Leadership articles – Page 7

Start Tomorrow Today

Effective leaders in healthcare, and across corporate America, are known for being very busy and efficient using effective schedules. Those who make it to the top leadership positions may appear to have everything under control as they progress through massive schedules. Although top executives have a support staff to help them maneuver through the day, their ability to navigate the workload goes beyond a skillful staff. CEOs have learned early in the game to establish a daily routine and weave it into it an agenda that the support team helps bring to life. An important component of the daily schedule is the end of day routine where the leader closes today and plans for a productive tomorrow.

Healthcare leaders work in an especially chaotic environment and by the end of the day it is tempting to pack up and leave. But if you skip out the door too quickly, you will deny yourself the opportunity to grow as a leader. The end of the day is a special time for you to reflect on the successes and challenges of the day, and to prepare for tomorrow. Leaders at any level will benefit by following these examples for routine and reflection.

• Block the last slot on your calendar for your shut down routine.
• Clean the clutter from your desk and your computer. Remove scrap paper and throw away everything that you do not absolutely need to keep. When in doubt, throw it out. Close any open files on your computer and reply ONLY to urgent email. Caution: Do not sacrifice your EOD routine by browsing through email and social media.
• Review the tasks on today’s to-do list and assess your effectiveness in bringing things to closure. Assess whether or not you were successful in completing your top priorities and determine which items to move to tomorrow’s to-do list.
• Close your eyes and visualize your biggest challenge. Relax and ask yourself WHAT questions such as, “What are other resources that I have not used?” “What if I re-prioritized my to-do list?” or “What piece of information is needed to allow the project to move forward?” Writing in the British J. of Psychology, Wieth and Zacks note that your brain is most creative when it is groggiest. Relaxing you tired brain and thinking through your upcoming challenges may give you insight that will solve tomorrow’s problem.
• Thank someone for their contribution to your personal success or the success of the team. Regularly recognizing others puts you and someone else in a positive frame of mind. In addition to showing thankfulness, sometimes offering forgiveness is important and appropriate.
• Review both your schedule for tomorrow as well as your to-do list. Make sure that your list reflects your priorities and that you have adequate resources to complete your list.
• Leave work at work and go home. On occasion you may need to finish something at home but routinely extending your work day into the evening will cause burnout and actually detract from your effectiveness.

Place value on your own after-work activities and develop the routine that works for you. To end my day with an established routine after leading a team of 110 healthcare workers, I created CROTE. Clean, Reflect, Organize Thank, Exit.

It’s All About You

It’s All About You: Keeping Resolutions

By Thomas Davis, CRNA
Follow @procrnatom

For many of us, starting the New Year is an opportunity to hit the reset button and change things that are not working well. When you look back this year, do you see a list of good intentions that were never accomplished? Do you know why? Here is some solid advice for making New Year’s Resolutions that you can keep.

It’s All About You. Simply making a list of good intentions, does not solve a problem. To be effective, your resolutions must represent you and your resources. If you cannot reasonably achieve them, you are wasting your time and your commitment will only lead to frustration without results. When resolving to make change, consider the following:

Resolutions must be doable. By definition, a New Year’s resolution begins January 1. Be sure that a goal is within your grasp and that all the resources are available so you can start now.
The resolution must be within your control. You will not lose weight by asking others to give up cake for dessert. Likewise, resolving to help a child achieve straight A’s second semester is also a lofty goal, but you can’t control the final outcome. However, resolving to lose 5 pounds and to read 6 news books this year are goals that are totally under your control…as long as you are the one giving up the cake.
NYR’s must be specific and measurable. A resolution described in general terms leaves you with vague intent rather than firm commitment. “Ing” intentions like losing weight, exercising more, smoking less, or being happier are undefined with no end point. In contrast, “I commit to losing 10 pounds by exercising 30 min 3x a week,” or “I will stop smoking completely by April 1,” are both specific and can be measured. With an appropriate and measureable resolution, you will be able to answer yes/no as to whether or not the resolution was kept.

Accountability enhances success. Accountability can provide an incentive to actually make the change that you want. You can avoid the easy anchor of status quo and create accountability by attaching a timeline to your resolution. Ensure that your resolution is doable, under your control and measurable, and give yourself a deadline. After setting a goal of losing 10 pounds, resolve that you will lose 1 pound per week for the next 10 weeks so that by a certain date you will weigh ten pounds less. Important: Put your timeline on your calendar.

