According to Hugh Morgan, quality assurance officer of Somnia Anesthesia, anesthesia quality has traditionally and narrowly focused on clinical quality and the prevention of medical errors. As cost-cutting and regulatory standards become more important through healthcare reform, though, anesthesia groups will be tasked with judging "quality" on a broader basis and aligning with hospital interests. Here Mr. Morgan answers a series of questions on involving anesthesia groups in cutting costs, improving quality and building relationships between providers and administration.
Q: How does staffing play a role in anesthesia quality, and how can anesthesia groups and hospitals improve the recruitment and credentialing process?
HM: It really does begin with the process for how the anesthesia group recruits, develops and retains clinicians.. It should be a transparent process and involve surgeons and hospital leadership as well the anesthesia group. Oftentimes there's a disconnect between the facility and the anesthesia group, and the facility and the group have their own ideas of what coverage should be, and rarely are they in alignment.
I think it's a matter of hospital administrators and anesthesia group leaders stepping back and saying, "Can we be more efficient and more productive without sacrificing quality and safety?" I think any and all staffing models need to be considered — the all-MD model as well as the care-team model, which involves CRNAs and physician extenders. We typically find that the use of CRNAs [through the care-team model] does allow a lot more flexibility and efficiency and the ability to facilitate patient throughput and general efficiencies, as well as attend to other important anesthesia care areas such as pre- and post-operative evaluations. We often find that the all-MD model delays process efficiencies because an MD can only be in one place at a time. A prime example of the more efficient use of the care team model is when a CRNA can finish an OR case while the supervising anesthesiologist can start preparing the next case, starting IV lines, epidurals, etc.
I think in the recruitment process, you definitely need to be selective. The challenge in the specialty is that anesthesia has become viewed as a commodity. It's become the point of view of most surgeons or hospital administrators that anybody can do the job — that if you just get a warm body in place, you'll be okay. That's not acceptable, for a variety of reasons. If you're trying to replace a staff who's retired or left the practice, you should be very selective in the screening process. The process shouldn't be done in a vacuum by the anesthesia group, but should involve surgeons, hospital leadership and nursing leadership. Your decisions should be based on objective methodology, which means looking at a provider's background and talking to them about their [most recent experience with your hospital's specific needs]. If you have a need for regional anesthesia, ask how many successful and unsuccessful regionals the provider has done in the past year.
The credentialing process is similar in that you should work closely with administration throughout the process to avoid unnecessary steps or duplicate work. At the very minimum, there should be a bi-annual evaluation of each credentialed provider, be it the anesthesiologist or the CRNA, to make sure their skills are up to snuff, which, by the way, is also a requirement of the Joint Commission.
Q: How should anesthesia groups and hospitals track quality to ensure effective, safe anesthesia provision?
HM: Several indicators should be tracked on a daily basis that are above and beyond the basic regulatory and accreditation measures and very specific to the anesthetic care of the patient. That could mean tracking post-operative nausea and vomiting or the incidence of failed regional epidurals. You might have an effective anesthetic that [resulted in] a successful outcome, but there are different indicators [aside from clinical success] that clearly affect a patient's true care experience. I often describe these factors as the "bookends" of an anesthetic procedure. Hopefully a patient has no clue what's happening to them anesthetically, so it's the bookends of care that affect how they feel about the care. On the front end, if your IV is being administered and someone's treating you like a pin cushion, you'll likely remember that afterward because you arm hurts. On the back end, after the procedure, you'll remember it if you're sick or in an unusual amount of pain. The one question I think is so critical and telling that should be asked on every anesthesia survey is, "Did you feel safe and comfortable prior to going into your procedure?" Satisfaction survey results are critical in validating the care provided to your patients and in support of your surgeons and should be used regularly to improve performance and outcomes.
Obviously if there is a significant incident, such as a medication error or something along those lines, you want an immediate peer-review process done. Leadership should be looking at those incidents immediately, because you want to address those issues, especially systemic issues, and make sure they don't happen again. If you see a trend where a certain doctor's patients are staying in the PACU longer and having severe post-operative nausea and vomiting, you want to look at that compared to his/her peers and if possible, national benchmarks, in order to improve performance and outcomes. Focusing on those critical areas that affect the patient experience is really where you differentiate a great anesthesia group.
