March 18, 2009

The answer to the question “Should Anesthesia Run the Operating Room?” is: IT DEPENDS. Both “running the OR” and “Anesthesia” need to be defined. If “Anesthesia” means an anesthesiologist with the requisite leadership and organizational skills, patient safety and OR management knowledge and inclination toward systems- thinking, then yes, that individual would obviously have a significant contribution to make to the success of an OR.

What does “running the OR” encompass? Perioperative services typically account for one-half or more of a hospital’s margin. Increasing or at least maintaining the volume of surgical procedures is at the top of every hospital’s list of goals. The OR needs to run smoothly and efficiently in order to attract and retain the right surgeons. The first priority in running a successful OR is, therefore, meeting the needs of the surgeons and by extension of their patients. These needs include:

• Access to the surgical schedule
• On-time starts, few delays and rapid turnover of rooms
• Anesthesiologists who make both surgeons and patients comfortable
• Nursing staff with excellent clinical and interpersonal skills
• High scores on quality and safety metrics
• Up-to-date facilities and equipment
• Sound financial management
• Marketing and business development strategy

In many hospitals, the responsibility for attending to these needs is vested in a “medical director” of perioperative services; very commonly, the medical director is an anesthesiologist. Many anesthesiologists, as a function of their training and clinical work, have a number of attributes that qualify them for the job of medical director:

• Anesthesiologists have as great a financial stake as does the hospital in the smooth running of the OR.
• Recognizing this stake by appointing an anesthesiologist as the medical director of the OR helps to ensure the quality of the anesthesia services themselves, an important factor in the retention of surgeons.
• The OR is the anesthesia group’s “office;” they are there more than other specialties, and they offer greater stability than many non-physician OR managers.
• They have a broad-based perspective on the different types of surgical procedures and are in a good position to make needed changes.
• They understand perfectly that the surgeons are the valued customers of the OR. As fellow physicians, they also have the ability to address behavioral problems as peers, something that is not true of OR directors who are professional administrators or nurses.
• Anesthesiologists are accustomed to assessing data needs, developing systems to collect and validate data, and analyzing and utilizing data to drive change. Often the anesthesia department’s record-keeping is superior to that of the hospital because of the time-based nature of anesthesia billing.
• An increasing number of anesthesiologists have earned either MBAs or the American Society of Anesthesiologists’ Certificate in Business Administration. Graduates of either MBA or the CBA programs should be familiar with basic accounting and financial analysis; negotiating strategies and interrelationships within the healthcare industry; compliance, regulatory and legal issues; human resources issues; basic marketing principles and business communications.
• Anesthesiology remains justifiably proud of its history of improving patient safety. Many perioperative measures of quality as well as safety protocols in use today (SCIP, Joint Commission etc.) are under the control of the anesthesiologists.
• Management of the OR has long been part of the culture of anesthesiology. Articles on OR management and efficiency issues are extraordinarily well represented in the peer-reviewed anesthesia literature.
• The American Association of Clinical Directors, which will be holding its annual Workshop on OR Management in San Diego on March 20-22, was born as the Association of Anesthesia Clinical Directors in 1987.
• Most anesthesiologists recognize the name Franklin Dexter, M.D., Ph.D. of the University of Iowa, associating Dr. Dexter with the development of numerous statistical methods for OR productivity analysis and with the OR management educational programs offered through his department (as well as his consulting services).

Managing perioperative productivity and especially the scheduling of surgical cases is the overarching challenge in running the OR. Planning and administering the block schedule, monitoring utilization and handling needed day-to-day or system chances are tasks that an anesthesiologist-medical director should be well-equipped to undertake – provided that he or she has the organizational and leadership skills, as well as enough time to do the job. A lot of work goes into ensuring OR utilization rates of 75, 80 or even 90 percent. In most ORs, the medical director function occupies 25% to 100% of an anesthesiologist’s time, and that anesthesiologist must be compensated accordingly by the hospital whose bottom line the physician is protecting.

We must note that it isn’t necessary or always wise to place the entire OR management burden on one individual physician. An anesthesiologist may have excellent interpersonal skills and be highly competent at maximizing patient throughput, fostering quality initiatives and handling overall physician and staff issues, but there may be a hospital employee with greater expertise in financial analysis, budgeting, materials management and business development. Appointing a “surgical services business manager” might be the right answer for some hospitals. Likewise, nursing leadership may be a far more appropriate choice to exercise the responsibility for nurse selection, training and scheduling.

The hospital does need to give the medical director the authority to enforce the OR policies and to hold surgeons and perioperative personnel accountable. There have been several well-publicized instances where “Anesthesia” was charged with improving OR operations but failed because the administration did not require cooperation from the surgeons, nursing or nonclinical management. Ideally, all of the stakeholders should be represented in the collaborative management of the OR. An OR committee might consist of well-respected surgeons, anesthesiologists, nurses and administrators. Such a committee would be able to set block schedule policies (including release timetables), develop physician codes of conduct, and establish other policies that the anesthesiologist medical director will find easier to implement if his or her authority or wisdom in setting the rules is not subject to challenge.

The prerequisite for a successful perioperative service is effective governance. In all hospitals, a very strong commitment from the C-Suite to the OR medical director and to the OR committee, if there is one, is indispensable.

As always, we welcome readers’ questions and comments.

With best wishes,

Tony Mira
President and CEO