Benchmarks help reduce unplanned events
Cancellations, inpatient admissions drop
How you structure your preadmission program not only affects cost and efficiency, but it also can lower your rates of last-minute cancellations and unplanned admissions after surgery.
That is the lesson St. Joseph’s Hospital in Elmira, NY, learned through a quality improvement program based on data from the Quality Indicator (QI) Project of the Maryland Hospital Association in Lutherville, MD. That national database provides percentile rankings and trend reports based on more than 1,000 facilities around the country.
By streamlining and strengthening the preadmission process, St. Joseph’s lowered its rate of unplanned admissions after surgery to just .13%, compared with a QI Project median of 1.5%. St. Joseph’s cancellation rate is 1.1%, compared with a median of 2.3%. In 1995, when the quality improvement program began, the hospital’s rates were .83% for unplanned admissions and 2.91% for cancellations. That placed St. Joseph’s slightly above the median, or 50th percentile, for cancellations, but still below the mean, or average, rate for unplanned admissions, which was about 3%.
"We try to anticipate everything that will happen during the surgery so there won’t be any complications or any reason to admit the patient," says Barbara Quinn, LPN, the preadmission nurse who chairs the quality improvement team.
The QI Project is one of the oldest databases available to same-day surgery managers. It began in 1985 as a pilot project of seven hospitals in Maryland and has grown to include facilities around the country. Freestanding surgery centers can participate through affiliation with a corporate health system, an alliance, or a sponsoring organization that is a project participant. (For project data, see box, at right.)
The project doesn’t highlight "better performers." Instead, it shares information on how facilities used the indicators to implement improve- ments. "Our philosophy is that it’s not the data [that matters], it’s what you do with it that’s important," says Nell Wood, director of marketing and communications.
St. Joseph’s same-day surgery program already was performing somewhat better than average for cancellations and unexpected admissions before nurses, physicians, clerks, and administrators met as a Preadmission Testing Improvement Team.
Still, Quinn, the team leader, wanted to use the data as benchmarks to improve physician satisfaction and customer service. As a valuable side benefit, revamping the process raised productivity. When the team formed in 1995, patient volume in day surgery was about 2,500 patients. In 1997, the volume surpassed 3,000 patients.
The improvements flowed from a new process dubbed "One call does it all." Previously, scheduling could take up to four phone calls, which caused delays and the possibility of miscommunication. "When the [surgeon’s] office calls about a gallbladder surgery, they only have to make one call to the hospital," Quinn says. "It’s booked in the OR. At the same time, the patient is given an anesthesia appointment and a preadmission testing appointment a week to 10 days before the surgery."
Those patients who don’t need preadmission tests or receive them from their internist can meet with an anesthesiologist or anesthesiology nurse and visit the day surgery unit. Or they may receive the pre-surgery patient education by phone, Quinn says.
Meanwhile, Quinn gathers the information from the preadmission testing or phone call and provides a chart for the anesthesiologist to review at least 48 hours before the scheduled surgery. If there is a question about an abnormal EKG or blood test, the patient has time to have additional testing and possibly avoid a cancellation, she says.
A thorough preadmission review also can reduce avoidable surgical complications and subsequent inpatient admissions. In fact, in some reporting periods, none of the day surgery patients at St. Joseph’s Hospital required admission.
Not every same-day surgery program can find such a smooth path to such low unplanned admissions and cancellation rates. For example, facilities that serve a sizeable population of non-English-speakers and less-educated patients face barriers in teaching them about pre-surgery protocol. Sometimes, the communication breakdown is in-house. Physicians may schedule patients in the day surgery unit and know there is a high likelihood they will need to be admitted as inpatients.
"It’s a way for physicians to get on the OR schedule," says Donna Wilson, RN, MPH, director of quality improvement for Beth Israel Medical Center in New York City.
The hospital educated physicians through medical staff bulletins and improved documentation of the reasons for unplanned admissions. To gain physicians’ cooperation, it helps to have data and comparisons with a national database and with hospitals of a similar size and patient population, Wood says. "When it comes right down to it, everybody needs to be committed to changing things if rates are going to be improved."
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