By Thomas Davis, DNAP, MAE, CRNA
Over the past 30 years healthcare has seen a steady shift from inpatient to outpatient surgery. I’m now in my 5th decade as a CRNA and I can recall the early days of my career when regardless of the nature of the procedure, the patient was required to be admitted to the hospital the day before surgery…it was assumed that patients could not follow pre-op instructions and needed to be watched by nurses. We’ve come a long way and now we see patients for the first time on the day of surgery in the pre-op area and they are walked to their car following the procedure.
Ambulatory surgery centers are not one size fits all and several scenarios exist for models of ownership and management. Writing for Anesthesia business consultants, authors Greenfield and Locke list five common business arrangements for ASCs.
- Hospital owned outpatient facilities.
- Freestanding ASCs that are a joint venture between a hospital and private owners.
- Surgeon owned freestanding unit.
- Single specialty centers such as eye and endoscopy.
- Physician’s office practice.
Several journals including Jama have noted that the shift to outpatient surgery increased markedly during the COVID outbreak when hospital beds were full and ORs were ONLY available for emergency cases. Necessary non-emergent cases such as breast and thyroid surgery were shifted to the outpatient setting and due to increased efficiency and patient satisfaction, the surgeons preferred to continue at the ASC unless the case mandated hospital level care. Many surgeons simply won’t use the main hospital OR unless absolutely necessary.
The shift to outpatient surgery is well documented however, the best format for staffing the outpatient centers is still being debated. Published by Anesthesia Experts and featured by Becker’s hospital review, author Patsy Newitt notes that ASCs make a huge mistake by viewing anesthesia as a service rather than an essential partner. The provider of the day format creates a transactional relationship and prevents collaborative buy-in by the anesthesia provider.
Coronishealth interviewed directors of ASCs seeking opinions about the best relationship between ASCs and anesthesia providers. As described by the directors, the perfect anesthesia partner would help build the culture of the center and do more than cover a room. ASC directors seek anesthesia providers who are strong partners and bring stability and collaboration to the unit.
Some ASCs are fortunate and have full-time dedicated anesthesia staff who become an integral part of organization. However, more commonly, a variety of providers flow through the outpatient center and anesthesia staffing changes day to day. ASCs connected to a hospital tend to get people who rotate back and forth to the main OR in the hospital. Other centers contract to Anesthesia staffing organizations that hire per diem providers to fill in as a side gig to their primary job. The bottom line is that many ASCs receive inconsistent coverage from providers who are not concerned about the overall well-being of the ASC.
A review of the literature reveals the following as advantages of having a full-time dedicated anesthesia staff working in the outpatient surgery center.
- Improved safety and patient outcomes. The adage is true…you get good at what you do and that applies to the ASC workplace. The workflow and the resources are different in the outpatient setting and those who work in the same environment every day become familiar with the supplies, equipment, and expertise of the support staff. Human errors are reduced as are the risks of patient complications.
- Increased efficiency and workflow. Consistently working with the same people leads to better communication and anticipation of each other’s needs. The turnover between cases goes faster and smoother and there is better resource utilization. Because the schedule is completed more efficiently, there is a reduction in overtime. Patients recognize competence and collaboration and, not surprisingly, patient satisfaction scores are higher.
- Greater surgeon satisfaction. Surgeons want consistent and competent anesthesia care for their patients and are reassured when they recognize the face at the head of the table. Working together on a regular basis allows the surgeon and the anesthetist to anticipate the needs of each other, allowing both parties to work more efficiently. Overall, stress in the operating room is reduced and patient outcomes are improved.
- Improved workplace culture. People who work together consistently get to know one another beyond the scope of their work…they know and each other as unique individuals. Dedicated anesthesia staffing enables the anesthesia provider to become an integral part of the ASC team. Rather than being another body at the head of the table, the provider has buy-in for the overall function of the workplace and participates in initiatives to improve the workflow.
Regardless of the ownership of the ASC, there are many advantages to having consistent, dedicated anesthesia staffing in the outpatient center. If owned by the hospital, the ASC must have a dedicated core staff with rotators used as sparingly as possible. If the ASC has a contract with an anesthesia staffing company, the contract must require a core of full-time dedicated staff with others filling in only as needed for relief work. Group owned specialty clinics that hire their own anesthesia staff must offer pay that is competitive with the hospitals and seek as many full-time workers as possible. The plug-and-play model of anesthesia staffing will get the cases done but bypasses the opportunity to optimize the culture, workflow, outcomes, and patient satisfaction that come with full time staffing.
Tom is an experienced leader, educator, author, and requested speaker. Click here for a video introduction to Tom’s talk topics.