beyond surgical call coverage: reaping the benefits of a surgical hospitalist program

Back in 2008, Sutter Medical Center, Sacramento (SMCS), a tertiary-referral community hospital with 652 beds on two campuses in California, needed help with its surgical call coverage. The hospital was evaluating between 60,000 and 75,000 patients annually in its emergency department (ED) at that time, and the numbers were continuing to grow. SMCS determined that the best way to provide consistent coverage and improve clinical and financial performance was to develop a surgical hospitalist program.

In the process, SMCS discovered that a surgical hospitalist program is much more than a solution for surgical call coverage. By helping a hospital address the ongoing challenges of reducing complications and increasing efficiencies, such a program can provide a foundation for success in an industry moving toward value-based payment.

A Growing National Problem

For years, emergency surgical coverage at SMCS was provided by a mandatory, rotating schedule of general surgeons to cover the ED call panel. Each surgeon was required to be on call for 24 hours of emergency surgical coverage, during which the surgeon was responsible for all acute surgical consultations and procedures at SMCS. Failure to participate meant that the surgeon would lose staff privileges at the hospital.

Yet the surgeons were being spread too thin. Between their private practices and required ED surgical coverage, scheduling conflicts became inevitable. Surgeons became frustrated and did not have time to take call, resulting in long wait times for patients to receive the care they needed. Postoperative continuity of care also was becoming an increasing challenge for patients who had inadequate or no insurance coverage, leading to greater ED patient volume. Long hours in the ED coupled with poor reimbursement contributed to the general surgeons' frustration, eventually causing them to object to having to participate in the ED call panel.

These sources of conflict between hospital administrators and surgeons not only created discord within the hospital, but also compromised the hospital's ability to successfully operate in a pay-forperformance world. The hospital's costs rose and its revenue decreased as its ED coverage problems collided with the crisis of a national physician shortage and a growing influx of patients presenting to the ED each year. A lack of consistent care increased the likelihood of complications, creating inefficiencies and driving up réadmissions and costs.

With an understanding that they needed a new solution, SMCS's leaders first defined the following goals:

> Offering 24/7 call coverage for acute care surgery

> Improving the timeliness of surgical care

> Providing immediate consultations for physicians

> Improving clinical outcomes

> Decreasing length of stay (LOS)

> Improving the affordability and predictability of expenses

> Raising physician satisfaction

Implementing the Hospitalist Program

After a thorough review of options, SMCS's leaders chose a new ED surgical solution that involved contracting to have a group of unencumbered surgeons available to serve as surgical hospitalists, providing in-house emergency surgical coverage 24/7.

Like hospitalists who deliver inpatient medical care, these hospitalists-also called surgicalists-are surgeons who focus solely on acute surgical care in the hospital. They tend primarily to the needs of ED patients with traumatic and other surgical issues who need immediate care. They also are available on-call to deliver general surgical care in the hospital and to consult with attending physicians.

The majority of patients seen by surgicalists are from the ED, but surgicalists' patients also include those who do not have a primary care physician. Hospital administrators can employ or contract with surgicalists to augment their ED services, or they can engage the services of a surgical hospitalist provider to implement the program.

SMCS's program was designed to ensure the hospitals would have ongoing in-house coverage for their emergency surgical patients, delivered by board-certified, fellowship-trained surgeons and a team of mid-level practitioners (nurse practitioners and physician assistants). In addition, the program was provided with management that handled all the provider recruiting and training, thereby taking a huge burden off the hospital's administration.

SMCS's surgical hospitalist program incorporates the acute care surgery model for managing patients using evidence-based, physician practice management guidelines and best practices. The program is structured so that each 24-hour shift is staffed with 3.5 full-time, board-certified general surgeons. On average, each surgeon has two 24-hour shifts per week. On-duty surgeons always are on the hospital campus, with only one focus: to care for patients arriving at SMCS with acute surgical needs.

The team also includes a full-time nurse practitioner and physician assistant to ensure a high quality of interactions with patients and their families. These team members are critical for achieving the program's aims of effectively maintaining continuity of care, managing patient flow, and facilitating communication among patients, families, and the healthcare team.

