Anesthesiology's Role in Effective OR Governance

Jerry Ippolito
President, OR Efficiencies, LLC

Last year the publishers of the Communiqué asked me to comment on whether anesthesiology should have a role in OR schedule planning and administration. I feel so adamantly about this matter that I titled the article “Who’s Really Running Your Business” – I chose that title because if anesthesiology does not participate in schedule planning and administration, then anesthesiology can only react to the decisions of others. The same holds true with regard to OR program governance. When anesthesiology does not take a proactive role in fostering and enforcing effective governance, then anesthesiology will remain in a reactive mode and will not be able to optimize satisfaction levels of its customers (surgeons, administration, nursing, and last but not least the patient).

Too frequently we hear of anesthesia referred to by nursing and administration as “A Necessary Evil”. In my experience anesthesiology typically has a sound grasp on what is necessary to run an efficient and marketable OR program. Maintaining program efficiencies and garnering new business is even more important to anesthesiology than to the hospital as an anesthesiology group does not have the same level of financial reserves as a hospital. Unfortunately however, rather that being a “Champion” for program reform by promoting program development, anesthesiology typically points fingers at administration and nursing. Due to the perception of anesthesiology being a “necessary evil” or “having an agenda of its own”, regardless of how sound recommendations may be, nursing and administration seldom listen to anesthesiology.

A lot is written in the literature these days as to whether or not anesthesiology should be running the OR. Running the OR and fostering development of effective governance are two different issues. I was recently interviewed by the publication OR Manager, and asked whether anesthesiology or nursing should run the OR. My response was that if effective governance is in place, then it does not matter which constituency of the four-legged stool (anesthesiology, nursing, surgeons, or administration) runs the OR on a daily basis. Running the OR is the implementation, execution, and enforcement of the policies and procedures developed by the governance body. Some feel that anesthesiology should run the OR because in order to maintain an effective OR program physicians must be positioned to police physicians. Others feel anesthesiology should run the OR as OR Directors come and go from institutions and anesthesiology is generally a more stable entity. Lastly, there is a school of thought that anesthesiology should run the OR because anesthesia is “ever-present” in the OR.

I don’t totally disagree with any of this thinking, but I must indicate that making anesthesiology the “policeman” of the OR without holding other constituencies accountable will only result in fostering the reputation of that “necessary evil”. About seven years ago I was engaged by a major mid-Atlantic university hospital to assist in improving operating room efficiencies. To this day I use this case study as an example of what happens when effective governance is lacking. In this instance the Chairman of the Department of Anesthesiology was sponsoring the engagement for the hospital. The anesthesiology chair had been directed by the Dean of the university and hospital CEO to “fix the OR”. The OR was totally dysfunctional; surgeons did whatever they wanted whenever they wanted; the environment was total chaos. The Chair continues to be a highly regarded individual and has a sound grasp of what is required to maintain an effective OR program. The Chair proposed sound strategies for change and promoted sound policies and procedures. Needless to say the Chair remained very frustrated as progress was not being made and it was alleged to be the fault of anesthesiology. Progress was not being made as only one constituency of the four legged stool was being held accountable: anesthesiology. I was simultaneously engaged at a university on the opposite side of the city where effective governance was developed and each of the constituencies was held accountable. Anesthesiology championed the process through its “ever-presence in the OR” and there was tremendous progress.

Generally when there is a lack of effective governance silos develop among the four constituencies and it is difficult to have effective program management and optimized satisfaction levels among the constituency members. Indeed each of the constituencies does have an agenda (see Figure 1 below).

The OR’s 4-Legged Stool

Typically in siloed environments constituency members maintain an expectation that their wants and needs will be fulfilled, by others, to a 100 percent level, 100 percent of the time. In this environment constituency members do not take responsibility for their actions and are unwilling to police themselves, much less each other. The Director of Surgical Services and Anesthesiology remain in a “NO-WIN” situation until both anesthesiologists and surgeons recognize that they must be accountable for their actions, be responsible for development of solutions, not maintain expectations that their needs will be fulfilled by others, be champions of program change and prosperity as opposed to complainers.

