Preoperative preparation. Value, perspective, and practice in patient care.
Preanesthesia preparation will continue to stimulate creativity and debate. Strategies for process improvement will take various shapes and require tools previously unfamiliar to many medical managers. At UNC Health System, anesthesiologists currently are committed to the centralized preanesthesia clinic approach used in PreCare. To date, their strategies have been validated by their institutional measures of success: a 0.7% first-case AM work-up rate, a 5% no PreCare visit rate, a 5% consent problem rate, and a 0% rejected specimen rate, with a 43% blood-draw rate for all patients. As their health system expands, however, other strategies and preparation modalities may become necessary. Telemedicine and Internet-dependent processes are appealing in the highly educated and technologically sophisticated marketplace. As the region becomes increasingly urbanized, local employment patterns prevent easy access to services, and functional compromises, such as bypassing PreCare or reliance on telephone or on-line interviews for preparation, may become necessary. The need to expand PreCare in the near future is already evident. As was found during initial planning, process improvement and space planning are enhanced by computer modeling. UNC Health System employed a proprietary animated simulation modeling (ASM) tool, MedModel, (ProModel, Orem, UT), although other techniques exist for the same purpose. Use of ASM as a strategy management tool allowed generation of ideal space-time-personnel scenarios that could expose potential problems before resources and physical restructuring occurred. ASM also can be used to compare data obtained from real-time observations to any reference scenario, including any that looks at economic measures of process, to help refine strategic visions before instituting tactical solutions. Used in this manner, ASM can reveal physical, temporal, personnel, and policy-related factors not otherwise seen as exerting effects on overall preprocedural preparation processes. Coupled with other classic planning techniques, such as time-motion studies, modified Delphi techniques, customer satisfaction surveys, benchmarking studies, and financial analysis and growth projections, ASM has helped enhance total quality management efforts in PreCare and other planning projects at UNC Health System. Other researchers have used other simulation techniques to assess clinic functions. Operational challenges that exist in preanesthesia preparation clinics place these clinics on the same level as other kinds of medical service clinics. The lessons learned in most clinic settings may be applied in a cross-wise manner to the preanesthesia clinic. Dexter contends that efficient delivery of care that respects patients' time and needs does more than assist the procedural preparation process; it also supports the physician's ethical obligation to the patient to give the best possible care. Documenting patient medical information, education efforts, and maintaining the medical-legal integrity of the preanesthesia preparation materials is another area of increasing concern and research. When hand-held computers capable of linking by way of infrared technologies or that use rented downloadable software to run specific applications become commonly used, the complexity of ensuring privacy will grow. The complexity, however, will not be insurmountable. Privacy problems exist in any information management system, whether paper-based (i.e., reducing redundant forms, eliminating indiscriminant photocopying of records), electronic-based (i.e., encryption, server access, system failure), or both. Electronic conveyance of medical information faces more legal and economic than technical hurdles. The penetration in US households of Internet services presently is less than 40%, whereas the penetration of personal computers is just over 50%. These figures are compared with penetration of corded telephones, televisions, and radios at levels greater tha