Share your intent with others. Telling others about your resolution is another means of accountability that puts you in a position to reach the goal and get praised, or to fail and look foolish. It’s even more helpful if a friend with a similar resolution joins you and holds you both accountable. If you mutually establish 3 workouts per week as your resolution, arrange to exercise or walk together several times a week.

Seek support on social media. Social media is another venue for getting accountability. Publicly sharing your goal and your progress takes courage and invites a large and connected community to cheer you on. Nobody wants to fail while their 400 best friends are watching, and by revealing your resolution, you may also generate support from your true friends.

New Year’s Resolutions mark the passage of time and open the door to opportunity. Create your list with confidence and use positive language by stating your goals like affirmations. Begin each item with the words “I WILL” and mean it, and if you lapse, don’t abandon your resolve. Double down and get back on track. Realistic New Year’s resolutions, combined with commitment and accountability, will ensure success.

Thomas Davis is an experienced clinical anesthetist, leader, speaker and CEO of Frontline Synergy. Enhancing leaders, Empowering teams

Who wants to be a millionaire leader?

By Thomas Davis, CRNA

Keep up to date with healthcare leadership topics, Follow @procrnatom

After several decades in the workforce observing the leadership skills of former bosses as well as peers in leadership roles, I have yet to meet anyone who wants to fail as a leader. Regardless of the leadership position, from entry level to CEO, people want to be recognized for their excellence. They want to be remembered as being a great boss. They want to meet organizational expectations while engaging and empowering each team member. In their minds, they want it all.

Not all leaders make it into the elite group who are remembered as being a “best boss.” Though all start with the same desire and most will follow up with honest effort to be the best, some will be remembered fondly while others will be remembered as failures. Why do some excel while others fail? Try taking a little game show advice to create your leadership game changer.

In 1999 Regis Philbin introduced the popular British TV game show Who Wants To Be a Millionaire? to America. Like people in leadership positions, the contestants on the show were given a series of questions to solve. Each contestant drew upon their personal knowledge base to answer progressively more difficult questions. When a contestant was unsure of the answer, they were allowed to use lifelines and ask for help. Contestants would ponder the nature of the question and choose between asking help from an expert, a friend, or by polling the audience.

As a leader, you are presented with problems on a daily basis that require your attention. Because of your background knowledge of both the organization and your team, you are usually able to quickly find solutions to problems. However, like the contestants on the game show, now and then you are unsure and need help. Turn to your lifelines for support.

Ask an expert. Seeking the advice of an expert is a viable option when stumped with a problem that is tied to a specific body of knowledge. Large organizations tend to have more experts on staff and advice is readily available. If your organization is small, you may need to look outside to find a similar expert. Regardless, you want to be successful so contact an expert and ask your question. Caution: Although the expert has advanced knowledge, he does not know your workplace, your team or the context of the problem you with which you are faced. An expert may suggest applying general principles to what they think is the problem. Sometimes that’s a hit and sometimes it’s a miss, so when you seek advice from an expert, consider that they may be wrong. If your results are similar to the TV show, an expert will only get the right answer about 50% of the time.

Ask a friend. If the expert didn’t know the answer, your friend may. When people use a friend as a lifeline, they usually pick a friend who has a broad knowledge base and a lot of common sense. As your friend, they have a general idea of what you do and the challenges you face. As a leader who needs to ask a friend for advice solving a work-related problem, talking to a trusted peer or mentor will open a discussion with someone who can understand the nature of the problem. If you were on the TV show, your friend would be right about 65% of the time.

Poll the audience. In your workplace, you don’t have to poll a group of ordinary people who happened to score a ticket to the show. You have a qualified audience called a team. Gather your team into a town hall meeting and discuss the problem. You already know your own thoughts so be careful not to poison the pool of knowledge by sharing your ideas before listening to theirs. A better approach is to present the problem to the group, then close your mouth and listen. Take notes and ask follow-up questions to clarify ideas. Your team is on the front line and will be the ones implementing the solution. They have first-hand knowledge of the implications of the problem and the solution. If you were on the TV show, your team would be right a whopping 95% of the time

Open your mind to the concept that the collective wisdom of your team holds the answers to most of your challenges. Listen carefully and agree on a plan that includes a timeline for implementation. Use your lifelines wisely and you will score points with administration and with your team for being a great problem solver and a millionaire leader.

Thomas Davis is an experienced clinical anesthetist, leader, speaker and the owner of Frontline Team Development and Leadership.

