The perioperative process: a system of providing quality, convenient, cost-effective surgical services

In the current health care environment, many customary procedures, developed in an era when cost containment and market competition were not major concerns are no longer compatible with the operation of a successful surgery service. This article outlines a perioperative system that accomplishes the goals of cost containment and patient and surgeon satisfaction without sacrificing quality of care. This system entails streamlining the entire perioperative process, from the initial interface with the surgeon's office to discharge from the facility. In addition, the system eliminates unnecessary waste that remains rampant in most surgery departments, and addresses scheduling problems that limit efficiency.

HCIA study concludes top hospitals more likely to use low-cost first-line antibiotics

When it comes to presurgical antibiotic prophylaxis, less is more. A benchmarking survey of America's top health systems shows that better-performing hospitals use fewer antibiotics, with no untoward effects on patients. Review the survey results.

[Drug expenses from anesthesiologists]

OBJECTIVES

To assess expenses generated by prescriptions from anaesthesiologists in the operating theatre, recovery rooms, surgical intensive therapy units, postoperative care on surgical wards (digestive surgery, orthopaedics, gynaecology, obstetrics, paediatric surgery).

METHODS

Prospective study (one year) with evaluation of the costs induced by intravenous and volatile anaesthetics, morphinic and non morphinic analgesics, neuromuscular blocking agents, crystalloids, antibiotics, intravenous nutrient solutions, blood substitutes, anticoagulants, vitamins and vasoactive drugs.

RESULTS

The expenses resulting from these prescriptions reached the quarter of the total drug hospital budget. They were equally distributed between anaesthesia and intensive therapy units on the one hand and postoperative care on surgical wards on the other hand. Intravenous anaesthetic agents, antibiotics, crystalloids, represented each one more than 10% of the total cost.

CONCLUSIONS

This study demonstrates the weight of prescriptions by anaesthesiologists in the hospital budget. At our hospital, it was mainly due to their activity outside the operating theatre, especially on surgical wards. Therefore anaesthesiologists are essential partners for the elaboration of a cost containment policy.

Has surgical subspecialization gone too far?

Subspecialization is currently fashionable, but with present hospital organization, the need to cover emergencies and the lack of convincing evidence for its superiority, the tide is on the ebb and the place of the general surgeon is secure.

[Prospective study of spontaneous medical utilization of antibiotics on the normal surgical ward--rationale and economic aspects]

For 8 months, the spontaneous behaviour of the surgeons concerning the use of antibiotics (AB) was studied. The study focused on the indication itself, the chosen substance, the method of drug administration, and the treatment duration. It was evaluated whether the use of AB was rational and what the economic consequences of inadequate use of AB are. Of a total of 1168 pts 21.1% received AB, 88% of them i.v. The intention of AB treatment was therapy in 56.3%, and prophylaxis in 43.7% beside the regular perioperative single shot regimen. More than every second AB prescription was irrational. More rational behaviour (indication, therapy once daily, sequential therapy, no postoperative prophylaxis, less i.v. AB) by the prescribing surgeons would have led to a saving of more than 60% of the total costs of DM 215,000 without any loss of antiinfective efficacy. Moreover, a more rational use of AB would mean prevention of infectious hospitalism and would save a lot of staff time.

Pediatric surgical workload during the past decade: impact on clinical activity and hospital finance at a children's hospital

PURPOSE

The authors hypothesized that there are significant differences in clinical effort among the faculty of the various departments at an academic Children's Hospital, and that the clinical workload of surgeons has increased over the past decade.

METHODS

A retrospective analysis of clinical practice and financial performance of the five departments (anesthesiology/critical care medicine, pathology, pediatrics, radiology, and surgery) at the Children's Hospital of Philadelphia from 1987 to 1997 was performed including clinical activity parameters (admissions, discharges, clinic visits), departmental faculty rosters, number of operations for the department of surgery as a whole and for individual surgeons in each pediatric surgical specialty, and professional and hospital financial data.