Q: How can anesthesia groups and hospitals improve relationships between anesthesiologists and surgeons?
HM: It's very difficult and challenging, but it comes down to transparency and communication. The anesthesia group must be engaged with the surgical department, and the anesthesia leadership needs to meet as regularly as possible with the director of surgery to facilitate care improvements. In successful groups, some anesthesia providers should have a seat at the department of surgery meetings and address issues that their surgeon peers bring up. Many anesthesia groups are simply operating in a vacuum, and they show up every day and "pass gas" and then go home. Those are the groups that are in jeopardy right now. Those are the groups that are either being replaced and taken over because facilities are fed up with them [being absent for most of the year] and then showing up annually to ask for more money. The successful anesthesia groups are the ones that create value above and beyond providing a safe anesthetic.
Q: How can the anesthesia group — often a relatively separate entity — align itself effectively with the goals of the hospital?
HM: I think there should be a requirement for anesthesia to participate in the critical committees and teams of a hospital. I think having a seat at the table for the medical executive committees and the committees related to anesthesia — pharmacy and therapeutics, for example — is important to engage the group as hospital leaders. The CMO of the facility should have periodic meetings with anesthesia leadership to keep them on their toes. The meetings should be used to review data and look at reports that are critical to the functioning of the group.
Q: How can hospitals involve anesthesia groups in cost-cutting measures?
HM: The biggest area and cost item is anesthesia staffing, so first and foremost, you have to make sure you have the most efficient and productive staffing. Facilities should look critically at utilization of areas that are being staffed. Because anesthesia is a relatively high-cost staffing expense, hospital administrators need to look prudently at areas being covered — whether they are in the ORs or out of the ORs — to make sure those areas are being effectively utilized. We'll see areas where you want anesthesia coverage that are just not being used effectively, but you still want an anesthesia provider there all the time.
From an additional cost perspective, often anesthesia groups do not really contribute to the general cost management of facility supplies and equipment. They should be engaged and responsible for looking at those costs — looking at the costs of the equipment, drugs and supplies they're using and looking at opportunities to use different items to reduce costs. For example, anesthetic gases are one of the highest ticket items, and you can use gases differently in practice and save a lot of money. A lot of anesthesia providers will think, "That's the hospital's responsibility" and not look at that, so it's critical to involve them.
Learn more about Somnia Anesthesia Services.
Q: How does staffing play a role in anesthesia quality, and how can anesthesia groups and hospitals improve the recruitment and credentialing process?
HM: It really does begin with the process for how the anesthesia group recruits, develops and retains clinicians.. It should be a transparent process and involve surgeons and hospital leadership as well the anesthesia group. Oftentimes there's a disconnect between the facility and the anesthesia group, and the facility and the group have their own ideas of what coverage should be, and rarely are they in alignment.
I think it's a matter of hospital administrators and anesthesia group leaders stepping back and saying, "Can we be more efficient and more productive without sacrificing quality and safety?" I think any and all staffing models need to be considered — the all-MD model as well as the care-team model, which involves CRNAs and physician extenders. We typically find that the use of CRNAs [through the care-team model] does allow a lot more flexibility and efficiency and the ability to facilitate patient throughput and general efficiencies, as well as attend to other important anesthesia care areas such as pre- and post-operative evaluations. We often find that the all-MD model delays process efficiencies because an MD can only be in one place at a time. A prime example of the more efficient use of the care team model is when a CRNA can finish an OR case while the supervising anesthesiologist can start preparing the next case, starting IV lines, epidurals, etc.
I think in the recruitment process, you definitely need to be selective. The challenge in the specialty is that anesthesia has become viewed as a commodity. It's become the point of view of most surgeons or hospital administrators that anybody can do the job — that if you just get a warm body in place, you'll be okay. That's not acceptable, for a variety of reasons. If you're trying to replace a staff who's retired or left the practice, you should be very selective in the screening process. The process shouldn't be done in a vacuum by the anesthesia group, but should involve surgeons, hospital leadership and nursing leadership. Your decisions should be based on objective methodology, which means looking at a provider's background and talking to them about their [most recent experience with your hospital's specific needs]. If you have a need for regional anesthesia, ask how many successful and unsuccessful regionals the provider has done in the past year.
