By David Bergman, DO
Many people hear the term perioperative surgical home (PSH) and wonder what it actually means. This is a logical question, considering if you ask five people to define it, you may get five different answers. Putting the name interpretations aside, the PSH delivery model is based on improving care, saving costs, and helping ORs embrace value-based payment models across the country.
If your outpatient OR isn’t already working toward a PSH model, you’re leaving all those benefits on the table.
What is the PSH?
The PSH is a coordinated care model developed by the American Society of Anesthesiologists (ASA). Its name comes from its similarities to the medical home model that’s been widely accepted in primary care.
First introduced around 2012, the PSH model is a patient-centered, team- and evidence-based effort targeted at improving outcomes and lowering costs. Under the model, the anesthesiologists coordinate closely with nurses, surgeons, and other key players involved in surgical patient care. The model goes into effect as soon as the decision to operate has been made and extends until 30+ days post-discharge.
The model has been implemented in numerous operating rooms and healthcare systems around the country since 2013, and the results are impressive. Participating institutions have reported (American Society of Anesthesiologists, 2019):
- Up to 75% reduction in readmissions
- Up to 50% reduction in length of stay
- $4,000–$10,000 in cost savings per case
- Improved quality and patient satisfaction—for example, a 75% decrease in pain scores
- Significant alignment with bundled payment and accountable care organization (ACO) programs
The PSH in an outpatient setting
Much of the early focus on the PSH model was on hospital-based care. So, the natural question becomes: Can the PSH model deliver the same types of benefits in an outpatient setting? In short, yes.
A recent clinical study (Qiu et al., 2017) conducted at Kaiser Permanente Baldwin Park looked at the effects of implementing a PSH model on over 1,900 patients undergoing outpatient laparoscopic gallbladder removals. The study found that the implementation of the PSH in this outpatient setting was responsible for:
- A 40% reduction in length of stay
- A fivefold improvement in patients who bypassed the PACU after surgery
- A fivefold reduction in unplanned hospital admissions
- A 25% reduction in median pain scores
Those are numbers any outpatient OR would be thrilled to achieve.
A pathway to value-based payments
There’s no question that value-based payments are the future of medical reimbursement in the United States. There are quite a few ways to get there, from bundled payments to ACOs and other models. But all those models share common characteristics that can be helped by the implementation of a PSH:
· Payments: The delivery of value. At their core, all value-based payment programs reward providers and facilities for delivering more value. The PSH model is centered on delivering more value throughout the entire surgical experience.
· Data collection matters. A big part of CMS’ push toward value-based payments involves data collection and reporting. The PSH collects data throughout the surgical process that’s used for reporting, documentation, and to drive evidence-based care protocols.
· Collaborative care is critical. Multiple studies have borne out that healthcare providers collaborating closely deliver better care. Collaboration throughout the pre-surgical, surgical, and post-surgical experience is at the core of the PSH model.
· Patient satisfaction matters. Value-based payment programs all take patient satisfaction into account, and study after study has shown that the PSH model helps boost key patient satisfaction metrics.
Getting started with the PSH
When you look at the benefits of the PSH model, it’s difficult to find a reason why you shouldn’t at least consider its implementation at any surgical facility you’re involved with. Here are a few steps to get the ball rolling toward a successful PSH implementation:
- Identify areas for improvement and gather educational materials. Give everyone involved in the decision-making process the education they need to make an informed decision.
- Get buy-in from leaders. Whether it’s the C-suite, physicians, or clinical staff, no new team-based program can be successfully implemented without buy-in from core members of the entire team.
- Get the right tools. Educational materials will support the process, and the right software will help deliver content, automate a reproducible model, and help you measure the impact, which will keep you moving in the right direction.
- Know where to start small and where to go big. Certain value-based models are well suited for specific service lines. Specific opportunities to cut costs (e.g., decreasing delays and cancellations) can also be addressed more globally. Implementing a PSH model isn’t necessarily an all-or-nothing, facilitywide program. Identifying the areas with greatest opportunity should help your facility focus the model appropriately.
- Improve continually. The PSH model isn’t a one-and-done project. Instead, it’s a process of continual progress, review, assessment, and improvement that will help your operating room become better and better over time.
PSH implementation tools
Here are a few resources that can help you get started on a PSH implementation:
The ASA’s PSH website: The PSH model originated with the ASA, and they’ve put together a wide range of educational materials, case studies, research, and other resources dedicated to the PSH. https://www.asahq.org/psh
Kaiser’s ambulatory PSH implementation study: The outpatient PSH study from Kaiser Permanente Baldwin Park goes into detail about the implementation process and the changes that were made. It’s worth a read for anyone considering a similar program. https://journals.lww.com/anesthesia-analgesia/Fulltext/2017/03000/An_Ambulatory_Surgery_Perioperative_Surgical_Home.16.aspx#pdf-link
PSH 101: The ASA offers a free online course titled “Cases From the Perioperative Surgical Home: A Journey to Improve Quality and Patient Safety,” aka “PSH 101.” The first module goes through several PSH implementation case studies, while the next two modules are designed to guide you through creating your own PSH performance improvement action plan. https://www.asahq.org/shop-asa/e018g01w00
PSH software: For years, our company has been developing software that helps surgical facilities implement a successful PSH model. Today, it’s a fully developed tool that connects with most major EHRs, and last year we started officially collaborating with the ASA. https://epreop.com/surgicalvalet
David Bergman, DO, is an anesthesiologist and CEO of ePreop, Inc. Dr. Bergman completed his anesthesia training at UC Irvine in 2004, and began practicing anesthesia at the St. Jude Medical Center in Fullerton, California. In 2008, he founded ePreop, a software company that offers a suite of tools designed to help operating rooms improve care and increase efficiency. Today, the ePreop software suites are being utilized to coordinate care in facilities across the country, while capturing outcome data in nearly 2,000 facilities for over 28 million procedures to date.
American Society of Anesthesiologists (ASA). (n.d.). Learning collaborative overview. Retrieved from https://www.asahq.org/psh/learning%20collaborative/an%20overview
Qiu, C., Rinehart, J., Nguyen, V. T., Cannesson, M., Morkos, A., LaPlace, D., … Kain, Z, N. (2017). An ambulatory surgery perioperative surgical home in Kaiser Permanente settings: Practice and outcomes. Anesth Analg, 124(3), 768-774.