RESULTS

Pediatric surgical specialists represented 15% of the total full-time physicians throughout the decade. In 1997, surgeons were responsible for 29% of hospital admissions, 28% of total outpatient visits at all clinical care sites, 37% of total professional fee revenue, 39% of hospital-based revenue, and a substantial portion of the hospital margin. Compared with 1987, the department of surgery in 1997 had a 60% increase in outpatient visits and a 58% increase in total operative case load (10,265 to 16,266). In terms of individual surgeon's workload during the decade, the outpatient visits per surgeon increased 45% and the operations per surgeon increased 27%, yet total reimbursement per surgeon slipped 16%.

CONCLUSIONS

For the Children's Hospital that was studied, pediatric surgical specialists are doing more clinical work compared with 10 years ago, which may impact teaching, research, and administrative responsibilities. Surgeons have a greater responsibility than nonsurgeons for the hospital's clinical activity and financial health.

Building better team charters: an example from reengineering the preoperative system

This article illustrates a six-step chartering method using a successful project at the West Los Angeles VA Medical Center. The annual savings generated from this project were estimated at $13 million.

Skeletal traction versus external fixation for pediatric femoral shaft fractures: a comparison of hospital costs and charges

OBJECTIVES

To compare the hospital costs, charges, and reimbursement for treatment of pediatric femur fractures by two treatment methods: external fixation and 90-90 traction with spica casting.

DESIGN

Retrospective clinical review.

SETTING

Department of Orthopaedic Surgery, Children's Hospital Oakland, regional pediatric trauma center.

PATIENTS

Twenty-nine consecutive patients between the ages of five and ten with a fracture of the femoral shaft were treated by one of two methods: external fixation (sixteen patients) or 90-90 skeletal traction followed by spica casting (thirteen patients).

INTERVENTION

External fixation or 90-90 traction followed by spica casting.

MAIN OUTCOME MEASURE

Hospital billing data including costs, charges, reimbursement for the initial inpatient hospitalization, and outpatient financial data until fracture union and cessation of treatment.

RESULTS

There was no difference in age, total treatment time, mechanism of injury, or number of associated injuries between the two groups. The average charge for treatment with skeletal traction and spica casting was $32,094 per patient versus $21,439 for external fixation (p < 0.001). The average cost for treatment with traction and spica casting was $22,396 per patient versus $11,520 for external fixation (p < 0.001); reimbursement was $30,846 and $7,490, respectively (p < 0.001). The number of days in the hospital was larger for the traction group than for the external fixation group (22.3 days versus 4.7 days, p < 0.0001).

CONCLUSIONS

External fixation of pediatric femoral shaft fractures results in decreased hospital costs and length of hospitalization, but produces significantly less income for the hospital when compared with skeletal traction followed by spica casting.

The surgeon and casemix

Casemix funding has markedly increased surgeons' awareness of the economies of the activities they undertake. Surgery has become a major focus at all large public hospitals, because of its high earning potential, and this pressure to maximise funding could influence surgical practice. Casemix funding's emphasis on length of hospital stay has encouraged forward planning for earlier discharge after surgical procedures. Patients are now assessed in pre-admission clinics, educated about their condition and their hospital stay, and a plan formulated for their discharge and rehabilitation. Funding for major surgical procedures of long duration in patients with complex conditions should reflect the higher level of resource utilisation. Tertiary referral centres, because of their commitment to training and research and their more severely ill patient population, are less cost-effective and require funding to ensure their viability. The improved information that casemix generates should be used to evaluate outcomes and improve patient care; efficiency must not take precedence over quality of care and compassion.

Image-guided dialysis access ports more successful, less costly than surgery

Percutaneous dialysis catheters. Interventional radiologists can implant dialysis catheters quicker and more reliably than vascular surgeons, which can translate into big savings. A study from Yale University suggests that surgical dialysis sites may cost three times as much as percutaneous devices.

