UvA-DARE (Digital Academic Repository) Improving the preoperative assessment clinic Edward, G.M. Link to publication

UvA-DARE (Digital Academic Repository) Improving the preoperative assessment clinic Edward, G.M. Link to publication Citation for published version (APA): Edward, G. M. (2008). Improving the preoperative assessment clinic General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl) Download date: 23 Nov 2017

Improving the Preoperative Assessment Clinic Gitara Edward

Cover design: Supracodex Printing: Ponsen & Looijen B.V., Wageningen The printing of this thesis was generously supported by: Abbott B.V., B. Braun Medical B.V., ChipSoft, EuroCept, Grünenthal B.V., Linde Gas Therapeutics Benelux BV, McKesson Nederland B.V., Pentapharm, Plexus Medical Group, Schering-Plough Nederland

Improving the Preoperative Assessment Clinic ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. dr. D.C. van den Boom ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel op vrijdag 14 november 2008, te 14:00 uur door Gitara Mela Edward geboren te Ashton-under-Lyne, Engeland

Promotiecommissie Promotores: Prof. dr. M.W. Hollmann Prof. dr. J.C.J.M. de Haes Co-promotores: Dr. L.C.J.M. Lemaire Dr. B. Preckel Overige leden: Dr. P.J.M. Bakker Prof. dr. M. Džojic Prof. dr. R.J. de Haan Prof. dr. C. Kalkman Dr. A. de Roode Prof. dr. W.S. Schlack Faculteit der Geneeskunde

Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. A.A. Milne

Table of Contents Chapter 1 General Introduction 9 Chapter 2 Comparing the organisational structure of the preoperative assessment clinic at eight university hospitals 21 Chapter 3 Patient flow in the preoperative assessment clinic 35 Chapter 4 Simulation to analyse planning difficulties at the preoperative assessment clinic 51 Chapter 5 The Patient Experiences with the Preoperative Assessment Clinic (PEPAC): validation of an instrument to measure patient experiences 73 Chapter 6 Setting priorities for improving the Preoperative Assessment Clinic: the patients and the professionals perspective 91 Chapter 7 The effects of implementing a new schedule at the Preoperative Assessment Clinic 105105 Chapter 8 Summary & General Discussion 119 Dutch Summary 135 Appendix: PEPAC questionnaire 143 Acknowledgements 163

Chapter 1 General Introduction

Chapter 1 Anaesthesia traditionally refers to the intentionally induced state of having no conscious sensations during medical interventions. This enables patients to undergo surgical and medical procedures without having to suffer pain and distress. The term comes from the Greek word άναισθησία, which means without sensation. Nowadays, anaesthesia care encompasses the relief of pain and total care of the surgical patient before, during and after surgery: the pre-, per-, and postoperative period. Preoperative assessment The aim of the preoperative assessment is to ensure optimal anaesthesia, reduce the morbidity associated with surgery, to increase the quality and decrease the cost of perioperative care, and to rapidly restore the patient to the desired level of functioning. 1 In addition, the preoperative meeting is an appropriate time to educate the patient on anaesthesia, perioperative care, and pain treatments, to reduce anxiety, to develop care plans, and to obtain informed consent. 2 In order to reduce the risks of surgery, to restore the functioning to the desired level, and to develop a care plan, the patient s health status has to be assessed. This encompasses a medical history, physical examination, and sometimes additional diagnostic testing or consulting another medical specialist. The preoperative physical status of patients is classified using the American Society of Anesthesiologists (ASA) physical status classification system (Table 1). 3 Table 1. ASA physical status classification system ASA 1 ASA 2 ASA 3 ASA 4 ASA 5 Normal healthy patient Patient with mild systemic disease Patient with severe systemic disease Patient with severe systemic disease that is a constant threat to life Moribund patient not expected to survive without the operation 10

General Introduction The preoperative assessment clinic Traditionally, the anaesthesiologist who would give the anaesthesia would visit the patient for preoperative assessment the evening before or on the day of surgery. In 1949, Lee proposed to perform preoperative assessment on an outpatient basis. 4 However, it was the introduction of day-case surgery and same-day admissions that catalyzed the implementation of anaesthesia outpatient clinics for preoperative assessment. Many different names are used for outpatient clinics for preoperative assessment, e.g. Preoperative Assessment Clinic (PAC), 5 Preoperative Assessment Testing Clinics (PATC), 6 Preoperative Anaesthesia Consultation and Evaluation (PACE) Clinic, 7 Preadmission Evaluation Centre (PEC), 8 and Anaesthesia Preoperative Evaluation Clinic (APEC). 9 In this thesis the term PAC is used. In contrast to the traditional preoperative assessment the evening before or on the day of surgery, the person performing the preoperative assessment at the PAC is usually not the same person as the one giving the anaesthesia. However, the anaesthesiologist giving the anaesthetic has complete responsibility for proceeding with the anaesthesia. Nowadays, many hospitals utilize PACs. This is not surprising, as research has clearly shown that performing the preoperative assessment on an outpatient basis, several weeks or days before surgery, increases cost-efficiency. 8-13 When an operation is cancelled close to the time of surgery, the chances are great that the operating room slot that becomes available cannot be utilised by another patient. By optimizing the medical condition of the patient prior to surgery, operating room cancellations and delays for medical reasons are reduced significantly. 9-11;13 Identifying special prerequisites for the perioperative period in an early stage can improve operating room scheduling and reduce operating room cancellations. For example, a patient who does not fulfil the requirements for day-case surgery will need a hospital admission, and a patient requiring intensive care after surgery will need an intensive care bed. Performing preoperative assessment on an outpatient basis reduces the preoperative admission time and enables day-case surgery, thus reducing the length, and therefore the costs, of the hospital stay. 12-14 When the 11

