A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts.
OBJECTIVE
Authors hypothesized that building safe hospital systems to improve value-based surgical outcomes is predicated on workflow redesign for dynamic risk stratification, coupled with "real-time" mitigation of risk. We developed a comanagement model for hospitalized surgical cohort, and determined whether this iterative process redesign for surgery will be adaptable to disparate hospital systems and will be beneficial for combined medical/surgical adult inpatients.


BACKGROUND
Concerns about preventable harm in hospitalized patients have generated a plethora of both, process-driven and outcome-based strategies in US Healthcare. Although comparison between hospitals is a common mechanism to drive quality, other innovative approaches are needed for real-time risk mitigation to improve outcomes.


METHODS
Prospective implementation of Surgical Continuum of Care (SCoC) model in hospitals initially for surgery patients; subsequently Continuum of Care (CoC) for medical/surgical population. Redesign of hospital care delivery model: patient cohorting, floor-based team building, and intensivist/hospitalist staffing of progressive care unit (PCU). Work flow redesign for clinical effectiveness: multidisciplinary team rounds, acuity stratified care rounding based on dynamic risk assessment into a novel HAWK (high risk)/DOVE (low risk) patient grouping, intensivist/hospitalist comanagement of surgical patients, and targeted response.


METHODS
Pre- and postintervention with concurrent cohort control design.


METHODS
Academic medical centers for SCoC and integrated health system hospital for CoC.


METHODS
SCoC Pilot Study-Campus A: Preintervention control group 1998-2000, Intervention Group 2001-2004; Campus B: Comparator Control Group 1998-2004. SCoC Validation Study-Campus C: Preintervention Group 2001-2005; Intervention Group 2006-2008. CoC Study-Campus D: Hospital-wide Group 2009. METRICS: Mortality, length of stay (LOS): overall, surgical intensive care unit and PCU, readmission rates, and cost. Case mix index for risk adjustment.


RESULTS
Total >100,000 admissions. There was a significant reduction in overall surgical mortality in both, pilot (P < 0.002) and validation (P < 0.02) SCoC studies and overall hospital mortality in the medical/surgical CoC study (risk-adjusted mortality index progressively declined in CoC study from 1.16 pre-CoC to 0.77 six months post-CoC implementation; significant at 75% confidence level). Case mix index was unchanged during study period in each campus. Nested study in validation cohort of hospital-wide versus surgery alone (observed/expected mortality index) demonstrated significant benefit to SCoC in intervention group. The mortality benefit was primarily derived from risk-stratified rounding and actively managing risk prone population in the PCU. Surgical intensive care unit, PCU, and total hospital patient-days significantly decreased in SCoC pilot study (P < 0.05), reflecting enhanced throughput. LOS reduction benefit persisted in SCoC validation and CoC studies. In addition to decreased LOS, cost savings were in PCU (range, $851,511-2,007,388) and top diagnosis-related groups, for example, $452 K/yr for diagnosis-related group 148.


CONCLUSIONS
SCoC is patient-centered, outcomes-driven, value-based approach for hospital-wide surgical patient safety. The principles of this value paradigm are adaptable to other hospitals as demonstrated in our longitudinal study in 3 hospital systems, and the initial experience of CoC suggests that this model will have benefit beyond surgical hospital cohort.
Ravikumar
Thanjavur S
TS
Divisions of Quality/Innovation, Geisinger Health System, Wilkes-Barre, PA 18711, USA. tsravikumar@geisinger.edu
Sharma
Cordelia
C
Marini
Corrado
C
Steele
Glenn D
GD
Ritter
Garry
G
Barrera
Rafael
R
Kim
Mimi
M
Safyer
Steven M
SM
Vandervoort
Kathy
K
De Geronimo
Marcella
M
Baker
Lindsay
L
Levi
Peter
P
Pierdon
Steven
S
Horgan
Meg
M
Maynor
Kenric
K
Maloney
Gerald
G
Wojtowicz
Mark
M
Nelson
Karen
K
D000328:Adult; D016009:Chi-Square Distribution; D003266:Continuity of Patient Care / Q000592:standards*; D003953:Diagnosis-Related Groups; D005240:Feasibility Studies; D013502:General Surgery / Q000592:standards*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016014:Linear Models; D008137:Longitudinal Studies; D019300:Medical Errors / Q000517:prevention & control*; D017146:Models, Organizational; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000592:standards; D010359:Patient Readmission / Q000706:statistics & numerical data; D010865:Pilot Projects; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D017751:Safety Management / Q000592:standards*; D018709:Statistics, Nonparametric