The Surgical : : Growing Pains in Southern alifornia n rain, M hief of Service, Woodland Hills alifornia Impetus for Surgical ER and all coverage for General Surgery omplexity and lack of payment Unpredictability of add-on cases Lack of time to deal with the medical and social issue of inpatients hange in mind set of younger generation life style r. Kildare
r. oug Ross Problems with General Surgery all Trend toward specialization in General Surgery isruption of elective schedules with on-call duties Mismatch in surgeon s s available time to perform the emergency workload ifficulties in obtaining call coverage Problems Specific to Kaiser Permanente Inflexibility of schedules to utilize unplanned OR availability Reluctance to accept transfer of patients from outside hospitals Not maximizing advantages of group practice (retention of surgeons)
Surgical Traditional Trauma overage Medical overage of Surgical Patients Emergency onsults and Surgery uring aytime Hours Emergency onsultation and Inpatient Management of cademic enters with Residents Traditional all with Emergency Surgical Service onsultation and Inpatient management of all Trauma/Emergency Patients Trauma/Emergency Inpatient onsultation and Inpatient Management by a edicated Group Surgical and Intensivist Team Requirements Program ontinuity of care (Quality) Patient satisfaction Internal customer satisfaction epartmental satisfaction ost effectiveness Obstacles in reation of the Surgical Unknown costs ew functional programs to model Surgeon s s reluctance
Initial Model Week ay all Night call Monday Tuesday Wednesday Thursday riday Sunday onsultation and Inpatient Management of all Trauma/Emergency Patients Week ay all Night all Monday Tuesday Wednesday Thursday riday Sunday urrent Model Week Sunday Monday Tuesday Wednesday Thursday riday Sunday urrent model hr call ack up call E Traditional all with Emergency Surgical Service Week hr call E ack up call E
urrent all Schedule efining Roles of Surgical s hr all Second all hr all Second all Jane Jane Sunday Jane Monday Tuesday Wednesday Thursday riday E Sue The hospitalist owns the service Physician to physician handoffs for all transfers of patient care ll patients admitted during a all (SO) shift will be seen by that physician the following day before transferring the care hr all E Second all John John efining Roles of Surgical s Upon discharge, the non-operative operative patients are seen in follow up by the hospitalist and not the admitting physician The hospitalist will contact the operating surgeon upon discharge to discuss the care plan The SO will directly hand off to the on coming SO leftover operative cases rather than the hospitalist efining Roles of Surgical over vacationing surgeons over Utilization Rounds for surgical pts over vacationing surgeons ssists in the care or discharge of elective patients (e.g. chest tube removal)
efining Roles of Surgical Special onsiderations Language needs ultural considerations End of Life decisions efining Role of Surgical oes not manage elective surgical patients oes not manage or readmit complications of elective cases oes not manage those patients with an established relationship with a surgeon Results Workload of Surgical Workload Length of Stay Patient Satisfaction Physician Satisfaction Program osts epartmental Issues 007 verage Inpatient ensus pt verage Surgeries (7a-7p) 7p) verage Surgeries (after 7p) 0. verage Hours in clinic.hr 008 verage Inpatient ensus verage Surgeries (7a-7p) 7p) verage Surgeries (after 7p) 0. verage Hours in clinic.hr 6
Work Load of Surgical Patient Satisfaction ssist call surgeon and others in OR ssist Wound are Nurses with Vs, debridements and management of difficult pts Perform urgent OR cases See urgent outpatients Physician Satisfaction (Internal ustomers) Medical E Utilization ase Managers epartmental Satisfaction fter year fter years 00% satisfaction (not all cases transferred to the service) 00% remain in the system but one surgeon expresses frustration 7
dvantages to the epartment Normalization of schedule while not on call Reduction in after hours work for the department when not on call Promotes group practice Scheduled time for complex dressing changes, family discussions and coordination of care with other specialties dvantages to the epartment Reduces penalty for accepting complex transfer patients Increases collaboration within department Increases collaboration with Medical s Reduces turf battles in the ER osts One additional TE Surgeon No discernable difference in LOS for elective cases Unable to track Emergency Surgery LOS Potential for babysitting and increased LOS osts Savings 00 potential - hour slots unused annually (ixed OR cost, nesthesia, Nursing) >00k Uncertain change in number of after hour cases 006 /month 007 7/month 008 7/month (60k physician costs) 8
ost Savings Repatriation of Patients Trauma and post operative patients Single largest potential cost savings Greatly appreciated by the department Issues See imperfections of your colleagues care Set defined expectations Maintain open communication within the department hange the program as it evolves Issues Set limits on TWs epartmental discussions for improvement of the program e prepared for difficult conversations with colleagues hanges in our Rules Personal call or voice mail on all discharges Must sign out to by 0 am Only one person can write orders Pre-arrange for /Sunday Handoffs 9
hanges in our Rules ook the case when the decision for surgery is made n intervention is a surgery patient with multiple intervention will go to the first operating surgeon Patient preference is the over riding concern Is this the uture? ddresses Patient satisfaction Physician satisfaction Trend toward sub specialization and its effect on call coverage ddresses Typical inflexibility of a surgical career Mismatch between workload and available time of the surgeon to do add-on cases aytime OR utilization when unexpected time becomes available 0
ddresses osts of adding additional manpower hanges in expectations of the younger generation Projected shortage of General Surgeons r Halsted uture irection of Surgical and Intensivists Team within Kaiser