment takes places. Patients suitable for care pathways or protocols are identified (e.g., obstructive sleep apnea, perioperative beta blockade) and special arrangements are made (e.g., move a diabetic to first case of the day; order STAT potassium day-of-surgery for a dialysis patient). Personal communication between the clinic Medical Director, surgeons, primary care providers, and the anesthesia consultant ensures that any questions or concerns regarding the patient’s condition and appropriateness for surgery are discussed. This avoids day-of-surgery delays and potential cancellations secondary to questionable patient suitability for surgery.

Once risk has been assessed and a plan devised, this information must be communicated to all members of the healthcare team. This communication is often conducted via an EMR. Unfortunately, both progress notes and best practice alerts within EMRs are frequently overlooked. The alerts can result in a type of “fatigue” whereby the provider, after receiving too many alerts, begins to ignore and/or override the alerts. Prolonged alert fatigue can negatively impact patient care as important alerts may be ignored [51]. Introduction of checklists, on the other hand, has been associated with a significant decline in the rate of complications and death from surgery. While the exact mechanism of improvement is not known when a checklist-based program is in place, the evidence of improvement in surgical outcomes is substantial [52]. Therefore, the development and consistent use of patient checklists should serve as the foundation for and communication of a patient’s perioperative management plan.

Once established, the perioperative plan must be effectively communicated to the patient. Patients should receive explicit information on medication management and pertinent information concerning the surgical process, including anticipated length of stay and probable outcomes. For communication of preoperative information to be effective, the information should be available in many forms, such as visual, auditory, or face-to-face education. Preoperative teaching has several well documented advantages, including decreased length of stay, less demand for analgesia postoperatively, and increased patient satisfaction [53, 54]. Despite the known benefits of patient education, this component of preoperative preparation is unfortunately often overlooked.

Economics of Preoperative Evaluation and Management

Given today’s cost conscious environment, there are concerns about appropriate resource use in nonrevenue generating areas. Preoperative evaluation falls within this category for most hospital administrators. They view preoperative evaluation as a cost-intensive operation for which they receive no incremental reimbursement. That is, sending a patient through a preoperative clinic or phone-based preoperative evaluation is considered part of the surgical service provided by the hospital and therefore is bundled within the global reimbursement for the surgical fee. Consequently, the adoption of physician-directed preoperative clinics has been slow.

Physician-directed preoperative clinics, however, have consistently demonstrated value in excess of the cost of the evaluation itself via their impact on patients’ health status; improved resource utilization; and reduced day-of-surgery delays and cancellations. In fact, use of physicians to evaluate patients and order indicated tests was shown to have the potential for reducing preoperative testing costs by several billion dollars without negatively affecting patient care.

Furthermore, inadequate preoperative evaluation is a contributory factor in adverse operative outcomes. Of the first 6,271 incidents reported to the Australian Incident Monitoring Study, 11 percent of the reports listed inadequate preoperative evaluation as a contributing factor. Well over half of the incidents were considered preventable. The investigators did not make an estimate of the economic impact of these adverse cases, but many of the adverse outcomes noted – case cancellation (5%), unexpected death (4%), prolonged hospitalization (7%), and use of intensive care facilities (9%) – are understood to rapidly consume resources [55].

In addition to realizing cost savings, proper preoperative preparation has the potential to generate incremental revenue for a hospital by justifying (1) increased disgonsis-related group reimbursements for co morbidities that would otherwise have been overlooked and (2) reimbursement for professional fees. “Usual preoperative care” as performed immediately prior to a procedure is not a billable service. However, physicians and physician extenders are entitled to separate reimbursement for professional fees if the service does not fall within the Medicare surgical global period. In addition, the following requirements must be met: (1) the consultation is being performed at the request of another practitioner seeking advice regarding evaluation and/or management of a specific problem; (2) the request for the consultation and the reason for the request are recorded in the patient’s medical record; and (3) after the consultation is provided the practitioner prepares a written report of their findings.

Finally, as patients take on more responsibility for their healthcare decisions with the rise of consumerism, well executed preoperative evaluation can serve as a competitive differentiator for surgical providers. Given a patient’s first encounter with a healthcare facility is often during a preoperative evaluation, it is imperative that hospitals and surgical centers critically assess patient experience and satisfaction during the preoperative evaluation process. Length of time waiting and overall time spent in a preoperative clinic correlate inversely with patient satisfaction. Long patient waiting times due to late start/finish of appointments are the result of poor triage, incomplete health information, suboptimal operational workflow, and poorly defined staff goals and incentives. Consequently, hospital administrators and preoperative clinic Medical Directors would be well served to mitigate these issues to ensure a positive patient experience.

Embracing the Preoperative Clinic

In today’s competitive surgical environment, efficiency, quality, and patient satisfaction are important criteria by which consumers and their insurers select healthcare providers. Increasingly only those hospitals and surgical providers that deliver high quality care and high patient satisfaction at an affordable price will maintain their financial viability. Consequently, there is growing appreciation for the health and economic benefits of proper perioperative evaluation and management; yet hospitals and surgical providers continue to struggle with optimizing the flow of patients through the surgical episode of care. The solution to this dilemma lies in proper perioperative evaluation and management via physician-directed preoperative clinics.

