Author Archive

Hospitals are searching for a workable system for 24/7 ED emergency surgery coverage. Unfortunately for the hospitals, there’s a shortage of surgeons. This, combined with many surgeons’ frustration with ED call coverage and their desire to have more regular hours, is exacerbating the problem. It’s often a major source of conflict between hospital administrators and surgeons, which can potentially negatively impact the quality of care.

That’s one of the reasons Surgical Affiliates was founded: to be the solution to this problem. Our surgicalist model delivers proven, high-quality, 24/7 coverage for patients needing emergency surgeries, while offering healthcare professionals (surgeons, NPs and PAs) an option they never thought was possible: having a challenging and rewarding career AND time for personal priorities. In addition to general surgery, our surgical hospitalist program encompasses specialties such as trauma, and orthopedic surgery.

Here are a few reasons to consider becoming a member of the Surgical Affiliates team:

• You can be part of a new and satisfying field as a surgicalist.
• You can be in a practice unlike any you’ve known, with the professional satisfaction of doing what you were trained to do.
• You can focus on your patients while all of the management services are handled for you.
• You can have dependable and regular schedules that afford you the time and benefits to attain work-life balance.
• You can enjoy your free time with the security of knowing that your patients are receiving the highest quality of care from your practice partners who are as committed to quality patient care as you are.

The hospitalist lifestyle and career afforded by our model is what enables us to bring teams of high quality and talented healthcare personnel to our partner hospitals. When we look for healthcare professionals to join our team, in addition to the usual criteria of board certifications, etc., we seek out people who are passionate about their job and the patients’ well-being, who have a record of achieving high patient satisfaction scores, who are involved in their community and who thrive on working in a team-oriented environment. We look for top people because we want the doctors in our partner hospitals to say they “want their family members to be treated by our doctors.”

For surgeons especially, Surgical Affiliates’ model offers more options. For example, the surgeon who may be thinking of retiring may re-consider with the option of a more flexible schedule on the surgical hospitalist team or a private practice without the stress of taking ED call. Younger surgeons may thrive on the challenge of doing emergency surgeries while not worrying about patient insurance or the billing and enjoying the lengthier blocks of free time for family or other pursuits.

We are always looking for:

• General surgeons
• Trauma surgeons
• Orthopedic surgeons
• Nurse practitioners
• Physician assistants

Why not join us and be part of a team that is transforming emergency surgical care across the U.S.? Here’s a link so you can learn more about surgical hospitalist careers: https://www.samgi.com/join-our-team/

>Recently, for the fifth time, Sutter Medical Center, Sacramento (SMCS) was named one of the Top 100 Hospitals in the U.S. by Truven Analytics. It was recognized, along with the other hospitals selected, for consistently delivering outstanding quality of care, satisfaction and community value at a reasonable cost.

For the first time, SMCS also earned the Top 100 Hospitals Everest® Award—one of only 17 hospitals in the nation and the only hospital in California to simultaneously set the national benchmark for both “balanced excellence in a single year” and “greatest improvement over five consecutive years.”

Truven selected the hospitals based upon an independent analysis of public data. The criteria used included both financial benchmarks (hospital profitability, as well as Medicare per beneficiary spending) and clinical measures; for example, 30-day readmission and mortality rates metrics.

Surgical Affiliates Management Group’s surgicalist program was one component that helped SMCS achieve this major recognition. Our collaborative surgical hospitalist program boosted performance throughout the hospital, improved patient care and reduced costs, as documented in a five-year study undertaken by SMCS and Surgical Affiliates, which was published in the prestigious peer-reviewed Journal of the American College of Surgeons. The study validated that surgical hospitalist programs improve key hospital performance metrics. For SMCS this included:

• Decreasing length of stay by 12%
• Reducing complications by 43%
• Lowering costs by 31%—a total of $2 million in a single year

According to Jean Chenoweth, senior vice president at Truven Health Analytics, if all Medicare inpatients received the same level of care as those treated in the award-winning facilities:

• More than 164,000 additional lives could be saved.
• Approximately 82,000 additional patients could be complication free.
• More than $6 billion could be saved.
• The average patient stay would decrease by nearly half a day.
• And if the same standards were applied to all inpatients, the impact would be even greater.

We’re delighted that Sutter Medical Center, Sacramento has once again been honored as one of the nation’s top hospitals. If you are interested in learning more about how our partnership with SMCS helped accomplish these results, please read our most recent case study “The Verdict Is In: Surgical Hospitalist Programs Deliver Improved Results throughout the Hospital.” To request a copy, please visit www.samgi.com

Patients undergoing emergency surgical procedures are extremely vulnerable.

