Towards high performance pre-operative assessment

Historically, fragmented clinical assessment of patients is being slowly unpicked and redelivered using a variety of models in varying locations.

Patients are at the forefront of driving this change, desiring healthcare delivered by a provider they have chosen, at a location to suit them and at a time which is convenient.

For those of us that have been working in healthcare for some time this change appears challenging. However, it is not only patients who are driving this change. With rising costs of delivering healthcare and the ever increasing array of costly treatments, politicians want to ensure that patients are not only provided with services that are convenient but that the healthcare that they receive is appropriate.

So who will support healthcare organisations in delivering timely appropriate surgical care? Is this a challenge for managers or clinicians?

Appropriate surgical care for patients can only be delivered by clinicians and managers working together who have adopted common skill sets and who have a shared vision.

To deliver high performance preoperative assessment services, clinicians and managers require:

We cannot expect clinicians and managers to simply acquire these skills and develop a shared vision for delivering appropriate surgical care for their local patients.

Executives and directors are required to create ways of providing this support to ensure that their organisations deliver high performance pre-operative assessment services and create sustainable clinical and business change.

External support may be appropriate but executive boards would be wise to resist utilising traditional consultancy companies who focus on solutions from a single (business process) perspective.

There are, however, new companies that will create solutions, integrate expertise and speed change from both a clinical and business process perspective. Perigon Healthcare is such an example.

Having reviewed and developed the skill set of the workforce that will deliver appropriate surgical care, organisations, as a result of the current political landscape, are required to ensure they are developing or have developed high performance preoperative assessment services.

Traditionally, the acute sector has taken ownership of developing pre-operative assessment services, many examples of which were set up in response to the reduction of junior doctors’ working hours. Despite much work to date, many do not have a shared vision from clinicians and managers and lack high level support and investment. Surgical patients have been directed to these services only after the decision to operate has been made by the surgeon. In many organisations there are still patients who do not have a preoperative assessment and as a result organisations and patients are not realising all the benefits these services can provide.

The future will require: “High performance pre-operative assessment services that facilitate the successful navigation of patients along pathways, across healthcare providers and between primary and secondary care.” (Perigon Healthcare, 2006). As a result, services previously delivered within the acute sector will need to be delivered in a variety of locations supported by primary care. This challenge will need to be addressed by managers and clinicians working together and in addition employing a blend of delivery models.

Considered for delivery models employed to deliver high performance preoperative assessment services should be:

• Healthscreen questionnaires.
• Primary care screening.
• Outpatient screening.
• Telephone screening.
• Electronic screening.
• One-stop clinics.
• Face-to-face assessment.
• Anaesthetic clinics.

Healthscreen questionnaires

Questionnaires have been successfully designed both on paper and electronically to capture information required to determine a patient’s ASA (American Society of Anaesthesiologists 1963) status. This enables organisations to assess a patient’s appropriate identification as either an inpatient or day surgery patient. Screening questionnaires are very flexible either when electronic or paperbased and can be used in a variety of locations and returned completed via the primary care setting, an outpatient department, telephone or the use of other communications technology.

When a questionnaire has been completed by a patient it is imperative that it is reviewed by a competent member of the pre-operative assessment workforce to determine the anaesthetic risk or ASA score. Following this verification there may be an indication that a patient requires no further assessment. In this case, the preoperative assessment service will need to provide patient information and ensure that the patient provides notification of any changes that occur. The patient must also be informed about who to approach if questions arise.

Some patients will require further examination and assessment from the preoperative assessment workforce in the form of a “face-to-face” pre-operative assessment. Whatever the blend of assessment offered to the patient it is imperative that discharge planning is commenced at the earliest opportunity.

Primary care screening

The fitness of patients being referred for surgical procedures should be identified prior to referral so that any potential problems can be highlighted. In future the referrer must work with the pre-operative assessment service to identify the most appropriate treatment and to address concerns regarding the fitness of patients.