Perioperative evaluation and management is complex and requires close coordination and cooperation between several members of a multidisciplinary team. Physician-directed preoperative clinics, when properly designed and managed, can achieve this coordination by serving as the epicenter for patients’ surgical care, both inpatient and outpatient. The benefits these comprehensive clinics can offer are well documented, yet there adoption has been inhibited by the substantial investment of capital and ongoing operating expense they require. Fortunately, the costs of starting and managing these clinics can be substantially reduced through the use of best practice workflow techniques; timely, remote triage of patients to the right level of care; evidence-based perioperative management; and well-managed reimbursement. As such they should be embraced by clinicians, administrators, and patients alike for the important benefits they can deliver to surgical care.

Introduction

The perioperative surgical home represents a framework to transform the healthcare delivery process. From total joint pathways to enhanced recovery after surgery protocols, anesthesiologists and perioperative leaders are finding themselves increasingly involved in discussions extending beyond the intraoperative period [2]. For anesthesiologists, this platform should sound familiar. Since 1994 with the inception of the preoperative evaluation clinic by Fisher at Stanford University [3], anesthesiologists have recognized that preoperative evaluation, and now optimization, may be critical for a subset of the surgical patient population. These discussions are essentially breaking down the barriers between different periods of time in the perioperative process and bringing forward the implications of coordinated anesthesia and surgical care across the life cycle of a patient.

However, these developments have not been without obstacles or difficulties. Kain et al. have commented on the operational, administrative, and financial barriers [4]. For instance, they identified the difficulty in scaling the coordination necessary to make sure that all patients adhere to protocols. For anesthesiologists, they recognized the lack of professional training when it comes to implementing LEAN management techniques and team-building skills. In the current fee-for-service model, proponents of the perioperative surgical home have yet to lay down a definitive fiscal plan that reimburses anesthesiologists for the additional services provided as the architect. Overriding these concerns, Kain et al. pointed out that our specialty has two core values: an underlying commitment to individuals in pain and a “compelling commitment to improve the care and safety of our patients.” How we achieve these in the future will most likely change.

Although the preoperative process represents a module of the perioperative period, we believe that the lessons, thus far, from the perioperative surgical home scale down and provide an effective framework to identify bottleneck constraints. In this chapter, we will identify and discuss potential obstacles to the redesign of a preoperative system at an institution. For instance, some readers may encounter administrative and financial obstacles. Other readers may find themselves with a lack of local expertise or collaboration with their surgical and nursing colleagues. For now, we will concentrate on the following issues:

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   1. Organizational management and leadership

   
   
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   2. Systems optimization

   
   
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   3. Financial and healthcare resource constraints

   
   
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   4. Information technology

   
   
5. 
   

   5. Anesthesiology as big business

   
   
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   6. Social and cultural factors

Then, we will explore a framework to transform the preoperative process and view the necessary changes from the perspective of a different healthcare system. Underlying this entire chapter is the understanding that improving the preoperative process will create a bottleneck somewhere else in the system. Constant vigilance, unwavering dedication, and an unflappable belief in building a sustainable system are necessary.

Organizational Management and Leadership

Before approaching any change process, anesthesiologists should have a basic understanding of the difference between management and leadership. In a Sense of Urgency, Kotter clearly delineates the responsibilities and tasks for managers and leaders [5]. For managers, the tasks of planning, budgeting, organizing, staffing, and problem solving are all directed at creating predictable, stable processes. By contrast, leaders are responsible for establishing direction, aligning employee’s values, motivating individuals and ultimately, inspiring change. For many physicians, the distinction between these two skill sets is important because undergraduate and graduate medical education focuses solely on the fine-tuning of management skills. Should anesthesiologists approach a systems-based change with management skills, they might find themselves alone, inciting conflict, and worst, negatively affecting patient care.

So how do anesthesiologists create and lead change in perioperative processes? Mintzberg viewed management and leadership as right-sided and left-sided neurocognitive skills [6]. Traditionally, the leftside is equated with analytic, data-driven skills, not dissimilar to the responsibilities of any manager. The rightside is usually associated with artistic and emotional processes; this is where the art of leadership comes into play. Anesthesiologists involved in creating change should appreciate that both sides of the brain are necessary. There will be times when inspiring individuals and laying out a vision is critical. Other times, there will be a need to make sure that budgets are met and staffing is available. The key to being an effective manager/leader is the ability to decide which skill set to use. Most times, human beings resort to their strengths and physicians may rely on management skills (i.e., telling someone what to do) when leadership, or listening skills would be more appropriate.

Anesthesiologists leading any change effort should understand that the dynamic set up between management and leadership should create tension, specifically, creative tension. In Leading in a Culture of Change, Fullan points out the fallacy of management and the myth of leadership [7]. Pure management systems are essentially at equilibrium; they are static. Think of a finely tuned manufacturing process where the management teams understand the necessary inputs and can quantify the outputs. By contrast, leadership, through adoption of the latest management technique or blind, sweeping culture changes, usually creates an exhausted, aimless organization. It is rare that change leadership follows a checklist or a recipe. Fullan believes that leadership, true leadership, is the practice of creating a learning organization. In these organizations, leaders may arise from any level of an organization. On an individual level, they understand that leadership requires a moral purpose; the opportunity to invest for the long term; a network of relationships and accountability; a platform to disseminate knowledge; and the time for sense-making. The opportunities for adopting this recursive practice in the preoperative setting will be echoed in the remaining sections.