And with most hospitals struggling to provide consistent surgical call coverage, patient safety and quality of care can be threatened. That’s why we developed our unique, proven System of Care© – to help hospitals and surgeons transform the delivery of emergency surgical care to their patients, throughout the U.S. This comprehensive Acute Care Surgery service not only delivers dedicated surgicalist teams but also improves safety and outcomes boosting results throughout the hospital. What we call the ‘halo’ effect are improvements brought out by the Acute Care Surgery service that radiates to departments throughout the hospital.

What’s our System of Care’s “magic formula”? In a recent roundtable presentation at the Becker’s Hospital Review Annual Meeting, we shared the secret to its success:

• Leadership from expert surgeons and executives
• An outstanding surgicalist team that delivers standardized surgical care according to evidence-based guidelines; this ensures decreased variations in care and produces measurable results
• Collaboration with the hospital to consistently improve patient care, quality and safety

As you can see, there’s really no magic involved. But there is a lot of hard work and dedication every single day – resulting in improved outcomes, increased satisfaction, lower costs, and reduced length of stay without an increase in readmission rates.

Our hospital clients are reporting amazing results such as decreasing the rate of complications from acute care surgeries by 72%, dropping the 30-day readmission rate by 66%, and decreasing length of stay by 12%.

It’s exciting to see that each day we and our hospital partners are advancing the delivery of Acute Care Surgery and decreasing patient morbidity and mortality.

For more information about our System of Care visit: https://www.samgi.com/surgical-programs

Since our first surgical hospitalist program entered the medical scene in about 2007, Surgical Affiliates has been diligent about working with our hospital partners in measuring the results of these programs.

Originally, our mutual goal was to ensure consistent, quality surgical care for patients presenting with emergent surgical needs. In program after program, not only was that goal met, but we made the gratifying discovery that the surgical hospitalist collaboration boosted performance throughout a hospital, by improving the quality of care, reducing costs, and decreasing length of stay.

Now, these findings are official with the publication of five-year results from our collaboration with Sutter Medical Center, Sacramento, a tertiary referral community hospital with 654 beds in California. Published in the prestigious peer-reviewed Journal of the American College of Surgeons, the study validated the fact that surgical hospitalist programs improve hospital results across the board and produce outcomes that are measurable and sustainable.

As reported in the Journal, the Surgical Affiliates Management Group’s acute care surgery model improved key hospital performance metrics:

• Decreased length of stay by 12%.
• Reduced complications by 43%.
• Lowered costs by 31%—a total of $2 million in a single year.

The importance of this study can’t be overstated: the outcomes, both clinical and financial, have been amazing. Surgical hospitalist programs have indeed come of age and proven themselves to be a valuable tool for hospitals and health systems to meet their clinical and financial goals.

Download the Case Study to read it in its entirety.

Michael S. O’Mara, MD, FACS; Timothy F. Daly, MBA; Cynthia C. Leathers, MPH, MBA; Leon J. Owens, MD, FACS

In 2007, Sutter Medical Center, Sacramento found itself in the same position as many other facilities across the country. Rising costs and decreasing revenue had collided with the crisis of a national physician shortage. The increasing demands of busy practices coupled with long hours and poor reimbursement were crushing the desire of the general surgeons to cover emergency and in-hospital call. The success noted by other hospitals in creating surgical hospitalist and acute care surgery programs spurred the administration to look for a similar solution.

The problem they faced was that no umbrella existed under which surgical hospitalists could reside. In most other hospitals with such programs, the emergency and acute surgery is integrated with the trauma programs; in others, the academic nature of the institution allows 24-hour, seven-day-a-week coverage in-house in the form of residents with attending back-up. Sutter Medical Center, Sacramento, operates two separate hospitals on two campuses approximately two miles apart with a total of 650 acute care beds. The only affiliated residency program in family medicine. Neither campus houses a trauma program. All acute general surgery coverage until January 2008 was done on a rotating basis by members of the medical staff who had general surgery privileges.

The real dilemma that exists when investing in a new paradigm in medical care is to address the mandate of the modern era: improve safety, enhance quality, increase patient satisfaction, and lower costs. A common thought is that if you do the first three, lower costs will follow. To lead the process, Sutter Medical Center brought in Surgical Affiliates Medical Group, Inc., a local group with experience in developing a trauma model in a community hospital setting without an established trauma or academic service. This acute care surgery, the hospital-based program became the model for the surgical hospitalist program at Sutter Medical Center.

The Program

Sutter Medical Center, Sacramento, contracted with Surgical Affiliates Medical Group, Inc. (SAMGI), a privately held corporation, to implement a surgical hospitalist program. SAMGI provides 24/7 in-house general surgery coverage to both hospitals through a subsidiary group, Acute Care Surgery Medical Group (ACSMG). These general surgeons are available in-house for all acute surgical consults. The joint mission for SAMGI and Sutter Medical Center Sacramento is as follows: To provide acute surgical care in an expert, efficient, team-oriented manner, accomplished by: Establishing a workable system whereby a select group of general surgeons, focusing upon the care of the acute surgical patient in the hospital setting, can act to provide expedient, expert care.

