New Hanover Regional Medical Center (NHRMC) is an 855-bed level II trauma community-based hospital serving seven rural counties in southeastern North Carolina. As the only trauma center in the area, the sheer volume of patients requiring care and eventual hospitalization resulted in significant capacity issues for our organization. Moreover, the lack of standardization substantially created variability in the quality of surgical care being delivered. These emerging themes resulted in increased complications and readmissions, as well as OR inefficiencies, and case delays and cancellations, leading to millions of dollars in CMS financial penalties.

Within the scope of our perioperative care, inadequate patient outcomes created the need to examine our delivery of care methods and identify those variable practices requiring clinical standardization overhauls. While a laborious task, cause-and-effect thinking identified archaic traditions requiring the adoption of an evidence-based best practice improvement pathway. Subsequently, the adoption of the Perioperative Surgical Home (PSH) model offered solutions to our most burning pain points.

PSH success

Fortunately, NHRMC was a participant in all three iterations of the ASA PSH Learning Collaborative. This design created a comprehensive approach to care quality for the surgical patient, which increased patient satisfaction, a CMS absolute for reimbursement. Additionally, the physician-driven program highlighted the value of the anesthesia provider, which created great organizational synergies.

Because our PSH program was implemented as a partnership between all stakeholders within the episode of care, alliances were formed between the anesthesia group, surgeon colleagues, and the staff and administration of the hospital. Transforming the culture, values, and norms compelled stakeholders and providers to move away from outdated traditional practices to current best practice. This targeted course required the need for a dedicated resource of a nurse navigator experienced in the surgical arena. Working with the anesthesia team, the nurse navigator's role was to bridge program pillars, aligning phases of care stakeholders, harvest data, and support patient care and throughput by way of a concierge care model. After proving the PSH concept with total joints, hospital administrators saw the value and wanted to expand to additional service lines. Therefore, the anesthesia group was able to monetize its efforts through a Hospital Quality and Efficiency Program. Further, program success increased responsibilities for program growth and sustainability.

After implementing the PSH in 2015, NHRMC has not paid a CMS readmission penalty. Our PSH also contributed to the reduction of over 1 million oxycodone tablets, supporting national efforts to combat the opioid epidemic. Due to these efforts through the PSH, NHRMC achieved the following accolades:

  • #1 top-ranked hospitals in North Carolina for hip and knee surgeons experience

  • Top 10 in North Carolina for lowest length of stay

  • Increased patient satisfaction scores to over 97%

In 2018, with eight service lines, we saved $12 million and created 2268 hospital bed days, which allowed us to provide care for an additional 768 patients. To date, we now have 16 fully scaled surgical service lines and continue to expand to new areas of quality.

Shared insights

Following the launch and success of the PSH at NHRMC, it became apparent other organizations also faced similar barriers and implementation struggles. The anesthesia team and navigator regularly received multiple member and nonmember sharing requests for program information through the collaborative after learning of our success. Without hesitation, we began informal mentoring to make clear the project's impact on our community and organization, communicating the critical message: “The PSH method is essential for quality of care to meet the quadruple aim and prepare for value-based payments.”

Mentoring included invitations for on-site tours with a PSH program overview, collaborations with phase-of-care providers and department leaders, material sharing, and extensive Q&A sessions with expert anesthesia leaders and the nurse navigator. The collegial contributions provided insightful perspective and improvement solutions for redesigning perioperative care, including missteps and lessons learned. Opening mentoring channels created opportunity to gain valuable insights, not only for visiting organizations, but for NHRMC to understand other perspectives for possible implementation and honing of our processes.

Although a large undertaking, the importance of making a mentoring experience available supports the need for PSH programs in all types of health care organizations. Our experience with large urban systems, academic organizations, community-based health care, and critical access hospitals show the foundational story is the same. Guidance from an experienced team will offer structural insights to establish a complete professional PSH model for any size health care composition. We believe their success is our success. The PSH program is how our group is preparing for value-based health care.

For More Information

From small anesthesia practices to large academic centers, the PSH model has been successful in achieving the quadruple aim of bettering population health, improving health outcomes, improving patient experience, and increasing clinicians' professional satisfaction in different health care settings and countries. Learn how other institutions implemented the PSH model of care through free case studies, interviews, and more at asahq.org/psh.

Rob Shakar, MD, FASA, Chair-ASA Perioperative Surgical Home Steering Committee, New Hanover Regional Medical Center, Wilmington, North Carolina.

Rob Shakar, MD, FASA, Chair-ASA Perioperative Surgical Home Steering Committee, New Hanover Regional Medical Center, Wilmington, North Carolina.

Kim Duggan, MHA, BSN, RN-C, Perioperative Surgical Home (PSH) & Enhanced Recovery Manager, New Hanover Regional Medical Center, Wilmington, North Carolina.

Kim Duggan, MHA, BSN, RN-C, Perioperative Surgical Home (PSH) & Enhanced Recovery Manager, New Hanover Regional Medical Center, Wilmington, North Carolina.