Paper Informed Consents Sabotage Your Surgical Services Economies 

It’s an age-old truth: the more moving parts you have, the more opportunity there is for something to break. The Surgical Services process is no different. Any delay in “first case of the day” surgeries can have a cascading effect, causing delays in all subsequent surgeries sharing the same OR. One study found that 84% of “first case of the day” surgeries start late. That’s an incredibly high percentage. Let’s take a look at the top five reasons why this happens. 

1. Surgeons and Anesthesiologists arriving late. 

As simple as it sounds, late arrival of surgeons or anesthesiologists ranks highest for causing delays. The same study referenced above found this to be true at New York University Langone Medical Center. NYU instituted a plan to alter the culture, including Chiefs of Surgery personally speaking with surgeons who arrived late. Emails were sent to surgeons reminding them to arrive 20 minutes prior to their scheduled surgery. The combination of these steps resulted in vast improvements of on-time surgeries (from 24% to 80% on-time starts.)

2. Patients arriving late

According to one study, 65% of patients arrive late. When this occurs, the odds of a delayed start to surgery increase by 35%. Interestingly, the data also suggests the odds of a delay increase by 9% with every 10-year increase in patient age.

3. No recovery room available

In another study, it was determined that of all delayed procedures, 31.8% were delayed due to no post-operative bed being available. Again, this may be attributed to a breakdown in communication or process in the pre-hospital/scheduling phase of the patient journey.

4. Missing or incomplete informed consents

There are many studies with sample sizes of greater than 1,000 surgeries that cite 85% or more of patients either had missing or incomplete paperwork. Advancements in EMR technology have helped solve this challenge to a large degree, but EMRs can still lack a complete solution for capturing patient forms and signatures. According to one study, 66% of patients were specifically missing Informed Consents, which caused a delay in 14% of surgical cases.

5. Staff too busy

What are the primary reasons for delays in Surgical Services in your hospital? Is the solution a quick fix in staff mindset, or do you have a fundamental process problem that may be impacting your hospital both financially and in overall patient satisfaction?

Time is money. When it comes to surgical delays, this is all too true. Unfortunately, delayed operative procedures are a daily occurrence. One culprit cited in causing delays in 14% of operative cases? Missing paper Informed Consents. 

In a recent JAMA Surgery study, the authors write, “Missing consent forms at surgery can lead to delays in patient care, provider frustration and patient anxiety.” The study also indicates much of the burden of obtaining consents falls on residents: “In many instances, the missing consent forms interfered with team rounds and resident educational activities.” 

In cases of lost consent forms, 78.9% of residents called to the OR to re-consent spent just five minutes talking with the patient, according to the JAMA study. Almost 66% of residents had to halt their rounds once a week to deal with re-consenting, and 13% were interrupted daily. 

The fiscal fallout from delayed operative cases

All this extra work doesn’t just divert clinical and administrative staff from patient-centric tasks, it also incurs fiscal costs that impact the bottom line. 

The writers of an International Journal of Surgery paper entitled “Optimizing your Operating Room: Or, Why Large, Traditional Hospitals Don’t Work” (Girotto, Koltz and Drugas) found at University of Rochester Medical Center (URMC), each hour of unused operative time in the OR costs $3,600. That means each lost minute cost $60.

As high as these numbers are, they don’t even include lost surgeon time or account for 11 years of inflation since the study’s publication. Over just a two-week period, URMC lost $90,720 in “first start” cases that were delayed or canceled. URMC has 20 operating rooms, so extrapolating those initial figures out to five days per week for 50 weeks represents 7,500 postponed or cancelled “first start” cases annually. 

The total delay time in first start cases is 98,100 minutes annually, which equates to a loss of $5.9M. 

The lost revenue would be far greater if we included all the subsequent procedures in the day. 

Here are a few other staggering statistics:

• At URMC, surgical delays led to the hospital exceeding its overtime budget by $960,000. 

• Total overtime pay for nursing staff approached $1.4M, almost a 200 percent variance from the budget of $500,000.

• A Journal of Patient-Centered Research and Reviews paper found the average surgical delay across multiple hospitals was 24 minutes and 88 percent of cases were delayed. 

• Even if we took the lower per-minute cost of $60, this means the typical delayed case costs a hospital $1,440, which adds up very quickly over the course of a fiscal year.

The bottom line? The more delayed cases a facility has, the bigger the overtime bill, the more time wasted, and the harder the negative impact on patient care, service and satisfaction.

Taking back lost time + revenue 

Going back to the URMC case example, Girotto, Koltz, and Drugas suggest that reducing the average surgical delay by just 10 minutes could make a big difference, including one extra procedure being performed each day. That would gain back $30,000 per week, leading to an annual cost savings of $1.5 million. Even at a smaller hospital with less operative cases, creating such efficiency could greatly improve profitability and make it easier for the organization to plan and stick to realistic budgets. 

But how would a hospital surgical services department go about taking back such lost time? One powerful answer: Replacing paper consents with electronic forms launched directly from within the EMR and completed via tablet or iPad. With such a system, complete and current information could be obtained the first time every time, removing the need for patients to re-consent and eliminating the paper chase between administrative and clinical staff

The authors of a JAMA Surgery study entitled Allegations of Failure to Obtain Informed Consent in Spinal Surgery Medical Malpractice Claims found that of the 233 claims they evaluated related to spinal surgery malpractice, 153 lacked informed consent. That’s a whopping 66 percent! To understand this problem further, let’s first look at how a theoretical definition of “Informed Consent” often differs from real-world practice. 

