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Published Tuesday, July 5, 2016

Amid Concurrent Surgery Controversy, How Can Hospitals Respond?

Concurrent surgery occurs when a primary surgeon is responsible for multiple surgeries in multiple operating rooms for at least a portion of the procedure. Often, a surgical resident, a physician assistant or nurse practitioner will open or close the surgery while the surgeon moves on to the next operation. In October 2015, a series of articles in the Boston Globe placed concurrent, or overlapping, surgery under the spotlight; hospitals across the U.S. have been engaging in this practice for many years.

When implemented appropriately, concurrent surgery is considered an efficient technique to improve efficient use of resources, through effective operating room scheduling and implementation of appropriate cost containment measures. However, disputes arise when operations unexpectedly overlap for extended periods. The practice of concurrent surgery also becomes distressing to patients, who assume that their physician would remain in the operating room for the entire surgical procedure and then learn that their primary attending surgeon neither opened nor closed their surgery. Insufficient governance of this practice, moreover, has resulted in cases where surgeons fail to return to an operating room when summoned, delegate surgical care to an unqualified resident, or subject waiting patients to prolonged anesthesia time, potentially resulting in serious complications or death.

The Potential Costs of Concurrent Surgeries 
According to the CNA Hospital Professional Liability Claim Report 2015, surgical claims were the third most costly, with an average total paid of $264,396 per closed claim1. While claims involving concurrent surgery are not common, they often far exceed this average. Concurrent surgery also may lead to allegations of Medicare fraud and abuse issues based upon a failure to submit Medicare claims that accurately reflect the professionals who performed the procedures, resulting in civil and criminal sanctions.  For example, in Wisconsin, a medical school paid $840,000 in 2015 to settle a lawsuit alleging that neurosurgeons illegally billed Medicare for simultaneous spine surgeries that were largely done by unsupervised medical residents. A similar situation, involving an urban hospital and an orthopedic surgical group, resulted in a $1.5 million settlement for illegal Medicare billing1.

How Hospitals Can Respond 
Hospitals that develop and implement a transparent policy on concurrent surgery – and incorporate the concurrent surgery practice in their informed consent forms – can help to diminish the risk of agitating patients and facing lawsuits.

The following issues should be considered when developing a policy on concurrent surgery:

  • Outline the clinical indications for overlapping surgeries within medical staff bylaws, rules and regulations, and clearly define “critical components.”
  • Define “qualified practitioner” (i.e., surgical resident, nurse practitioner, physicians’ assistants and surgical assistants).
  • Ensure that attending surgeons who are delegated to cover the first operation are immediately available.
  • Review surgeon compliance through established performance evaluation processes.
  • Inform patients of the likelihood of concurrent surgeries.
  • Document assurances that the primary attending surgeon is an active participant, when needed.

CNA’s AlertBulletin® outlines the clinical indications for overlapping surgeries within the medical staff bylaws, rules and regulations. CNA’s Healthcare page provides additional resources to help healthcare organizations’ leadership manage risk and stay current with industry trends.

1 CNA, Hospital Professional Liability Claim Report, 2015.

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