Effective Listening

Keys to Effective Leadership: Listening

By Thomas Davis, CRNA

Nurse Managers and other frontline healthcare leaders want to be known as the boss that everybody wants to work for. It is only natural to want to set goals that build your personal reputation and the success of your workgroup. Being a good listener is foundational to achieving your goal and here are 2 guaranteed ways to increase your listening skills

Listen to understand
Listen to emotions

Listen to Understand

People want to be heard and understood. When asked about the traits of their best boss, people will frequently say that it was a person who listened and at least tried to understand them. Conversely, when asked about their worst boss, they describe a person who was distant, isolated and out of touch with the needs of the individuals in the group.

The key to effective communication is effective listening. Leaders often put two barriers between themselves and effective listening: the hectic pace of the workplace and the demands on time. Both factors place the leader at risk to be distracted while talking with a member of the team. Just like the raffle at church, you have to be present to win. Somebody on your team finally has the courage to open up to you with a problem and your mind is elsewhere! Whether you’re in the hallway or in the office, value the information that each member of your team offers and give them 100% focus when they talk to you.

The second and more difficult barrier to overcome is the tendency to prepare your response while the other person is talking. I call it agenda listening. You can’t fully appreciate the message the person is delivering if you are focused on your rebuttal. Serious listening is like drilling into the mother lode. By listening to learn, you will gain insight that will elevate you as a leader. Forget about your reply and listen carefully and hear everything that is said. You don’t have to agree but you will benefit from knowing their point of view.

Points:

Learn from listening. Appreciate the gift you are being given.
Restate the other person’s position to ensure you both agree on what has been said.
Encourage the person to tell you more. Build on what they say with replies like, “Tell me more about…”
Encourage the person to clarify by asking how questions. “How can we do that?” “How will that benefit the group?”
Avoid questions that put the person on the defensive. Asking “why did you” puts them on the defensive and looking for an explanation.

Listen to emotions

As educated professionals, we listen with an academic ear. As team leaders, we must listen to both content (actual words) and the emotion that drives the words. We like to think that we are rational beings and that the argument founded in fact will win. Not so. We also have an emotional side and emotions frequently trump logic when interacting with troubled team members. In a famous study, Albert Mehrabian noted that only 7% of what is communicated comes from actual words. Tone of voice and body language make up the other 93% of communication. Maybe that is why so many email and text messages are misinterpreted. As an effective leader, listen not only to the words but also listen to the tone and watch the body language to pick up on the emotion behind the message.

Points:

Allow people to feel how they feel. Telling them how they should feel ends communication.
Make open-ended statements about the emotions that you observe and listen to responses.
- “I sense that you are uneasy with this proposal”
- “You appear concerned about….”
Welcome and encourage team members to suggest solutions.

As a leader, your greater goal is to have a cohesive and effective team where each member is valued not only for the work that they do but also for the person who they are. Listening is the foundational element to build a one on one relationship with each team member.

Thomas Davis is an experienced clinical anesthetist, leader, speaker and the owner of Frontline Team Development and Leadership.

Building Common Purpose

By Thomas Davis, CRNA

Follow @procrnatom

This is the third in a series of blog articles applying political quotes to frontline leadership. Previous articles have applied the words of Hillary Clinton and Mike Pence to frontline healthcare management. There is no intention of supporting or disparaging any candidate or party but rather learning from their words of wisdom. We will have to wait and see whether or not politicians and parties can turn words into action.

“You are the director of your own movie; if you aren’t enjoying what you are doing, change it.” “Stand up for principles and offer a real alternative.” Gary Johnson

Same stuff, different day. Is that your experience as a frontline leader and manager? Going back a few years, the basic murder mystery was the backbone of evening television. A crime was committed, several suspects were identified, surprise evidence emerged, and the bad guy was caught. The format was predictable, however in 1971 “Columbo” reversed it. A crime was committed with the perp identified up front. Viewers were kept on the edges of their seats while alibis melted away until justice prevailed.

To enable your group to achieve excellence and to keep the job interesting, rewrite your daily script. Engaging your team to edit the script creates a common purpose and becomes the cement that binds the team

Develop a common purpose. If you think you have problems building consensus and motivating a team, consider the challenge faced by Coach Mike Krzyzewski when he agreed to coach the Olympic men’s basketball team. Taking a group of millionaire all-stars and asking them to give up their summer vacations in order to play even more basketball was not an easy task. To be successful, the team needed a common purpose. Coach K took the team to Arlington Cemetery and the tomb of the Unknown Soldier and talked about people giving their lives for their country. He then took the team to the area of the cemetery where recent casualties are buried and they viewed gravestones of people younger than they. He arranged workouts at the military academies where young people were preparing to give all for their country if necessary. When all was done, the team was no longer playing summer basketball; they were playing for the honor of their country and all those who have given their lives to defend it. They had a common purpose.