Outpatient screening

Patients who have just seen a consultant, and a decision to treat is agreed, can be seen by a “one-stop” pre-operative screening and assessment service. All patients should be screened. However, if it is not convenient for the patient who requires a “face-to-face” pre-operative assessment to stay longer then a further appointment should be agreed directly with the patient.

Telephone screening

Nationally, there have been a variety of approaches to telephone screening. However, a structured approach should be taken to the telephone call using a written questionnaire. The questionnaire should be processed by the pre-operative assessment service to determine the patient’s suitability for surgery at a pre-defined location.

Patients should be advised that they will be receiving a telephone call and asked to give their consent. In addition they should supply telephone numbers where they can be easily contacted.

Electronic screening

There is increasing capacity from technology suppliers to support the screening of patients via the internet or an organisation’s intranet and to transmit the patient information safely. Suppliers have presently taken two approaches to software design. The first approach merely involves electronic versions of paper-based preoperative assessment practice. The second approach is exciting in that there are predictive elements which support assessors in identifying those patients with a clinical risk.

One-stop clinics

Many organisations offer one-stop pre-operative assessment clinics that, following screening, provide the patient with a “face-to-face” assessment on the same day if required.

Services such as these are often located in the outpatient departments particularly as this then facilitates the easy access to pre-operative testing etc. One-stop clinics may form part of an integrated clinical assessment and treatment service (ICATS).

Face-to-face assessment

Patients who are identified through screening as requiring a face-to-face assessment, can book such an assessment on a date convenient to them. This assessment will ensure they are directed to appropriate investigations and that their cases receive input from other clinical specialists. The patients may have to attend outpatients as part of a one-stop service, a day surgery unit or another facility in an acute care or primary care setting.

Anaesthetic clinics

For a small group of patients, a more detailed anaesthetic assessment prior to surgery will be required – and conducted by an anaesthetist. Some organisations have now invested in anaesthetic clinics that work alongside the pre-operative assessment service designed to support patients with the most complex needs.

DELIVERING HIGH PERFORMANCE

When designing pre-operative assessment services that meet local patient population’s needs, managers and clinicians may not need to utilise all of the above delivery models. However, they will be required to use many of them to ensure organisations are positioned to deliver high performance pre-operative assessment services. While a range of delivery models will drive up the quality of pre-operative assessment services, benefits of a high performing service will not be realised unless organisations have attracted the resources identified in Figure 2. Wherever pre-operative assessment features in the patient pathway it must have attracted these essential resources.

Anaesthetic support

It is ultimately the responsibility of an anaesthetist to ensure that his or her patient is fit for anaesthetic. In a world without constraints there would be many anaesthetic clinics organised for patients prior to surgery and run by anaesthetists. However, working within these constraints and with the support of a high performing pre-operative assessment service that includes screening, the anaesthetist can be confident that he or she has receipt of all information pertaining to patients prior to surgery. As a result, the anaesthetists can focus on the more complex patient prior to surgery. In many organisations anaesthetic departments support pre-operative assessment by having a lead anaesthetist who supports the assessors by being available on an “as required” basis to support clinical decision making. In addition an anaesthetic clinic is planned into the anaesthetic rota that allows assessors to bring the more complex patient back to be seen face-to-face by an anaesthetist.

Executive support

Without support from the executive team, pre-operative assessment will not realise optimum benefits for patients or the organisation. It is imperative that the pre-operative assessment team identifies an executive sponsor. In addition, support will be required from the lead of the audit or information department so that mangers and clinicians can evidence how their pre-operative assessment services contribute to the delivery of wider organisaitonal objectives.

Centralised management

While it may be unrealistic to centrally locate the pre-operative assessment service, probably due to pressures within an organisation on accommodation, it is essential to manage the pre-operative assessment workforce centrally. This will mean restructuring with support from the executive team and directors of multiple surgical specialties.

The result should be a coherent effective service with every speciality offering a standardised “process pathway”. A lead should be appointed to support the organisational development of the preoperative assessment service and to provide the “assessor” workforce with a single manager.

