Looking to improve outcomes for their highest risk patients, three of New York's leading hospital systems have joined together to launch an ambitious surgical safety initiative. Supported by Hospitals Insurance Company (HIC), physicians from Maimonides Medical Center, Montefiore Medical Center and Mount Sinai Health System are working together on a multi-pronged initiative to improve surgical outcomes.
An inter-disciplinary team of physicians with strong support from hospital leadership has developed a four-part program covering pre, intra and post-operative care, with an additional emphasis on care of obese surgical patients.
In discussing the impetus for the project, HIC Chief Medical Officer David L. Feldman, M.D. stressed the variability of surgical care and its implications. "If we can standardize practice and reduce adverse events relating to surgery, we can improve the quality of care at our hospitals while also delivering long-term savings. It also happens that for most hospitals, the highest frequency of claims arise from surgical cases," said Dr. Feldman.
Led by the inter-hospital patient safety team, the program has standardized forms and processes to promote compliance with best practices in the care of surgical patients.
The first step in the process is a standard POMA – a pre-operative medical assessment. This requirement for the sickest surgical patients ensures that three experts – an internist in addition to a surgeon and anesthesiologist – review each patient's health record. From a medical perspective, this commonsense approach means enhanced quality of care through a better understanding of the risks and likelihood of medical complications arising from surgery. From a malpractice perspective, this adds valuable layers of scrutiny which can go a long way in preventing and defending lawsuits.
While changing culture at large hospitals can be difficult, each hospital has met compliance requirements ahead of schedule thanks in large part to the focus on collaboration and teamwork. This commitment to the team concept has been reinforced through the TeamSTEPPS training program.
"Our multidisciplinary approach is based on the principle of taking a team of experts and building an expert team," said HIC Chief Nursing Officer Pat Kischak.
This approach is put into practice right at the start of every operation, in which the surgical team takes a time out to review procedures before moving forward. As part of the surgical safety initiative, a group of surgical safety experts (OR nurses, anesthesiologists and surgeons) identified the eight most important TeamSTEPPS based skills that should be used during the time out.
For most patients, the first time they notice these enhanced surgical safety procedures is during post-operative care with the expanded co-management process. Surgical patients enrolled in this program receive a card from his or her hospitalist describing co-management and the role of the hospitalist. While still early, feedback has been extraordinarily positive – both from patients and clinicians.
"Nurses report back to us that co-management has made an enormous difference in assisting them in helping their sickest patients after surgery," said Kischak.
After initial findings demonstrated that co-managed patients are much less likely to suffer post-operative complications, HIC's member hospitals have decided to double the initial investment in co-management.
The final piece of the initiative is the special emphasis on obese patients and the recognition that obesity is a key risk factor for a number of serious complications. In fact, obesity is quickly overtaking smoking at the predominant risk factor for surgical patients.
With this in mind, the HIC collaborative has put in place best practices informed largely by bariatric surgeons. Prior to launching this initiative, many physicians didn't treat obese patients any differently than other patients. With increased attention, surgeons are now more aware of the risks of obesity.
The surgical safety initiative is the latest project led by HIC on behalf of its member hospitals. The HIC program grew out of a partnership established in the mid-1970s when four large New York hospitals created a shared professional liability program, HIC, with their own risk management advisors, FOJP Service Corporation. The central mission of HIC and FOJP—unlike those of most private insurers—is to improve patient safety and quality of care within member hospitals. HIC does not have traditional shareholders and is not driven to recruit members or build profit margins. Instead, HIC and FOJP focus resources to reduce patient injury and improve clinical outcomes, even with the understanding that any impact on claim costs will not be observed or measurable for years to come.