Systems Optimization

While in depth review of optimization can be explored elsewhere [8], the method can be summarized as finding an ideal condition, given the constraints at hand, that will result in the lowest “cost” to the system. The cost of establishing a new preoperative process will consist of a variety of other metrics that will influence decision making. A simple example of a cost function would be setting the thermostat in the middle of winter in Vermont; in this case:

J=Fcomfort(temperature)+Fcost(temperatures)

With F_comfort demonstrating the effect the temperature has on a person’s comfort, F_cost the effect of temperature on monetary cost and J being the “cost function” that we seek to minimize. It is important to note several points in this example:

1. 
   

   1. Each individual function is constructed in such a way that “lower is better.”

   
   
2. 
   

   2. F_comfort in this situation is dependent on the person living in the house: two individuals may perceive comfort with different ideal temperature. This will influence the “weight” applied to the individual function, which determines how strongly it impacts J. A heavily weighted function will ensure a stronger cost/penalty if it, individually, is not minimized.

   
   
3. 
   

   3. Comfort has other dependencies that are influenced by individual preferences: one person may wish to wear t-shirt and shorts while at home, while another may be equally comfortable in woolen pajamas.

One immediately notes the tradeoffs between cost and comfort although they are not always reciprocal. Increased temperature will result in increased cost but beyond a certain temperature as an individual becomes uncomfortably hot. Reciprocally, below a certain temperature the cost may become catastrophic (e.g., after a water pipe freezes and then bursts).

Cost functions should be generated for any change in a preoperative period and can be used to guide decision making during the implementation period, and as a component of the continuous improvement process. The concept of bottleneck constraints fits within the paradigm of optimization and needs to be properly understood when seeking to minimize the cost function. Again, these bottlenecks may appear upstream or downstream.

Finally, in the preoperative evaluation setting, it is important to identify the variables that can impact the “cost function” in order to identify the areas that may be optimized. The opportunities – this list is not inclusive – may include the following:

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   1. Cost of the system which also includes infrastructure cost

   
   
2. 
   

   2. Operating room (OR) time lost for cancelled cases

   
   
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   3. Cost to society including time lost due to travel or clinic visit; this includes lost wages, lost job productivity for not only patients but also supporters who would assist the patient (e.g., parents or children of the young/elderly patient)

   
   
4. 
   

   4. Patient satisfaction

   
   
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   5. Physician satisfaction

   
   
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   6. “Quality metrics” that influence reimbursement

   
   
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   7. Procedure reimbursement, which can only be modified as a function of the operating surgeons’ skills

The above variables may be modified at both “macro” and “micro” levels. A macro change may be represented by a decision to centrally locate a preoperative clinic, establish a telephone call center, or simply relying on a note from the primary physician with a full assessment performed at the day of surgery. The micro level change would be more focused and specific (i.e., where to locate clinic/call center or minimizing preoperative laboratory tests for specific surgeries). We return to the idea that “macro” and “micro” decision are made in parallel when we examine a platform to streamline preoperative testing patterns.

Healthcare Resource and Financial Constraints

Over the past two decades, there has been a proliferation of preoperative evaluation processes. While the preoperative evaluation clinic remains the gold standard, many anesthesiology groups and academic departments have adopted telephone-based preoperative centers and web-based technologies [9, 10]. The system which develops at each institution is the end result of a myriad of administrative decisions, the preference of the anesthesiology and procedural groups, the information technology infrastructure, and the flexibility of the primary care network. Under the current fee-for-service reimbursement system, preoperative evaluation processes represent a fixed cost for most institutions [11]. For many, anesthesiologists may find themselves at the heart of this constraint. The world of accounting, business plans, and return on investment has usually taken a backseat to clinical outcomes, surgeon satisfaction, and quality measures. However, anesthesiologists need to develop the business acumen and language in order to build the value proposition for a preoperative process. For some anesthesiologists and perioperative managers, additional professional training may be a suitable route [12, 13]. For others, mentorship and administrative experience may suffice, which remains as a standard practice in many corporate environments.

One of the bottleneck constraints an anesthesiologist may encounter is the inability to find the appropriate clinical care provider for a specific task. For physical preoperative evaluation clinics, there are the medical directorship, clinical personnel, and administrative roles. For example, our institution created a telephone-based preoperative assessment center in the 1990s. Today, every patient undergoing surgery at our hospital receives a telephone-based evaluation. The University of Vermont Medical Center does not have a physical preoperative evaluation clinic, although surgeons have the option to call and schedule a clinic visit should the patient’s condition or comorbidities warrant further evaluation by an anesthesiologist. During the workweek, nurses call patients at home or at work, and conduct a review of systems, educate the patient on the perioperative process, and answer any questions about the perioperative process. Lozada et al. showed that patients largely prefer a telephone- based preoperative assessment and one would be tempted to presume that this is due to the minimal disruption in their lives compared to an office visit [14]. Yet, have we fully optimized the resources and staffing of the telephone-based preoperative center? Is there a way to increase the efficiency of information transfer using the institutional electronic medical record? Can we better prepare patients for surgery? Are we duplicating services already covered by the surgeon’s office?