Providing a schedule that allows the individual surgical hospitalist to provide complete care to the patient while allowing clear handoff between surgeons and sufficient time off to maintain a rewarding lifestyle.

Providing coverage and support for non-elective surgical consults, allowing the non-hospitalist surgeons to provide improved surgical care to their elective and established patients while allowing enhancement of their own lifestyles.

Establishing a system of communication and professional respect with referring physicians that allows the care of their patients to be assisted by our surgical hospitalists and with consulting physicians that provide care that goes beyond our training or expertise.

Creating a system of review using physician practice management guidelines (PPMG’s) that are evidence-based with the goal of providing safe, sensible, and successful patient care.

Intervening for surgical patients in an appropriate and expeditious fashion to shorten the length of stay and decrease the risk of complications, thereby decreasing cost and increasing hospital bed availability while improving resource utilization.

The surgical hospitalist program functions with the following guidelines:

• A board-certified general surgeon is in-house at all times.
• The general surgeons on the team average two non-consecutive 24-hour shifts per week. There are about four full-time equivalent general surgeons.
• The general surgeons are supported by physician extenders. NP/PAs work under the supervision of the on-call physician during morning rounds and clinic and provide back-up for emergencies and surgical assistance 24/7.
• Most acute surgical consults in the hospital or in the emergency room are referred to the surgical hospitalist on call. Requesting physicians have the right to consult any surgeon they wish, and are not limited to the surgical hospitalists.
• The surgical hospitalists do daily rounds and sign-out with one another and with the consulting medical hospitalist and intensivist teams.
• An outpatient clinic is held two half-days per week and is limited to only follow-up appointments from inpatient procedures.
• No elective surgery is performed by the surgical hospitalist team.
• A monthly quality assurance meeting is held by the surgical hospitalists to evaluate care in an ongoing fashion.
• The surgical hospitalist team creates policy and procedure guidelines for patient care both for internal consistency and to inform consultants of the preferred mechanisms of evaluation and care.

The Result: Improved Patient Care and Serving the Underserved

Institution of the surgical hospitalist program has improved patient access to in-hospital acute surgical care. Annualized data from the first nine months of 2008 show a significant increase in the number of operations and consults over 2007. In 2007, an estimated 600 acute surgical procedures were performed; in 2008, over 700 are expected to be done. Projected consults from 2007 data were 1,115; nearly 2,500 consults will have been done by the surgical hospitalists in 2008. The majority of consults and operations are for the core of acute surgery: cholecystectomies (32%), appendectomies (29%), laparotomies (21%), and drainage of abscesses (8%). This distribution is similar to what was seen in 2007.

The availability of surgical hospitalists has led to care that is more expeditious. For the evaluation of the patient with biliary disease, the time to consult from the time of emergency admission decreased from 11.3 hours in 2007 to 6.2 hours in 2008. For appendectomy, there has been no real improvement in the time it takes for a surgeon to see the patient, this taking 5.4 hours from the time of emergency room admission in 2007, and 5.6 hours in 2008. However, this delay is the time it takes for the admission and evaluation of acute appendicitis in the Sutter Medical Center emergency department (exam, labs, and computed tomography scanning).

For appendicitis, there has been no significant change in the interval from the time of presentation to the first incision in the operating room: 8.3 hours in 2007, and 9.7 hours in 2008. For cholecystectomy, this time has dropped from 40.4 hours in 2007 to 21.5 hours in 2008. This rapid evaluation coupled with the round-the-clock surgical and OR availability has reduced the length of stay in cases of both appendectomies and cholecystectomies. Patients with appendectomies have seen a reduction in the average length of stay from 3.0 days to 1.7 days. Those undergoing cholecystectomy have had a length of stay shortened from 5.1 days in 2007 to 3.6 days on average in 2008. This LOS reduction comes from rapid movement to the operating room and the surgical hospitalist availability to evaluate the patient for discharge at any time of day, unencumbered by office hours or other practice responsibilities.

Looking at the patients who have undergone appendectomy and cholecystectomy by the surgical hospitalists in 2008, the outcomes are excellent. A 1.2% readmission rate is unchanged from that of 1.3% in 2007. No returns to surgery have been needed, and no patients have died following appendectomy or cholecystectomy. Preliminary data on the other operations performed by the surgical hospitalists (laparotomies, abscess drainages) display similar good results and decreased the length of stay.