The incremental cost of second and third ambulatory procedures

The discount factor applied to payments for second and subsequent ambulatory procedures in a payment system based on ambulatory patient groups (APGs) is important in determining the financial incentives of the system and the adequacy of the payment rates. A 1995 empirical study of data from all ambulatory surgery cases done in acute general hospitals in Maryland suggests that the incremental charges associated with an APG when it is a second procedure APG are about 24% of the charges that are incurred when the APG is the only procedure APG in an encounter. For the third procedure APG, the percentage drops to 16%. This 24% factor is much lower than the discount factor generally used in APG payment systems. The article presents APG-adjusted charges by payer to show differences in resource use by payer. These results will be useful for organizations developing APG-based payment systems for ambulatory surgery or desiring to use APGs for benchmarking purposes.

Does hospital procedure-specific volume affect treatment costs? A national study of knee replacement surgery

OBJECTIVE

The long-run cost savings potential of private sector reform efforts, such as selective contracts with providers, depends in part on the relationship between procedure-specific volume and average hospital resources that are consumed in treating patients associated with that specific procedure. Study examines a model that estimates the relationship between hospital procedure-specific volume and average hospital treatment costs, using an elective surgical procedure as an example.

DATA SOURCES

Medicare Provider Analysis and Review (MedPAR) files for 1989 for hospitalizations in which a Medicare beneficiary received a knee replacement (KR) surgery during 1989. Hospital information was obtained from the American Hospital Association's 1989 Annual Survey. All patient-level data were aggregated to the hospital level to create a data file, with the hospital as the unit of observation.

STUDY DESIGN

This study used administrative claims data and regression analysis to estimate the effect of hospital procedure-specific volume on average hospital treatment costs of patients receiving KR surgery. We also examined the stability of the volume-cost relationship across hospitals of different sizes.

PRINCIPAL FINDING

The average treatment costs associated with KR surgery are inversely related to a hospital's KR volume in the regression equation estimated using all hospitals performing KR surgery. The inverse relationship between cost and volume is found to be robust for different-size hospitals.

CONCLUSIONS

The potential cost savings associated with performing KR surgery at incrementally higher hospital volume level can amount to as much as 10 percent of the hospital's average treatment cost. However, the incremental cost savings associated with increased patient volume depends on the hospital's current volume level and its size.

Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports

OBJECTIVES

Quality report cards are becoming increasingly more common and receive much publicity. They can have significant impact on competition among providers, costs, and quality of health care. The authors test the hypotheses that hospitals and surgeons with better outcomes reported in the NYS Cardiac Surgery Reports experience a relative increase in their market share and prices.

METHODS

Information from the New York State Cardiac Surgery Reports was linked with physicians' claims submitted to Medicare and was used to calculate market shares and average prices for hospitals and physicians performing CABG surgeries. Regression models were estimated to test hypotheses. All 30 hospitals offering coronary artery bypass graft (CABG) were studied as well as a majority of surgeons (114 or approximately 80%) performing CABG surgery in New York State during the 1990-1993 period.

RESULTS

Findings indicate that hospitals and physicians with better outcomes experienced higher rates of growth in market shares. Physicians with better outcomes also had higher rates of growth in charges for this procedure.

CONCLUSIONS

Patients (and referring physicians) seem to respond to information about quality of individual surgeons and hospitals as expected. The magnitude of the association between reported mortality and market shares varies geographically, potentially reflecting differences in sociodemographic characteristics. The association tends to decline over time, suggesting that it is primarily due to "new" information.

[Regionalization of surgical research in Germany]

Surgical research can only be effective if there is good cooperation between clinical and basic researchers. Surgeons should be given the opportunity to practise surgical research as a full-time job for several years. We present part of the data obtained from all surgical departments of German universities concerning the organisation of their surgical research.

