Navigating the Handoffs Between Stakeholders in the Surgery Lifecycle: The Challenges of Coordinating Surgical Care
By Carisa Brewster and Jonathan Reimer
This is the first of a three-part series on the challenges of surgical care coordination and solutions to create a smoother patient experience.
For most patients, their surgeries go smoothly without a hitch. The complicated dance of surgical care coordination–the series of handoffs between stakeholders throughout the surgery lifecycle–is performed mainly in the background. Those stakeholders include physician offices, schedulers, pre-admission testing, insurance verification, vendors, sterile processing, supply chain, anesthesia, and surgery.
But what does it look like when the process doesn’t go smoothly? The ultimate result is case cancellations, which cause unhappy surgeons, frustrated (and untreated) patients, and stressed staff.
The operating room is the backbone of the hospital, producing 60-70% of revenue. The percentage is even higher for ambulatory surgery centers. Reducing elective surgeries during the COVID pandemic has put the financial health of organizations in the red. Now, post-COVID, growth has been the main focus.
Improving surgical care coordination can be a significant cost-saver and revenue boost.
In this article, directors of surgical services and a physician office manager will discuss all the major pain points in surgical care coordination. These include:
- Reliance on antiquated technology for communication
- Outdated/missing H & Ps and consent forms
- Insurance denials due to administrative error
- Hours of wasted labor tracking down missing information
- Not addressing specific patient needs for the procedure
- Inadequate patient education
Each organization represented has a unique way of managing these challenges. But what is the best potential solution? Read to the end, and you’ll find out.
Surgical care coordination starts with the patient. Whether it’s a health issue or a cosmetic concern, deciding to have surgery is significant. The biggest pressure point at this stage is using outdated communications technology to transmit information to the OR. Because many physician offices and surgical facilities are unaffiliated – and do not share the same EMR (electronic medical record) – they often rely on antiquated technologies such as phone, fax, and email to schedule cases and coordinate care.
“Physician offices and hospitals are the last realms of the fax machine”Anne Schermerhorn, Medical Practice Administrator
“Physician offices and hospitals are the last realms of the fax machine,” says Anne Schermerhorn, medical practice administrator. “If I’m scheduling three cases, I have to schedule one, fax the data, then move on to the next case and hope someone looked at the 5 or 6 pages underneath.”
The reality is that Schermerhorn can’t rely on the hope that someone saw that information. She must call the OR scheduler to ensure the case is on the hospital’s schedule, the insurance has been verified, the equipment is available, and the sales rep has been notified (for instance, if the sales rep doesn’t show up, the surgery can’t happen). Physician office employees spend many hours going back and forth with surgical facilities via the phone ensuring that information is correct.
In addition, physician offices cannot see the care coordination workflow status for each case and which stakeholders have finished their portion of the work. This lack of visibility can cause enormous stress for physician office staff as they manage pressure from their surgeon to ensure everything is ready for that case.
From the point of view of the physician’s office, they need to know two things: that their case was put on schedule and final insurance verification is complete.
For Brittney Williams, ASC administrator, the biggest issue at her previous facility was verifying insurance authorizations promptly. For them, it starts with ensuring that the OR scheduler receives all the necessary information to correctly enter that case into the EHR (electronic health record). The OR schedulers carry the burden for each case to make sure all the stakeholders involved are well informed in the days leading up to surgery.
“Surgeons have a choice on where to do business, just like patients do”Brittney Williams, ASC Administrator
“Surgeons have a choice on where to do business, just like patients do,” says Williams. “Many of them are credentialed at multiple facilities. It becomes a matter of being the easiest button for them and their office to press.”
Every procedure has many moving parts and requirements leading up to the day of surgery. Total joint procedures can be the most challenging due to the following:
- Ensuring H&P forms are complete and not expired
- Updated CT scan
- Completed lab orders
- Pausing certain medications, such as blood thinners (within 30 days of surgery)
“We had a patient who was ill and didn’t show up for their H&P,” says Jillian Smith, director of perioperative services. “No one called to follow up for a reschedule, and the patient didn’t reschedule. They showed up for surgery, but there is no H&P in their chart. We had to cancel the surgery.”
