Enhanced recovery after surgery, or ERAS, is a set of protocols used by the surgical team to ensure the best possible outcomes. The PSH service delivery model is a patient-centered, physician-led, coordinated model of care designed to improve population health, reduce costs, and elevate patients’ and providersl experience. Functionally, PSH serves as an umbrella structure of coordination under which ERAS protocols come into play. In other words, PSH an ERAS are different, but highly complementary.
One important distinction is that ERAS focuses on the immediate preop, intraop, and postop care period. The PSH model, by comparison, addresses patient care from the moment a patient decides to have surgery through recovery. In other words, PSH views care from a wider lens, which means PSH incorporates considerations such as preparing patients prior to surgery by addressing significant medical co-morbidities (diabetes, anemia, obesity, smoking, etc.). PSH is also highly iterative, enabling continuous improvements. And, it’s modular, encouraging care teams to employ only the tactics and components that meet their needs then customizing to scale the model across settings and service lines specific to each site. (Learn more here: https://www.asahq.org/psh/education)
Yes, PSH can help care teams create a more satisfactory work environment and establish systems to improve patient satisfaction as well. In fact, many care teams have used the PSH model to do just that.
PSH practitioners have employed a range of tactics to elevate provider satisfaction. The PSH model breaks down silos among clinicians and helps develop coordinated multidisciplinary teams using internal data dashboards. The PSH can also create collaborative practice agreements and new OR scheduling processes, which offer real solutions, and give clinicians the tools to execute them.
Care teams employing the PSH model have also improved the patient experience by developing educational tools and materials, incorporating more telehealth options, improving surgery scheduling initiatives, and a host of other tactics explained in depth in the PSH Implementation Guide.
PSH is a patient-centered, team-based care model intent on optimizing care across the perioperative continuum, then measuring success and adjusting to improve. The systems and practices advanced by PSH truly do lead to improved care and better patient outcomes.
Because a patient’s care experience is paramount, PSH uses the principles of human-centered design to improve patient outcomes, putting patients at the center of their own surgical journey and promoting partnerships with patients and their families. Using PSH systems and components, PSH care teams have improved patient care and outcomes by designing preoperative optimization clinics, risk assessments, and stratification tools; building optimization pathways and care protocols; establishing transitional care programs; and improving communication with care providers and patients at all stages of the perioperative journey. These practices and others from the PSH model have real impacts on patient experiences and outcomes, maximizing patients’ return to function after surgery. The data confirms it: one comprehensive analysis of 152 peer-reviewed studies conducted at Texas A&M concluded that PSH effectively improved patient safety, the quality of care, and cost-effectiveness.
Because of regulatory requirement increases, hospitals now carry more risk burden with less reimbursement and support from government payors. Fortunately, PSH can help organizations decrease, even eliminate, penalties.
Supported by the principles of quality improvement, the PSH model dovetails with the relentless efforts of CMS to lower the cost of health care without reducing quality. PSH gives care teams a roadmap for demonstrating improvement and avoiding penalties. Because it’s modular, you can choose the solutions that address the issues triggering penalties for your organization.
Practitioners of the model have enjoyed real success. New Hanover Regional Medical Center in North Carolina, for example, started with one PSH—their Total Joint service line—then expanded to 16, motivated specifically by the need to stop paying CMS penalties. The results? They haven’t paid a penalty to CMS since. Better yet, their success has been replicated by organizations across the country. PSH is intentionally designed for scaling once implemented.
Through the ASA Learning Collaboratives, many ideas were shared for monetizing efforts with implementation of the PSH model. A few examples include co-management agreements, Hospital Quality Efficiency Programs (HQEPs) and Gain-sharing Programs. These examples are described in-depth in the ASA’s PSH Implementation Guide.
PSH empowers clinicians to coordinate care team workflow, improving care, costs, and satisfaction at all stages of the perioperative continuum. PSH outlines processes at every phase of the perioperative journey, laying out activities, tools, and strategies for gaining buy-in across the care team and executing coordination within the care team. These pathways and protocols can be found in the PSH Implementation Guide Index, which is a valuable resource loaded with useful information.
The PSH model can help you decrease the costs of care and increase savings, with no negative impact on patient care. PSH standardizes processes, moving away from outdated practices and inefficiencies. This gives health care organizations that are experiencing pain points systems and components that can be adapted and employed to target costly problems.