Chapter 1 anaesthesiologist orders the preoperative tests, less preoperative diagnostic tests are performed, which also reduces costs. 8;9;14 The PAC in the Netherlands In 1997 the Dutch Health Council recommended hospitals to implement a PAC. 15 Now the majority (90%) of the Dutch hospitals has a PAC. 16;17 However, the patient groups who are assessed at the PAC differ between hospitals. Not all surgical patients necessarily visit the PAC, this is only common practice in 64% of the Dutch hospitals. 17 The Dutch Health Council and the Netherlands Society of Anaesthesiology hold the surgical specialist as well as the anaesthesiologist responsible for the preoperative evaluation. 15;18 The anaesthesiologist is generally responsible for the preoperative assessment at the PAC. The Netherlands Society of Anaesthesiology states that the one performing the preoperative assessment does not necessarily have to be the same person giving the anaesthesia, but the patient should be informed about this. 18 There is no uniformity in the way PACs are organized in the Netherlands. The Dutch Health Council recommended performing preoperative assessment in an outpatient setting. However, no recommendations were made on how to organize preoperative assessment at a PAC. 15 Quality of healthcare services Traditionally, healthcare services were largely paternalistic and the focus of healthcare services was on diagnosing and treating the patient. The quality of healthcare was mainly assessed by medical outcomes: a concrete indicator of quality. 19 Though medical outcomes are a good measure for the effectiveness and quality of medical care, they do not include all relevant aspects of healthcare services. Therefore, quality assessment studies now generally use three categories of quality measures, based on Donabedian s structure-process-outcome model. 20 Structural measures of quality refer to professional and organizational characteristics, e.g. the capacity of the PAC and the qualifications and competence 12

General Introduction of medical staff. Process measures investigate the process of care itself instead of its outcomes, e.g. respectful treatment of patients. Outcome measures refer to the outcome as a result of the care processes, e.g. trust and reduced morbidity and mortality. 19 Structure, process and outcome are interrelated. Good structure increases the chance of good process, and good process increases the chance of good outcome. 21 Thus, structure is related to outcome. Outcome is related to both the technical performance of the practitioner and the interpersonal processes between patient and practitioner. The first is dependent on the practitioner s knowledge, judgement and skill. The latter is the agent to implement technical care. 21 Patient flow logistics In the Western world a substantial part of the Gross Domestic Product (GDP) is spent on healthcare; in the Netherlands this is approximately 13%. 22 Controlling healthcare costs is high on the political agenda. Ideally this is achieved without negatively impacting patient care; one way to do this is by improving the process or operational efficiencies. Performing preoperative assessment on an outpatient basis rather than clinically was shown to be cost-efficient, 8-13 but the most cost-efficient way to perform preoperative assessment at a PAC has not yet been studied. There is no unity in the way PACs are organized and no recommendations on the best way to organize a PAC have been done. Improving the structural and process measures of the PAC might further reduce the costs of preoperative assessment. Patient flow logistics are an important component of logistic processes. A strong correlation exists between the time spent at the PAC and patient satisfaction. 6;23 Waiting times are dependent on both the structure and the processes of the PAC, 23 illustrating the relationship between structure, process and outcome. 19 Improving the patient flow logistics of a PAC could improve cost efficiency and increase patient satisfaction. Patient satisfaction can be used not only as an outcome measure, but also as a process measure, to evaluate the way care was delivered. 24 13

Chapter 1 Patients experiences In recent years, it has been acknowledged that non-medical issues are of great importance to patients and patient satisfaction can be used as an indicator for the quality of healthcare. 21;25 Healthcare services are progressively shifting from paternalism to patient-centred care; patients views and perceived priorities are being used to help improve the quality of healthcare services. 26-30 Often a patient survey is used to assess these views and perceived priorities. There are three styles of survey questions: attitudinal ratings, reports, and openended questions. Open ended questions are more difficult to analyze and summarize than closed questions. 31 Patient satisfaction questionnaires, which ask patients to rate their satisfaction with the care received, tend to have mainly positive evaluations. 32;33 They do not give a clear indication on how to improve service areas that are rated poorly. Therefore, it has been recommended to ask patients to report their experiences in detail on specific aspects of the care received. 34 Instead of being evaluative, the responses are more factual and help identify the existing problems specifically; these problems can then be tackled. Report style questions can be used to assess the patient-centeredness of care, report and compare performance, and to improve the quality of care. 35 The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, 35 the World Health Organization (WHO) responsiveness surveys, 36 and the national (NHS) surveys 37 all measure patient experiences instead of patient satisfaction. In anaesthesia care, there are validated questionnaires to measure the quality of perioperative anaesthetic care. 38-40 Some items on preoperative care are incorporated in these questionnaires, but they do not focus specifically on the preoperative care delivered at the PAC. Patients experiences with the PAC have hardly been studied. 14

General Introduction Aims of the thesis This thesis concerns the anaesthetic PAC with the focus on non-medical issues. The aim was to explore the organization and logistic processes and to obtain feedback from patients and professionals on the quality of the PAC, in order to determine how improvement of the PAC can be attained. In chapter 2, the differences in organisational structure of the PAC at the eight Dutch university hospitals are explored. In chapter 3 the logistic processes of the PAC in two university hospitals are compared. Chapter 4 describes the analysis of two organizational planning difficulties, i.e. long access times and long waiting times. The development and validation of the Patient Experiences with the Preoperative Assessment Clinic (PEPAC) questionnaire is describes in chapter 5. Chapter 6 shows how the PEPAC questionnaire can be used to set priorities for improvement of the PAC, taking both the patient s and the professional s perspective into account. Chapter 7 describes the effects of implementing a new appointment system on waiting times and patient experiences with the PAC. In chapter 8 the results and conclusions of this thesis are discussed and summarized. 15

