In recent years, healthcare reform has taken center stage in both political and medical society debates. As healthcare providers seek a safer, more economical approach to treating their patients, we have begun to implement evidence-based, standardized practices and protocols. At the same time, lawmakers demand high-quality and low-cost solutions. Traditional surgical episodes are fragmented— into the preoperative episode, the operative episode, and the postoperative episode. These three episodes traditionally are managed by differing physicians, all led by the surgeon team leader.

In most surgical cases, a surgeon initially sees the patient and recommends surgery. The patient then sees an independent physician for medical clearance and meets the anesthesiologist for the first time right before surgery. Postoperatively, the patient is then cared for by the preoperative clearing physician, the operating surgeon, or another, independent hospitalist. This fragmentation can diminish the quality and efficiency of patient care through delays and gaps in longitudinal management, and increased lengths of stay.

The Perioperative Surgical Home
In an effort to combat these issues and add value and quality to patient care, the Perioperative Surgical Home (PSH) was created by the American Society of Anesthesiologists (ASA). The ASA describes the surgical home as "a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience." The concept centers around the anesthesiologist as the "perioperativist." After the surgeon recommends surgery, the patient will see the anesthesiologist preoperatively, who will then assume the role of the perioperativist. That role will extend throughout the operative episode and will enable the patient's care to be managed by a single physician, rather than by multiple physicians.

The anesthesiologist is uniquely positioned to assume the role of leader in the care of the patient because of his or her understanding of the complex nature of medical issues surrounding the operative episode. Although surgeons should not and are not expected to relieve themselves of patient-care duties, their skills can be usefully augmented given the vast experience anesthesiologists bring to perioperative medical management. 

For this system to succeed, a set of standard protocols must be developed, thereby removing extraneous tests, expediting care, and decreasing costs. Shared decision making and constant communication is necessary in the pre- and postoperative period.

The PSH divides perioperative care into three key episodes involved in patient care.  Each of these contains key elements necessary and important to the success of the system.

• Preoperative. Admission should be centralized in a preoperative area or clinic. Standardized protocols for preoperative workup should be established as well as a central system for gathering patient health records. A triage system with a multidisciplinary approach should be utilized to identify complex issues in the preoperative clearance and optimization of patients.
• Intraoperative. The main focus of the PSH intraoperatively is patient care and efficiency.  Becoming familiar with the patient preoperatively enables the anesthesiologist to streamline the preoperative blocks and procedures for the case. All this, in turn, leads to fewer cancellations and increased throughput in the operating room.
• Postoperative. The postoperative episode is managed by the anesthesiologist with input from the surgeon. Key elements here include coordination of care between all services with mutual decision making. The anesthesiologist will coordinate pain management, discharge education, and discharge to home or rehabilitation facility.

Benefits
Numerous benefits exist with the implementation of standardized protocols and shifting the management of patient care to a single system. While studies are just beginning to emerge on the American version of the PSH, European physicians have experience with their "Enhanced Recovery After Surgery" (ERAS) protocol. This model uses a multimodal approach to standardize preoperative counseling, intraoperative anesthetic technique, and standardized postoperative recovery pathways to increase efficiency, strengthen patient care, and decrease length of stay. The ERAS system is a building block of the current PSH. Multiple studies out of Europe show decreased length of stay, decreased hospital costs, and increased patient safety with the standardized process. Similarly, a goal of the PSH will be to increase quality of care and increase patient safety while decreasing unnecessary resource utilization.

Obstacles
As with any new system, there are potential road blocks. The most significant hurdle in this model lies in the amount of work required by all parties on the front end of implementation. Significant communication and time are required to develop consensus around the protocols that all parties must follow. Furthermore, it has been mentioned that some surgeons may feel as if they are not captain of the ship any longer for care of their patient. While this can be seen as a negative, having an experienced anesthesiologist augment the three episodes of care can be beneficial for all parties. Finally, this model is ever-changing. With new evidence and literature, the system and its participants must be amenable to change as necessary.

Future Direction
Just as high-performance organizations, such as nuclear power plants or airlines, rely on standardized protocols to increase efficiency and reduce errors, the future of surgical episodes should rely on organized protocols to deliver care.

Brad Waddell, MD, is a fellow in Adult Reconstruction and Joint Replacement at the Hospital for Special Surgery, New York, N.Y. Scott F. M. Duncan, MD, MPH, MBA, is chair of the Department of Orthopaedic Surgery, Boston University School of Medicine and a member of the AAOS Now editorial board.