Unlike many capital expenditures in medicine that implicate more layers of costly care, the sedation suite at the Dana-Farber Cancer Institute (DFCI) allows for the reallocation of capital and labor resources to promote patient value and process efficiency. Traditionally, patients at medical centers such as the DFCI receive all surgical care at an affiliate hospital. For DFCI’s pediatric patients, this was Boston Children’s Hospital (BCH). However, the resource-intensity at a major hospital such as BCH is often unnecessary for routine procedures. By shifting the site of care from BCH to its own sedation suite, the DFCI has executed a series of strategies that successfully promote its mission of providing high-value care to patients.
I. Patient Stratification. The DFCI recognizes that different patients require different types of care. For “high-risk” patients, as classified by the American Society of Anesthesiologists, care continues to be provided at BCH. However, for patients without anesthesia risks, a value-based alternative is used, optimizing clinical outcomes and patient satisfaction as a function of cost. Stratification was successful in assigning patients of lower risk classifications to receive care at the DFCI, as there were no differences between the outcomes of patients randomized to the traditional system versus the sedation suite.
II. Predictable Procedure Schedule. The sedation clinic offers a small selection of procedures, all of which are routine and predictable. While the sedation suite houses much of the same equipment as a traditional operating room, the setup and the range of resources required in the room is more limited. Most importantly, the procedures that are undertaken in the suite are extremely predicable in length, thus minimizing the cycle time of an episode of surgical care. Since emergency procedures are not scheduled at the sedation suite, the operating schedule does not have to allocate provisionary time-slots for potential emergencies. By knowing with more certainty the procedure length and the occupancy of each space during the various phases of the procedure, labor and capital use can be optimized.
III. Fewer Patient Handoffs. In traditional surgical settings, each clinical staff member has a specific set of roles at a very specific point during the care process. While the process works in managing large numbers of highly complex procedures, it can be unnecessarily time consuming for shorter and simpler procedures. In contrast, the DFCI model has a single duo of nurses in addition to the core physician team see a patient through all phases of care, thus minimizing handoff time.
IV. Patient Satisfaction. Patients and their parents express advantages to receiving surgical care at the DFCI, including feeling less apprehensive about the surgery and more confident in the team’s execution of care. These sentiments appear to drive perceived quality of care and cause parents to feel more comfortable leaving the recovery area after their child has been stabilized instead of unnecessarily lingering. This behavior thus potentially shortens the average throughput time of the recovery phase, leading to time and cost savings.
V. Precise Value Measurement. While the precision of clinical outcomes has long been a focus of the medical community, less attention has been paid to satisfaction and true costs of care. The DFCI and BCH jointly evaluated all three of these elements in order to measure how the implementation of the sedation suite and its processes were optimizing value. Importantly, costs are not measured using the hospital-based algorithmic allocation based on charges. Rather, true costs derived from Time-Driven Activity Based Costing studies are used to derive more accurate value measurement.,
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Delivering on patient value is becoming increasingly more important as insurance companies negotiate contracts that reward value, patient outcomes/unit cost, and penalize low-value care. Through the sedation suite initiative, the DFCI has been able to impact both components of the value equation. With respect to outcomes, the model has improved patient satisfaction while maintaining clinical outcomes. With respect to costs, there has been a dramatic reduction in costs (upward of 20%). These cost savings can be used to cross-subsidize other procedures that are inherently more complicated, and thus may not be amenable to alternative care structures. Additionally, the time savings can facilitate more expedient surgical care at BCH, as the current surgical schedule is limited in its capacity to serve patient demands.
Value-based performance is a reality that will universally hit almost all healthcare institutions. Thus, continuous process innovation initiatives like the sedation suite will help to position the DFCI to excel in this new healthcare compensation climate.
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