Chapter 1 References 1. Roizen MF: More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000; 342: 204-5 2. Roizen MF: Preoperative laboratory testing: necessary or overkill? Can J Anaesth 2004; 51: R13 3. American Society of Anesthesiologists: New classification of physical status. Anesthesiology 1963; 24: 111 4. Lee JA: The anaesthetic outpatient clinic. Anaesthesia 1949; 4: 169-74 5. Cantlay KL, Baker S, Parry A, et al: The impact of a consultant anaesthetist led pre-operative assessment clinic on patients undergoing major vascular surgery. Anaesthesia 2006; 61: 234-9 6. Hepner DL, Bader AM, Hurwitz S, et al: Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic. Anesth Analg 2004; 98: 1099-105 7. Parker BM, Tetzlaff JE, Litaker DL, et al: Redefining the preoperative evaluation process and the role of the anesthesiologist. J Clin Anesth 2000; 12: 350-6 8. Starsnic MA, Guarnieri DM, Norris MC: Efficacy and financial benefit of an anesthesiologistdirected university preadmission evaluation center. J Clin Anesth 1997; 9: 299-305 9. Fischer SP: Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996; 85: 196-206 10. Ferschl MB, Tung A, Sweitzer B, et al: Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005; 103: 855-9 11. Pollard JB, Zboray AL, Mazze RI: Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesth Analg 1996; 83: 407-10 12. Pollard JB, Garnerin P, Dalman RL: Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery. Anesth Analg 1997; 85: 1307-11 13. Van Klei WA, Moons KG, Rutten CL, et al: The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002; 94: 644-9 14. Rutten CL, Post D, Smelt WL: [Outpatient preoperative examination by the anesthesiologist. I. Fewer procedures and preoperative hospital days]. Ned Tijdschr Geneeskd 1995; 139: 1028-32 15. Health Council of the Netherlands, Committee on Preoperative Evaluation. Preoperative evaluation [in Dutch]. 1977 16. Lemmens LC, Van Klei WA, Klazinga NS, et al: The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals. Eur J Anaesthesiol 2006; 23: 962-70 17. Van der Wal G. Preoperative Process [in Dutch]. http://www.igz.nl/15451/475693/2007-02_rapport_preoperatie1.pdf. 2007 16

General Introduction 18. Netherlands Society of Anesthesiology. Viewpoint on preoperative care [in Dutch]. http://anesthesiologie.ewise.nl/uploads/150/27/anesthesiologischezorgverlening.pdf. 2004 19. Donabedian A: Evaluating the quality of medical care. Milbank Q 2005; 83: 691-729 20. Donabedian A: Explorations in quality assessment and monitoring. Ann Arbor, MI, Health Administration Press, 1980 21. Donabedian A: The quality of care. How can it be assessed? JAMA 1988; 260: 1743-8 22. Statistics Netherlands. Provisional figures on costs and financing of care. http://statline.cbs.nl/statweb/publication/?dm=slen&pa=70636eng&d1=0-1,16,23-29&d2=a&la=en&hdr=g1,t&vw=t 23. Dexter F: Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies. Anesth Analg 1999; 89: 925-31 24. Picker Institute Europe. Survey Information. http://www.pickereurope.org/page.php?id=21. 25. Fung D, Cohen MM: Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998; 87: 1089-98 26. Scott G: The voice of the customer: is anyone listening? J Healthc Manag 2001; 46: 221-3 27. Cleary PD: The increasing importance of patient surveys. Now that sound methods exist, patient surveys can facilitate improvement. BMJ 1999; 319: 720-1 28. Delbanco TL: Enriching the doctor-patient relationship by inviting the patient's perspective. Ann Intern Med 1992; 116: 414-8 29. Rogers G, Smith DP: Reporting comparative results from hospital patient surveys. Int J Qual Health Care 1999; 11: 251-9 30. Cleary PD, Edgman-Levitan S, Roberts M, et al: Patients evaluate their hospital care: a national survey. Health Aff (Millwood ) 1991; 10: 254-67 31. Reeves R. NHS trust-based patient surveys: acute hospital trusts. Outpatients Departments 2004/05. Listening to your patients. http://www.nhssurveys.org/filestore/documents/outpatients_guidance2005_v3.pdf. 2004 32. Fitzpatrick R, Hopkins A: Problems in the conceptual framework of patient satisfaction research: an empirical exploration. Sociol Health Illn 1983; 5: 297-311 33. Hall JA, Dornan MC: Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med 1988; 27: 637-44 34. Jenkinson C, Coulter A, Bruster S, et al: Patients' experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care 2002; 11: 335-9 35. Agency for Healthcare Research and Quality. https://www.cahps.ahrq.gov. 36. World Health Organization. Health System Responsiveness. Responsiveness Questionnaires. http://www.who.int/responsiveness/surveys/en 17

Chapter 1 37. NHSSurveys.org. Picker Institute Europe. http://www.nhssurveys.org. 2007 38. Auquier P, Pernoud N, Bruder N, et al: Development and validation of a perioperative satisfaction questionnaire. Anesthesiology 2005; 102: 1116-23 39. Fung D, Cohen M: What do outpatients value most in their anesthesia care? Can J Anaesth 2001; 48: 12-9 40. Heidegger T, Husemann Y, Nuebling M, et al: Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. Br J Anaesth 2002; 89: 863-72 18

Chapter 2 Comparing the organisational structure of the preoperative assessment clinic at eight university hospitals G.M. Edward, J.D. Biervliet, M.W. Hollmann,W.S. Schlack, B.Preckel Acta Anaesthesiol Belg 2008; 59: 33-7