The Result: Patient and Physician Satisfaction

A survey was sent to members of the medical staff, nursing, and case managers. The overwhelming response was positive, with 33 of the 55 responders (60%) indicating very good overall satisfaction with the surgical hospitalist program. Fifty of the 55 responses (91%) stated good or very good satisfaction. Only five responses implied only fair satisfaction, and no one replied that dissatisfaction existed with the surgical hospitalists.

Consulting physicians are universally happy with the new program, with 100% of emergency physicians (11 of 11) remitting good or very good satisfaction. One physician went so far as to say the availability was the best he had seen in his decade in the emergency room. Medical hospitalists were likewise satisfied, with 95% indicating good or better satisfaction (18/19). Ninety percent stated that the response time and overall program had improved greatly from the situation before the surgical hospitalists’ presence. The non-participating general surgeons revealed the most dissatisfaction with the program, with three of nine responses indicating only a fair satisfaction with the program. Concerns seemed to focus around the urgent and acute surgical cases changing the operative schedule for the day and delaying elective cases. Nursing satisfaction was also high (all good or very good) with the primary comments centering on the excellent availability of the surgeons.

As for the surgical hospitalists themselves, there has been a great improvement in the quality of their lives. The rotating schedule and flexibility have allowed them time for family and outside projects not always readily available to surgeons in private practice. Reliability of income has left the surgeons more interested in patient care and less on the maintenance of an office, overhead, and insurance issues.

The Result: Lower Costs and Increased Income

By decreasing the time it takes to get to the operating room and decreasing length of stay, the surgical hospitalists have decreased hospital costs. Appendectomy cases have seen a reduction in cost from 2007 to 2008 of 30%. Cholecystectomy cases have seen a 20% decrease in costs. The top five billed procedures during 2008 have been laparoscopic appendectomy, laparoscopic cholecystectomy, open appendectomy, laparotomy with lysis of adhesions, and laparotomy with small bowel resection. When evaluated, the profit margin of these five procedures in 2007 was in the negative; in 2008, a positive profit per case was identified. This includes all insured and uninsured patients. The result of this swing, for the top five operative procedures being performed by the surgical hospitalists, was to convert a substantial dollar loss in 2007 into what promises to be a profit in 2008, a remarkable turnaround that has enhanced Sutter Medical Center, Sacramento’s mission of providing more affordable healthcare to its community.

Beyond the tangibles of cost and profit for the cases directly performed by the surgical hospitalists, are the intangibles of increased bed availability and decreased emergency room utilization. With a reduction in length of stay, for just the cases of appendectomy and cholecystectomy, we predict an increase in the availability of 600 bad days because the patients have been discharged appropriately and expediently. This results in beds being available for other patients increases emergency department throughput, potentially increases hospital revenue, and makes care available to more patients.

Patients who previously had been seen multiple times in the emergency room for surgical problems are now evaluated by the surgical hospitalists. Now, these chronic, recurrent problems (including intractable biliary colic, recurrent incarcerated hernias, et al) are dealt with on an urgent basis regardless of patient insurance status. This helps alleviate the impact on the emergency department by these chronic problems. The revolving door nature of these urgent problems is definitively addressed, stopping the continued drain of hospital resources with the appropriate operation.

Conclusions

Implementation of a surgical hospitalist model has been shown previously to be good for patient care and physician satisfaction. With the current decrease in the availability of general surgeons, surgical hospitalists provide the necessary care in an efficient, cost-effective manner. Patient care is, at worst, no different than that provided by private practice general surgeons; and at best, an improvement over what surgeons burdened with elective practices and busy offices can provide. By improving patient care, surgeon efficiency, and employee satisfaction, we have shown that a surgical hospitalist model can also decrease costs and provide more efficient use of hospital resources.

The model of acute care surgery can be taken outside of the academic center, away from the trauma program, and implemented in a community hospital in need of general surgery coverage. By building on existing models and employing a system dedicated to providing acute surgical care, surgical hospitalists can provide high quality, cost-efficient patient care. At Sutter Medical Center, Sacramento, the surgical hospitalist program has resulted in a successful, sustainable program for the care of acutely ill patients.

Michael S. O’Mara, MD, FACS is the medical director of Acute Care Surgery Medical Group, Inc. He can be contacted at [email protected]

Timothy F. Daly, MBA, is Assistant Administrator of Surgical, Ancillary, and Support Services for Sutter Medical Center, Sacramento. He can be reached at [email protected]

Leon J. Owens, MD, FACS is president and CEO of Surgical Affiliates Medical Group, Inc. He can be reached at [email protected]. SAMGI operates a website at www.samgioncall.com where further information is available.

Cynthia C. Leathers, MPH, MBA, is the COO for Surgical Affiliates Medical Group, Inc. SAMGI operates a website at Surgical Hospitalists Services and Programs | www.samgioncall.com where further information is available.