Govindarajan has argued that the study of healthcare systems outside of the United States affords the opportunity to understand the waste, redundancy, and inefficiencies of the current American system [15]. From this perspective, he describes the resource optimization framework for a rural healthcare system in India. For the United States and the rest of the world, cataract surgery is the most common procedure performed. For the United States, there is already a shortage of ophthalmologists and this labor shortfall is even greater worldwide. In India at the Aravind Eye Care Center, where “necessity spans innovation,” healthcare policy maker and hospital administrators recognized the traditional work schedule for an American surgeon made it difficult, if not impossible, to hire the number of surgeons to fully staff an operational, functional ophthalmology surgical center. The hospital administrators prioritized the surgeon’s expertise and clinical skillset in the OR and developed a system whereby the clinic and preoperative processes were handled by mid-level healthcare providers and technicians. In turn, the new framework lowered the fixed costs of delivering care.

This framework can be applied in the preoperative processes which have proliferated across the United States [9, 10]. Under the current anesthesia reimbursement system, the preoperative evaluation is included in the Base Unit for each surgery or procedure. Again, we know that preoperative clinics reduce cancellation rates and on an operational level, the decision to fund preoperative clinics represented a financial hedge against the impact of a cancelled case on the day of surgery. Yet, there is little discussion on how best to staff a preoperative process. Fischer’s model and many other models rely on a physician, anesthesiologist or primary care physician, as the captain at the helm [3]. But is it really necessary for a physician to evaluate each patient before surgery? Does the anesthesiology group have the labor force to staff a preoperative clinic? Consider that Philips et al. showed that for the patient evaluated at an ophthalmology clinic before surgery, providers identified a new, chronic condition in less than 1 percent of patients and none of the new diagnoses delayed surgery [16].

Again, the authors believe that neither an anesthesiologist nor financial support should be a bottleneck constraint to a better preoperative process. Historically, anesthesiologists evaluated all surgical patients at the bedside, decided what laboratory or diagnostic tests were necessary to optimize the patient, and educated the patient about the type of anesthesia they would receive. Today, we know that preoperative evaluation clinics and telephone call centers can be staffed by nurses or mid-level providers [14]. For healthy, low-risk patients undergoing low-risk surgical procedures, we could also argue that the clinical attention from a mid-level provider might be a poor match of clinical skillset and patient demands. Perhaps a nurse or medical assistant could guide this patient through surgery. In fact, web-based technologies and clinical decision support systems (sans healthcare provider) have already demonstrated similar efficacies with a lower cost [17, 18]. Using the value-based proposition where value equals outcomes divided by the cost of delivering the care, better optimized preoperative processes inherently provides more value [19].

We started this section with a discussion on the optimization of resources and staffing for preoperative evaluation processes and we end with a note on the opportunities of eliminating this bottleneck constraint. At the Mayo Clinic, Trentman et al. demonstrated that a simplified algorithm and optional screening tool enabled surgeons to appropriately target patients for a preoperative evaluation [20]. To restate, they were able to generate cost savings by optimizing the appropriate level of care for each patient and using the available, remaining resources to target patients with diabetes. Similarly, Davenport et al. demonstrated that preoperative risk factors account for 33 percent of the cost variation, 23 percent of the work relative value units, and 20 percent of the complications downstream [21]. In other words, a patient’s preoperative risk factors account for a large proportion of the cost variation. The discussion of financial constraints should ultimately recognize that the healthcare system is currently unsustainable. Anesthesiologists should lead effort towards financial stewardship by optimizing the preoperative resources the necessary to provide safe and effective care [22].

Information Technology

In Nonzero, Wright argued that the increasing efficiency of information transfer underlies the basis of human civilization [23]. Over the past two decades, anesthesiology groups have driven the transition from a paper-based record to an electronic database [24]. The predominant literature supporting the importance of IT for anesthesia-driven processes is during the intraoperative period, where documentation and billing compliance errors are reduced [25–27]. However, a recent retrospective review by Chow et al. showed that electronic communication could advance patient-centered care by transmitting clinical information in a timely manner [18]. We also note that there are well-developed papers laying out the infrastructure necessary to develop an effective, efficient anesthesia information management system [28]. As the capabilities of the electronic medical record continue to expand, anesthesiologists need to continue to lead not only the adoption of the platform, but building of the infrastructure to support an array of nonclinical, administrative functions. Depending on the environment, the adoption of an electronic medical record or database may or may not be a constraint.

Porter believes the underpinning transformation to a value-based healthcare delivery system is the recognition that information technology is pivotal [19]. The decision to use information technology should be driven by the opportunity to improve preoperative processes. However, Archer et al. clearly laid out the four potential obstacles:

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   1. Physicians’ autonomy

   
   
2. 
   

   2. Lack of “buy-in” and support

   
   
3. 
   

   3. Skewed incentive structures

   
   
4. 
   

   4. A short-term view for returns on investment [29]

The skills required to build these capabilities are closer to industrial engineering and scientific programming than to medical informatics. At our institution, we have a clinical informatics lead with previous experience as a registered nurse in the OR. She leads a team that bridges the gap between technical and clinical stakeholders. This team has helped our organization drive the change from a paper-based system to a fully accepted perioperative clinical system that currently encompasses the preoperative and intraoperative period. With this team and the automation of documentation, we have been able to drive to clinical improvements based on clinical documentation, build a preoperative evaluation interface, and fully operationalized an anesthesia scheduling system replete with preoperative patient information.