Chapter 2 Abstract The preoperative assessment clinic (PAC) has been implemented in most major hospitals. However, there is no uniformity in the way PACs are organised. We compared the organisational structure of the PACs from all eight university hospitals in the Netherlands, looking at the following variables: number of patients visiting the PAC, staffing of the PAC, opening hours, scheduling, and additional preoperative diagnostic testing. The number of patients seen yearly varies from 7.000 to 13.500. In all clinics, the preoperative assessment was performed by anaesthetists and residents. In five PACs, preoperative assessment was also performed by physician assistants or nurse practitioners. Opening hours varied. Consultations are by appointment, walk-in, or a combination of these two. In four clinics additional testing is performed at the PAC itself. This study shows that the organisational structure of the PAC at similar university hospitals varies greatly; this can have important implications when designing a benchmarking process. 22

Comparing the organisational structure of the PAC Nowadays, stakeholders of the health care system, i.e. governments, health insurance companies, and patients, expect transparent outcome measures and tools to compare similar health care services in different hospitals with regard to quality and cost efficiency. 1-3 This contributed to the increase of benchmarking projects in health care. Benchmarking is a process first practised by Xerox Corporation (Rochester, NY). The concept can be described by the Japanese word dantotsu, which means striving to be the best of the best. An operational definition of benchmarking is finding and implementing best practices. 4 The practice of learning from the best has spread from office copiers, business and industry to the medical health care system. Traditionally, preoperative assessment was performed the evening before or on the day of surgery. However, performing the preoperative assessment on an outpatient basis several weeks or days before surgery has shown to enhance costefficiency. 5-10 It reduces preoperative diagnostic testing, 5;9 operating room cancellations and delays for medical reasons, 5-7;10 and length of the hospital stay. 8;10 Therefore, a preoperative assessment clinic (PAC) has now been implemented in the organisational structure of most major hospitals. 11 Although some organisational aspects of the PAC have been investigated, such as patient satisfaction, 12;13 staffing, 14;15 and scheduling of the PAC, 12 there is no consensus on the best way to organise a PAC. In a previous study 16 we compared the patient flow time at the PACs of two university hospitals and encountered several difficulties in interpreting the differences between the hospitals. Though the two hospitals were similar in respect of tasks, i.e. routine care, high-level clinical care, and high-level reference care, the number of patients visiting the PAC of each hospital was significantly different, as was the staffing of the PAC. Not only did these factors influence patient flow time, but also costs-efficiency. Differences in organisational structure should thus be taken into account when benchmarking. The purpose of this observational study was to explore the differences in organisational structure of the PAC in similar hospitals within the Netherlands, which has a relatively uniform health care system. 23

Chapter 2 Methods & results We visited all of the eight Dutch university hospitals and compared the organisational structure of the PAC. In detail, we looked at the following variables: the number of patients per annum and per day, opening hours, scheduling, staffing, the organisation of additional preoperative diagnostic testing, and electronic medical records versus paper records. The number of patients seen yearly at the PAC ranged from 7.000 to 13.500. The mean number of patients seen daily ranged from 35 to 60. Opening hours varied between 6¼ and 9½ hours per day. Six clinics are open 5 days a week; 2 clinics are open 4,5 days a week. Three clinics are closed for an hour at lunchtime. Consultations are by appointment in two clinics and are on a walk-in base in one clinic. In five clinics, there is a combination of appointed and walk-in consultations (Table 1). All clinics have anaesthetist and residents for the preoperative assessment. In addition, in five PACs the preoperative assessment is also performed by physician assistants (PAs) or nurse practitioners (NPs). Supporting administrative and clinical tasks are performed by nurses (3 PACs), or by doctor s assistants (5 PACs) (Table 2). The clinics have similar guidelines for additional preoperative testing. In four clinics, electrocardiograms and/or venepunctures are performed at the PAC itself (Table 1). In the other clinics, these tests are performed at the general outpatient laboratory. Other additional preoperative tests, e.g. chest X-rays, pulmonary function tests, and echocardiograms, are not performed at the PAC, but at other outpatient departments. Four PACs have electronic records; the other four PACs work with paper records (Table 1). All eight hospitals perform ambulatory surgery. One PAC has an additional paediatric session, with a paediatric anaesthetist available for the preoperative assessment. One PAC has an extra clinic session for patients undergoing cardio-thoracic surgery in cooperation with a cardio-anaesthetist. 24

Table 1. Characteristics of the preoperative assessment clinic Centre Patients Patients Hours Hours Consultations Additional testing E -records per year per day open per open per (mean) day week AMC ± 11.000 55 7,5 37,5 Appointed No No VUMC ± 10.000 40 8,5 42,5 Walk-in ECG No UMCG ± 13.000 60 9 45 Appointed & walk-in ECG + venepuncture Yes LUMC ± 7.000 35 8,5 42,5 Appointed & walk-in ECG + venepuncture Yes UHM ± 13.000 60 9,5 43 Appointed & walk-in No No UMCN ± 12.000 55 7 32,5 Appointed & walk-in ECG + venepuncture Yes Erasmus MC ± 10.000 40 9 45 Appointed & walk-in No No UMCU ± 12.000 50 6,25 31,25 Appointed No Yes E-records = electronic records; AMC = Academic Medical Centre; VU = Free University Medical Centre; UMCG = University Medical Centre Groningen; LUMC = Leiden University Medical Centre; UHM = University Hospital Maastricht; UMCN = University Medical Centre Nijmegen; Erasmus MC = Erasmus Medical Centre; UMCU = University Medical Centre Utrecht; ECG = electrocardiogram Comparing the organisational structure of the PAC 25

