Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care

The Perioperative Surgical Home supported by the American Society of Anesthesiologists is a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence.1,2 Surgical care is complex. Achieving the “Triple Aim” (improving patient experience, improving population health, and reducing health care costs)3,4 requires an integrator such as the Perioperative Surgical Home.5 Although the Perioperative Surgical Home has been implemented in academic settings2,6,7 and within the Kaiser system,8 there is no single ideal Perioperative Surgical Home model. The model that works at one facility will be created within the infrastructure of local resources, personnel, and politics5 and may not work at another facility. The purpose of this The Open Mind article is to examine the applicability of the Perioperative Surgical Home model to the Veterans Affairs (VA) health care system. OVERVIEW OF THE VA HEALTH CARE SYSTEM AND THE NATIONAL ANESTHESIA SERVICE The VA is the largest networked health care system in the United States. At present, there are approximately 9 million veterans enrolled in VA health care.9 Six million veteran patients are seen in the VA’s 151 medical centers and 820 outpatient clinics each year.10 Historically, the quality of care delivered in the VA has been rated highly, outperforming Medicare on 12 of the 13 quality of care indicators11 and matching or surpassing non-VA surgical programs in morbidity and mortality.12–14 Since 1994, the VA has had a physician-led National Anesthesia Service based within VA’s Central Office Specialty Care Services in Washington, DC. The Director is a board-certified physician anesthesiologist appointed by the Central Office. The Deputy Director is a certified registered nurse anesthetist. The National Anesthesia Service maintains its own national handbook,15 which describes the structure and procedures that are to be used for the practice of anesthesiology, including moderate and deep sedation and emergency airway management, within the VA Health care system. The National Anesthesia Service governs the practice of all anesthesia professionals (anesthesiologists, certified registered nurse anesthetists, and anesthesiologist assistants) located at 135 facilities. All but 4 of these sites employ at least 1 physician anesthesiologist. With this number of VA facilities staffed by physician anesthesiologists, there is potential for widespread implementation of the Perioperative Surgical Home. Recent events10,16 have called into question the value of the VA health care system, and now is the time to refocus its mission and promote innovation. VA HEALTH CARE’S HISTORY OF INNOVATION VA health care has a history of embracing innovation and promoting change. Under the leadership and vision of Dr. Ken Kizer in 1994, the VA focused on 3 core missions: (1) providing medical care for veterans to improve health and functionality; (2) training health care professionals; and (3) conducting research to improve veteran care.17 The ensuing transformation took form as 5 major strategies (Table 1) that were nearly completed by 1999.17 Integral to these change strategies was the rollout of a national electronic health record (EHR) in 16,000 in fiscal year 2014 (with the addition of the RAAPM and Perioperative Surgical Home consultant). Implementation of a Perioperative Surgical Home at the VA Palo Alto has been a vehicle for initiating clinical practice changes in a collaborative fashion with surgery. For example, the Perioperative Surgical Home anesthesiologist ensures that the many elements of enhanced recovery programs are performed. A locally developed database generates a daily Perioperative Surgical Home “rounds list” in addition to dashboards for tracking cases and outcomes. To date, we have collected information for more than 4000 patients who have received anesthetics at VA Palo Alto and have initiated a number of quality and research projects related to advancing clinical care. Future plans include expansion of anesthesiology joint management to other surgical specialties, a multidisciplinary spine care program, and extension of our pain Perioperative Surgical Home model to more advanced preoperative evaluation and long-term postoperative follow-up to aid the transition back to primary care. In summary, the VA health care system has a history of innovation. The VA is well positioned to achieve the Triple Aim in the perioperative setting by adopting the Perioperative Surgical Home as the integrator. For many reasons, the VA may be the ideal system for widespread implementation and testing of the Perioperative Surgical Home. DISCLOSURES Name: Edward R. Mariano, MD, MAS. Contribution: This author helped prepare the manuscript. Attestation: Edward R. Mariano approved the final manuscript and is the archival author. Conflicts of Interest: Edward R. Mariano has received unrestricted educational funding paid to his institution for conducting workshops on regional anesthesia from I-Flow/Kimberly-Clark (Lake Forest, CA) and B. Braun (Bethlehem, PA). Name: Tessa L. Walters, MD. Contribution: This author helped prepare the manuscript. Attestation: Tessa L. Walters approved the final manuscript. Conflicts of Interest: This author has no conflicts of interest to declare. Name: T. Edward Kim, MD. Contribution: This author helped prepare the manuscript. Attestation: T. Edward Kim approved the final manuscript. Conflicts of Interest: This author has no conflicts of interest to declare. Name: Zeev N. Kain, MD, MBA. Contribution: This author helped prepare the manuscript. Attestation: Zeev N. Kain approved the final manuscript. Conflicts of Interest: This author has no conflicts of interest to declare. ACKNOWLEDGMENTS We acknowledge Doug Rotter, Program Specialist for the National Anesthesia Service, and Steven K. Howard, MD, Staff Anesthesiologist at the VA Palo Alto, for their valuable input in preparation for writing this manuscript. This manuscript was handled by: Steven L. Shafer, MD.