While our institution has found a fair amount of success in using IT to streamline the preoperative process, it should also be recognized that this solution can be challenging to implement for smaller hospitals and small, private anesthesia practices. Even if these locations or groups were able to invest in the startup cost of building the IT infrastructure necessary for this process, they would also require ongoing maintenance of the system with its own cost structure. This would include the hiring and staffing of several positions, including that of a “clinical informatics lead” as described previously. One option to minimize the system overhead of the preoperative process would be either to outsource or consolidate with multiple other institutions, thereby distributing the overhead cost amongst multiple parties as described below.

Anesthesiology Meets Wall Street

In 2012, Galinanes commented on the increasing popularity of mergers amongst anesthesiology groups [30]. Two years later, there were over 80,000 anesthesiologists and nurse anesthetists in the United States performing an estimated 40,000,000 anesthetics annually and driving the $19 billion American anesthesia industry [31]. The financial reach of anesthesia-driven healthcare services is even noted on the American stock exchanges. For instance, MEDNAX/American Anesthesiology (NYSE:MD) and Team Health Holdings (NYSE:TMH) are listed on the New York Stock Exchange [32]. In 2014, further consolidation of the anesthesia industry occurred when AmSurg Corporation, a publicly traded operator of ambulatory surgery centers, acquired Sheridan Healthcare for $2.4 billion. Again, this $2.4 billion represents almost 10 percent of the anesthesia services provided on an annual basis. Today, 13 percent of the anesthesiology groups in this control employ nearly 75 percent of the anesthesia healthcare providers. Readers may find that the local and regional anesthesia markets are dominated by five major players – MEDNAX, NAPA, Sheridan Healthcare, USAP, and TeamHealth.

From an operational and strategic perspective, these mergers and acquisitions make financial sense [33]. With the passage of the Accountable Care Act, larger groups can create capital pools under risk-sharing arrangement models and access capital for infrastructure investments (e.g., anesthesia information management systems, electronic quality metrics, web-based preoperative evaluation processes). Matching the recent mergers of the healthcare insurance industry, the consolidation of anesthesia groups should provide negotiating leverage, the opportunity to transfer high reliability processes and scale operational efficiencies such as a telephone- or web-based preoperative assessment system or electronic reporting systems.

However, what are the true day-to-day implications for anesthesiologists? It has been noted that hospital administrators are expecting more and more of their anesthesia providers with a concomitant demand to increase efficiency and demonstrate quality. For instance, anesthesia teams are asked to increase coverage throughout the hospital for ICU/critical care, obstetrics, acute pain management, non-OR anesthesia cases, and other services. Traditionally, the financial model for anesthesia groups included labor subsidies payments for staffing these underserved, inefficient areas [34, 35]. With the consolidation of the anesthesia industry, anesthesia providers may find that their negotiating capabilities are relegated to the administrators of large consolidated anesthesia groups.

We have included this brief discussion on the trends in the anesthesiology industry because we believe that anesthesiologists should appreciate the opportunities afforded by and the constraints imposed from the aggregation of anesthesia services. Anesthesiologists examining the preoperative process may find that another practice uses a telephone-based preoperative center and its expansion may be limited by the number of nurses. On the other hand, some may discover that the variability of clinical practice as it pertains to the preoperative testing patterns may increase as group with historically different practice patterns become a single entity. Again, before embarking on a journey to change the preoperative process, anesthesiologists should understand the local, departmental, and institutional context within which they work. No organization or department is too big to fail.

Social and Cultural Factors

Until recently, the development of preoperative processes has focused primarily on the infrastructure resources and financial implications of well-honed systems. There has been little research into the social and cultural factors directly or indirectly affecting the patients and their families [36]. Further, Ankuda et al. showed that 13 percent of patients undergoing elective surgery showed informed consent deficits, usually related to sociodemographic and language factors [37]. However, the impact of the preoperative process may be significant, especially for patients with chronic conditions. For example, Montori et al. showed that diabetes management improved when patients were directly involved with the decision-making process [38]. In a similar vein, Wilson et al. showed similar outcomes for patients with asthma [39]. The fact that both chronic conditions, diabetes and asthma, have implications for the anesthetic care and perioperative pathways should encourage anesthesiologists to develop a better understanding of the processes, especially when shared decision making can reduce the cost of delivery care.

Shared decision making in the preoperative process can also help reduce bottlenecks which occur on an operational level [40]. Chandrakantan and Saunders argued that the shared decision making process can be used in the preoperative evaluation of higher-risk patients. Charles et al. suggested that shared decision-making processes have the following characteristics:

1. 
   

   1. There are two participants, physician and patient

   
   
2. 
   

   2. Information is shared

   
   
3. 
   

   3. Consensus is built in a step-wise fashion

   
   
4. 
   

   4. An agreement is reached on the treatment plan [41]

From a system-based perspective, anesthesiologists may discover that a shared decision-making framework may assist patients and help them develop not only an appreciation of the risks and benefits of a surgical procedure, but also a deeper understanding of the implications of anesthesia. In the long run, anesthesiologists may be able to reduce the costs of care by reducing rates of unnecessary surgery or delaying such procedures. For example, in 2012, Group Health in Washington State demonstrated that a shared decision-making educational platform reduced both surgery rates and costs for total joint replacements [42]. Although this study was observational, the authors brought forward a broader discussion of the anesthesiologist’s role. Despite these findings, readers should be wary of the argument that delaying a surgery can be cost-saving because it only takes into account the insurance and immediate health cost. In order to move shared decision making forward, anesthesiologists need to facilitate conversations with surgeons, hospital administrators and insurance companies.