Chapter 2 Table 2. Staffing of the preoperative assessment clinic Centre Anaesthetist Resident NP PA Nurse Doctors assistant Clerk AMC 1 2 - - 2-3 - 2 VUMC 1 2-1 - 1 2 UMCG 1 1 2 - - 5 - LUMC 1 2 1 - - 2 1 UHM 1½ 2-1 - 6 - UMCN 1 3-1 3-2 Erasmus MC 1 2 - - - 4 - UMCU 1 2-4 - 3 NP = nurse practitioner; PA = physician assistant; AMC = Academic Medical Centre; VU = Free University Medical Centre; UMCG = University Medical Centre Groningen; LUMC = Leiden University Medical Centre; UHM = University Hospital Maastricht; UMCN = University Medical Centre Nijmegen; Erasmus MC = Erasmus Medical Centre; UMCU = University Medical Centre Utrecht Discussion The uniform aim of all PACs is preoperative assessment of the patient in order to reduce the morbidity/mortality associated with surgery and anaesthesia, increase the quality of care, decrease the cost of perioperative care, and restore the patient to the desired level of functioning. 17 In addition, the preoperative visit is an appropriate time to educate the patient on anaesthesia, perioperative care and pain treatments, to reduce anxiety, to develop care plans, and to obtain informed consent. 18 Preoperative assessment allows the patient to consider a second opinion by another surgeon or anaesthetist (according to the Belgian law of 2002 The rights of the patient ). Although the aim of the PACs studied is the same, the organisational structure of the PACs is not as uniform. Even though the hospitals are all tertiary care centres within the same health care system, the number of patients visiting the PAC annually and the organisation of the PAC differ considerably between the institutions. 26

Comparing the organisational structure of the PAC Staffing of the PAC The staffing of the PAC varies. All clinics we visited have anaesthetists and residents for the preoperative assessment, who rotate daily. In addition, in five PACs the preoperative assessment is also performed by physician assistants or nurse practitioners under the supervision of an anaesthetist. Doctor s assistants and nurses assist the physicians, NPs, and PAs with the preoperative assessment; they do not assess patients. Doctor s assistant versus nurse In the Dutch healthcare system, doctor s assistants are unlicensed health care workers who perform administrative and clinical tasks. Direct supervision of a licensed healthcare provider, e.g. registered nurse or physician, is required when performing direct patient care procedures, e.g. doing venepunctures or taking electrocardiograms. Nurses are healthcare professionals, licensed to perform defined patient care procedures. Tasks include treating and educating patients, and providing advice and emotional support to patients family members. As opposed to NPs and PAs, nurses are not licensed to provide diagnostic medical care. Nurse practitioner (NP) versus physician assistant (PA) In the United States, the NP and PA professions emerged in the 1960 s as a result of the shortage of physicians. 19;20 The job description for NPs and PAs are similar, but their educational background and clinical experience differ. Whilst NP students are registered nurses, PA students have a more diverse background in health care. Both NPs and PAs provide diagnostic, therapeutic, and preventive health care services. They take medical histories, examine and treat patients, order and interpret diagnostic tests. Both practise with the supervision of a licensed physician. With approximately 115.000 practising NPs and 63.000 practising PAs, the two professions are completely embedded in the United States health care system. In Europe, the United Kingdom has approximately 3.000 practising NPs; 27

Chapter 2 the profession of PA is still in development. Both professions are fairly new in the Netherlands. The global shortage of anaesthetists has led to the incorporation of PAs and NPs in the field of anaesthesiology, particularly at the PAC, where additional manpower is required for the preoperativeassessment. 5;14;15;21-25 The accuracy of preoperative screening by nurses was studied by Vaghadia & Fowler 23 and Van Klei and colleagues. 15 In both studies, the negative predictive value, i.e. the probability that the nurse identifies those patients who are ready for surgery without additional work-up, was high (93% versus 98%), but the positive predictive value, i.e. the probability that the nurse identifies those patients who require additional work-up, was considerably lower (29% versus 34%). Thus, nurses seem better at identifying patients who are ready for surgery without additional work-up, than identifying patients who do need additional work-up. When benchmarking the quality of the medical assessment at the PAC between hospitals, a differentiation should be made between the different types of staff performing the preoperative assessment. Patient flow time The patient flow time is dependent on 1) waiting time and 2) consultation time. At the PAC, consultations are either by appointment, walk-in based, or a combination of these two. In general, an appointment-based PAC will have a shorter average waiting time in the waiting room, because there is less variability in arrival times. 12;26-28 Dexter states that an appointment-based PAC will always provide a better service than a walk-in PAC. 12 However, we found that some hospitals deliberately chose for a (partly) walk-in PAC, in order not to subject patients to an additional hospital visit for preoperative assessment. The consultation time is dependent on various parameters. On average the preoperative assessment of patients with a higher American Society Anesthesiologists (ASA) class requires more time. 15 Van Klei et al. 15 showed that nurses needed 1.85 times longer for assessing the patient than an anaesthetist. No studies are available comparing the consultation time of NPs, PAs, residents, and anaesthetists. In many clinics NPs and PAs only assess ASA class 1 and 2 patients. A specific, discriminative health questionnaire can help to make a good 28