As a frontline healthcare leader, you most likely will not be able to take your workgroup on a field trip to a National monument. Therefore, you must find common purpose within the environment where you live and work.

Create a common purpose

Focus on patient safety and satisfaction when rewriting the way you conduct your business.
Openly discuss concerns and explore remedies
Actively listen to each member of the team as they offer fresh ideas
Have a former patient or family member talk to your team and tell their story

Change the Script. As a leader, the team looks to you for guidance and wants you to motivate and provide direction. Be bold and confident when interacting with your team. Meet regularly and link the new script to each member personally. Tie common purpose to a sense of urgency and role model the new behavior that is expected of the group

Implement Change

Display competence and confidence when sharing expectations
Clearly outline expectations as you role model the desired behavior
Actively listen to and address concerns of team members. Ask what it would take for them to be fully on board.
Establish benchmarks to document progress toward achieving the larger goal
Recognize and reward desired behavior.

Some tasks have to be repetitive, but no one enjoys watching the same movie day after day. As a frontline leader, you will improve the workplace for both patients and workers by making a new script that infuses energy and improves outcome.

Thomas Davis is an experienced clinical anesthetist, leader, speaker and the owner of Frontline Team Development and Leadership.

When a Barrier Falls

By Thomas Davis, CRNA

Follow @procrnatom

This is the second in a series of blog articles applying political quotes to frontline leadership. There is no intention of supporting or disparaging any candidate or party but rather learning from their words of wisdom. We will have to wait and see whether or not politicians and parties can turn words into action.

“Whenever a barrier falls in America, it clears the way for everyone.” Hillary Clinton

On the heels of two political conventions, one-line catch phrases are as abundant as bugs on the windshield after a drive in the country. Instead of using the quotes to defend or denigrate a candidate, good leaders listen and apply the principles from the quotes to their workplace and the team they serve. For managers, identifying and removing barriers is often the difference between success and failure.

Back in the day, as the population moved from the East coast to populate the vast continent, it was important to have more than the vision of “go west.” Forward scouts were the trailblazers who led the way. They not only charted the course but also removed obstacles so that the wagon train could move forward. Likewise, the successful frontline leader is the person who not only knows the direction but also is able to move barriers.

Removing personal barriers

Recognizing and removing barriers is an ongoing activity for most frontline healthcare managers. Obstacles arise not only in response to implementation of change but also to maintaining the status quo. Though we frequently claim that someone or something is in the way, the first barrier often lies within. In leadership, lack of self- confidence or lack of knowledge are internal rocks in the road that must first be addressed before tackling external boulders. To prepare yourself:
• Study and thoroughly understand the present state. Know the greater goal of the organization and the history of policies that govern your daily activities.
• Have a clear vision of what you want to achieve and why it is important.
• Develop a network of trusted colleagues both within your workgroup and your organization whose support is reliable and trusted. Talk with them, ask questions and “listen to understand.”
• Move forward with confidence knowing that others share your desire for success.

Removing team barriers

As an all-star frontline worker it was all about you. You were recognized for excellence and your work was held as an example for others to follow. Now, as a leader, you are no longer judged by your personal work but rather by the results achieved by the team. The engaged and collaborative work of your team will ensure success. The good news is that your team wants to do a good job. Giving them the right tools is essential.

• Information: Communication with the team is essential. They must understand and share a clear vision of the desired outcome and have confidence that your leadership will support their efforts.
• Involvement: Make sure that every member of your team has responsibility and feels that each is, and all are, an important part of the overall success. Make this about the team and not about you.
• Goals: Identify benchmarks that are readily measured and visible to all. When the larger task is divided into smaller steps, each having a benchmark, the team will be eager to achieve the next goal.
• Reward: Celebrate success as each step is achieved. Small steps can be rewarded with recognition for a job well done. When the greater goal is achieved, a large celebration is in order.

All political candidates, regardless of party, speak in platitudes that describe an ideal world. They all make promises that cannot be kept. As frontline leaders and managers, you are in a unique position to take the principles put forth by the candidates and apply them directly to the workplace where they can and will make a difference. Be a trailblazer, leading the way with confidence and integrity, and turn the barriers into little bumps in the road.

Thomas Davis is an experienced clinical anesthetist, leader, speaker and the owner of Frontline Team Development and Leadership.

