Preventing Post-Operative Readmissions with Surgical Safety Net
Last updated
Share PrintReadmissions after surgery negatively impact lives of Veterans and Institutional quality metrics. In 2019 VA Pittsburgh Healthcare System (VAPHS) was facing persistently elevated rates of surgical readmissions. We created a Surgical Safety Net that not only reduces readmissions but also enhances veteran perioperative experience.
Origin:
April 2020, Pittsburgh VA Medical Center-University Drive
Adoptions:
1 successful, 8 in-progress
Awards and Recognition:
Joint Commission Recognized Best Practice Initiative, VHA Shark Tank Winner, Promising Practice VISN 4 , Presented at FY2024 NSO Leadership Conference
Partners:
Anesthesiology, Care Management and Social Work Services, Office of Primary Care, Physical Medicine and Rehabilitation, Surgery
Recent Updates
Overview
The problem
Readmissions after surgery negatively impact lives of Veterans and Institutional quality metrics. In 2019, VA Pittsburgh Healthcare System (VAPHS) was facing persistently elevated rates of surgical readmissions. We needed a process to reduce readmissions. The Interdisciplinary Medical Preoperative Assessment Consultation and Treatment Clinic (IMPACT) leads t
...
Readmissions after surgery negatively impact lives of Veterans and Institutional quality metrics. In 2019, VA Pittsburgh Healthcare System (VAPHS) was facing persistently elevated rates of surgical readmissions. We needed a process to reduce readmissions. The Interdisciplinary Medical Preoperative Assessment Consultation and Treatment Clinic (IMPACT) leads the nation as a Joint Commission recognized Best Practice initiative providing state of the art preoperative evaluation and optimization and has successfully kept mortality and complications below the national average for 12 years. Based on this successful track record, the VAPHS Chief of Staff challenged IMPACT Clinic to develop a strategy for reducing readmissions
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more
The solution
We built a high-reliability process within IMPACT to identify at-risk patients using our prediction model. The Nurse Navigator connected veterans to existing but underutilized resources to prepare themselves, their caregivers, and their homes for post-operative care. She also made calls on post-discharge days 2, 5, 14, and 30. Veterans were given a 24/7 dedi
...
We built a high-reliability process within IMPACT to identify at-risk patients using our prediction model. The Nurse Navigator connected veterans to existing but underutilized resources to prepare themselves, their caregivers, and their homes for post-operative care. She also made calls on post-discharge days 2, 5, 14, and 30. Veterans were given a 24/7 dedicated phone number to coordinate care.
This Nurse Navigator meets the Veteran before surgery to enhance their comfort level and guide them through the surgical journey at VAPHS. The physical therapy pre-habilitation team identifies and mitigates vulnerabilities that increase readmission risk. Social work services address caregiver and home safety issues. The Telehealth team trains Veterans to use virtual devices comfortably and provides hotspots to Veterans who lack home internet services, especially in rural areas. The 24/7-staffed phone service provides a safety net to the Veterans and families through easy and smooth communication of time sensitive issues.
These processes prevented readmissions, improved Veterans’ trust in VAPHS, and increased satisfaction with their surgical journey. Veterans stated they had a wraparound “Surgical Home” akin to the “Medical Home” concept. Our surgeons, anesthesiologists and other stake holders wholeheartedly supported the process. See more
This Nurse Navigator meets the Veteran before surgery to enhance their comfort level and guide them through the surgical journey at VAPHS. The physical therapy pre-habilitation team identifies and mitigates vulnerabilities that increase readmission risk. Social work services address caregiver and home safety issues. The Telehealth team trains Veterans to use virtual devices comfortably and provides hotspots to Veterans who lack home internet services, especially in rural areas. The 24/7-staffed phone service provides a safety net to the Veterans and families through easy and smooth communication of time sensitive issues.
These processes prevented readmissions, improved Veterans’ trust in VAPHS, and increased satisfaction with their surgical journey. Veterans stated they had a wraparound “Surgical Home” akin to the “Medical Home” concept. Our surgeons, anesthesiologists and other stake holders wholeheartedly supported the process. See more
The results
From October 2019 to October 2022 SAIL readmission rate improved from 11.2 to 8.4 and rank improved from 52nd to 40th among the 126 VAMCs (P=0.012), demonstrating a clinically meaningful improvement that is statistically significant.