The credentialing process is similar in that you should work closely with administration throughout the process to avoid unnecessary steps or duplicate work. At the very minimum, there should be a bi-annual evaluation of each credentialed provider, be it the anesthesiologist or the CRNA, to make sure their skills are up to snuff, which, by the way, is also a requirement of the Joint Commission.
Q: How should anesthesia groups and hospitals track quality to ensure effective, safe anesthesia provision?
HM: Several indicators should be tracked on a daily basis that are above and beyond the basic regulatory and accreditation measures and very specific to the anesthetic care of the patient. That could mean tracking post-operative nausea and vomiting or the incidence of failed regional epidurals. You might have an effective anesthetic that [resulted in] a successful outcome, but there are different indicators [aside from clinical success] that clearly affect a patient's true care experience. I often describe these factors as the "bookends" of an anesthetic procedure. Hopefully a patient has no clue what's happening to them anesthetically, so it's the bookends of care that affect how they feel about the care. On the front end, if your IV is being administered and someone's treating you like a pin cushion, you'll likely remember that afterward because you arm hurts. On the back end, after the procedure, you'll remember it if you're sick or in an unusual amount of pain. The one question I think is so critical and telling that should be asked on every anesthesia survey is, "Did you feel safe and comfortable prior to going into your procedure?" Satisfaction survey results are critical in validating the care provided to your patients and in support of your surgeons and should be used regularly to improve performance and outcomes.
Obviously if there is a significant incident, such as a medication error or something along those lines, you want an immediate peer-review process done. Leadership should be looking at those incidents immediately, because you want to address those issues, especially systemic issues, and make sure they don't happen again. If you see a trend where a certain doctor's patients are staying in the PACU longer and having severe post-operative nausea and vomiting, you want to look at that compared to his/her peers and if possible, national benchmarks, in order to improve performance and outcomes. Focusing on those critical areas that affect the patient experience is really where you differentiate a great anesthesia group.
Q: How can anesthesia groups and hospitals improve relationships between anesthesiologists and surgeons?
HM: It's very difficult and challenging, but it comes down to transparency and communication. The anesthesia group must be engaged with the surgical department, and the anesthesia leadership needs to meet as regularly as possible with the director of surgery to facilitate care improvements. In successful groups, some anesthesia providers should have a seat at the department of surgery meetings and address issues that their surgeon peers bring up. Many anesthesia groups are simply operating in a vacuum, and they show up every day and "pass gas" and then go home. Those are the groups that are in jeopardy right now. Those are the groups that are either being replaced and taken over because facilities are fed up with them [being absent for most of the year] and then showing up annually to ask for more money. The successful anesthesia groups are the ones that create value above and beyond providing a safe anesthetic.
Q: How can the anesthesia group — often a relatively separate entity — align itself effectively with the goals of the hospital?
HM: I think there should be a requirement for anesthesia to participate in the critical committees and teams of a hospital. I think having a seat at the table for the medical executive committees and the committees related to anesthesia — pharmacy and therapeutics, for example — is important to engage the group as hospital leaders. The CMO of the facility should have periodic meetings with anesthesia leadership to keep them on their toes. The meetings should be used to review data and look at reports that are critical to the functioning of the group.
Q: How can hospitals involve anesthesia groups in cost-cutting measures?
HM: The biggest area and cost item is anesthesia staffing, so first and foremost, you have to make sure you have the most efficient and productive staffing. Facilities should look critically at utilization of areas that are being staffed. Because anesthesia is a relatively high-cost staffing expense, hospital administrators need to look prudently at areas being covered — whether they are in the ORs or out of the ORs — to make sure those areas are being effectively utilized. We'll see areas where you want anesthesia coverage that are just not being used effectively, but you still want an anesthesia provider there all the time.
From an additional cost perspective, often anesthesia groups do not really contribute to the general cost management of facility supplies and equipment. They should be engaged and responsible for looking at those costs — looking at the costs of the equipment, drugs and supplies they're using and looking at opportunities to use different items to reduce costs. For example, anesthetic gases are one of the highest ticket items, and you can use gases differently in practice and save a lot of money. A lot of anesthesia providers will think, "That's the hospital's responsibility" and not look at that, so it's critical to involve them.
Learn more about Somnia Anesthesia Services.