Anesthesiologists as Operating Room Directors: The Advantages

For the first time, we are using an issue of the Alert to reproduce a third-party article in full.  Dr. Steven Boggs’s thoughts on “anesthesiologists as operating room directors” add such a lot to the concept of “anesthesiologists as medical directors” that they deserve to be read unabridged, undiluted and unencumbered by extraneous ideas.  We are grateful to Dr. Boggs and to PhySynergy for granting us permission to publish this article, which appeared on PhySynergy’s AnesthesiaReviews Blog on March 10, 2014.
 

Anesthesiologists as Operating Room Directors: The Advantages

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“The only thing worse than a coach or CEO who doesn't care about his people is one who pretends to care. People can spot a phony every time.”
Jimmy Johnson

 

What is the advantage or even usefulness of having an anesthesiologist as an Operating Room (OR) director? I have been asked to answer that question, However, I first must consider some of the responsibilities of an OR director.  Historically, there have been medical directors in operating rooms.  These individuals have been either anesthesiologists or surgeons.   Their duties have encompassed several of the following responsibilities:

• Leadership – leading and managing perioperative patient care
• Collaboration – working with all stakeholders in the suite to establish and ensure harmonious function.
• Protocols, Policies and Procedures – initiating and/or helping to establish protocols for patient management towards patient safety and ensuring compliance.
• Scheduling – verifying with surgeons, the anesthesia team and nursing personnel that appropriate l anesthesia coverage is available for scheduled cases.
• Regulatory Affairs – ensuring adherence to the standards of care and guidelines of involved regulatory agencies.
• Fiscal Management – maintaining the fiscal integrity of the OR program to implement a cost-effective patient care.
• Liaison -the OR director acts as the liaison between the various surgical subspecialties and the anesthesia and nursing departments...

In contrast, OR directors have most frequently come from the department of nursing.  As a consequence, the description of functions associated with an OR director differ significantly as follows:

1. There is much more interaction with staff members with whom anesthesiologists typically do not work directly, such as the staff in the sterile processing department (SPS), transporters, and housekeepers responsible for cleaning the operating suite.  There is also a much closer interaction with the nursing staff, introducing a learning curve for an anesthesiologist.  SPS is an unknown world – at least for most anesthesiologists – and therefore it is critically important to partner with staff in that area.
2. As OR director, it is imperative that surgeons have their required equipment and that this equipment is maintained appropriately.  Moreover, it is important that necessary disposable items are appropriately available (not outdated) and that the ordering of instrumentation and consumables is matched to the demand of the appropriate service in a timely fashion.
3. Protocols, policies and compliance issues that concern an OR Director are larger in scope than those for medical director.  In addition to anesthesia policies and protocols concerning the workflow of patients are all institutional policies that pertain to OR personnel.  One example would be ensuring universal compliance of time out protocols.
   
   Advocacy for other groups is essential.   In managing an anesthesia group, an anesthesiologist has a somewhat parochial view, maintaining the needs of the anesthesia group, the quality that is needed to defend patients from an anesthesia perspective and certain standards that are seen as beyond compromise.  As an OR director, that responsibility continues.   However, the needs of surgical colleagues (equipment and time requirements) nursing staff (perhaps, more staff or different scheduling), and PACU nurses for more staff or a change in scheduling must be articulated.
4. There is an ongoing requirement to make improvements, not only in one’s area of expertise, but also with all the staff to determine ways to improve efficiency, reduce costs and maximize throughput – frequently, in alien areas.
5. Working with staff on personal development is important.  There will be individuals at all phases of their careers.  Some are happy to remain at status quo; means to incentivize these individuals must be determined so that they can perform optimally.  Others are eager to take on new projects, to push the scope of their abilities and perhaps go on for further training.  In these cases, the OR Director acts as advocate and counselor.
6. Emergency planning needs to be redone for a much wider group, the entire operating suite.  Simulation and other disaster scenarios may be quite useful here.

Overall, I believe that anesthesiologists can be ideal candidates to serve as OR directors.  They work in all areas of the operating suite—namely, every subspecialty of surgery and with all ages of patients.  They know many of the requirements of their surgical colleagues and can bring a physician’s understanding to the problems facing surgeons.  Furthermore, as many procedures have moved out of the operating room to offsite areas such as radiology, cardiology labs and interventional suites, it is anesthesiologists rather than nurses or surgeons who have adapted to these different environments.

Since coordination of services remains centralized in this model, the operating room director in this case can consider it to be another service line:  cardiac, neuro, obstetrical, non-operating room procedures (NOR).  This maintains efficiency.  The same thing can be said for the utility of having one individual responsible for all functions in the operating suite:  pre-op nursing, intraoperative nursing, SPS, PACU, patient preparation, equipment and cleaning.

Obviously not every physician has the interest or skill set to undertake a job like this.  Truly, the door has to be open at all times.  No complaint can be too small.  And, the physician has to be willing to diversify and learn about many areas not typically in his/her arena.

Nonetheless, building teams to work on problems is the primary, requisite skill.  Coalitions from SPS, nursing, surgical specialties and anesthesiologists must be established to optimize.

Cost is a critical issue.  Fundamental to the practice of anesthesiology is the demonstration of how these physicians utilize medical and management skills for the benefit of the organizations where they work.  As changes in healthcare continue to occur, the days when an anesthesia group can merely provide the professional component of care for patients in a facility without other management responsibilities are gone.  Having worked in private practice, academics, the military and multispecialty groups—and the federal system now—in each practice setting I realize there are more and more demands on groups to contribute managerial skills.  Service as Operating Room Director is a logical extension of this process.

Salary lines are usually added for “OR Director.”  Most hospitals will fund time that will more than repay itself to the professional OR Director. The sum will not fully compensate what an anesthesiologist may feel is required.  But, going forward, I believe that hospital and anesthesia groups must hang together or surely we shall hang separately.

The ideal goal is to make patients' experiences in the operating suite as short, as pleasant, as efficient, and with as little cost as possible.  Patients need to arrive optimized for surgery, with every element required for their case present exactly when it needs to be. Thereafter, the patient, equipment and operating room need to be returned to their original state as soon as practicable.

On a personal note, the most important thing that I have discovered being an OR director is that it is like being a coach.  You have to support your staff, encourage them and advocate for them.  If something is not perfect, it is critical that retraining occur.  If you do not understand a process, you must ask the people who are on the front lines.  And, most importantly, you have to get everyone working together for the same end.  Because, when all is said and done, surgery is a team effort—it is not an individual event.

Steve Boggs, MD, MBA
Chief of the Anesthesia Service
Director of the OR
The James J Peters VA Medical Center
Bronx, NY
Associate Professor, Anesthesiology
The Icahn School of Medicine at Mount Sinai
Manhattan, NY

Dr. Boggs has identified new ways in which anesthesiologists can add value to their hospital relationships.  As he writes, not everyone will be willing to expand his or her role to take on the responsibilities of an OR director – but we suspect that some of our readers will consider taking advantage of Dr. Boggs’s insights.  Again, we appreciate the opportunity to bring you this information.  We also welcome your comments, on today’s or other topics.