NSO readmission rate fell from 14.7% to 12.7%, approaching statistical significance (P=0.065).
Since the program’s incep ... From October 2019 to October 2022 SAIL readmission rate improved from 11.2 to 8.4 and rank improved from 52nd to 40th among the 126 VAMCs (P=0.012), demonstrating a clinically meaningful improvement that is statistically significant.
NSO readmission rate fell from 14.7% to 12.7%, approaching statistical significance (P=0.065).
Since the program’s inception, 50-70 readmissions were avoided with an estimated cost savings of up to $1,064,000.
Patients and families reported a high degree of satisfaction. Common themes are “increased trust in the VA” and “feeling better-cared for”. Providers express relief the program exists.
*UPDATE*
fiscal year 2023, the Surgical Safety Net program identified 223 high risk surgical patients for readmission, of which 193 were not readmitted. If the Safety Net program avoided these readmissions, the total cost savings for VAPHS was $2,933,600 or nearly $3 million dollars. See more
NSO readmission rate fell from 14.7% to 12.7%, approaching statistical significance (P=0.065).
Since the program’s incep ... From October 2019 to October 2022 SAIL readmission rate improved from 11.2 to 8.4 and rank improved from 52nd to 40th among the 126 VAMCs (P=0.012), demonstrating a clinically meaningful improvement that is statistically significant.
NSO readmission rate fell from 14.7% to 12.7%, approaching statistical significance (P=0.065).
Since the program’s inception, 50-70 readmissions were avoided with an estimated cost savings of up to $1,064,000.
Patients and families reported a high degree of satisfaction. Common themes are “increased trust in the VA” and “feeling better-cared for”. Providers express relief the program exists.
*UPDATE*
fiscal year 2023, the Surgical Safety Net program identified 223 high risk surgical patients for readmission, of which 193 were not readmitted. If the Safety Net program avoided these readmissions, the total cost savings for VAPHS was $2,933,600 or nearly $3 million dollars. See more
Images
Above:
Change in Surgical SAIL readmission rates following program launch
Above:
Change in NSO readmission rates following program launch
Metrics
- Readmissions rates by SAIL and NSO
- Patient/provider satisfaction
- Cost Savings
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Videos
Above:
Rationale and Testimonials for the Surgical Safety Net
Implementation
Timeline
-
November 2019
IMPACT team was tasked to find a solution to the high readmission rate problem -
By December 2019
* Initiated Surgical Readmission Prevention Task Force with part time commitment from IMPACT team members (1 physician, 3 registered nurses(RN), 1 quality and safety nurse)* Developed 8-point Readmission Prediction Model by chart review which included: Frailty, Alcohol use, Tobacco use, Diabetes, social issues, Caprini score, MELD score, high risk surgery. -
By February 2020
A dedicated Nurse Navigator(NN) Position was created to implement the process by:* Identifying and contacting high risk patients before surgery* Providing a 24/7 contact number to the Veteran* Arranging VA Video Connect(VVC) training for the Veteran* Consulting Ancillary services which included Physical Therapy, Social Work and Goals of Care teams* Providing wrap-around care by making and documenting phone calls on post-discharge days 2, 5, 14 and 30 and documenting in the chart* Addressing problems by contacting the surgical Point of Contact (POC) through medical chart for less acute issues and by telephone for urgent issues -
By March 2020
* Secured buy in from Surgical Service line to provide points of contact for each surgical service* Covered phoneline after-hours by leveraging the existing Surgeon on Duty* Collaborated with Ancillary services* Developed Protocols and Templates -
By April 2020
Phase 1 roll out of three surgical services with highest readmissions -
By September 2020
Phase 2 roll out to all surgical services -
By November 2020
Phase 3 roll out of unplanned inpatient and inter-hospital transfer surgeries -
Started Sept. 2022
Multidisciplinary Clinic (MDC)The purpose of this subset clinic within the Surgical Safety Net Clinic is to provide a more extensive multi-disciplinary evaluation for highest risk patients based on IMPACT providers IMPACT Comprehensive Assessment. This meeting takes place via VA Video Connect and happens prior to surgery. We tailor the MDC appt. to meet each veterans specific needs. Examples of participants: veteran, Impact provider, surgeon, social work, prehab, nutrition, pain management, behavioral health and goals of care. We strive to meet each veterans specific needs prior to surgery to give them the best outcomes after surgery and a smooth surgical journey. -
