Who Is Really Managing Your Practice?

Jerry Ippolito
Vice President & Principal

Once again I've been flattered by the request to write an article for the Communiqué. On this occasion the question was posed, "what do you see as most challenging issues to anesthesiology practices in the area of perioperative services?" One might readily respond reimbursement, however I believe that is a prevailing challenge to the healthcare industry overall and not unique to anesthesia. Others might suggest low OR and anesthesiology utilization. In my consulting practice I have the opportunity to work with fifteen to twenty hospitals and anesthesiology practices each year. The most prevailing and challenging issue encountered for anesthesiology, and the question I'm posed most often by anesthesiologists is, "should we have a services agreement and should we be involved in the schedule?". Some anesthesia groups, and physicians in general, still maintain an old-school outlook of being independent practitioners on a voluntary medical staff and functioning independently of the hospital. In other instances, even where there is an exclusive contract between a hospital and anesthesia group, expectations are not clearly defined. Yet in additional instances, anesthesiologists will suggest to me, "Why would I want to participate in managing the schedule? - Why would I want that headache?" My response to these issues is that if a services agreement and expectations are not in place (even where there is no exclusive contract) you, anesthesia, will never be able to meet customer expectations. Keep in mind that anesthesia's customers are numerous including at least surgeons, hospital administration, the director of surgical services, and oh yea, the patient (not even yet addressing GI; OB; radiology; Cysto; etc). Also keep in mind that the perception is always that, "The OR would run better if anesthesia stepped up to the plate." If expectations are not defined and anesthesiology is not proactively participating in schedule planning and administration in collaboration with OR management, then anesthesiology can only be reactive and subject to the decisions of OR management; this frequently results in dissatisfaction and conflict. If expectations are not in place and anesthesia is not involved in the schedule, then "YOU ARE NOT IN CONTROL OF YOUR BUSINESS."

If anesthesia is to successfully step up to the plate and fulfill expectations there needs to be reasonable definition of expectations. (Where are the plates located; Do you mean a plate or a bowl? How big a plate do you want ? When do we serve meals?). No group or body or person can successfully deliver services and fulfill expectations on an ongoing basis without definition and direction. To this point, and for anesthesiology and perioperative services, development of expectations should at least include definition of:

• Numbers of rooms staffed by hour of day and day of week;
• Call coverage (in v. out-of-house; anesthesiologist or CRNA; etc);
• What services are required by obstetrics and what is considered timely delivery of services;
• Development and delivery of effective and efficient pre-admission screening services;
• Case/patient familiarity prior to day of surgery;
• What services are provided to peripheral sites and when (endo; radiology; response to codes; etc);
• What is the role anesthesia plays in schedule planning and administration?
• How are the requested/expected anesthesia services compensated for if there is insufficient revenue from anesthesia professional fees?

Anesthesia's proactive involvement in schedule planning and administration is most paramount to the successful delivery/fulfillment of expectations. When anesthesia is not involved in the schedule, then anesthesia is continuously in a reactive mode; communication breaks down; expectations remain unfulfilled; dispute results even with best intentions for success.

A formalized charge anesthesiologist or board-runner function needs to be considered for every OR program each weekday, during normally active working hours (and on weekends where there is an active elective schedule). Charge anesthesiologist function and responsibilities (i.e. expectations) should be uniformly developed and one lead anesthesiologist should be assigned. The lead charge anesthesiologist position must be assumed by an individual with strong leadership, administrative and organizational skills and personal attributes. The lead anesthesiologist should be given responsibility for organizing all facets of the position; establishing protocols with nursing, OR management, the OR committee and training the others assigned as back-up charge anesthesiologists in the established protocols. In most programs, the back-up charge anesthesiologist position generally rotates among remaining anesthesiologists. Frequently the daily responsibility is assigned to the physician on call as it may have already been determined that the oncall anesthesiologist serves in a "light-duty" capacity. Ideally, the daily charge anesthesiologist position should be limited to as few individuals as possible (although typically no one person relishes this position). Regardless of the number of individuals assigned to the function, it is critical that decision making, policy/procedure enforcement and OR scheduling/operations support be maintained in a consistent manner.

Individuals assigned to the daily charge position should have their direct care responsibilities minimized as greatly as possible. For practices maintaining an MD-Direct Care model, where anesthesiologists are in rooms and directly administering anesthesia to patients, anesthesiologists assigned the charge position should make efforts to schedule themselves in rooms with shorter, lower complexity cases and to patients of lower acuity levels. For practices using the Care Team model of physicians medically directing CRNAs, in addition to supervising assigned CRNA cases of routine complexity, the charge anesthesiologist can provide support to PACU, Pre-admission Screening, the holding area, and emergency case coverage. Whenever possible no more that two CRNAs should be under the medical direction of the charge anesthesiologist.

The most critical role of the charge anesthesiologist is to work with nursing in management and maintenance of the schedule; optimize case throughput; and to organize, from an anesthesiology coverage standpoint, all add-ons/changes to the schedule. The charge anesthesiologist is also responsible for reviewing the following day's schedule and making anesthesiology assignments for following day's schedules. In collaboration with the charge nurse, the charge anesthesiologist should be reviewing and assisting to coordinate OR scheduling as far out as 72 hours prior to time of surgery. The charge anesthesiologist functions, in very general terms, as the "go to person for anesthesiology", however the function is proactive in participation of schedule planning and administration rather than reactive to daily and immediate needs of the schedule.

The charge CRNA should round throughout the OR as frequently as possibly and be knowledgeable regarding status of individual cases and rooms. In practices without CRNAs, the charge anesthesiologist should circulate throughout the OR as frequently as possible/ allowable based on direct care responsibilities. The OR charge nurse should maintain this practice regardless of anesthesiology delivery model. Together, the charge anesthesiologist and charge nurse maintain responsibility for expediting the day's activities through their familiarity with each room's status and determining when to call following patients to holding or OR. The burden of rounding in the OR and maintaining effective communication with the charge anesthesiologist is more greatly assumed by OR charge nurses in practices using the physician direct care model. The function of being knowledgeable of each case and room status and maintaining communication between nursing and anesthesiology remains the same regardless of anesthesiology model and in the MD-direct model the need to proactively plan the schedule in advance is even more paramount in order to minimize anesthesiologists' distraction from direct patient care on any given day. Zone phones provide a reliable means of communicating with a charge anesthesiologist when that individual must leave the OR proper to attend to responsibilities in peripheral sites.

Case assignments for following day's cases are typically made by the charge anesthesiologist enabling anesthesiologists and CRNAs to familiarize themselves with the following day's schedule; patients' conditions and case requirements; facilitate general planning of following day's activities. Specific protocols regarding how assignments are to be made and the time they will be made should be established and followed by all charge anesthesiologists. Indeed, some may correctly contest that being too specific in delineating expectations will also lead to unfilled expectations and dispute. OR management, administration, surgeons and anesthesiology must come to reasonable compromise as to definition, direction, expectations, and responsibilities. Ignoring or evading the need for expectations development and anesthesiology's participation in schedule planning and administration only "Puts Someone Else in Control of Your Anesthesiology Practice."