Trained assessors

A fully trained and competent assessor is required to deliver face-to-face assessment and “verify” the outcome of screening questionnaires.

The assessor may be a nurse or other professional/practitioner as described in the publication Pre-operative Assessment, The Role of the Anaesthetist, published by the Association of Anaesthetists of Great Britain and Ireland (2001).

In recent times, the now devolved National Health Service University and NHS Modernisation Agency supported the development of an e-learning course for the NHS, now delivered by the University of Southampton. This is a course that establishes assessors “knowledge to practice” in pre-operative assessment.

However, clinical skills need to be assessed locally. One of the benefits of delivering pre-operative assessment services with trained assessors is that they will navigate the surgical journey for the patient and the organisation successfully, whatever the level of complexity.

It would be prudent to include the learning and development of assessors in Trusts’ commissioning plans for education and development.

Clerical support

A pre-operative assessment service cannot be high performing without adequate clerical support. It reduces the capacity of the service to verify screening or provide clinical assessments if assessors are spending time on administrative tasks. Inevitably there will be some aspects of administration supported by the assessors but it should not be their role to do this exclusively.

Technology

The national drive is to improve efficiency and effectiveness in the development of clinical practice and delivery of health services (NHS Plan 2002), by ensuring healthcare professionals have access to high quality technology to support their practice and improve communication. The role of technology is developing rapidly in pre-operative assessment practice. The patient administration system has played a very important part in supporting pre-operative assessment services to date, coupled with increasing access by assessors to booking systems, pathology systems and theatre schedulers.

It is imperative that the pre-operative assessment service has adequate hardware available to assessors and administrative staff – they should not have to share.

Provision of appropriate software, such as that for booking, pathology and administration systems, is essential. Given the benefits that a high performing pre-operative assessment service provides to the organisation, the service should be prioritised in terms of training and support provided by technology staff.

Finance

When redesigning the management structure of pre-operative assessment organisationally, an opportunity will be provided for the centralisation of financial resource for the pre-operative assessment service. Given the benefits that a high-performance preoperative assessment service will achieve for the surgical specialties, significant investments should be made. Financial resource should be centralised and a single budget code identified to provide a coherent approach

to the purchase of equipment, the appointment of assessors and clerical staff and the approach taken to professional development. A robust business case will be needed to support this redesign.

Standardised documentation

A common approach to the documentation of patient information is regarded as the first step in developing consistency in the preparation of a patient prior to surgery. The patient’s details are recorded, either on paper or electronically, in a manner that facilitates easy access by healthcare professionals and clerical staff.

Implementing screening as part of the blend of delivery models adopted may provide the opportunity to review each specialty’s approach to patient information gathering and identify the common questions asked.

Appropriate accommodation

Locally and nationally there has been much debate on what constitutes appropriate accommodation for pre-operative assessment services. There is no doubt that location is important and should focus on easy access for patients.

Outpatients and day surgery departments may be suitable as long as the rooms are exclusively for the use of the pre-operative assessment service and are large enough to accommodate all required equipment. Patients waiting for pre-operative assessment should not be mixed with patients who are recovering post operatively.

Also, wards are not considered suitable unless the entire ward has been redesigned and is exclusively for the use of a preoperative assessment service.

In appropriate accommodation there will be a waiting area for patients and their carers, space for patients to complete a screening questionnaire, accommodation for administrative staff and rooms that can be used for face to face assessment without the risk of patient confidentiality being breached.

Structured communication

The strategic and clinical development of a pre-operative assessment service requires a robust written effective communication strategy owned by the appointed preoperative lead, while being supported and delivered by the executive team and the wider pre-operative workforce. As a matter of principle, organisational and clinical information needs to be available via a variety of routes to ensure that everyone contributes to the common vision of delivering pre-operative assessment to all patients that visit the organisation for surgery.