A Preoperative Platform

The opportunities to decrease variability in preoperative testing patterns remain. Wijeysundera et al. demonstrated a lack of consistency and a large degree of variability amongst different hospitals in a Canadian province [43, 44]. The same holds true for American systems. In the Pacific Northwest, Thilen et al. demonstrated that in an integrated healthcare system, different surgical subspecialties order preoperative tests without any prudent guidance or clinically driven processes [45]. Mackey argued that any effort designed to decrease variation in medical practices has been “hampered by (1) a lack of understanding of the fundamental link between outcomes variation and medical quality improvement, (2) physicians practicing with an individualist, artisan-like approach in a fragmented medical practice environment, and (3) individual physicians and individual institutions relying on their own practice outcomes data for quality improvement” [46].

Again, the variability in the system cannot be emphasized enough despite associated additional healthcare costs and patient morbidity. These findings lie in stark contrast to the financial, operational, and clinical opportunities framed by the Perioperative Surgical Home. Here, Dexter and Wachtel have pointed out that there are ultimately two strategies that will result in net cost reductions with the perioperative surgical home [47]. The first strategy suggests that anesthesiologists should aim to reduce unnecessary interventions in the preoperative period that provide little or no benefit to the patient. To advance the discussion on reducing variability in preoperative testing patterns, we have redrawn the guidelines set forth by the ACC/AHA as a three by three matrix (Figure 19.1).

Figure 19.1 ASA/ACA guidelines redrawn in a 3×3 matrix.

White circle: Low-risk patient, low-risk surgery. Any tests ordered for patients in this category are an unnecessary expense.

Gray rectangle: Moderate/high-risk patients, low-risk surgery. The current ASA/ACA guidelines do not delineate the type of anesthetic for the case. For certain cases (e.g., carpal tunnel releases, cataracts), the risk of the regional anesthetic is minimal.

White rectangle: Low-risk patients, low- to high-risk surgery. The ASA has recommended that healthcare providers should not order baseline diagnostic cardiac testing in asymptomatic patients with stable cardiac disease undergoing low- or moderate-risk noncardiac surgery [49, 50].

Black circle: High-risk patients, high-risk surgery.

Gray circles: Moderate-risk patients, moderate-risk surgery; moderate-risk patients, high-risk surgery; and high-risk patients, moderate-risk surgery.

Using this matrix, the anesthesiologist should be able to design a road map to better understand the opportunities available when assessing which preoperative tests are necessary before surgery. In addition, we are able to elucidate how variability affects the healthcare system when we use this matrix as a starting point to discuss medical quality improvement in a fragmented healthcare delivery system. Again, any reduction in unnecessary perioperative testing can reduce healthcare costs in two ways: not testing or reducing false-positives [48].

By framing the discussion of the preoperative evaluation for surgical patients with this matrix, we show that there are several opportunities to fundamentally change the way we deliver perioperative services. For instance, patients in the blue circle (low-risk patient, low-risk surgery) and yellow rectangle (moderate/high-risk patient, low-risk surgery) do not need any further cardiac risk stratification or a history and physical by a primary care physician, regardless of the risk of the patient, provided the patient is a reliable historian and the team can undertake a proper medical history. Working in concert, anesthesiologists, surgeons, and administrators can now develop processes to minimize preoperative tests patterns.

By example, anesthesiologists could work collaboratively with ophthalmologists to redesign the perioperative process for patients undergoing cataract surgery. Ideally, the anesthesiologist (or preassessment nurse) reviews the history and the surgeon performs a brief physical exam. This fulfills the compliance requirements for a preoperative history and physical. Although patients with cardiac disease deserve a more thorough review, most times, patients have stable cardiac conditions. A web-based or telephone preoperative evaluation with the appropriate anesthesiologist oversight should suffice and most educational points can be performed over the phone (e.g., patients taking antiplatelet medications can be instructed to discontinue their medications in an appropriate time interval before surgery). By using this platform as a basis to build a different healthcare delivery system, the knowledge and framework should be expanded to other specialties. More importantly, the reduction of variability for this subset of patients has financial ramifications for a large, tertiary academic healthcare system [51, 52]. These opportunities currently exist, can be implemented immediately, and are based on research and national consensus statements.

Continuous Process Improvements

Presciently, Shafer recognized that the current process improvements are limited in scope [53]. He concluded:

For anesthesiologists interested in the preoperative process, the preeminent study dates back to Fisher’s in 1994 [3]. Six years later, Wu and Fleischer commented that the development of the perioperative surgical home necessitated an individual responsible for outcomes measurements [54]. Anesthesiologists need to drive these changes with transparent, data-driven processes utilizing electronic medical records and clinically relevant outcomes data.

For most physicians, the decision to build a process is not dissimilar to a hospital CEO’s strategic initiative to build a new patient unit. However, the process should not stop once the bricks and mortar are up. The impetus behind the perioperative surgical home lies in the fact that anesthesiologists work at the nexus of all the healthcare providers for the care of the surgical patient [55]. With the changing healthcare environment, current anesthesiologists may find their nonclinical, systems-based skills lacking, while program directors are looking for direction and strategies to ensure that future anesthesiologists are trained to build multidisciplinary teams and to create effective processes change. Rathmell and Sandburg argued that anesthesiologists should approach process improvement with scientific rigor and minimal confirmation biases [56].