PSH practitioners have improved the bottom line by reducing OR delays, surgical cancellations, length of stays, medical errors, readmissions and more. And they’ve improved efficiencies with real-time electronic dashboards, pro formas, and a host of other solutions built into the PSH model. Multiple studies have underlined the fact that PSH reduces costs. One study, for example, found that eliminating unneeded tests reduced costs by over a million dollars over the course of the study, up to $112 per patient.
Yes, value-based care can be implemented using the PSH framework and guidelines. Indeed, the delivery of value-based care is a key operational principle in PSH designs. Value-based care promotes perioperative care that optimizes quality and cost for patients and providers. This proposition goes hand-in-hand with the Quadruple Aim of PSH: improving population health, reducing costs, and satisfying providers and patients.
The PSH model provides a strategic approach to entering various new payment models such as Medicare’s bundled payments or the next generation Accountability Care Organization (ACO). CMS has identified the PSH as a leading example of value-based care and it qualifies for payment or meeting their regulatory requirement. Clinicians participating in PSH can report the PSH’s MIPS Improvement Activity, IA CC 15, PH Care Coordination, which achieved a high-weight for the future MIPS Value-based Payment Plan (MVP) as an Improvement Activity.
The PSH model gives care teams the framework and guidelines needed to advance best practices that reduce variations in care and continuous quality improvements, optimizing value for patients and health care organizations at every stage of the journey.
PSH is modular, which means the model is adaptable to all settings, service lines, and institution sizes. It also means the model can be employed to focus on an isolated problem or to tackle broad, deep systemic issues. PSH’s modular solutions and systems have been crafted, tested, and enhanced by top thought leaders in the field. We’ve learned it works best when practitioners are invited to personalize PSH components to fit organizational processes, framework, and language, thereby owning modifications and embedding changes.
PSH practitioners have used the model to achieve a wide array of individualized challenges. The preoperative phase has been optimized with assessment processes that minimize wait times and testing, detailed social history checklists, streamlined communication with perioperative providers and ancillary services, and improved medication reconciliation processes, to name only a few proven tactics of the PSH model. In the intraoperative phase, tools such as checklists for nurses and the anesthesia interview along with hand-off communication tools have been key. And the postoperative phase has benefited from tactics that improve patient education, reduce per capita costs with fewer consultations and test, and tools that drive lower readmissions.
Evidence of the model’s success improving operational efficiencies and reducing the use of unnecessary resources is voluminous. For example, focusing on how PSH can reduce time spent, Beaumont Hospital in Michigan used the PSH model to reduce the time patients spent waiting to go from the ED to the OR from 48 to 32 hours and length of stay from 8 days to 6. Similarly, Children’s Hospital of Milwaukee decreased length of stay from 174 to 127 hours and reduced ICU length of stay from 75 to 73 hours. This is a small sampling of the success PSH practitioners have found using the model to tackle problems, both isolated and broad.
We’ve heard this before. PSH can seem intimidating. The model is complex, but it’s also user-friendly and specific.
In 2020, ASA formally defined the principles and components of the PSH model to include a patient-centered approach, team-based collaborative culture, comprehensive perioperative care, and value-based care. These principles and components promote clarity, create efficiencies, accelerate recovery, and drive greater satisfaction for patients and providers. The best place to find more information is the PSH Implementation Guide, available at asahq.org/psh. The Guide is a “how to” manual with tools designed to help health care professionals scale the adoption of principles for creating cultures of interdisciplinary coordination and standardization across the perioperative continuum. It’s the best way to really dig into all the varied specifics of the PSH model.
Yes, we do. In 2021, the society released the PSH Implementation Guide. The PSH practitioners who had joined ASA’s PSH Learning Collaboratives in the last decade found such remarkable success, we wanted to scale the education and opportunities so more anesthesiologists, and their organizations and patients, could benefit from what we’d learned. The Guide includes chapters on building a team, making your case to the c-suite and beyond (including sample elevator pitches), tactics that lead to high functioning teams, tips for overcoming barriers (including a checklist), and much more. It's not only a roadmap for the execution of PSH principles and solutions, but also for addressing concerns, earning buy-in, and ensuring you’re well supported on your journey. You can find the Guide at asahq.org/psh.