[Profile and structure of future-oriented visceral surgery in a non-university environment]

A nationwide limitation of the total health care budget requires the shutdown of certain departments or complete hospitals in order to increase the budget for the surviving hospitals. This development involves surgical departments as well, which have to be re-designed for an economic future.

[Measures for increasing efficiency in surgical departments of the Hamburg LKB with special reference to regional hospital comparisons]

A comparative study was performed using the medical records of 40,000 inpatients undergoing treatment in surgical units of 10 hospitals. The results show that the number of patients, the kind of diseases or injuries and the time required for their treatment do not correlate with the classification of the hospital or the degree of specialization of the surgical unit. Therefore, for every group of diseases (expressed as ICD number), standards (mean, median, benchmark) can be defined which should be followed in order to reduce the time of treatment and to improve the efficiency of the unit.

[Verifying routine preoperative diagnosis between private practice and the surgical university clinic]

In an attempt to shorten the preoperative in-patient period and to avoid unnecessary investigations, a cooperative patient management model was established for a number of surgical operations at the University Department of Surgery, Anaesthesiology and their referring Specialist and General Practitioners. The latter were requested to carry out the previously defined preoperative routine investigations, which allowed for a marked reduction in hospital diagnostics. Ambulatory preoperative patient management and a new admission routine resulted in a 57% decrease of the average preoperative in-patient stay for the observed procedures.

[Optimal and computer-assisted hospital cost control by the surgeon]

Considering the legal conditions there is no question that with the health reform law (GSG) changes in hospital infrastructure have to be made by the surgeon and the administration cojointly. From our experience an efficient budget control needs a complete and correct data recording--employing an efficient software--as well as strict medical control of profits along with continuous communication between the surgeons themselves and with the administration.

[Managing position of the surgery executive]

Recent legislation on health service has once again made the head of the department of surgery aware of his managing responsibilities. Cost saving will be possible in the areas of laboratory and high-tech diagnoses, surgery materials, storage of supplies, and administration of drugs. Since 70% of hospital costs are personnel costs, a substantial reduction in the hospital budget can only be obtained by reducing staff. In planning for the long term, we will be obliged to discuss "total quality management", which demands continuous improvement of the quality of our management and our patient treatment.

[Surgical research with limited resources: research concepts and research cooperation in a surgical University Clinic]

The decreasing financial support of surgical research requires new strategies and, in particular, an intensive collaboration with basic science and biotechnology. This concept of "lean research" includes output-orientated research activities, which can be measured, using the "impact factor". Effective research requires a well-organized and structured department.

[Electronic data processing in ward management--possibilities for rationalization and cost control]

Electronic data processing in ward management increases cost and time efficiency. Nurses and doctors will have more time to concentrate their genuine rather than administrative duties. Therefore the presented model has gained high acceptance.

What is the value of preventing postoperative infections?

The importance of postoperative infections depends on the frequency with which infection occurs as well as on the additional cost per patient with infection. For example, in our hospital the additional cost per patient with infection after hernia repair was $600, compared with $2,106 per patient with infection after colonic surgery. However, the total excess cost per year was similar for hernia surgery ($44,800) and colon surgery ($48,440). The reason is that hernia surgery is much more common than colon surgery. It is a general principle of clinical audit that the importance of problems should be defined by their frequency as well as their individual severity. A third important consideration is the likelihood that the problem can be corrected. Undue attention has been given to the health resource costs of postoperative infection at the expense of information about the intangible costs to the patient (these are nonfinancial costs such as pain and disability). Health resource costs are very dependent on medical practice variation, and comparative studies between countries reveal marked differences in the way that apparently similar infections are managed. Moreover, comprehensive audit of infection-control management often reveals wasteful practice, e.g, antibiotic treatment of patients who do not in fact have infection. Audit of postoperative infection should focus on eliminating wasteful practice (e.g., prophylactic antibiotics continuing > 24 hrs after surgery) as well as on reducing postoperative infection rates.

