We believe that now would be a good time for readers of Anesthesia & Analgesia to review the concept of disruptive innovation and its relevance to our medical specialty. The term disruptive innovation was first introduced by Clayton Christensen in 1997, referring to it as a process “by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”a In 2008, Christensen et al.1 authored the book The Innovator’s Prescription: A Disruptive Solution for Health Care, in which they apply the principles of disruptive innovation to the health care system in the United States. In the following The Open Mind article, we will apply some of the principles of disruptive innovation in health care and examine their relevance to the perioperative environment and the field of anesthesiology.
The concept of disruptive innovation may be best demonstrated by examples from the computer industry. In the 1970s, Digital Equipment Corporation was one of the world’s leading computer companies and focused on the development and production of the expensive mini-computers. At that time, a new product, the personal computer (PC) was being developed and introduced to the marketplace. In contrast to the mini-computer, the PC was an inferior product that was not as powerful and could not perform at the same level of a mini-computer. As a result of the PC’s inferior performance, most mini-computer companies scoffed at those involved in making PCs. They underestimated the marketplace, however; the general public was delighted with the introduction of the PC. Most individuals, small businesses, and educational institutions did not need a high-performance mini-computer; they only needed a simple electronic machine that could perform basic functions such as word processing and spreadsheet development.b As sales climbed and the underlying technology improved, PCs became more sophisticated and capable.b In just a few years, there was a total transition in the market leading to the demise of mini-computers. Digital Equipment Corporation failed. Ultimately, the downfall of nearly every mini-computer company of that era was the irresistible temptation to favor incremental improvements instead of the pursuit of disruptive technology.
Why is this example relevant to anesthesiology? Incremental improvement in the future may not support the continued evolution of the specialty. Anesthesiology has been touted in the past one of the most transformative medical specialties with regard to patient safety.2 Since then, however, it can be argued that the specialty has improved patient care and safety only incrementally. In addition, market forces associated with payment trends of commercial insurers and government health care agencies suggest that there is an increasing reluctance to provide incremental payment for anesthesia services that are only marginally improving patient safety and cost-effective care. We submit the urgent need for anesthesiology to develop and adopt transformative changes. Such transformative changes may include the development and wide adoption of new integrated perioperative patient care models.
The key word here is “integrated” compared with disjointed, fractured, or modular. Let’s return to the computer industry, using the recent devolution of the PC as an example. PCs are modular, with parts coming from many manufacturers and assembled into working units. Different parts, modules, or functions such as faster processors, bigger hard drives, and more memory may be improved from year to year, but the impact is incremental improvement in PC performance. Apple Computers, Inc., realized 10 years ago that it needed to jump beyond incremental improvements in its PCs and develop a more integrated system for the market. The company transitioned, moving to mobile electronic devices and integrating the production and assembly processes of its products. The company even changed its name (Apple, Inc.), but it never changed its core principles: empathy for the needs of their customers, focus on the things that really matter, and providing a professional, creative product.
Perioperative care in the United States is modular and, with few notable exceptions, rarely fully integrated. Although many well-intentioned people in multiple disciplines work together to deliver excellent care to perioperative patients, in many instances, we work independent or minimally dependent on others. The current perioperative system often is assembled with modular components that are pushed together to deliver care. Each of these components strives to improve performance, but it is nearly impossible for any single component to change the overall quality of the perioperative continuum. Anesthesiology has very successfully improved its performance and safety, but as a system, perioperative care remains fragmented, unpredictable, expensive, and fraught with hazards, complexity, and complications. We suggest that our specialty must change its approach from incremental improvement to the pursuit of disruptive alliances and transformative integrated care. We need to deliver integrated care to our patients.
The Perioperative Surgical Home (PSH) is a model that promotes integration, clinical pathways, safety, and cost-reduction.3–6 Within the context of disruptive innovation, the PSH model is the disruptor and the current fragmented perioperative care model is the disruptee. The PSH can be defined as an integrated delivery care model that transforms the way surgical and procedural care is delivered. The underlying tenet of the PSH is improved coordination of care throughout the entire perioperative continuum, from the minute the surgeon/proceduralist and patient decide a procedure is needed until the patient is safely home and fully recovered. Clinical pathways of care and increases in reliability are hallmarks of this clinical care model.1–4 The PSH concept is inclusive and highly collaborative. All groups that impact patients, directly or indirectly, play key roles in this model of care. The PSH concept extrapolates some of its core constructs from the medical home model, which was created to improve the outcomes of patients who had complex medical issues and comorbidities.7 It originated as an effort to improve the widespread concerns of growing medical care costs, patient dissatisfaction, and variable quality of care. Thus far, trials of the medical home concept have not demonstrated consistent improvement in patient outcomes, satisfaction, and cost-effectiveness.8,9 It is likely that both the medical home and PSH concepts will be proven effective in unique patient groups but not in all patients. The American Society of Anesthesiologists Learning Collaborative on PSH models is an American Society of Anesthesiologists-supported approach to gain early information on what models and patient populations the PSH concept might most positively impact. To date, however, initial studies of the PSH concept have been promising.10
In a PSH model, anesthesiologists should assume important roles in developing clinical pathways, improving reliability of our processes, and using our organizational, system-based skills to maximize the integration of the perioperative care that our patients will experience. In this model, preoperative clinics will no longer focus on “clearing the patient for surgery” but rather “optimizing the patient for surgery.” The focus shifts from “can the patient medically tolerate the procedure?” to “how can we help the patient thrive throughout the perioperative period?” The intraoperative phase may be modified to facilitate improved postoperative care, patient safety, and cost-effectiveness, with unique focus on eliminating process, procedural, and medical complications. In this model, anesthesia care does not end in the immediate recovery period. What we do, and what we can do, can have extended positive impact.