Additionally there are some external communications that organisations are increasingly required to participate in. The pre-operative lead will be able to support the organisation with patient outcome data, in turn helping patients, managers and clinicians with their decision making. Additionally, attention to internal communications will help share the benefits of pre-operative assessment with the wider organisations.

To support the organisation, the website, newsheets and notice boards should all declare the benefits of pre-operative assessment.

Patients will require written information about their pending surgery and this should be provided in a variety of formats. The quality of this communication should be of a high standard. The communication should be badged with the organisation’s logo, and contact numbers for the preoperative assessment service should be provided.

Access to pre-operative testing

Pre-operative assessors require access to pre-operative testing services or alternatively will need to adopt clinical skills to be able to do this themselves for their patients.

Thought should be given to how far patients have to walk to services such as radiology and phlebotomy and this should influence the geographical location of the pre-operative assessment service within the organisation.

Assessors should be mindful of national guidelines for the testing of patients prior to surgery and use these to inform local practice to avoid over testing of patients.

BENEFITS

Once organisations have invested in preoperative assessment services using the essential resources identified above, it will be possible to release significant organisational and clinical benefits.

The benefits of high performance pre-operative assessment services are:

• Improved patient outcomes.
• Changed working patterns.
• Cost savings.
• Time savings.
• Organisational efficiency.
• Reduction in variation of clinical and organisational processes.

Improved patient outcomes

Pre-operative assessment has improved patient outcomes by:

• Reducing same day cancellations for all reasons from approximately 4% to less than 1%.
• Reducing inappropriate laboratory studies and other tests.
• Reducing surgeon, patient and primary care complaints with the pre-operative process.
• Increased patient satisfaction. The source for the above four points is the Advocate Lutheran General Hospital, Park Ridge, Illinois US.

Changed working patterns and time savings

Working patterns have changed as a result of reducing duplication of effort by both clerical and clinical staff collecting the same patient information.

Working patterns have changed; anaesthetists are focusing on the more complex patients as a result of not “reassessing patients” having instead accepted information collected by other health professionals.

Source for these statements is the Diakonessenhuis Utrecht, The Netherlands.

Cost savings

Financial savings have been made by reducing the cost of the surgical patient pathways ensuring the organisation delivers care just below the national tariff. Source: Nottingham City Hospital, England.

Organisational efficiency

Streamlined process and clinical pathways have impacted upon the ability to reduce cancellations and improve theatre utilisation. Source: Salford Hospital, England.

Reduction in variation of clinical and organisatonal processes

Centrally managed pre-operative assessment has reduced variation in clinical and organisational processes resulting in an improvement in the quality of care patients receive.

Source: St Albans Hospital, England. Managers and clinicians together will be required to evidence benefits such as those examples above, having amassed a comprehensive range of data.

In conclusion, a pre-operative assessment service that evidences the benefits it provides for patients and organisations and supports the delivery of current political objectives such as the 18 week wait, choice and appropriateness of care, will enjoy an increasing profile and be resourced and supported. Can managers and clinicians together rise to the challenge of ensuring that pre-operative assessment is indeed high performing?

REFERENCES

1 Department of Health (NHS Modernisation Agency (2002): National Good Practice Guidance on Pre-operative Assessment for Day Surgery. London. DOH.

2 Department of Health (NHS Modernisation Agency (2003): National Good Practice Guidance on Pre-operative Assessment for In-patients. London. DOH.

3 Department of Health. The NHS Plan (2000) HMSO. London.

4 Department of Health. Care and resource utilisation: ensuring appropriateness of care (2006).

5 National Institute for Clinical Excellence (2003). Guidelines for Pre-operative Testing. Ref: CG2003.

6 Association of Anaesthetists of Great Britain and Ireland (2001). Pre-operative Assessment, the Role of the anaesthetist. AABGI. London.

7 British Association of Day Surgery (2002) Integrated Pathways for Day Surgery.

8 American Society of Anaesthesiologists physical class system (1963).

9 Department of Health, Social Services and Public Safety, Northern Ireland. Design and deliver guide for Pre-operative Assessment (2007).