Operative outcome and hospital cost

INTRODUCTION

Because of concern about increasing health care costs, we undertook a study to find patient risk factors associated with increased hospital costs and to evaluate the relationship between increased cost and in-hospital mortality and serious morbidity.

METHODS

More than 100 patient variables were screened in 1221 patients undergoing cardiac procedures. Simultaneously, patient hospital costs were computed from the cost-to-charge ratio. Univariate and multivariate statistics were used to explore the relationship between hospital cost and patient outcomes, including operative death, in-hospital morbidity, and length of stay.

RESULTS

The greatest costs were for 31 patients who did not survive operation ($74,466, 95% confidence interval $27,102 to $198,025), greater than the costs for 120 patients who had serious, nonfatal morbidity ($60,335, 95% confidence interval $28,381 to $130,897, p = 0.02) and those for 1070 patients who survived operation without complication ($31,459, 95% confidence interval $21,944 to $49,849, p = 0.001). Breakdown of the components of hospital costs in fatalities and in cases with nonfatal complications revealed that the greatest contributions were in anesthesia and operating room costs. Significant (by stepwise linear regression analysis) independent risks for increased hospital cost were as follows (in order of decreasing importance): (1) preoperative congestive heart failure, (2) serum creatinine level greater than 2.5 mg/dl, (3) New York state predicted mortality risk, (4), type of operation (coronary artery bypass grafting, valve, valve plus coronary artery bypass grafting, or other), (5) preoperative hematocrit, (6) need for reoperative procedure, (7) operative priority, and (8) sex. These risks were different than those for in-hospitality death or increased length of stay. Hospital cost correlated with length of stay (r = 0.63, p < 0.001), but there were many outliers at the high end of the hospital cost spectrum.

CONCLUSIONS

We conclude that operative death is the most costly outcome; length of stay is an unreliable indicator of hospital cost, especially at the high end of the cost spectrum; risks of increased hospital cost are different than those for perioperative mortality or increased length of stay; and ventricular dysfunction in elderly patients undergoing urgent operations for other than coronary disease is associated with increased cost. Certain patient factors, such as preoperative anemia and congestive heart failure, are amenable to preoperative intervention to reduce costs, and a high-risk patient profile can serve as a target for cost-reduction strategies.

Principles of operating room organization

The importance of the changing health care climate has triggered important changes in the management of high-cost components of acute care facilities. By integrating and better managing various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. The leadership that physicians can provide is crucial to the success of this undertaking (1). The importance of the use of primary data related to patient throughput and related resources should be strongly emphasized, for only when such data are converted to INFORMATION of functional value can participating healthcare personnel be reasonably expected to anticipate and respond to varying clinical demands with ever-limited resources. Despite the claims of specific commercial vendors, no single product will likely be sufficient to significantly change the perioperative process to the degree or for the duration demanded by healthcare reform. The most effective approach to achieving safety, cost-effectiveness, and predictable process in the realm of Surgical Services will occur by appropriate application of the "best of breed" contributions of: (a) medical/patient safety practice/oversight; (b) information technology; (c) contemporary management; and (d) innovative and functional cost-accounting methodology. S "modified activity-based cost accounting method" can serve as the basis for acquiring true direct-cost information related to the perioperative process. The proposed overall management strategy emphasizes process and feedback, rather than specific product, and although imposing initial demands and change on the traditional hospital setting, can advance the strongest competitive position in perioperative services. This comprehensive approach comprises a functional basis for important bench-marking activities among multiple surgical services. An active, comparative process of this type is of paramount importance in emphasizing patient care and safety as the highest priority while changing the process and cost of perioperative care. Additionally, this approach objectively defines the surgical process in terms by which the impact of new treatments, drugs, devices and process changes can be assessed rationally.

