Improving Perioperative Care through IT: An Automation Imperative

November / December 2008
Improving Perioperative Care through IT:
An Automation Imperative

Patient Safety and Quality Healthcare
Photo courtesy of Surgical Information Systems

Surgical procedures account for a major share of a typical hospital’s overall financial performance. It is estimated that surgical services and associated care often generate around 60% of a hospital’s total revenues and some 30% to 40% of a hospital’s total expenses. Yet even as clinical information systems evolve forward rapidly in many areas of hospital operations, the vast majority of hospital organizations still have not yet fully automated their surgery processes.

The many reasons for this include the sheer complexity of surgical information systems, the multidisciplinary input required to develop and implement such systems, the resources needed to make them work, and the fact that best practices in perioperative automation have not moved ahead as they have in some other clinical areas. But the need is there, both to improve patient safety and quality of care and to enhance the efficiency of processes and the workflow of clinicians. Indeed, those involved in such work say that whatever enhancements can be made to improve clinicians’ efficiency they also inevitably improve the care delivery process and the quality of care itself.

Two hospital organizations that have made major strides in this area are Bassett Healthcare, in Cooperstown, New York, and the University of Connecticut Health Care Center in Farmington, Connecticut. Clinical leaders have helped move automation forward at both organizations and have seen major improvements in patient safety, clinician productivity, and process efficiency.

The Mary Imogene Bassett Hospital, Bassett Healthcare’s core inpatient facility, reported several improvements following their initial implementation of an automated perioperative system: on-time first case starts increased by 35%; turnaround times improved by 33%; case supply costs decreased by $200 per case; and surgery-related charge capture increased by 30%. At the University of Connecticut Health Center, which began implementing its surgical information system a few years after Bassett, the efficiency of anesthesia management has been strongly enhanced since implementing an anesthesia component, and charge capture for billing has also been improved.

Bassett’s Growth “Problem”
Spurs Change

At Bassett Healthcare, located in upstate New York, the decision to implement a perioperative information system was spurred by a number of factors, among them, the positive “problem” of rapid growth. Several years ago, hospital system executives found themselves anticipating an initial 10% increase in procedures at a time of general expansion for the hospital system. “What was happening at that time was that we were getting ready to expand significantly due to closings and downsizing of nearby hospitals,” recalls Kathy Brooks, PA, administrative director, anesthesia and surgical support systems, for the health system. “In 1999,” Brooks says, “I had just moved to the operating room as the OR director. We were planning to open a cardiac surgery program, and building two ambulatory surgery centers” to accommodate swelling market growth. The task facing her, Brooks says, was to “manage the entire perioperative services program from an operational and clinical perspective, including all of the staffing and logistical requirements across a fairly large geographic area.”

“We were anticipating a 10% growth rate over 18 months; and it was very apparent to us that we needed technology to leverage everything from quality assurance data to productivity data,” Brooks continues, noting that recent hospital closings and downsizings in the region were serving to increase surgical volume at Bassett’s main inpatient hospital and its outpatient facilities.

Knowing that automation was the solution of course marked only the beginning. In 1999, very few nurses in the OR at Bassett had ever worked with computer, Brooks notes; and there were only three computer terminals in the whole OR area. One of the requirements, Brooks says, was that the vendor she and her colleagues chose be comprehensive in its approach, and offer solutions that covered the spectrum of care and activity at Bassett. After a careful evaluation process, Brooks and her colleagues chose Surgical Information Systems of Alpharetta, Georgia. The solution, including scheduling, nursing documentation, PACU, patient flow, anesthesia, and analytics, was broad enough to help the staff at Bassett optimize their surgical processes through a comprehensive approach.