But now, that CT scan is a ticking time bomb. It’s only valid for six months, so they must reschedule the patient ASAP. The physical therapist must also be rescheduled, which could be complicated depending on their schedule.
One solution Smith has implemented is creating and hiring a surgical care coordinator role to work with all the stakeholders in the surgical care coordination process. It doesn’t solve the issue entirely but introduces a solid point of contact for the patient and helps coordinate the surgical care needs leading up to the procedure. Many patients leave the physician’s office, and days go by without communication from the facility.
However, there’s often a good reason for that.
“They think we’ve forgotten about them, but what’s happening is that we’re waiting for insurance verification. A care coordinator can help avoid miscommunication. Ours is a godsend; the work she does on the backend is amazing”Jillian Smith, Director of Perioperative Services
“They think we’ve forgotten about them, but what’s happening is that we’re waiting for insurance verification. A care coordinator can help avoid miscommunication. Ours is a godsend; the work she does on the backend is amazing,” says Smith.
EHRs, such as EPIC and Cerner, are some of the tools used to share and communicate information today. However, they are imperfect and weren’t designed to track and manage workflows or connect all stakeholders coordinating care.
“It’s clunky because there isn’t one place to see everything, and while everyone has access, with EPIC, your lens is a little different depending on your job,” says Smith.
When an employee from imaging logs in, they will see the imaging template. But if someone from another department needs to see those images, they can’t access it with their login. They need to choose a different job/department. Smith’s care coordinator must login as a different job to reschedule rehab for a patient.
“Being a rural organization, we lease EPIC through a larger organization. We don’t control the building and development of what we need [in the software]. Certain programs aren’t available for us. You can ask for them, but it’ll take three months to a year. So if you have a problem right now, you have to find a workaround,” says Smith.
Another complication with faxing is security and protecting patient information.
“You get one number wrong, and you’re sending someone’s chart to a mechanic in Detroit. That possibility is unnerving, yet the medical industry still heavily relies on faxes to transmit medical information,” says Joshua Ast, director of surgical services.
“Blurred EKGs, missing pages, paper jams, unreadable numbers. The cardiac clearance may be on page 5 of a 20-page fax, and that page is missing,” says Kim Viadero, surgical services administrator.
An OR scheduler has to be great at multitasking, communication, and project management to ensure surgical case requests are initiated and properly coordinated leading up to the procedure. All of the manual processes along the way make care coordination cumbersome for any OR Scheduler, making it easier to make mistakes.
Insurance companies have a litany of requirements before signing off on surgery. If one item of information is missing, the risk of a delay or cancellation is almost guaranteed. Insurance companies do not make it easy for staff to verify cases last minute.
Insurance verification depends on collecting all the necessary case and patient information early to complete the verification process correctly. The case coordination process is often delayed or at a standstill until verification is finished at the surgical facility. The insurance verification team can spend many unproductive hours collecting missing information to complete a case, causing delays with all the stakeholders in the process.
“We probably spend a minimum of 5 hours a week making phone calls to track down information”Joshua Ast, Director of Surgical Services
“We probably spend a minimum of 5 hours a week making phone calls to track down information,” says Ast. “This can lead to overtime because we’re trying to avoid canceling the case. The doctor’s office could be closed by the time they can get on the phone to make calls.”
Because insurance verification is multi-layered, it is difficult to track whether or not cases have been verified. Most facility technologies need more visibility into the process and a foolproof method to track incomplete verifications.
“There were frequent instances where we’re cutting it down to the wire, making constant phone calls back and forth,” Williams says. “It’s the day before surgery, and we’re still asking if we’re approved. And if we’re not, we have to reschedule. Patients have already rearranged their schedules for this, so it’s a huge inconvenience for them.”
There are many regulatory guidelines to follow based on each patient’s profile and case type that dictates the site of service, billing, and reimbursement of any procedure. These guidelines help guarantee that each patient gets safe care and the most optimal outcome. If any of these guidelines were compromised, it could equate to reimbursement denials, resulting in lost revenue for the facility.
“Last year, we had three hysterectomy denials because we didn’t have the sterility consent 30 days before surgery,” says Smith. “The typical reimbursement for hysterectomies is between $30,000 to $48,000. Times that by three. And that doesn’t account for supplies, time, and staffing you just utilized for free.”