Optimizing hospital reimbursement through physician awareness: a step toward better patient care

We instituted a training program to improve the overall accuracy of medical record coding through greater physician awareness to enhance hospital reimbursement and maintain quality patient care. A physician-targeted course reviewed the prospective payment system, diagnosis-related group guidelines, ambulatory surgery reimbursement, and the relationship between accurate physician documentation and medical record coding. Annual increases in charges from prospective surgical case assignment, proper conversion of outpatient to inpatient status, and more accurate coding of inpatient comorbidities and complications led to an estimated increase in hospital charges of $1.6 million.

Rethink outpatient surgery strategy? Study finds hospitals lose money on 56 procedures

A new study reveals hospitals are losing an average of $268 on each Medicare patient who has outpatient surgery. Losses depend on procedures, ownership structure, and how often the particular type of surgery is performed.

Stereotaxy reduces cost of brain tumor resection

BACKGROUND

Health care professionals are under increasing pressure to contain the cost of health care. Simultaneously, medical technology continues to advance. Medical institutions must therefore consider the costs and benefits before using a new technology. Using a direct costing system, we determined the cost efficacy of stereotaxy applied to the resection of brain mass lesions.

METHODS

Twenty-nine patients underwent a stereotactically guided craniotomy and brain tumor resection. Fifteen of them underwent general and fourteen received local anesthesia. Twelve other patients, comprising a historical reference group, underwent a standard craniotomy and brain tumor resection under general anesthesia. costs were determined for every hospital charge item in all patients. Cost efficiency was then compared between the two groups.

RESULTS

Patients treated stereotactically incurred additional costs in frame placement and neuroimaging. These costs were offset by savings in operating room time, patient acuity, length of stay, respiratory care, and medications. Savings were greatest for patients who had local anesthesia. Overall, patients treated by stereotactic craniotomy had a total hospitalization cost of $8,495.19, whereas those treated with standard craniotomy incurred a cost of $11,365.23 (p < 0.001).

CONCLUSION

Stereotaxy is cost effective for the surgical treatment of brain tumors. Accurate estimates of cost can justify the use of medical technology. Directly measured cost data is a useful index for any cost containment program.

Cost savings associated with the nonroutine use of carotid angiography

BACKGROUND

To evaluate the economic impact of performing carotid endarterectomy based only on a diagnosis of duplex scanning, we evaluated a cohort of patients treated at our institution during 1 calendar year.

METHODS

Ninety-seven patients were evaluated and divided into two groups: those with and without arteriogram prior to their operation. Duplex scan and arteriogram results were reviewed to determine their effect on the operative plan. Hospital charges and physician fees were assessed for each patient admission. Operative results, complications, and total charges were compared between the two groups.

RESULTS

There was one operative stroke in each group for a stroke rate of 2%. Angiographic complications included one stroke and one femoral artery thrombosis. Two arteriograms led to a change in the operative plan. The hospital charges for patients without an arteriogram was $10,292 verses $13,906 for patients with an arteriogram (P < 0.01). Physician charges for patients without an arteriogram were $3,882, with angiograms and $6,297. The total charges related to the endarterectomy were $14,174 and $20,203, respectively. Arteriograms accounted for an increase of 43% in total charges.

CONCLUSION

Nonroutine use of angiography does not increase operative risk or postoperative length of stay, and preoperative angiography increases total charges by 43% ($6,029) per patient.

Hospital outpatient surgery cost, reimbursement, and utilization data find Medicare a loser

Data Library: Outpatient surgery costs, reimbursement, and utilization benchmarks. This new CHIPS survey finds providers consistently lose money for 56 outpatient procedures under Medicare. The only winners are those in high managed care areas and high-volume facilities. The data offer some valuable benchmarks by geographic area, managed care penetration, as well as age and sex.