Effective surgical program governance is best achieved by considering the OR as a business corporation. The OR is the “Financial Engine of a Hospital” and should be governed as such. Corporations have boards of directors and CEOs. CEOs do not make unilateral decisions; CEOs brief boards of ongoing situations and changes in the environment, provide data and information, and guide decision making after having analyzed facts and circumstances. Boards develop strategic and tactical plans and develop policies and procedures. CEOs and management teams implement and enforce decisions of the board. In this regard, what we typically refer to as the hospital’s OR Committee acts as the board; the Director of Surgical Services, in partnership with Anesthesiology acts as the CEO. To this point you may say to yourself, “Our hospital has an OR Committee, but the OR is still dysfunctional and chaotic. In my experiences most hospitals’ OR Committees are dysfunctional, lack value and clout for the reasons listed in Table 1.

Generally the OR Committee lacks clout because it has not been formally constituted and given a specific hospital operations charge by the hospital’s CEO (differing from the Department of Surgery, which is a medical staff body). Similarly, if the CEO does not bestow formal authority on the OR Committee and support Committee decisions, disgruntled individuals (usually surgeons) make “end-runs” to the hospital’s CEO around the Committee. In these instances the CEO typically intercedes, makes decisions based on the anecdotal evidence provided by the complaining party and undermines the Committee’s authority and effectiveness. Committee members lose interest and are unwilling to invest their personal time; a negative spiral develops.

The foundation of effective surgical services program governance is based on the composition, authority, mission, charge, and enforcement of the OR Committee. The foundation of effective OR governance is the development of a culture so that programs are developed and governed by that culture and not by one or several individuals. Some key activities and attributes of an effective OR Committee follow:

• Fulfills its charge of fostering development of and maintaining a quality oriented, effective, efficient, and marketable surgical services program through the development and enforcement of effective policies and procedures;
• Is charged and supported by the hospital’s board and CEO as a hospital operations committee; decisions of the Committee are not overruled by hospital administration, the Board, or departments of the medical staff. The OR Committee is not subordinate to medical staff bodies (e.g. Department of Surgery or medical staff as a whole) and does not require their approval of its decisions.
• Maintains a philosophy that the OR is a shared and common work place, is no one person’s or constituency’s domain: a place where compromise and consensus is paramount
• Is of a manageable size – typically of 11 to fifteen members
• Maintains representation of key and high volume surgical specialties as well as of anesthesiology;
• Assures that physician committee members (particularly surgeons) have a vested interest in the hospital and in the Committee’s decisions because those decisions affect them directly. Thus the surgeons on the OR Committee should be effective formal and informal leaders and:
• operate frequently at the hospital and use the hospital as their primary place of surgery;
• have an interest in developing their practices;
• have willingness to foster program change and success for the greater community;
• have the ability and willingness to approach their colleagues about issues or problems;
• have the qualifications appropriate for OR Committee service even if they are chiefs of their own services; and
• have an ability and willingness to enforce policies and procedures even against physician friends and business associates.
• Includes at least one anesthesiologist with good interpersonal, communicative, organizational and data interpretation skills, an anesthesiologist who takes a lead role — or the lead role — in the planning and administration of the schedule on a daily basis (this may not necessarily be the chief of anesthesiology);
• Includes representation of OR management (Director of Surgical Service, OR Manager) and Administration (VP over surgery, CNO, but not CEO)
• Meets on a monthly basis and has a planned agenda
• Is guided by data and factual information presented by Anesthesiology together with the Director of Surgical Services;
• Charges the Director of Surgical Services and anesthesiology to implement and enforce policies and procedures developed by the OR Committee

Where this structure is in place Anesthesiology is positioned to assist in championing program development and success but is not regarded as a “policeman or necessary evil.” Where this structure is developed each of the rationales for Anesthesiology’s running the OR referenced earlier in this article, physician-to-physician leadership, stability and omnipresence, takes shape in a formal and organized manner:

• Anesthesiology participates in enforcing policies and procedures among anesthesiologists and surgeons (physician to physician communication);
• Anesthesiology maintains a constant presence in the OR
• Directors of Surgical Services come and go, but a “culture” sustains program success.

When this governance structure is developed, it does not matter whether “anesthesia” or nursing runs the OR – neither does, as illustrated in Figure 2. Anesthesiology works in partnership with the surgeons and with nursing to guide the OR Committee in its decisions and to implement policies and procedures developed by the OR Committee.

Additional articles by Jerry Ippolito and complimentary learning tools can be obtained by visiting www.ORefficiencies.com