There have been many advances in perioperative automation since the initial implementation in 1999 and 2000. Among them:

  • Integrated anesthesia and nursing documentation. Brooks and her colleagues replaced the previous, typical, preadmission testing process, in which patients were required to repeatedly answer the same sets of questions for assessment nurses and CRNAs (certified registered nurse anesthetists), with an integrated system that has removed information-gathering redundancies, improved documentation accuracy, continuity of care, and enhanced patient satisfaction.
  • Automated preference card management. Clinicians and managers at Bassett organized their paper-based surgeon preference cards into an electronic format that is easily managed and updated by nurses.
  • Improved compliance, based on enhanced documentation capabilities. Using their surgical information system, Bassett clinicians have moved from approximately 80% compliance with quality measures to nearly 100%, according to Brooks.
  • Surgery-specific charge capture at the point of care. Within 1 month of implementation of a rules-based charging module, Bassett’s revenue capture had increased over 30% (based on an improvement in lost charge capture).

Looking broadly at all the advances that have been made since automation, Brooks says, “Probably the most impressive outcome is that we have usable, accessible data to drive decisions. And when I say data and decisions, I’m not only talking about just operational and business decisions, I’m also talking about clinical decisions.” The electronic prompts built into the system are especially important in terms of guiding clinicians to document and communicate patient care data efficiently and appropriately.”

“For example,” she says, “We’ve got electronic prompts for people. We have an electronic prompt on the operating room schedule; it says one or more of these scheduled procedures requires antibiotics. So now if a doctor has forgotten to order antibiotics, it prompts the nurse to call the doctor. That enhances patient outcomes.”

The use of such systems is simply an organized way to optimize care quality and patient safety, Brooks says, noting that it’s something that has long been accepted in other industries. “For many years, I flew with the military,” she says (Brooks was an Air Force officer), “and we had checklists. Everyone on the team had checklists, but we also knew what the other people’s checklists were, so we could cross-reference and make sure we were safe as we took off.”

Creating “standardization and checklist-type activities in order to ensure very tight communication among team members” is simply the right way to do business, whether flying airplanes or taking care of patients, she maintains. The gains she and her colleagues have made because they’ve successfully implemented a comprehensive surgical information system have changed the ways in which they take care of patients, communicate with one another, and proceed through their workdays in a myriad of positive ways.

UConn’s Step-by-Step Approach
At the University of Connecticut Health Care Center in Farmington, the organization’s inpatient facility and outpatient facility do approximately 5,000 and 4,000 cases per year, respectively. The annual volume of surgeries at the 204-bed facility was certainly high enough to justify the implementation of a comprehensive surgical information system. But in fact, the specific situation that triggered that implementation was an announcement in 1999 by the hospital’s previous surgical IT vendor that it would no longer support its DOS-based product, confirms Carol Schramm, RN, MSN, CNOR, a perioperative clinical nurse specialist at UConn.

Actually, says Schramm, “All the system had was scheduling and surgeon pick sheets; everything else, including all the documentation, was paper-based.” In any case, Schramm and her colleagues went about evaluating vendor products; what convinced them to choose Surgical Information Systems (SIS) was seeing SIS’s implementation at Bassett Healthcare in Cooperstown. UConn went live with a form of nursing intraoperative management called post-op data entry in October 2002, along with scheduling and most non-clinical modules. The UConn folks then went live with nursing intra-op, preadmissions, and holding in spring 2003; and with nursing PACU and post-op D/C in late summer 2003. Anesthesia went live in late 2006.

And how did UConn anesthesiologists feel about using a surgical information system? Implementing a new information system is always challenging, but once such a system is implemented, clinicians often praise its use. “On a day-to-day level, it has been simple to use our system,” says HyunSuk Lee, MD, an anesthesiologist and assistant clinical professor at the University of Connecticut Health Care Center. “I didn’t like writing everything in the anesthesia record, and knew there must be a better way, and that things were eventually going electronic, and the sooner we jumped in, the better.”

Adds Marc Paradis, MD, an attending anesthesiologist and associate professor with UConn, “We wanted to bring in an information system that would involve the whole perioperative arena. We were interested in nursing and also wanted to obtain an anesthesia module.” What’s more, adding in the anesthesia component after the nursing, scheduling, surgeon preference card, and materials management modules had already been smoothly implemented, made sense for everyone, and was a natural progression, Paradis says.