[Cost analysis of thyroid gland surgery in a university surgical clinic]

On 1 January 1996, the implementation of the new recompense system, the Bundespflegesatzverordnung (BPflV), at the Medical University Halle replaced the former German hospital financing system based on clinic-dependent individual prices. This was the beginning of a new price-performance system of the German hospital market. Since then, for all surgical procedures (catalogue section 301 SGB V ICPM 5061-5064) for benign and malignant thyroid diseases a detailed cost analysis has been performed. Our personnel and material inputs were documented on-line in the operating theatre on a special designed cost-analysis record. The cost analysis was based on 14 cases of lobectomy (average operative costs DM 1886.82), and 20 each of bilateral subtotal thyroidectomy (average DM 1970.48), unilateral subtotal thyroidectomy with contralateral lobectomy (average DM 2164.26) and total thyroidectomy (average DM 2396.70) respectively. In 12 cases the costs of total thyroidectomy with cervical and transthoracal lymphadenectomy have been analyzed (average DM 4664.48).

Joint data collection system saves hospital system $3.6 million

Knee and hip joint replacement costs at HealthEast in St. Paul, MN, were 33% too high, according to national benchmark data. However, before managers could lower costs, they had to gather their data. After a drawn-out manual compilation, healthEast piloted an automated system for tracking joint replacement data. That software is now available nationwide. By collecting the data, measuring cost and utilization, HealthEast has lowered its total knee and hip replacement costs by $3.6 million.

[What are the costs of pediatric cardiosurgery?]

A cost analysis of patients discharged from the Department of Pediatric Cardiology and Heart Surgery of "Bambino Gesu" Children's Hospital was performed. Analysis focused on the costs and revenue from Diagnosis-Related Group 108 ("other cardiovascular procedures") during a six-month period in 1994 (n. = 76). The sample of 30 charts reviewed (MLOS 20.36 +/- 27.87 days) showed a mean cost of 30,381,000 italian lire (ITL) vs a revenue of ITL 23,545,800. The Pearson correlation coefficient between LOS and total cost was high (R = 0.85; p < 0.001). Other cases in DRG 108 (n. = 46) had an MLOS of 29.13 +/- 25.25 days and a higher cost. We emphasize the usefulness of identifying the costs for patients grouped in a specific DRG in order to establish an accurate departmental budget as well as to ensure the financial survival of referral hospitals.

The impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center

OBJECTIVE

To determine the prevalence of gunshot wound related orthopaedic injuries in an urban trauma center and outline the socioeconomic background of this patient population.

DESIGN

Retrospective study conducted from January 1, 1994, through December 30, 1994.

SETTING

University-affiliated level 1 trauma center.

PATIENTS

Strict inclusion and exclusion criteria were established.

INCLUSION CRITERIA

All patients were admitted through the emergency room with a gunshot wound for which the orthopaedic surgery service was consulted. The study group consisted of 284 patients.

EXCLUSION CRITERIA

Those individuals excluded from the study were patients with an orthopaedic injury who died during or before attempts at resuscitation in the emergency room and patients treated on an outpatient basis.

MAIN OUTCOME MEASURES

Orthopaedic and nonorthopaedic diagnoses, etiology, procedures performed, number of hours from admission to the first surgical procedure, average daily hospital census, drug and alcohol screen results, and patient financial status.

RESULTS

The orthopaedic service was consulted on 284 patients admitted with gunshot wounds. This group comprised 24% of all orthopaedic admissions, 33% of the average daily orthopaedic census, and 14% of all orthopaedic surgery cases performed. Ninety-four percent were African American and 87% were male, with a mean age of 27 years. Approximately half were tested for alcohol and/or drugs, 45% of whom were positive for alcohol and 65% for drugs. Only 4% of the patients were privately insured.

CONCLUSIONS

During the period of this study, gunshot wound injuries required more orthopaedic trauma resources than any other single diagnosis.

Restructuring academic departments of surgery at university medical centers

BACKGROUND

The present administrative and financial structures of clinical departments in most medical schools date back to the beginning of the 20th century when changes were brought about as a result of the Flexner report. Since that time, there have been significant changes in the health care industry that compel us to reevaluate our goals in order to meet the needs of the 21st century.

