“Having clinical leadership as part of the governance structure is important so that you have standardization of quality and patient experience across your system, regardless of the setting.” — Nicole Spatafora, Vizient senior director, programs
Outpatient procedure volumes have experienced exponential growth over the past several years. In fact, nearly 85 percent of procedures are now performed on an outpatient basis, according to a report by Sg2, a Vizient subsidiary, but those procedures have largely remained inside hospital walls. During the next decade, Sg2 expects outpatient procedures to grow by 19% and many of the procedures to transition outside hospital walls to lower-cost, lower-acuity ambulatory care sites. Clinical leaders who begin preparing for the shifts now will be poised to take advantage of the ambulatory growth.
“The beauty of ambulatory settings is that they are often more convenient and closer to home for the patient,” says Mark Larson, principal, Sg2. “The downside is that care can become very fragmented, so clinical leaders need to think about how to pull it all together. Organizations that begin having planning conversations at the service line level now are going to be best positioned to be successful in the market.”
Following are the procedures that are predicted to shift, and four ways clinical leaders should begin to prepare.
Four procedure categories on the move
The Sg2 report, Procedure Sites of the Future, identifies the following service lines and procedures, which are key to hospital margins, that may experience notable shifts to outpatient and/or ambulatory settings during the next 10 years:
- Orthopedics and Spine—Elective knee replacement, elective hip replacement, cervical fusion, lumbar/thoracic fusion and spinal decompression/laminectomy
- Cardiovascular—Elective diagnostic catheterization, percutaneous coronary intervention, pacemakers and implantable cardioverter-defibrillators
- Gynecology: Benign hysterectomy and pelvic floor repair
- Medicine and Surgery: Appendectomy, abdominal wall hernia repair, cholecystectomy, thyroidectomy, open and transrectal procedures of rectum and benign prostatectomy.
How clinical leaders should prepare now for the shifts in procedure sites
According to Larson, the shift from inpatient to outpatient status within the hospital hasn’t resulted in significant changes to care delivery processes. A total hip replacement patient will move through the hospital environment from the perioperative process through post-acute care in much the same way whether they are undergoing an inpatient or outpatient procedure.
However, as care moves out of the hospital, clinical leaders need to begin preparing now to maintain high quality and patient experience in ambulatory care settings.
“As you start to move those patients into that ambulatory surgery center where there is specialized nursing, the training of your workforce in that setting becomes really important. It’s also important to ensure there’s a quality improvement structure in place across this setting,” says Nicole Spatafora, Vizient senior director, programs.
Here are some steps to take now:
Establish the right procedure site footprint—As procedure volumes continue to shift out of the hospital, now is the time to strengthen your capabilities and ensure you have the right procedure site footprint. Have conversations at the service line level to understand what the footprint is today and how it is going to change to ensure you optimize capacity, preserve margins, enhance growth and maintain high quality of care.
Understand where you have capacity constraints and excess capacity when making ambulatory strategy decisions, such as shifting ambulatory surgeries from the hospital setting to free up resources for higher-acuity cases. A large multi-system health system in the Midwest has made ambulatory surgery centers a key component of its ambulatory strategy over the past five years. It completed four retrofits and new builds in different markets, including a $55.5 million, 130,000-square-foot health center. The center improved access for patients in the area and decanted lower-acuity ambulatory volumes from the system’s tertiary hospital in order to free up capacity there for truly tertiary services.
Use cost and quality data to support decision-making—Analytics can help you understand your organization’s shorter-stay discharges, as well as which physicians are performing those shorter-stay procedures to help determine which procedures are ready to shift. To support decision-making, the Vizient Clinical Data Base brings cost and quality data together to identify opportunities and their potential impact by allowing users to identify variation across providers and to benchmark to other organizations. It also sheds light on patient outcomes, such as length of stay and complication and readmission rates by procedure and provider.
Analytics can also help planning to ensure costs are in line with revenue changes as care shifts to ambulatory settings. “It’s going to be important to home in on procedure costs,” says Larson, “especially for procedures moving to the ambulatory surgery center setting, where reimbursement really drops off. Understand what you are spending today and what you will need to spend tomorrow to maintain those margins.” Understanding the drivers of variation and moving toward reducing unwarranted variation becomes critically important to maintain margin when shifting procedures to sites with lower reimbursement rates.
Develop a governance structure and strong physician relationships—The shift to ambulatory settings will likely involve arrangements with sites that the hospital does not own. As a result, decision-making and alignment become more complex. Effective governance, including strong physician relationships, ensures incentives are aligned, clinical protocols are standardized across care settings and high-quality care and patient experience standards are maintained.
“Having clinical leadership as part of the governance structure is important,” says Spatafora, “so that you have standardization of quality and patient experience across your system, regardless of the setting. Strong governance ensures you’re working collaboratively as a team with the right dashboards in place to follow up on anything that becomes an issue.” When all parties in a joint venture are working together under an effective governance structure, everyone wins as volumes grow across the ambulatory surgery center and hospital inpatient and outpatient departments.
Implement processes that ensure clinical care coordination—Effective patient triage and navigation is critical not only across care sites but also throughout a patient’s journey, from pre-procedure preparation to post-acute care. Tightly coordinated clinical handoffs not only enhance efficiency, but also keep patients in the system of care and boost the patient experience. Spatafora notes that in orthopedics, for example, care coordination and navigation become critically important. “When care is delivered across multiple settings, it becomes even more important to make sure that it is being coordinates so that patient has a seamless episode of care,” she says.
An integrated electronic health record is an essential component of effective care navigation and coordination, helping to measure and manage readmissions, post-surgery emergency department visits, and other metrics. In addition, consumers value having access to all of their health information in one central location. “You’re going to have to be able to measure patient satisfaction and quality at each site across the ambulatory environment and that starts with integration around the electronic health record,” adds Larson. “An integrated EHR allows patients and providers to see where an organization is successful and where they’re missing the mark from a quality perspective.”
As procedure volumes continue to shift out of the hospital, organizations must connect the dots between quality outcomes, patient experience, capacity and cost at the procedure level across service lines and sites of care. Managing these ambulatory shifts requires clinical leaders to focus on the four key areas for success outlined above. Those who begin preparing for the shifts now will be best positioned to capture procedure growth.