Anesthesiologists coordinate postoperative care in a PSH model, collaboratively developing and assuring adherence to clinical pathways and care processes. There are a number of variations that currently are being developed and tested for postoperative care in this integrated model; anesthesiologists do not necessarily have to deliver the care themselves but rather can coordinate it and provide oversight. An important function of the postoperative team in this model is the early identification of complications and rapid interventions to avoid “failures to rescue.” The PSH model recently has been described, and several reports suggest that the model may be associated with decreased lengths of stay, reduced complication rates, lower perioperative expenses, and less frequent readmissions.11–13 Various PSH components address the 2 major public health care issues (cost and access), which typically are associated with successful introduction of disruptive innovations. Future studies need to demonstrate that the PSH concept is associated with reduced cost. Intuitively, reduced variability, adherence to clinical pathways, reduction in preoperative testing, reduction in hospital duration of stay, reduction in rate of postoperative complications, and reduction in readmission rate can result in overall reduction in cost.14 Also, increased coordination between the health care providers who are involved in PSH models and those involved in medical home models should result in lesser rates of hospital readmission or admission after ambulatory surgery. A preliminary investigation has indicated that implementation of a total joint replacement PSH model has driven direct hospital costs below US benchmark levels.6 That said, much of the cost after orthopedic surgery comes from what happens after the patient is discharged from the hospital; much research is needed to see whether the PSH model can reduce the cost in that area.15
The American Society of Anesthesiologists recently has launched a collaborative of 43 hospitals to examine the viability of various PSH models in large-scale settings, with the goal of developing and sharing best practices broadly.c
Our profession is remarkable. We dramatically improved patient care intraoperatively when the world of medicine needed that change. The world of medicine needs us now in a different role: to dramatically improve patient care across the perioperative spectrum. If we are to thrive, anesthesiologists must have a meaningful presence in medicine. We must assume a leadership role across the spectrum of perioperative care.16 We must ensure that our specialty will adapt to a changing environment, seek new discoveries that will better serve our patients, and expand our practices and leadership roles in health care, in essence, to ensure that our specialty will thrive into the future. We must be the anesthesiologists of the future. Who better than anesthesiologists to do this? Jim Collins,17 the best-selling author of Good to Great and other leadership books, found that great organizations are willing to change most everything they do except change their core values. We believe that our specialty has 2 core values: (1) an unrelenting commitment to 2 types of patients: those who are critically ill and those facing acute or chronic pain, including pain caused by procedures; and (2) a compelling commitment to always improve the care and safety of our patients. Everything else: how we provide care, where we provide care, and how we are recognized for our care, is likely to change.9
Name: Zeev N. Kain, MD, MBA.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Zeev N. Kain approved the final manuscript.
Conflicts of Interest: Zeev N. Kain lectures for Merck on team training.
Name: Jason Hwang, MD.
Contribution: This author helped write the manuscript.
Attestation: Jason Hwang approved the final manuscript.
Conflicts of Interest: The author has no conflicts of interest to declare.
Name: Mark A. Warner, MD.
Contribution: This author helped write the manuscript.
Attestation: Mark Warner approved the final manuscript.
Conflicts of Interest: The author has no conflicts of interest to declare.
This manuscript was handled by: Steven L. Shafer, MD.
a Available at: http://www.claytonchristensen.com/key-concepts/. Accessed December 12, 2014.
b Personal computer. Available at: http://en.wikipedia.org/wiki/Personal_computer. Accessed January 2, 2015.
c American Society of Anesthesiologists launches national Perioperative Surgical Home learning collaborative. Available at: https://www.asahq.org/sitecore/content/PSH/learning%20collaborative/. Accessed December 8, 2014.
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