Hospital Systems Work With HRA on a Pre-Op Assessment to Evaluate and Optimize High-Risk Patients for Surgery


Multiple hospital systems identified surgery as a high-frequency area for adverse events and claims. In concert with the Healthcare Risk Advisors (HRA) team, four large academic medical centers agreed to work together to reduce malpractice risks. This effort began with Prevent, the first of HRA’s three Ps (Prevent, Preclude, and Prevail).

These hospital systems turned to HRA as a collaborative partner for the prevention of adverse events related to surgery. Together, they implemented an intervention to lower surgical risks by optimizing high-risk patients for surgery.


HRA helped these hospital systems create, implement, and measure outcomes from a uniform preoperative assessment tool applied to high-risk patients to reduce both safety risks and liability risks.

HRA facilitated the development of an evidence-based standardized assessment template for pre-op evaluation, which each hospital integrated within its specific workflow. Experts in perioperative care from each of the medical centers convened in HRA offices to develop the template. With HRA’s help, they launched a new requirement for more vulnerable inpatients to undergo preoperative evaluation by a medical specialist, with perioperative expertise using this standardized assessment tool. The evaluation facilitated by the perioperative medical specialist occurs in addition to patients’ assessments by their surgical and anesthesia teams.

This evaluation is required for patients who meet a certain risk threshold according to the American Society of Anesthesiologists (ASA) Physical Status Classification System, which evaluates patients’ pre-anesthesia medical comorbidities. Patients rated ASA 3 or higher benefit from additional evaluation to help account for conditions like diabetes, pulmonary issues, or renal problems. The preoperative evaluation leaves the determination of surgical risk and surgical care as the responsibility of the surgeon but enables other experts, such as the patient’s pulmonologist, nephrologist, or endocrinologist, to contribute to the overall evaluation and management of the patient’s medical issues.


Although medical malpractice data is slow to accrue, the HRA team has not taken a wait-and-see approach but has instead proactively sought early indications of this new collaboration’s results. One such indication has been surveys of anesthesiologists, who are especially relevant providers of feedback, since they sometimes face pressure to proceed with surgery for patients who have not been thoroughly evaluated. The vast majority of anesthesiologists agreed or strongly agreed with the statement, “The presence of the PreOp Medical Assessment enhanced my management of the patient.”

To lower risks for high-risk patients, healthcare professionals from a variety of specialties have collaborated toward increasingly consistent use of the standardized assessment template. Hospital administrators have audited patient charts according to agreed-upon compliance criteria, steadily improving their compliance with the process during each audit period.

Over a six-year period, the frequency of claims attributable to inadequate preparation for surgery in high-risk patients dropped by 30 percent.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.