In the past two decades, we have seen the proliferation of various preoperative healthcare delivery models and a growth of literature supporting the establishment of standardized preoperative processes. We have been inundated with a plethora of studies demonstrating how we should design our preoperative processes. Hartnett et al. demonstrated that improving the clinical and organizational aspects of the preoperative process increases patient satisfaction [17]. However, it is rare that patient satisfaction is seen as a bottleneck constraint. More often than not, patient satisfaction scores serve as the ends, and not the means, for changes in clinical processes. Ultimately, we are missing the literature that describes the obstacles, barriers, and mountains which the authors overcame to implement their strategies and operationalize their healthcare delivery process.

While other authors have reviewed the economic and operational advantages of a preoperative testing clinic [57–60], the time is ripe for a technological and cultural shift for the preoperative evaluation. We believe that improving this process requires the systems-based engineering perspective Sandberg adopted for operationalizing an anesthesia information management system. In its basic form, it follows:

1. 
   

   1. Process modeling to create a reference process against which actual process progress can be compared, seeking noteworthy exceptions

   
   
2. 
   

   2. Data integration of multiple electronic sources and different data types

   
   
3. 
   

   3. Continuous process monitoring by recursive queries of the AIMS and other database to identify process exceptions

   
   
4. 
   

   4. Pushing data to key stakeholders, seeking to provide the right information to the persons who need it, at the time when it most useful [26]

In addition to the above, it is important for the relevant stakeholders to delineate the organizational priorities with clear goals as benchmarks that can be used for improvement. These stakeholders will help delineate the different weights that each metric/cost function variable will have in order to properly allocate effort and resources.

Embedded in the model above is Deming’s continuous process improvement: study, plan, do and act [61]. We have used this recursive framework throughout this chapter to address not only the bottleneck constraints one may encounter when they journey down a strategic decision to build a different preoperative evaluation process, but also to identify the numerous opportunities to continuously refine a system. Anesthesiologists should be acclimated to working in an environment with constraints. We do this each day with every patient when we design and implement an anesthetic plan based upon the comorbidities of the patient and the needs of the surgeon.

An Outside Perspective: The Canadian Single-Payer Experience

The provision of core health services in Canada is governed by the Canada Health Act [62]. This national legislation establishes core principles, from which the country’s provinces are responsible for all aspects of providing care. The Canada Health Act is founded on five core principles:

1. 
   

   1. Public administration – health insurance must be administered by a public authority on an nonprofit basis

   
   
2. 
   

   2. Comprehensiveness – all necessary health services must be insured

   
   
3. 
   

   3. Universality – all insured residents are entitled to the same level of care

   
   
4. 
   

   4. Portability – residents can move between jurisdictions in the country without a change in their coverage

   
   
5. 
   

   5. Accessibility – all insured persons should have reasonable access to healthcare and, in addition, all physicians and hospitals must be reasonably compensated for the services they provide

Within this framework there is considerable latitude for the structure of care delivery models and, notably for physicians, compensation structures. As such, the adoption of structures that parallel the Perioperative Surgical Home model varies between jurisdictions along similar stress points as US models. Where most successful, the system has addressed the key points raised in this chapter and accounted for some of the bottleneck constraints.

Canadian physicians, by and large, function as independent contract providers to the single provincial payer in each jurisdiction. Hospital privileges enable anesthesiologists to provide care in publicly funded institutions but physician compensation is derived from fee structures, which are uniform across jurisdictions. The relationship internal to institutions therefore depends heavily on a leadership model that promotes collaboration with the managerial structure of the hospital. This relationship extends through all levels of the perioperative period resulting in a greater focus on leadership skills development than managerial ability. The Royal College of Physician and Surgeons educational CanMEDS competency framework, which has gained international traction, was revised in 2015 to replace “Manager” with “Leader” in recognition of the importance of this shift when navigating the complex system of healthcare [63].

Cost constraints in single payer system, and the trade-offs within decisions, follow similar patterns to other systems when the question revolves around optimization. In the single-payer environment system level macro costs are frequently at the forefront however, with micro level decisions perceived to impact macro program or institutional opportunities or opportunity costs in a zero sum finding scheme. Anesthesiologists must make value arguments very clear in this environment, with a business case that emphasizes a savings impact in order to argue for infrastructure support associated with programs like the Perioperative Home.

Similar to the examples presented above, Canadian models of preoperative evaluation and testing are not static in their design. The incorporation of video and telephone capabilities was an early modification to accommodate the geographical constraints of small remote communities. Large suppliers for these services, like the Ontario Telemedicine Network, provide private sector innovation despite the single-payer funding source [64]. The emphasis on appropriateness of care and grassroots campaigns like Choosing Wisely have considerable traction in this environment [65]. In a move of support, the Canadian Anesthesiologists’ Society Choosing Wisely recommendations all address preoperative care and the choice of testing used during preoperative assessment and optimization [66].

Where successful, integration of Canadian anesthesiologists into preoperative patient optimization as part of overall care pathways has largely depended on a compensation structure that directly supports this model. Most anesthesia practices in the single-payer Canadian systems function predominantly on a fee for service model with compensation set at a provincial level between the government payer and physician representation organizations negotiating for all physicians simultaneously. When participation in perioperative care is recognized in the reimbursement structures, pre- and postoperative continuity of anesthesiologists is promoted. The relationship within hospitals is freed to focus on clinical care, with the physician compensation removed from the equation. However, institutional resource constraints remain significant with nursing, allied health and infrastructure costs borne by the hospital. In a similar vein, many jurisdictions in Canada continue to struggle with equivalent challenges to American perioperative surgical home proponents who seek appropriate compensation models to support this additional workload.