Immediate Improvements

SMCS quickly saw improvements. For example, there was an immediate, significant reduction in the average time it took to move patients from the ED to the operating room. Patients no longer had to wait for surgeons to finish elective surgeries before becoming available to care for acute cases in the ED. Hospital staff also no longer wasted valuable time looking for surgeons to perform procedures or provide consultations. And because the surgicalists had no outpatient practices, they could perform surgeries during the day as well as in the evenings and on weekends. Teamwork among all participants also improved, resulting in more efficient and more standardized care. Patients and their families also benefited from more timely communications by surgeons and better coordination of care by nurse practitioners and physician assistants.

Surgeons in private practice saw immediate benefits as well. ED surgical call coverage was no longer required, creating a better work-life balance for physicians and allowing local surgeons to focus on their elective surgeries.

Improved Outcomes and Cost Savings

A five-year study, published in the July 2014 issue of the Journal of the American College of Surgeons, focused on SMCS's experiences in implementing a surgicalist program and documented the following improvements.®

Costs and estimated savings. Hospital costs per surgery declined by 31 percent, from $12,009 in 2007 to $8,306 in 2011. Anticipated savings for a hospital of this size and type with this surgicalist program would be $2 million in a single year. Savings were attributed to gains in throughput resulting from a greater availability of hospital beds, as well as a lower cost per case-stemming in large part from a lower rate of complications-that helped increase margins.

Complications. Complications dropped 43 percent, falling from a rate of 21 percent in 2007 to 12 percent in 2011. As expected, because patients recover better and faster at home, the program's ability to get patients home at the earliest and most clinically appropriate time has helped prevent infections and other complications that can compromise outcomes and increase the cost of care.

Case mix index (CMI), LOS, and readmissions. SMCS realized a significant improvement in the hospital's overall CMI, raising it from 1.96 at baseline to 2.24 by the fourth year of the study.

Meanwhile, LOS declined, while readmissions remained stable or declined. The LOS for acute general surgery cases decreased by as much as 12 percent-down from 6.5 days to a low of 5.7 days in the second year of the program. In one year of the study, for example, LOS decreased 37 percent for appendectomies and 24 percent for cholecystectomies. Patient stays for these two conditions dropped from five days to three days in the first year because patients were taken to surgery more quickly, and the in-house surgical team was available to deal with all subsequent care.

Readmissions also showed a downward trend, although this change was not statistically significant. The important fact is that although LOS significantly decreased, the readmission rate did not increase.

The study data also showed that with the addition of the surgicalist program, patient volumes for surgeons in private practice stayed the same or increased.

Buy-In Is Critical

Creating a surgicalist program can be straightforward, yet it should not be undertaken without sufficient preparation and planning. The success of SMCS's initiative can be attributed in large part to the organization's preliminary efforts to obtain buy-in from key leaders. Hospital leaders also engaged in extensive communications with surgeons already working acute care cases prior to implementing the program to ensure that their concerns were addressed and that the program would be well-received. For example, local physicians were concerned about whether their patients would recieve the highest quality of care. SMCS had open dialogue with the local physicians in which the hospital leaders pointed to the high ED wait times the physicians' patients were experiencing for emergency surgeries. Leaders then explained how a surgicalist program would provide a better response time to emergency surgeries, because surgicalists are in-house, thereby bridging the gap with the local surgeons. As a result, local physicians began to understand that the surgicalist model was a complement to local surgeons' practices, ensuring the community received the highest quality of care, which was the goal of the local physicians and SMCS.

A Strategy for Value

The value to all communities, especially those in which the hospital may not have a trauma center that can provide access to emergency surgeries around the clock, is clear. A surgicalist program can help a hospital deliver high-quality surgical services on demand regardless of when they are needed. Such programs also have been shown to allow hospitals to reduce costs, thereby helping the organizations to be more competitive in their markets and, ultimately, achieve success under value-based payment models.

AT A GLANCE

* A surgical hospitalist program can address issues with surgical call coverage and help organizations prepare for value-based payment.

* Such a program can improve timeliness of care and reduce complications, length of stay, and costs.

* A surgical hospitalist program at one California hospital saved the organization an estimated $2 million a year.

a. O'Mara, M.S., Scherer, L., Wisner, D., and Owens, L J, 'Sustainability and Success of the Acute Care Surgery Model in the Nontrauma Setting,' Journal of the American College of Surgeons, July 2014.

Richard SooHoo is CFO, Sutter Medical Center, Sacramento, and a member of HFMA's Northern California Chapter.

Leon J. Owens, MD, FACS, is president and CEO, Surgical Affiliates Management Group, Inc., Sacramento, Calif.