Leading Frontline Change

Leading Frontline Change:

Today’s leadership investment yields tomorrow’s team dividends

By Thomas Davis, CRNA
Follow @procrnatom

Effectiveness as a leader is not based on popularity but rather on the ability to manage change

“The only constant is change.” Modifications to best practice protocols are initiated internally and are meant to improve both workflow and patient outcome. Other initiatives have an external source and are mandated by new regulations or alterations in reimbursement. Frontline managers and team leaders set the tone for how the work group will respond and the attitude projected by the leader will ultimately contribute to the success or failure of the initiative. Frontline Leaders are critical to success whenever the status quo is altered.

As recently as 5 years ago, in order to accommodate the need for Nurse Anesthetists and ICU nurses to work 12-hour shifts, several hospitals offered workers 3 X 12 hours per week to count and be paid as a 40 hour work week. The response was positive and the hospitals had a plethora of applicants working the popular shift. Over time, changes in healthcare reimbursement took place and the 36-paid-as-40 model was no longer viable. Hospitals were forced to implement new schedules that required 40 hours of work for 40 hours of pay. For example, two individual hospitals in the same community implemented the change to the 40-hour work week with very different results. Although the change was not popular at either hospital, one system made the change smoothly with the team focused on all of the other positive benefits offered by the employer. As a result, there were no resignations. At the second hospital, 18 members of the department abruptly quit their jobs. The difference was Frontline Leadership.

Status quo does offer a level of comfort, however, change is often an opportunity for the frontline healthcare leader to experience personal growth as well as growth and development of the team. The leader’s personal response to the change will set the tone for the entire workgroup. By using asset based thinking (ABT), creativity and good communication, your workgroup can lead the way in the implementation of change. Remember, change does not necessarily threaten your personal vision. With creativity, change can actually move your vision forward. In the example of implementing the 40- hour work week, the successful leader held true to the vision of making the hospital an employer of choice. The reason behind the change was thoroughly explained to the workgroup and the implications were revealed. The group learned that the change would bring financial stability to the organization and add security to their jobs. The group actively participated in creating a new schedule that was acceptable to all. When the change was made, even though they preferred the 36-hour work week, the change went smoothly. Conversely, at the other hospital the change was implemented as a mandate from above. The attitude was, “if you don’t like it, find another job”…and many did.

Build on a solid foundation

Change is commonly perceived as threatening when the frontline worker sees no personal benefit. Strong leaders have an opportunity to thrive during times of change as opposed to weak leaders who wilt and eventually perish. Leaders who are successful at embracing and implementing change are people who have a long history of being connected with the workgroup. A leader may safely assume that at some point policies and procedures will be altered. Establishing yourself as a trusted and confident person who cares about each team member on a personal level will give you credibility with the team when they feel threatened by the need to modify the status quo.

To be an effective leader:

Role model excellence in every phase of the job. Take your turn on the front line of patient care along with the members of your workgroup and earn respect for your skills.
Develop a one on one relationship with each member of your team. Know something personal about each person and have a sincere desire to promote their professional development.
Have a vision for the group and communicate it regularly. Every member of your team must know and support your vision. Encourage open discussion to clarify your vision.
Be upbeat and confidently demonstrate ABT. Anticipate success.

Do your Homework

With change comes anxiety and when people are uncertain, rumors emerge. You will be amazed at what a friend of a friend heard someone say in the elevator. Once gossip takes on a life of its own, it will taint how we perceive people and problems. Writing in Science, Eric Anderson states, “Gossip does not impact only how a face is evaluated – it affects whether a face is seen in the first place.” Once the gossip starts, time is of the essence to get it stopped. A leader must quickly understand the proposed change and the reasoning behind it, connecting the new policy to the greater goal of the organization, and then communicating it honestly and openly.

Before you talk with your team about the upcoming change, become the expert on the topic. Read the new policy and have a one-on-one conversation with your superiors and other stakeholders. Succinctly share your concerns privately in a proactive and asset-based manner. Always speak and listen with good intent and with a commitment to understand.

Before you meet with your team:

Clarify the specifics of the future state and the advantages that will emerge with the new policy.
Identify and utilize key stakeholders and sources of support.
Identify obstacles and explore ways to remove them.
Involve key people in the workgroup to help with the rollout of the new plan.
Develop a timeline and abide by it. Delaying will only give more time for rumors and gossip to spread.