Comparing the organisational structure of the PAC estimation of patients ASA physical status. By having patients complete such a questionnaire prior to making an appointment, it is possible to direct patients to the appropriate caregiver, improving efficiency. Patient flow time is also dependent on the capacity, i.e. the number of patients per day, the available staff, opening hours, and the organisation of preoperative diagnostic testing. In a comparison of the patient flow time at the PACs of two university hospitals, we found that the patient flow time was longer when ECG and venepuncture were performed at the general outpatient laboratory than when they were performed at the PAC. Total waiting time was shorter if a patient s co-morbidity was taken into account when planning the appointment interval. This study showed that the organisational structure of a PAC influences patient flowtime. 16 Costs In the Netherlands the salary costs of PAs, NPs, residents, and anaesthetists differ considerably. On average the salary of a resident is 25% higher than the salary of a PA or NP, and 50% lower than the salary of an anaesthetist. We found the staffing of the PACs studied to vary considerably: not only did the type of personnel differ, but also the staff (performing preoperative assessment) - patient ratio. A formal cost-effectiveness analyses was beyond the scope of this study. This would include the following costs: educating personnel, refresher courses, working hours, and the relative costs per patient as the working pace differs between the different types of staff. 15 Possible difference in the quality of the preoperative assessment between the various types of staff should also be analysed, as this can bring additional costs, e.g. an increase in the late surgical cancellation rate or an increase in preoperative diagnostic testing. Patient experiences Patient feedback can be used as a performance indicator for the quality of health care. 29 Therefore, patient experiences are a good benchmarking parameter. Surveys to obtain patient feedback can be used to compare the service level of i.e. 29

Chapter 2 communication, information and participation in decision-making of the PAC across institutions. The organisational structure of a PAC influences patient satisfaction: a strong correlation exists between the time spent at the PAC and patient satisfaction. 12;13 We have developed the Patient Experiences with the Preoperative Assessment Clinic (PEPAC) questionnaire, an in-depth questionnaire which can be used to measure patient experiences with the PAC. 30 In conclusion, this study shows that within one nation with one health care system the organisational structure of the PAC varies greatly, even when hospitals are similar. This should be taken into account when considering a benchmarking process within one nation, and more so when comparing different health care systems. Acknowledgements K. Gigengack, R. J. Huyzen, A. de Roode, R.R. Timmer, D. van Diejen, L. Visser, J. Moen 30

Comparing the organisational structure of the PAC References 1. Spoeri RK, Ullman R: Measuring and reporting managed care performance: lessons learned and new initiatives. Ann Intern Med 1997; 127: 726-32 2. Rubin HR, Gandek B, Rogers WH, et al: Patients' ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study. JAMA 1993; 270: 835-40 3. Blumenthal D: Part 1: Quality of care--what is it? N Engl J Med 1996; 335: 891-4 4. Camp RC, Tweet AG: Benchmarking applied to health care. Jt Comm J Qual Improv 1994; 20: 229-38 5. Fischer SP: Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996; 85: 196-206 6. Ferschl MB, Tung A, Sweitzer B, et al: Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005; 103: 855-9 7. Pollard JB, Zboray AL, Mazze RI: Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesth Analg 1996; 83: 407-10 8. Pollard JB, Garnerin P, Dalman RL: Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery. Anesth Analg 1997; 85: 1307-11 9. Starsnic MA, Guarnieri DM, Norris MC: Efficacy and financial benefit of an anesthesiologistdirected university preadmission evaluation center. J Clin Anesth 1997; 9: 299-305 10. Van Klei WA, Moons KG, Rutten CL, et al: The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002; 94: 644-9 11. Lemmens LC, Van Klei WA, Klazinga NS, et al: The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals. Eur J Anaesthesiol 2006; 23: 962-70 12. Dexter F: Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies. Anesth Analg 1999; 89: 925-31 13. Hepner DL, Bader AM, Hurwitz S, et al: Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic. Anesth Analg 2004; 98: 1099-105 14. Kinley H, Czoski-Murray C, George S, et al: Effectiveness of appropriately trained nurses in preoperative assessment: randomised controlled equivalence/non-inferiority trial. BMJ 2002; 325: 1323 15. Van Klei WA, Hennis PJ, Moen J, et al: The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study. Anaesthesia 2004; 59: 971-8 31

Chapter 2 16. Edward GM, Razzaq S, de Roode A, et al: Preoperative evaluation clinic analysis: a comparison of the organizational structure in two university hospitals. Eur J Anaesthesiol 2006; Suppl 37: 17 17. Roizen MF: More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000; 342: 204-5 18. Roizen MF: Preoperative laboratory testing: necessary or overkill? Can J Anaesth 2004; 51: R13 19. Stead EA, Jr.: Conserving costly talents--providing physicians' new assistants. JAMA 1966; 198: 1108-9 20. Silver HK, Ford LC, Stearly SG: A program to increase health care for children: the pediatric nurse practitioner program. Pediatrics 1967; 39: 756-60 21. Koay CB, Marks NJ: A nurse-led preadmission clinic for elective ENT surgery: the first 8 months. Ann R Coll Surg Engl 1996; 78: 15-9 22. Reed M, Wright S, Armitage F: Nurse-led general surgical pre-operative assessment clinic. J R Coll Surg Edinb 1997; 42: 310-3 23. Vaghadia H, Fowler C: Can nurses screen all outpatients? Performance of a nurse based model. Can J Anaesth 1999; 46: 1117-21 24. Whiteley MS, Wilmott K, offland RB: A specialist nurse can replace pre-registration house officers in the surgical pre-admission clinic. Ann R Coll Surg Engl 1997; 79: 257-60 25. Rai MR, Pandit JJ: Day of surgery cancellations after nurse-led pre-assessment in an elective surgical centre: the first 2 years. Anaesthesia 2003; 58: 692-9 26. Elkhuizen SG, van Sambeek JR, Hans EW, et al: Applying the variety reduction principle to management of ancillary services. Health Care Manage Rev 2007; 32: 37-45 27. Rising EJ, Baron R, Averill B: A systems analysis of a university-health-service outpatient clinic. Oper Res 1973; 21: 1030-47 28. Rhea JT, St Germain RP: The relationship of patient waiting time to capacity and utilization in emergency room radiology. Radiology 1979; 130: 637-41 29. Fung D, Cohen MM: Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998; 87: 1089-98 30. Edward GM, Lemaire LC, Preckel B, et al: Patient Experiences with the Preoperative Assessment Clinic (PEPAC): validation of an instrument to measure patient experiences. Br J Anaesth 2007; 99: 666-72 32