The UConn clinicians are clear about the advance in patient safety and quality of care that has been achieved. Says Paradis, “You certainly have an increased level of comfort” now, working in a demonstrably safe patient care environment. “Previously,” he says, “the accuracy of your documentation was something that you had to work very hard to get. Currently, that accuracy is effortless, because of the automation of the vital signs; that makes for quite an improvement. It especially helps you on very difficult cases. There are some cases where, in the past, the anesthesia record probably didn’t get filled out in a timely and detailed manner because the patient was so critical.”

Lee adds, “It becomes very important in a paper-based environment not to lose time with the patient, which means that in the paper world, you almost always take care of the patient first and document later.” In contrast, he notes, “With an electronic system, we can ensure that all vital signs and physiologic parameters are accurately and promptly recorded. In addition, much of the documentation can be done concurrently with patient care, even when a very sick patient is involved.”

Very importantly, Paradis says, the successful implementation of the system has changed the way in which the physicians (anesthesiologists and surgeons) interact with the nurses and others. “This probably represents a sort of a paradigm shift in how documentation gets done in medicine in general,” he says. “It used to be that everybody sort of had their own documentation. And a lot of things got repeated in that process. What happens now is that things tend to flow more quickly while still being accurately verified. Accuracy is further enhanced due to the fact that the anesthesia module operates on the same (not a separate) database as the rest of the perioperative information system.”

Speaking for UConn’s nurses, the comprehensive surgical information system is “wonderful,” says Schramm. “I could never go back to a paper record.” What’s more, she says, “Now, when the Connecticut Department of Health is changing data-gathering requirements, or CMS is asking for core data sets, it’s easy to comply.” That also applies when complying with requests for Joint Commission indicator information and other data requests, she notes.

What’s more, Schramm says, it’s in the documentation area where efficiency and patient safety become one and the same issue to resolve. The current system that UConn has implemented allows for the creation of “wizards,” or pre-set data fields with specific fields that appear in a predetermined order for clinician users, and which prompt documentation and communication tasks. “For example,” says Schramm, “in nursing intra-op, there’s a prep tab, and a counts tab, and so on. You wouldn’t want people to have to hunt and peck around 15 tabs and keep straight what they have to document. As a result, we’re presented with everything we have to document, and it’s all right there in the middle of the screen.” The benefits to the clinicians are clear, she says.

As Schramm explains it, “Once anesthesia was automated, and we had an automated feed of vital signs, it went significantly better, so the nurses in the recovery room didn’t have to enter vitals, this was a side benefit of the anesthesia intra-op going live.” Implementing the anesthesia modules paved the way for automated entry of some vital signs into the SIS application and into the records, she adds.

Schramm and Paradis both agree that implementation of a comprehensive surgical information system has helped the clinicians at UConn make huge strides forward in ensuring enhanced patient safety, as well as in efficiency and clinician workflow. The sequencing of the go-live of the various modules was important, Schramm adds.

“The system provides opportunities for improving patient safety, quality of care, and operational efficiency,” says Kevin Larsen, UConn’s operating room administrative director. “I can tell you, on the operational side in terms of efficiency,” he says, “the system is invaluable in providing us with the data we need to move toward our targets. We wouldn’t be able to do that without this system.”

Says Bassett Healthcare’s Brooks, “Information technology alone is not the be-all and end-all. You must then use the data and leverage the technology to drive improvement and processes. And we have not consistently sustained everything that we gained initially. But,” she adds quickly, “we couldn’t do this without the information systems. I can’t imagine going back to a paper-based system and still adhering to all of the reporting and audit requirements and all the other mandates.” It is time to stop the paper-based, manual processes that have characterized perioperative processes for far too long.

Kermit Randa is senior vice president of Surgical Information Systems, a healthcare software company based in Alpharetta, Georgia. Randa may be contacted at

Mitch Work is president of The Work Group, Inc; a Chicago-area-based healthcare technology marketing firm specializing in emerging technologies. Work may be contacted at