April 2024
Surgical Hospitalist Team : A bridge between Impact and Surgical Safety Net-Provides optimization for inpatient transfer patients.- Ensures smooth discharge process-Facilitates post discharge follow up visits-Consults Surgical Safety Net for complex discharges
Departments
- Anesthesia
- Discharge planning
- Nursing services
- Information management
- Orthopedics
- Palliative and hospice care
- Physical therapy, occupational therapy and kinesiothology
- Social services
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
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TOOLS |
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Support Resources
| Resource type | Resource description |
|---|---|
PROCESSES |
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Risks and mitigations
| Risk | Mitigation |
|---|---|
| Identifying point of contact for surgical service | Pitched project to surgery section chiefs, who identified points of contact who are CRNPs or PAs. They helped with fielding surgery specific questions and suggest solutions without coming in to the Emergency room whenever possible. |
| After-hours phone coverage | Surgery VP authorized Surgeon on Duty to cover the hotline after hours. Because vast majority of calls occurred only during regular business hours, this was manageable to the Surgeon on Duty. |
| Workload management | Allocated 1 FTE RN from existing team as the Nurse Navigator, with minimal coverage by 2 other RNs |
| Veteran inexperience and hesitancy with VVC equipment | Collaborated with Telehealth department to educate and train Veterans to use VVC equipment at the time preoperative visit or through virtual visit. |
Contact
Comment
Comments and replies are disabled for retired innovations and non-VA users.
Email visala.muluk@va.gov with questions about this innovation.
About
Origin story
VAPHS Chief of Staff raised a concern about readmission rates for the Surgery Service Line (SSL), and IMPACT team, which is already providing comprehensive preoperative optimization, accepted the challenge.
Our team reviewed the readmissions at our institution for the past 3 years and realized that a big percentage of them are avoidable reasons. We also fe
...
VAPHS Chief of Staff raised a concern about readmission rates for the Surgery Service Line (SSL), and IMPACT team, which is already providing comprehensive preoperative optimization, accepted the challenge.
Our team reviewed the readmissions at our institution for the past 3 years and realized that a big percentage of them are avoidable reasons. We also felt that lack of compliance with follow up visits as well as poor communication led to poor outcomes. We needed a strong program to reduce these avoidable readmissions and enhance patient compliance and improve communication.
We put together a small team and included 3 surgical services that had high readmission rate as our initial group and over the year extended it to all surgical services.
Original team
Visala Muluk MD
Section Chief, IMPACT Clinic
Mindy Shuttleworth RN & Tonya Ledford RN
Surgical Safety Net Nurse Navigators
Jocelyn Scanlan RN
Quality and Patient Safety Nurse
Jenny Hartzell
Nurse Manager, IMPACT
Karen Wolfe
Assistant Nurse Manager, IMPACT
Kelly McCoy MD & Lindsey Herlinger RN
Surgical Service Line leaders
Pam Malicki RN
Clinical Nurse Coordinator, IMPACT
Recommend adoption nationwide
Wonderful work by this VAPHS team. I am the VAPHS Precall Registered Nurse in Same Day Surgery and utilize the High Risk for Surgical Readmission Patient Record Flag posting in my daily work to guide Veteran centered care.
Amazing work! A great demonstration of veteran centered care.
Thank you so much!
Incredible work!
Love the interdisciplinary aspect of this as well as putting the patient in the center of care!
A great example of collaboration between expertise and common sense. Simply brilliant!
Thank's a lot!
Excellent interdisciplinary work! Fabulous clinic concept for optimizing the care of surgical patients throughout the spectrum of care both pre & post op.
So very helpful for one of our most vulnerable populations! Thank you for all your hard work!
Great work by everyone on the team!!
Thank you John!
Nice
So proud to be apart of the IMPACT team!
Excellent!
This is a win on so many levels! Thank you!
Thank you!