Chapter 3 Patient flow in the preoperative assessment clinic G.M. Edward, S. Razzaq, A. de Roode, F. Boer,M.W. Hollmann, M. Dzoljic, L.C. Lemaire Eur J Anaesthesiol 2008; 25: 280-6

Chapter 3 Abstract Background and objective: Previous research has shown that a preoperative assessment clinic enhances hospital cost-efficiency. However, the differences in organization of the patient flow have not been analysed. In this descriptive study, we evaluated the consequences of the organization of the patient flow of a preoperative assessment clinic on its performance, by analysing two Dutch university hospitals, which are organized essentially differently. Methods: In the final analysis, the study included 880 patients who visited either academic centre. The performance of the two preoperative assessment clinics was evaluated by measuring patient flow time, various procedure times and the total waiting time. Patients age, ASA physical status and any preoperative tests requested by the physician were also recorded. Results: There was a significant difference in patient flow time between the two preoperative assessment clinics. More time was needed for the preoperative assessment when patients ASA class was higher. The patient flow time was longer when electrocardiogram and venepuncture were performed at the general outpatient laboratory than when they were performed at the preoperative assessment clinic due to longer waiting times. More tests were requested when they were performed at the preoperative assessment clinic. Conclusions: This study shows that the organization of patient flow is an important aspect of the logistic processes of the preoperative assessment clinic. It might influence patient flow times as well as the number of preoperative tests requested. Together with other aspects of logistic performance, patient satisfaction and quality of medical assessment, patient flow logistics can be used to assess the quality of a preoperative assessment clinic. 36

Patient flow in the PAC Introduction Establishment of a preoperative assessment clinic (PAC) for outpatients was prompted by medical progress in surgical and perioperative anaesthetic care and by the consequent introduction of ambulatory surgery. In the UK, day surgery rates have risen in the last years; 60 70% of all procedures are performed on an outpatient basis. 1 If patients are not evaluated at a PAC, where preoperative assessment is performed several weeks or days before surgery, then they are usually assessed by the anaesthetist the evening before, or on the day of surgery. However, previous research has shown that performing the preoperative assessment at the PAC improves the cost-efficiency of the hospital. 2-7 Since the PAC has now been implemented in the organizational structure of most major hospitals in The Netherlands 8 and the US and are being advised by the National Health Service (NHS) Modernisation Agency through the National Preoperative assessment Project, 9 the next step is to analyse the logistic processes of a PAC itself. This, in order to acquire insights, which processes could be changed to improve organizational efficiency of a PAC. Patient flow logistics are an important component of a PAC s processes. Since previous studies have shown patient satisfaction to strongly correlate with the time spent at the outpatient clinic, 10-13 we studied the patient flow at the PACs of two Dutch university hospitals. These hospitals have prearranged their PACs essentially differently Methods We studied the patient flow at the PACs of two Dutch university hospitals, i.e. Leiden University Medical Centre (LUMC) in Leiden and Academic Medical Centre (AMC) in Amsterdam. At both hospitals, all elective surgical patients are assessed at the PAC. Both hospitals perform ambulatory surgery. 37

Chapter 3 The differences in organizational structure of the two PACs are shown in Table 1. Annually, 3000 more patients are assessed at the AMC than at the LUMC. The PAC of the LUMC is opened 30 min longer per day than the AMC. At the LUMC patients with ASA III or IV are given an appointment of 30 min. Healthy patients and patients with limited co-morbidity (ASA I and II) do not require an appointment and can walk-in. At the AMC all patients are given an appointment time of 15 min. An important difference is the organization of the patient flow for preoperative testing. At the AMC, all preoperative tests can be performed without an appointment on the same day as the preoperative assessment. In contrast, at the LUMC only electrocardiogram (ECG), venepuncture and chest X-rays can be performed without an appointment; all other tests require an appointment. At the LUMC, ECG and venepuncture are performed by the doctor s assistants at the PAC, whereas at the AMC, ECG and venepuncture are performed at the general outpatient laboratory. In the LUMC and AMC, both anaesthetists and residents perform preoperative assessment. Both clinics have one anaesthetist at the PAC per day, but in the LUMC there are two residents, while in the AMC there is one. The junior resident in the LUMC only assesses walk-in patients (ASA I and II). In the LUMC supporting administrative and clinical tasks are performed by two doctor s assistants; in the AMC these tasks are performed by two nurses. At the LUMC, ECG and venepuncture are performed by the doctor s assistants. Except for this, the tasks of the personnel are same at both PACs. Both PACs do a hand-written assessment. Both PACs have similar guidelines for preoperative testing. All patients over 60 yr of age require a recent ECG and serum creatinine concentration determination. For specific disorders, medication-use and surgical procedures, both centres require the same preoperative tests. In both centres, tests are not ordered routinely; if the necessary tests were performed just prior to the patient s visit to the PAC, they did not need repeating. All patients visiting the PAC during a period of 2 weeks at the AMC and 3 weeks at the LUMC in 2005 were included in the study (fewer patients visit the PAC at the LUMC per week). There is little diversity in the number of patients visiting the PAC in the different months of the year, except for the holidays (data not shown). Since 38