METHODS

This paper proposes that we need to consider the administrative restructuring of our departments from the vertical hierarchical system to the horizontal matrix system in order to facilitate cost-effective use of our manpower as well as facilities. It also proposes a financial restructuring of the departments to cut the costs of billings and collections of the clinical practice, to develop a long-term program to raise departmental endowments, and to develop an effective incentive plan.

RESULTS

A novel mechanism is proposed to provide "stock options" for the faculty. Such a system would reward academic and clinical productivity, retain productive faculty, and offer options for those who are not productive.

CONCLUSIONS

In order to flourish in the health care marketplace, academic programs must be willing to promote a change in the culture of the departments and adapt to a more business-oriented environment.

Re-engineering surgical services in a community teaching hospital

The Grace Hospital Surgical Services redesign project began in December 1995 and concluded in November 1996. It was led by the Chief of Surgery, the Surgical/Anesthesia Services Director, and the Associate Director of Critical Care/Trauma. The project was undertaken in order to radically redesign the delivery of surgical services in the Detroit Medical Center (DMC) Northwest Region. It encompassed the Grace Hospital Main Operating Room (10 operating theatres) and Post-Anesthesia Recovery Unit, and a satellite Ambulatory Surgery Center in Southfield, Michigan. The four areas of focus were materials management, case scheduling, patient flow/staffing, and business planning. The guiding objectives of the project were to improve upon the quality of surgical services for patients and physicians, to substantially reduce costs, and to increase case volume. Because the Grace Surgical Services redesign project was conducted in a markedly open communicative, and inclusive fashion and drew participation from a broad range of medical professionals, support staff, and management, it created positive ripple effects across the institution by raising staff cost-consciousness, satisfaction, and morale. Other important accomplishments of the project included: Introduction of block scheduling in the ORs, which improved room utilization and turnaround efficiencies, and greatly smoothed the boarding process for physicians. Centralization of all surgical boarding, upgrading of computer equipment to implement "one call" surgery scheduling, and enlarging the capacity for archiving, managing and retrieving OR data. Installation of a 23-hour, overnight recovery unit and provision of physician assistants at the Ambulatory Surgery Center, opening the doors to an expanded number of surgical procedures, and enabling higher quality care for patients. Reduction of FTE positions by 27 percent at the Ambulatory Surgery Center. This yielded a total cost reduction of +1.5 million per annum in the annual budget of +10.3 million; Recruited 10 new podiatrists and increased the volume of cases brought to Northwest Region facilities by surgical specialists. This added 100 cases in 1996, and is projected to add 500 cases in 1997. A 14.5 percent reduction in the cost of operating the Surgical Services was achieved. This was accompanied by enhanced staff morale, physician satisfaction and a higher quality of patient care.

Benchmarking the perioperative process. I. Patient routing systems: a method for continual improvement of patient flow and resource utilization

The article presents an overview of the design and application of a real-time patient routing system, based on barcode and local area network technology, that was designed to track the progress of patients during the perioperative process. We present data on all patients undergoing ambulatory surgery. Patients' progress during their surgical stay was recorded at 17 strategic events using this real-time patient tracking technology. These times were used to identify inefficiencies in the perioperative process by identifying bottlenecks and areas of high variation. We found that both raw and actual operating room (OR) utilization efficiency was less than 50%. Points of high variation in a patient's progress occurred during the time from admit to the hospital until the patient was ready for the OR; the time from when a patient was ready for the OR until they were called for; and the time a patient spends in the OR preoperative holding room. Causes for variation were identified and traced back to individual procedures, activities, and work processes. Multidisciplinary improvement teams were created to improve the pinpointed problem areas. The real-time patient routing system is a process that has proven to be highly valuable to all participants in the surgical process in bringing about rational, data driven efficiencies in perioperative services. This process has the potential to facilitate multidisciplinary cooperation in efforts to contain and reduce costs of perioperative services.