The Necessity for Teamwork
The PPAC is an integrated partnership having visible alliances
with the departments of anesthesia and nursing, and often surgery and obstetrics,
but always with the hospital or health system administration. Frequently the existing
system of preoperative assessment is beleaguered by the need for change in many of
the time-honored traditions, structures, and processes.
TABLE 25-21 -- Key areas to consider in promoting cost-effective preoperative preparation
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1. Physician education and modification of physician practice
(e.g., learn the cost of each diagnostic test ordered preoperatively, plan length
of stay with pain therapy practitioners) |
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2. Practice guidelines |
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3. Clinical pathways (requires interdepartmental teamwork) |
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4. Information sharing (e.g., in areas of evaluative protocols
and avoiding duplication of services) |
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5. Economic analysis (e.g., cost-identification, effectiveness,
cost-benefit studies) |
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6. Medical resource management (e.g., in the efficiency and effectiveness
of the preoperative process) |
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7. Education about, and reassessment of, perioperative satisfaction
and plans for perioperative pain therapy |
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8. Outcomes measurement and management |
TABLE 25-22 -- Operational goals for a preoperative and preprocedure assessment clinic (PPAC)
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1. To improve the client's perception of the preoperative
evaluation experience by increasing personalized patient care, comfort, and convenience |
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2. To provide a centralized site for preoperative evaluation |
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3. To institute an anesthesia scheduling system for timely
patient access and flow |
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4. To ensure the presence of an anesthesiologist on site
when patients are present |
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5. To appoint a medical director of the PPAC to coordinate
all activities |
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6. To ensure the availability of medical records and surgical
notes at the time of the preoperative evaluation |
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7. To decrease logistical shuffling of patients to multiple
hospital service areas |
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8. To integrate and coordinate services through on-site
facilities for admitting/registration, insurance authorization, laboratory tests,
and electrocardiographic studies |
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9. To improve the education of patients and families about
the elements of their surgical procedure and the proposed anesthesia care, including
postoperative pain control options |
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10. To educate patients about what to expect regarding postoperative
feeding and discharge needs |
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11. To ensure and coordinate cost-effective ordering of preoperative
laboratory and diagnostic studies |
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12. To provide an anesthesia medical consultation service for
evaluation of medically complex inpatients and outpatients |
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13. To decrease the number of cancellations and delays in the
operative procedures on the day of surgery |
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14. To enlist the skills of a nurse practitioner to assist in
preoperative evaluations and patient/family education |
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15. To develop protocols, policies, and clinical pathways |
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16. To perform quality assurance reviews |
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17. To maximize efficiency in operating room function and turnover
time by coordinating all preoperative information at one location (the anesthesia
preoperative evaluation clinic [APEC]) |
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18. To enhance patient and surgeon satisfaction |
Figure 25-20
Example of letter to colleagues and their staffs in other
specialties about policies of the Preoperative and Preprocedure Assessment Clinic
(PPAC).
Figure 25-21
Preoperative and Preprocedure Assessment Clinic (PPAC)
referral guidelines (Form 1).
Figure 25-23
shows the fundamental goals that the PPAC strives to accomplish. These goals recognize
and encourage clinical responsibility in the portioning of services and, most important,
in the sharing of financial costs and savings in the PPAC enterprise. That is, because
the department that bears the cost of making the PPAC function is not always the
department that enjoys the subsequent savings, transfers of funds are necessary to
make the system really work fairly for all concerned. These transfers, plus agreement
on the incentives and goals, should be considered before
institution of the PPAC.
To encourage the referral of patients to the PPAC by surgeons,
anesthesiologists can identify the clinical (and perhaps marketing) advantages.
Interviewing surgeons regarding their concerns and problems with preoperative assessment
helps identify the changes that will be necessary. Likewise, administrators can
be interviewed regarding their desires for efficiency of patient care, for increased
patient education and satisfaction, and for marketing advantages. Such a process
marks the anesthesiologist as an active partner and a resource for improving perioperative
care.
In addition to the primary mandate of patient safety, our surgical
colleagues are also concerned with avoiding cancellations and OR delays, and with
reducing costs and improving patient satisfaction through education, in order to
facilitate marketing. To enhance the anesthesiologist's commitment to the PPAC and
to increase the patient referral base, an "informal assurance" may be given that
if the patient is deemed appropriate and remains medically stable, the patient's
care will proceed to surgery without cancellation or delay. This process requires
that the entire anesthesia group support the PPAC program and protocols, and means
that not all physicians can give consultations in the PPAC. It also means that this
position requires an experienced clinician.