Patient flow in the PAC procedure and waiting times can differ if activities are carried out differently, we modelled the routing of a patient at both the PACs in detail. The following times were registered: presentation of the patient at the counter; start and end of the consultation with the doctor, the nurse or the doctor s assistant; and the time when a patient booked out. These times were used to calculate the different procedure and waiting times. All using the same clock, the personnel in question registered when they started and ended their assessment. This was done on a form attached to the patient s medical notes. The patient s age, ASA physical status and any preoperative tests requested by the physician were also registered. Table 1. Differences between the AMC (Amsterdam) and the LUMC (Leiden). AMC, Amsterdam LUMC, Leiden 2 nurses 2 doctor s assistants 1 resident + 1 anaesthetist 2 residents (1 junior and 1 senior) + 1 anaesthetist Monday afternoon 1 anaesthetist, specialised in paediatrics No preoperative tests performed at the ECG and venepuncture performed at the PAC PAC Patients mainly on appointment Patients mainly without an appointment Open 5 days a week; 7 h day -1 Open 5 days a week; 7.5 h day -1 Over 10 000 patients per year Over 7000 patients per year AMC: Academic Medical Centre; LUMC: Leiden University Medical Centre; PAC: preoperative assessment clinic; ECG: electrocardiogram. In this study, the primary goal was to investigate the patient flow at the PAC, while differences in quality of assessment were not studied. The patient flow time was defined as the time from presentation at the counter until booking out of the PAC. Possible follow-up work after the patient had been discharged, necessary for completing the preoperative assessment, was not included in the patient flow time. Various procedure times were distinguished, i.e. the procedure time with the physician, the nurse or the doctor s assistant, and the time needed to complete 39

Chapter 3 ECG and/or venepuncture. At the AMC, patients leave the PAC and go to the general outpatient laboratory for an ECG and/or venepuncture. The procedure time to complete ECG and/or venepuncture at the AMC included the waiting time at the general outpatient laboratory. Only patients who returned to the PAC to discuss the results with the physician and who did not require other preoperative tests than ECG and/or venepuncture, were included in the procedure time to complete ECG and/or venepuncture. The total waiting time was defined as the sum of the waiting time before seeing the clerk, the nurse or the doctor s assistant and the physician. It did not include the waiting time at the general outpatient laboratory. We hypothesized that a patient s ASA physical status might influence the physician s procedure time. Therefore, we differentiated the procedure time for the physician per ASA class. As a patient s waiting time is dependent on the procedure time of the preceding patients, we did not differentiate the waiting time per ASA class. Since the organization of preoperative testing was completely different in both university hospitals and performing preoperative tests could influence the patient flow time, we also analysed the number of patients who required preoperative tests and the type of tests performed in each hospital. Statistical analysis SPSS 12.0.1 (SPSS Inc., Chicago, IL, USA) for Windows was used for statistical analysis. Because the data were skewed, values are given as median (25th 75th percentile). The U-test was performed to analyse differences between the AMC and LUMC. P < 0.05 was considered to represent a statistically significant difference. Results At the AMC, 430 patients were included; 13 data forms were not returned (n = 417 included in the final analysis). At the LUMC, 467 patients were included; four forms were not returned (n = 463 included in the final analysis). Patients age and ASA physical status were comparable in both groups (Table 2). 40

Patient flow in the PAC AGE-CATEGORY 0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 ASA CLASS I II III IV Table 2. Age and ASA physical status. Number of patients in various age categories AMC (n = 417) n 76 30 30 51 72 56 51 38 11 LUMC (n = 463) n 68 38 33 57 69 70 62 51 15 Number of patients & procedure time for the physician per ASA class AMC (n = 417) n (%) 194 157 62 4 median [25th 75th] 10 [7-15] 14 [10-19] 17 [10-24] 21 [12-35] LUMC (n = 463) n (%) 227 (49%) 176 (38%) 53 (12%) 3 (1%) median [25th 75th] 12 [8-15] 17 [12-24] 25 [16-35] 29 [20-60] Number of patient in various age categories, number of patients per ASA class and the procedure time for the physician per ASA class. The age of two patients from the AMC was not documented. The ASA physical status of four patients from the LUMC was not documented. ASA: American Society Anesthesiologists; AMC: Academic Medical Centre; LUMC: Leiden University Medical Centre. 41

Chapter 3 Figure 1 The patient flow in the AMC, Amsterdam and the LUMC, Leiden. The arrows indicate the moment the time was registered. AMC: Academic Medical Centre; LUMC: Leiden University Medical Centre; ECG: electrocardiogram. Figure 1 shows the patient flow at both PACs. Total patient flow times (i.e. the total time spent at the PAC) are presented in Figure 2. Total patient flow time of all patients visiting the PAC was significantly shorter at the LUMC; 49 min (33 69 min) vs. 65 min (41 92 min) at the AMC (P < 0.001) (Fig. 2). The difference mainly resulted from the increased patient flow time when venepuncture and/or ECG (the most frequently requested preoperative tests) had to be performed. For patients requiring venepuncture and/ or ECG, the patient flow time was 63 min (48 83 min) at the LUMC vs. 119 min (91 136 min) at the AMC (P < 0.001). For patients who did not require any preoperative tests, the patient flow time was 37 min (26 55 min) at the LUMC vs. 53 min (36 78 min) at the AMC (P < 0.001). The time to complete venepuncture and/or ECG was 6 min (4 8 min) at the LUMC vs. 40 min (27 54 min) at the AMC (P < 0.001) (Fig. 3). The total waiting time was 24 min (14 41 min) at the LUMC vs. 32 min (18 52 min) at the AMC (P < 0.001) (Fig. 2). The procedure times were as follows: 5 min (2 8 min) for the doctor s assistant (LUMC) vs. 8 min (5 11 min) for the nurse (AMC) (P < 0.001); 15min (10 20 min) for the physician at the LUMC vs. 12 min (9 16 min) at the AMC (P <0.001); and 4 min (2 42