The Role of Anesthesia Leaders in Driving Perioperative Performance

Jeffry Peters, MBA
Founder & Chairman, Surgical Directions, LLC, Chicago, IL

Derek Fine, MPH
Business Consultant, Surgical Directions, LLC, Chicago, IL

“Since we recruited a new System Medical Director of Anesthesia and Perioperative Services, our ORs are running better than they ever have before. She recruited new anesthesia providers and changed the entire culture. Surgeons are happy, the OR staff are happy, and our volume and margin have grown.”

– President, East Coast Hospital

Surgical services generate up to 75 percent of total hospital margin¹, making it a critical service line for health system profits and losses. Particularly in these trying times, keeping perioperative services running smoothly is essential to a health system’s financial health, and anesthesia departments are optimally positioned to drive this process. As such, hospital leaders have learned that strong anesthesia leadership is a prerequisite for success.

To illustrate this point, it’s helpful to consider the example of an east coast hospital that was in dire financial straits because of its OR’s chronic underperformance. There were frequent delays in starting cases, OR nurses and CRNAs felt unappreciated, and surgeons did not feel valued. Hospital leaders knew that a significant change was required to jumpstart the OR’s moribund performance, and they decided that a new anesthesia leader would be an essential part of this process. Eager to turn things around, they recruited a new Medical Director of Anesthesia and Perioperative Services and worked closely with her to craft a perioperative transformation plan centered around the following pillars:

• Implementing Collaborative Governance
• Rightsizing Block Time
• Improving OR Efficiency
• Making Data-Driven Decisions
• Creating a Culture of Respect

Implementing Collaborative Governance

Before the transformation could occur, the hospital needed to empower its anesthesia department to lead the change process. To do so, it created a Surgical Services Executive Committee (SSEC) that brought anesthesiologists, key surgeons, perioperative nursing leadership and administrative leadership together to govern the OR collaboratively. The SSEC was responsible for overseeing the transformation, and its inclusive composition allowed it to build consensus for necessary changes. To signal their commitment to the transformation work, the hospital’s president, CNE and CMO were on the SSEC and attended every meeting.

Crucially, this committee was co-chaired by the newly hired Medical Director of Anesthesia and Perioperative Services. By making her a co-chair (along with a surgeon), the hospital’s leaders sent a clear signal to the organization that its anesthesia department was expected to play a leading role in the day-to-day governance of the OR. Along with her administrative responsibilities, the Medical Director continued to practice clinically, which allowed her to take the pulse of the OR while modelling the changes required during the transformation.

Rightsizing Block Time

In addition to playing a leading role in hospital governance, anesthesia leaders must also be empowered to facilitate responsible utilization of the OR by surgeons. As is frequently true at underperforming hospitals, surgeon block time at this facility was not appropriately allocated and monitored. Surgeons were given block on days when they rarely operated, and surgical schedules that could be accommodated in one room were commonly performed in two. OR time is a precious resource, and this misallocation of staffing and demand drove up both anesthesia and nursing costs while creating a barrier to giving block time to new surgeons recruited by the hospital.

To address this, the hospital invested in predictive analytics that dove deeper than the traditionally used “% utilization of block” methodology. While % utilization is useful as a high-level snapshot of how a block is being used, it frequently masks lulls in utilization that can occur throughout the day. At this hospital, while overall block utilization was around 40 percent, this concealed significant variations in utilization throughout each day. Data on hourly utilization of each room was able to demonstrate that half of the ORs were sitting empty after 1 PM on most weekdays. Hour by hour, day by day, these more precise predictive analytics can shed light on previously unobserved gaps in the schedule and offer solutions for more appropriate block scheduling.

Armed with this more accurate data, the anesthesiologist Medical Director was able to have frank conversations with surgeons about their usage of the OR, facilitating the construction of a block schedule that was matched precisely to surgeon needs.

Improving OR Efficiency

While rightsizing the block schedule is a critical initial step in transforming the OR, this updated block must be built on the back of efficient perioperative processes. To help facilitate this, the hospital chartered a performance improvement team (PIT) that was led by an outside nursing consultant and the anesthesiologist Medical Director. Staff from the hospital’s pre-surgical optimization department, central sterile processing, and the OR were all included in the PIT, with representation from both frontline staff and department leadership. The inclusion of frontline staff on this team was particularly critical, as these staff had an acute understanding of the hospital’s inefficiencies, but had not previously been given a seat at the table to help craft solutions.

With this diverse roster in place, the PIT quickly identified that patients were often showing up on the day of surgery with clinical issues that should have been resolved prior to the patient’s arrival. Surgery was also frequently delayed because the anesthesia department needed additional lab tests and clearances, and case carts with missing instruments also contributed to delays.

After the group identified that more proactive management of patients was required prior to surgery, the hospital established a collaborative daily review with all relevant departments (anesthesia/nursing/CSP/pre-surgical optimization) to anticipate and resolve potential problems. At the daily review, the group confirmed the presence of H&Ps, consents and antibiotic orders and checked that the necessary equipment and implants were on hand, working quickly to resolve any issues that arose. By working three days out to mitigate the most common causes of case delays, this collaborative review helped to lower average turnover time by almost 30 percent while significantly reducing same-day cancellations, which minimized disruptions to the daily schedule and increased patient and staff satisfaction.