Something as simple as not having the correct insurance on file is costly. Smith says her facility has just under $1 million in insurance denials. Online portals like MyChart make updating their records easier, but not every patient has an account.
Another new trend: because outpatient surgeries are less expensive, insurance companies are reluctant to pay for inpatient surgeries if not medically necessary. Age isn’t necessarily the deciding factor.
“You need to have a solid reason to do a procedure as an inpatient,” says Karen Curley, nursing director of procedural services. “You may have someone who is 87 years old, but they are very healthy, full-functioning, and can go home the same day. A younger person may have comorbidities and no one at home to help them.”
Site of service selection is difficult to manage because there are many clinical factors and variables that can impact the patient’s surgical risk.
“Insurance companies will look at a procedure like joint replacements and hysterectomies and ask if it could have been outpatient,” says Smith. “You better have your documentation on the spot and ready to go, proving why they needed to be inpatient. Otherwise, you won’t get paid. If we’re denied, that is a significant loss of revenue.”
Many variables can contribute to whether or not a procedure becomes inpatient or outpatient. It is always a challenge for each surgical facility to determine the patient’s specific needs in preparation for surgery.
Pre-surgical and pre-admission testing is an integral part of the care coordination process as it ensures that patients are adequately prepped for surgery. There are challenges in gathering all the necessary clinical documentation because multiple sources and stakeholders are involved. While every patient needs a consent form and H&P within 30 days of surgery, specific procedures dictate if additional testing needs is required.
“For instance, a patient may need a cardiac clearance. Or if they have a certain medical condition, a medical clearance,” says Viadero.
Viadero’s facility has a Pre-Admissions Testing (PAT) Department consisting of three nurses and two coordinators. The patient will hear from central scheduling at the hospital and then have an interview with a PAT nurse. During that interview, a nurse may discover that additional clearances are required. PAT is responsible for keeping everyone updated on the latest information regarding patient status. The fallout is broad if a patient slips through the cracks.
“If a cardiac work-up is missing or a patient fails to stop their blood thinners at the right time, surgery gets canceled. You have patient and surgeon dissatisfaction. Supplies that have been opened need to be thrown away”Kim Viadero, Surgical Services Administrator
“If a cardiac work-up is missing or a patient fails to stop their blood thinners at the right time, surgery gets canceled. You have patient and surgeon dissatisfaction. Supplies that have been opened need to be thrown away,” says Viadero. “Let’s say that was a four-hour case. Now you’re calling patients at home to move them up. They’re not happy, and anxiety increases as they try to hurry up and get to the hospital. It’s a big snowball.”
Curley says that one of the leading causes of cancellations in her experience is physicians ordering cardiology consults for a patient who may not need one.
“Instead of going by the guidelines, it seems easier just to have them get one. But it takes time to get a cardiology appointment, which may not happen before surgery,” says Curley.
Vendor Management/Supply Chain
An incorrect implant selection is another aspect of joint cases that can result in cancellations. Suppose a patient has a nickel allergy, and the vendor representative is not alerted. In that case, they might bring an implant with nickel for the procedure, causing a patient safety risk, case delay, or cancellation.
“We have to make sure the implants we provide for this patient do not contain something that will cause an adverse reaction,” says Ast. “This should come to the staff’s attention much earlier than the day of surgery if we’re using a scheduling or reservation technology that highlights that.”
Facilities still follow manual processes to select and alert implant/product selection for patient procedures. Schedulers spend multiple hours per week calling vendors to alert them to an implant/product need. They spend additional hours verifying that the implant/product will be delivered with enough time to prep for the case. However, this leg of the process starts with the surgeon.
“We have items here on the shelf that we’ve purchased, and we obviously prefer the surgeon to utilize those, but ultimately they have the best idea of what is best for the patient,” says Ast. “We may need an item that we don’t have in our inventory, so the surgeon is usually responsible for contacting those reps and letting them know that their support will be needed for an upcoming procedure.”
For instance, Ast says that his facility does not own any sets for total joints. In this scenario, the surgeon would give the rep details about the schedule (some proactive reps will call the hospital and ask about the schedule for the following week). The rep will arrive the day before surgery with the appropriate instrumentation and biologicals so there is time to process and sterilize them. But the unexpected often happens.