In short, the success of structured preoperative evaluation processes and their full integration into the Canadian single-payer model has occurred to a variable degree across jurisdictions, as in the United States. Where compensation models support this structure, the system efficiency benefits of this model align with the physician resources and full integration has occurred. In these models, the opportunity and effectiveness of efforts like Choosing Wisely can flourish, representing a significant value addition toward system sustainability and quality of perioperative care.

Conclusion

At the American Society of Anesthesiologists annual meeting in 2016, keynote speaker Michael Porter laid out a framework to transform the healthcare system in America [67]. For far too long, physicians and hospital administrators had created a broken system devoid of value. From the physicians’ perspective, the goal of evidence-based medicine was to demonstrate that certain treatments provided better outcomes. However, physicians failed to recognize the cost of providing these treatments. On the other hand, hospital administrators implemented cost-cutting strategies in order to bend the cost curve in healthcare. These management techniques mostly ignored the outcomes of the treatments, alternatives, or research and development necessary to improve healthcare at the patient or population health level. By defining value as outcomes divided by the cost of healthcare delivery, Porter’s framework brings together both components [68].

Porter believes that the measurement of outcomes and the associated healthcare costs need to be measured beyond the patient–physician encounter. For instance, for patients with osteoarthritis of a hip joint, the value-based framework extends beyond the actual surgical replacement of a patient’s hip and whether or not the anesthesiologist administered an antibiotic at the appropriate time interval. In fact, he argues that value of any healthcare delivery system should include the time interval between when the patient is asymptomatic to the actual diagnosis. In short, the longer the period of time the patient is asymptomatic, the better the value proposition. For anesthesiologists, this is nothing new. Anesthesiologists have long understood that the preoperative process plays an important role in the perioperative care of surgical patients on several levels. In terms of patient safety and cardiac outcomes, anesthesiologists and cardiologists have fine-tuned a risk stratification system that lowers the risk of cardiac morbidity and mortality. On an operational and financial level, the benefits of a well-honed preoperative process are well defined.

So where do we go from here? Porter laid out the following structural framework for any physician or healthcare administrator:

1. 
   

   1. Create integrated practice units

   
   
2. 
   

   2. Measure outcomes and costs

   
   
3. 
   

   3. Move into a bundle payment care cycles

   
   
4. 
   

   4. Integrate delivery across facilities

   
   
5. 
   

   5. Expand valued services across a geographical region

   
   
6. 
   

   6. Build an information technology platform [68]

We have touched upon many of the agenda items in this chapter, but ultimately, by identifying the bottleneck (or constraints) in the preoperative process, anesthesiologists and perioperative leaders are essentially creating value. For instance, if an academic anesthesiologist is deciding whether to pursue a physical preoperative clinic or to build a web-based information technology platform, then they should understand the limitations (or opportunities) present in each process. A physical preoperative clinic limits the ability to integrate delivery across several facilities, but may make it easier to deliver care an integrate practice unit. By contrast, the president of a large, private practice anesthesiology group may view the constraint of the preoperative process as the number of anesthesiologists that may be available. Again, the six agenda items and the bottlenecks discussed in this chapter create a recursive and self-reinforcing matrix. In closing, we hope that the reader will be able to create a continuously improving, sustainable preoperative process that acknowledges the guidelines available from our national societies and challenges the status quo at the local, institutional level. At a minimum, we hope that the reader ventures forth and puts forward a plan of action.

Introduction

Anesthesia practice management today requires a unique set of survival strategies as payment cuts brought by the shift from fee-for-service to value-based reimbursement payment methodologies change the traditional approach to revenue cycle management. Surviving and thriving in this new healthcare environment requires functional knowledge of the fundamentals of how anesthesia is uniquely paid as a specialty as well as effective anesthesia practice management tactics around staffing, operational performance, contracting, regulatory compliance, technology, and revenue opportunities in value-based care models.

The success of the anesthesia practice is critical not just to the members of the practice that it employees but also to the healthcare organization with which it contracts because:

• 
  

  Nearly 30 percent of all US hospitalizations require a surgical procedure that typically represents a cost 2.5 times more than hospital stays for medical treatment alone [1].

  
  
• 
  

  Typically 50 percent of a healthcare organization’s total overhead is driven by surgery and perioperative costs but represents 50–70 percent of the Healthcare organizations total net revenue [2].

  
  
• 
  

  The anesthesiology service routinely takes care of the top 5 percent of high-risk patients that consume 50 percent of the annual healthcare expenditures nationwide [3].

  
  
• 
  

  Nearly 80 percent of hospitals are paying the anesthesia group a subsidy due to poor payer mix, fair market value compensation demands, anesthetizing location demands, and revenue cycle performance challenges [4].

Put succinctly, surgery and perioperative services are the major driver in hospital profit margins today so it is imperative that the anesthesia practice show value by optimizing operational and financial performance for the anesthesia practice itself, as well as the hospital or healthcare organization to which they provide services [5].

This chapter has three main sections; the first section will focus on the fundamentals of the fee-for-service billing methodology and quality measures unique to anesthesiology, the second section will focus on value-based payment methodologies as define by current legislation, and the third section will focus on key competencies and concepts necessary to run a successful anesthesia practice.