Making Data-Driven Decisions

In the past, the perioperative data the hospital shared was frequently questioned by surgeons, who lobbied for the reporting to be done in ways that inaccurately documented their performance. Surgeons were shown to be on time if they entered the OR within five minutes of a case’s scheduled start time, and they artificially doubled their block utilization numbers by ignoring flip rooms in the calculation. Led by its co-chairs, the SSEC established monthly perioperative metrics dashboards and tightened the definitions of the metrics it reported to align with national best practice. Information was presented both in aggregate and by surgeon for case volume, block utilization, first case on-time starts, turnover time, and same-day cancellations, and low-performing surgeons were held accountable.

Even though this basic information is tracked by most ORs, it is rarely displayed clearly and accurately, which is an essential part of improving OR utilization and persuading recalcitrant surgeons that changes are needed. As part of this process, the SSEC invited the hospital’s data professionals into its meetings to present the data and explain the methodology behind it, building consensus for the dashboards and eliminating surgeons’ frequent complaints about data accuracy.

Creating a Culture of Respect

In the past, inappropriate behavior by the hospital’s surgeons, anesthesiologists and staff was left unaddressed. There was a culture of finger pointing, yelling and general disrespect for other care team members. This led to higher staff turnover and risk of losing surgeons and their case volume to competing facilities.

To address the issues on the physician side, the anesthesiologist Medical Director and her surgeon co-chair worked to set and enforce behavior standards, with the full backing of the hospital administration. After some initial discontent, surgeon and anesthesiologist behavior markedly improved, and most nurses and CRNAs now felt respected and supported. On the staff side, there were additional communication and effective escalation paths established, which allowed issues to be addressed immediately in a respectful manner. As the culture of the OR improved, staff engagement went up, surgeons felt better supported, and turnover declined.

Conclusion

The hospital described above is one of hundreds of examples of organizations that have benefited from strong anesthesia leadership. Whether it’s leading hospital governance, championing reforms, or working on the front lines to change outdated processes, anesthesia professionals play a critical role in driving strong performance in the modern OR. As such, the choice of a Medical Director of Anesthesia and Perioperative Services is one of the most critical that hospital leaders can make. A successful candidate typically has strong interpersonal skills, is clinically active and respected, and has demonstrated the ability to effect organizational change. With the right candidate in place, the incentives of the hospital and its anesthesia department should be fully aligned, with both parties growing together as the OR’s performance improves.

¹ Resnick, A. S., Corrigan, D., Mullen, J. L., & Kaiser, L. R. (2005). Surgeon contribution to hospital bottom line: not all are created equal. Annals of Surgery, 242(4), 530–539. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1402352/

Surgical Directions is a national consulting, leadership and analytics partner to hospital systems and medical groups who seek to improve their perioperative and anesthesia services. Our team of experienced practitioners tackle critical operational problems and are committed to achieving the target financial, operational, and clinical outcomes. Surgical Directions has successfully helped more than 400 healthcare clients nationwide increase patient access, optimize governance, reduce cost and, most importantly, improve patient care. Additional information is available at www.surgicaldirections.com, and the firm may be contacted at info@surgicaldirections.com.

Jeffry Peters, MBA is Founder & Chairman of Surgical Directions. Mr. Peters has led the operational, clinical and financial improvement of over 300 hospitals across the country. He is an experienced healthcare business strategist with more than 25 years of experience collaborating with physicians and hospital executives. Leading teams of specialists, Mr. Peters has established a consistent track record of enhancing healthcare service delivery through the optimization of workforce, strategy, performance and the supply chain. He is an expert in addressing the operational, financial and political issues within hospital systems—from rural community hospitals to quaternary academic medical centers. Peters has worked with hundreds of surgical and procedural departments, and he understands the complexities and importance of these services to an organization’s financial performance and reputation. Mr. Peters is a national speaker, and he has published numerous articles on anesthesia support and negotiations, OR operations, perioperative benchmarks, block scheduling, physician & hospital relations and hospital organizational issues. He is a leader in healthcare consulting, sought out by healthcare organizations looking to transform services delivery, improve patient outcomes, control costs and ultimately achieve a sustainable competitive advantage in their markets. Mr. Peters can be reached at jpeters@surgicaldirections.com.

Derek Fine, MPH serves as business consultant for Surgical Directions, LLC. Mr. Fine supports clients by organizing and visualizing data to produce actionable insights and drive sustainable change. Prior to joining Surgical Directions, he interned in the Office for Excellence in Patient Care at Mount Sinai Hospital in New York City, where Fine worked on quality improvement initiatives and gained experience working with C-suite executives and key hospital stakeholders to optimize performance. Mr. Fine has a bachelor of degree in Neuroscience and History from the University of Michigan and a masters degree in Public Health, specializing in health policy and management, from Columbia University. He can be reached at dfine@surgicaldirections.com