The Virtual Pre-Op Clinic

2014 AMGA Institute for Quality Leadership

Randal Moseley, MD, FACP, FHM Galen Sorom, MD, FACP Timothy Barnwell, MD Marcus Miller, MHA Karen Lawson, RN, CAPA

Disclosures

• None

• Formed in 2013 as an affiliation between Wenatchee Valley Medical Center and Central Washington Hospital

• 12,000 square mile service area in North Central Washington State

• 10 locations

• 2 hospitals, 190 acute care beds

• 16 operating rooms

• 270 physicians and 100 advanced practice clinicians

• Cerner EHR inpatient, Epic outpatient

CONFLUENCE HEALTH

Using EHR Technology To Go Where No Pre-op Clinic Has Gone Before

Supported engagement of primary

care

Unified pre-op care coordination

Standardized pre-op

screening

The Problem: Surgical morbidity & mortality related to medical complications

Failure to recognize risk

Risk recognized, but not adequately addressed

Communication failures

The Traditional Solution

Fragmented care Creates

specialized knowledge

silos

Not patient-centered

Expensive

Surgeons send

any patient to the

pre-op clinic who

they believe is

high-risk

Our Solution: The Virtual Pre-op Clinic

Virtual Pre-op Clinic

Innovative Staffing Model

PCP Decision Support

EHR Tools

Virtual Pre-Op Clinic Key Elements

Uniform point-of-care risk assessment

Perioperative Nurse Clinician (PONC)

Supported PCP engagement

Organized communication

Point-of-Care Risk Assessment

Quick Screen System

What is it?

How was it developed?

How do we use it?

Quick Screen

Periop Nurse

Clinician

PCP Pre-op Visit

Organized Communication

Quick Screen

Perioperative Nurse Clinician (PONC)

Review quick screen

Assemble relevant

data

“Setting the table” for

PCP

Closing the loop

Quick Screen

Periop Nurse

Clinician

PCP Pre-op Visit

Process Oversight, Enhance Communication

Organized Communication

Standard PONC Documentation

The PCP Pre-Op Visit

Value of Continuity

Supported Documentation

Point-of-Care Decision Support

Focused Decision-Making

Quick Screen

Periop Nurse

Clinician

Organized Communication

PCP Pre-op Visit

Patient-Specific Decision Support

Reference Toolbox

Note Template/Decision Support Pane

Enhanced Communication

Notification of surgeon’s office when evaluation complete and patient medically optimized

Transmission of information to operative venue

Tracking pending tests

Coordination of sub-specialist

activities

PONC coordination note

Quick Screen

Periop Nurse

Clinician

PCP Pre-op Visit

Organized

Communication

Communication with Operative Venue “Closing the Loop”

Surgical Episode of Care

Enhances communication between care

teams

Replaces manual staff

data collection for surgical

packet

Ensures accurate and

relevant patient

information for surgical staff

The Framework for Transformation Kotter’s 8 Step Process for Leading Change

1) Establish Urgency

2) Build Guiding Teams

3) Develop a Change Vision

4) Communication for Buy-in

5) Empowering Action

6) Create Short-term Wins

7) Never Let Up

8) Make Culture Change Stick

Creating a Climate for Change

Engaging & Enabling the Organization

Implementing & Sustaining Change

Adapted from: Kotter, J. P. (1995). Leading Change: Why Transformation Efforts Fail. Harvard Business Review OnPoint (March-April), 1-10.

Outcomes

Quick Screen

Primary Care Visits

Measuring Impact

Quick Screens May 2013-August 2014

6,831 Total Quick Screens Performed

2,247 Failed Quick Screens -

Referrals for Pre-op

Evaluation (33%)

Primary Care Visits May 2013-August 2014

68% Completed

1528

24% Not Needed

539

8% Not Done

180

Pre-op Evaluation Visit Outcomes

Day-of-Surgery Laboratory Testing

30.0%

35.0%

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

Percent of Select Surgery Patients with Labs Resulted Same Day and Prior to Surgery Start

(Excludes Glucose and Coag)

January 2012 through June 2014

Pilot Start

Rollout Start

Physician Survey: Since the inception of our Pre-operative Medical Evaluation Process, patients are medically better prepared for surgery.

Don't agree or disagree

11%

Agree 72%

Strongly agree 17%

Anesthesiologists

Strongly disagree

7% Disagree

7%

Don't agree or disagree

27% Agree 60%

Surgeons

Disagree 11%

Don't agree or disagree

16%

Agree 53%

Strongly agree 21%

PCPs

Are We on the Right Track? NEJM April 10, 2014

11.1%

Remaining Challenges

Outside PCPs

Outside Surgeons

Data

Universal Adoption

Management

QUESTIONS?

Randal Moseley, MD, FACP, FHM randal.moseley@confluencehealth.org

Galen Sorom, MD, FACP galen.sorom@confluencehealth.org

Timothy Barnwell, MD timothy.barnwell@confluencehealth.org

Marcus Miller, MHA marcus.miller@confluencehealth.org

Karen Lawson, RN, CAPA

karen.lawson@confluencehealth.org