“We had a physician today who has a preferred vendor for a trauma procedure, and he has a case he wants to put on tomorrow’s schedule. That vendor could not provide support, so he contacted me and asked what options we had for him. Now at this point, the onus falls on the facility to reach out to vendors. I was able to touch base with a vendor that could come out and support the procedure,” says Ast.
While it’s common for vendor reps to assist the surgeon in technical support before and during surgery, some try to make the most of this facetime by upselling more expensive products. Ever conscious of the bottom line, most facilities have contractual protections against this.
“We don’t allow upselling by our reps,” says Viadero. “If a surgeon wants a new product, they must complete the required paperwork and submit it to the OR materials manager. It is then reviewed at the OR materials management meeting for approval.”
Another issue that can cause delays or cancellations is coordinating schedule changes with the vendors. Williams says this is one of the biggest hurdles for clinical administrators.
“If the physician has to reschedule a procedure, the clinical administrator or director has to notify up to 10 people about the change,” says Williams. “This includes coordination of loaner trays before the procedure and ensuring that you arrange ample time for sterilization. It becomes extremely time-consuming for the scheduling department and clinical leadership.”
Day of Surgery
Having to cancel a case a few days before is bad enough. But canceling the day of surgery is nothing short of disastrous.
“When we have to cancel cases, that block time is vacant,” says Ast. “Emerging from COVID, volumes are down. Hospitals cannot afford to have empty rooms and pay for people to sit around. This leads to apprehension for the staff because they’re worried about losing hours.”
“There is a lot that goes into planning a procedure. It’s like an orchestra coming together, working in unison to make sure you can perform when it’s time,” says Chris Chacon, hospital CEO. “The last thinking you want to hear is that a case was canceled due to system failure.”
Direct Financial Impacts
Although surgical services are the financial engine of every facility, some processes and programs must be updated, while others need to be more easily integrated with other platforms. Chacon says that many EMR platforms are robust but cannot optimize OR time, block utilization, and staffing.
“One of the main reasons case cancellations occur is because we don’t have the correct information or no pre-authorization,” says Chacon. “Seeing all of that ahead of time would save millions of dollars. Every minute surgery is delayed costs about $200. People don’t consider the underutilized time that is detrimental to your overall bottom line.”
“Sometimes you can fill the gap in the schedule and move patients up,” says Smith. “But most of the time, you can’t do that on such short notice. You’ve opened packs, supplies, and equipment. That’s all lost money.”
Importance of a Harmonized Surgical Experience
Staff and leaders are responsible for creating a smooth, stress-free surgical experience for the patient. There is a tremendous level of complexity in the surgical care coordination process. However, due to outdated communications technology, this process is made even more vulnerable to error.
Some consequences of errors are outdated consent forms, wasted hours tracking missing information, and insurance denials. Case cancellations and lost revenue result when these issues are not resolved promptly.
Given the current era of great technological innovation, there are options to explore that would bring some of these aspects of surgical care coordination into the 21st century. One is SurgiScript, a cloud-based platform developed by Medtel that stabilizes the surgical care process. Part two of this series will delve into how Medtel’s software improves the flow of communication among stakeholders and provides additional tools to accomplish department goals and improve patient care.
Carisa Brewster is the staff writer and media relations representative for Whitman Partners, a talent agency for surgical services directors. She holds a BA in Journalism and has 20 years of experience as a news reporter covering science, medicine, and health care.
Jonathan Reimer is an experienced healthcare leader with 16+ years of healthcare operational leadership experience in the surgical, sterile processing, and supply chain sectors. A subject matter expert in the industry, he has written major academic research articles and presented at many national education seminars. Jonathan joined Medtel in 2022 and is motivated to solve the problems facing the surgical care coordination market.
Medtel was founded in 2016 as a surgical care coordination technology pioneer with a customized solution developed for NYU Langone Orthopedic Hospital. Medtel has since evolved into an expert in the surgical care coordination space focusing on managing the workflows within the process by utilizing artificial intelligence technology. Medtel is strongly committed to improving surgical care experiences and outcomes for patients and their providers by developing technology solutions for every surgical episode of care.