Defining "informed consent"

An Informed Consent is not just another patient form. It carries with it patient expectations of being properly educated and assured of their impending procedure’s benefits and risks, as well as the legal statutes that protect them. An informed consent also allows providers to capture the patient’s signature to validate the interaction and their agreement. 

As K H Satyanarayana Rao writes in a Journal of Cutaneous and Aesthetic Surgery paper titled Informed Consent: An Ethical Obligation or Legal Compulsion?: “Mutual trust forms the foundation for [a] good relationship between doctor and patient.” For this trust to be maintained through the pre-surgery process, the author asserts that, “Informed consent must be preceded by disclosure of sufficient information. Consent can be challenged on the grounds that adequate information has not been revealed to enable the patient to make a proper and knowledgeable decision.” 

Let’s imagine I am an orthopedic surgeon and you come to me with a hurt right shoulder. After asking you a few questions and reviewing your medical history, I send you for an MRI. The results show a partially torn rotator cuff. I explain to you that there are several treatment options, one of which is a surgical procedure. I explain in detail the potential benefits and pitfalls of such a course of action, and the long road to recovery that inevitably accompanies rotator cuff repair. You tell me you understand the risks involved and would like to schedule the surgery. 

Next, I would need to complete an Informed Consent for your procedure. Consent verbiage should be worded so you can understand it and enter into a contract or mutual covenant with your surgeon with full confidence. This should be validated when both parties sign the document. 

What I as your surgeon tell you about your upcoming rotator cuff surgery should line up with the detailed description and risks outlined on the Informed Consent. Otherwise, there’s a disparity that can open up legal and compliance risks to me and the hospital, if you, the patient, later claim you didn’t receive a consistent and thorough verbal and written explanation.

When informed consents fall short, risk opens up

At Access, we’ve seen how thousands of hospitals manage Informed Consents, and there is no universal method. However, there are three common approaches, and the primary variance between these three is how procedure-relevant content (name of procedure, description of procedure, risks of procedure) is populated on the form. These approaches are: 

1. Handwritten information on the procedural consent 
2. Retrieve a pre-printed form for each procedure that includes specific procedural content 
3. Complete a generic informed consent 

In a recent Access webinar with more 450 hospitals in attendance, we polled the audience about which of these three methods they used. Here are the results of that poll:

• 54% Generic Consents w/ limited procedural content
• 23% Pre-Printed Content
• 23% Handwritten

The fact is all of these methods have potential pitfalls. Handwriting information can create inconsistency in how procedures and their accompanying risks are described from doctor to doctor, or even from case to case by the same physician. Such variability creates compliance issues. 

Managing and maintaining pre-printed forms is a logistical nightmare with hundreds or even thousands of individual forms in a massive, often difficult to search library of procedure-specific forms. But it’s the generic consent that might incur the biggest risks from a legal perspective. Without specific language for the individual procedure, it’s difficult for a hospital or surgeon to claim that the patient was accurately “informed” by the content on the form itself. No matter how thorough they might assert their verbal explanation of the surgery and its accompanying risks may have been. 

Version control impacts each of these informed consent methods. Policies, regulations, provider information and other form data changes over time. This requires a heavy-lifting consolidation effort if the facility is to avoid numerous compliance issues and possible legal exposure.

eForms offer protections for patient and provider

Replacing hard copies and print-on-demand consents with eForms eliminates, or at the very least minimizes, legal risks by ensuring that every form is signed by both the clinician and patient, and date/time stamped. Electronic consents also allow the hospital to easily replace the inherently risky generic consent with one that properly details specific procedural content. Then these forms can be easily tracked throughout their lifecycle and never lost or misplaced. 

We cannot overlook or underestimate the negative emotional and physical impact on an already stressed patient when their completed surgical Informed Consent goes missing. Imagine yourself all prepped for surgery, ready to roll, when an unknown resident physician enters the room. He explains that somehow your Informed Consent—the one you signed weeks earlier with your trusted surgeon—is missing. He needs you to re-consent, which means going through all those procedure details again. 

Any patient in this situation would feel a host of emotions— confused, angry, scared—and who could blame them? 

The industry numbers don't lie

This scenario is all too real for thousands of patients. A JAMA study titled “Missing Consent Forms in the Preoperative Area” found that 66 percent of patients feel uncomfortable when a resident obtains their Informed Consent—and just 47% of residents feel confident in the situation. 

An Arthritis Care & Research article by MR Johnson et al. titled “Patient Understanding and Satisfaction in Informed Consent for Total Knee Arthroplasty: A Randomized Study” found that in normal circumstances, only 33 percent of patients could recall the details of their Informed Consent a week after they’d signed it. So in an emotionally distressed state, their absorption of the information is probably even lower. This alone could give a patient grounds to file a lawsuit in which they claim that, while they did consent to surgery, they were not properly informed about it.

A better patient experience

Electronic Informed Consents allow you to pre-populate patient and procedural information on the form, saving tremendous time for surgeons and patients alike. Because electronic versions are tablet-integrated, providers and patients review procedural information and risks using an iPad. It’s quick and straightforward. Patient’s electronically sign right on the tablet, which includes a time and date stamp. And perhaps, most importantly, the electronic Informed Consent never gets lost in the paper shuffle! 

It’s important to note: A better patient experience isn’t just a noble calling. Improved satisfaction leads to higher HCAHPS scores—and those tie directly to your hospital’s reimbursement and patient loyalty. 

Your Surgical Services area is too vital of an area of your hospital to leave inefficiencies unchecked. Many opportunities exist along the patient OR journey where you can effect real change and vast improvement. By taking a closer look at the negative impacts of paper forms at each of these junctures in the journey, you’ve taken the first step toward stronger Surgical Services team cohesion, more positive patient attitudes and outcomes, and greater revenue potential.