Communicate

Sincere, two way communication is essential for implementing and managing change. Set a positive and confident tone when discussing the future. If members of your team perceive that you are uncertain and lack confidence, they will not openly support you. Your ambivalence will be compounded by the negative effects of rumors and gossip causing morale to drop along with the effectiveness of your leadership. Now is the time for you to display self-assurance and maintain control. Being recognized and respected as a leader is status that is earned over time. From day one a leader must earn the trust of the team. Once you have done your homework related to the change and you know the details of both why and how the change will be implemented, you are ready for one of the most important roles of a leader – keeping the team informed.

To keep the team informed:

Schedule a town hall meeting where the change can be openly discussed.
Be open and honest and share all that you have been asked to share. If you have been asked not to share something, don’t pretend that you don’t know. Simply state that you cannot yet share that detail.
Let people know that gossip is not acceptable(will not be tolerated?). Honestly answer all questions in order to prevent and dispel rumors.
Listen to each member of the team with the intent to understand. Acknowledge individual concerns.
Use ABT to focus on positive aspects of the change.
Where possible, connect the proposed change to your personal vision and the greater goal of the organization.
Challenge the team to actively participate with implementing the change.

As the leader of a team of frontline healthcare workers, you want everything to run smoothly on a daily basis with great workflow, safe patient outcome and a happy staff. Although change can be challenging to the team, it can also be an opportunity for the talented Frontline Leader to shine. Make a commitment to establish a solid foundation with your team and to connect with each individual. The groundwork that you lay today will pay huge dividends when it’s time to implement the inevitable change.

Thomas Davis is an experienced clinical anesthetist, leader, speaker and the owner of Frontline Team Development and Leadership.

Advice from Mom

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By Thomas Davis, CRNA

This is the first of a series of blog articles applying political quotes to frontline leadership. There is no intention of supporting or disparaging any candidate or party but rather learning from their words of inspiration. Only time will tell whether or not action follows the words.

“I watched my mother build everything that mattered: A family, a business and a good name.” Mike Pence.

Michael Richard Pence is the current Governor of Indiana and was named last week to be the Republican candidate for Vice-President of the United States. Born June 7, 1959 in Columbus, Indiana, Mike is a lawyer who previously served in the US House of Representatives. As stated in the quote above, Mike learned values from his mother and has incorporated them into the way he conducts himself and his business.

Putting party ties aside, there are management lessons to be learned from political leaders…and their mothers. Frontline leaders and managers in healthcare share a common quest for improving patient care, workflow efficiency and staff engagement. Let’s look at the things that mattered most to Mike’s mother and apply them to our work as frontline leaders.

Building a family

As a leader, building a team of fully engaged and collaborative workers is foundational to success. New frontline healthcare managers inherit a workgroup and must use their leadership skills to create a vision and convert independent workers into an effective team. With skilled leadership and a common purpose, over time your team will become your extended family. Teambuilding requires time, effort and basic leadership skills.

Start building your “family” by selecting and hiring the right people. Be selective and ensure that the new hire shares your values before you bring them into your team.
Have a vision for your team and openly share it. Meet with your team to clarify your goals and discuss your expectations of how your team will achieve results.
Communication is essential and must be two way. As a leader, listening can be more important than talking. By listening you will learn new details from frontline workers and you will reinforce to them that their thoughts are valued.
Empowerment of the team to resolve every issue at the lowest possible level increases efficiency and builds a sense of being valued. Delegating and then supporting the decisions of others builds their desire to be more productive.
Trust is the glue that holds the work family together. Integrity is the key to building trust.

Building a business

Healthcare reform, combined with new Federal Regulations, have changed the reimbursement that hospitals receive for services provided to the patient. As a frontline leader, you represent not only your work group but also the larger institution. Decisions must address not only what we do but how we do it.

Constantly review staffing and workflow to ensure that patient care is delivered in both a safe and efficient manner. Challenge your team to offer suggestions for improving efficiency.
Know the mission, vision and core values of the institution. Ensure that your management decisions are in alignment with the greater goal of the organization.
Build your interaction with your team based on trust, mutual understanding and an appreciation for the talents that each person brings to the group.

Building a good name

“Patient safety and satisfaction” are buzz words used by payers and repeated by upper level management at many Hospitals. Patients come to the hospital expecting that high quality care will be delivered in a safe manner AND that they will have a great experience. As noted by author Fred Lee, “Patients judge their experience by how they are treated as a person, not by the way they were treated for their disease.” To build the reputation of the organization, frontline workers must connect one on one with each patient and truly care about their experience and outcome.

Empathy and understanding are two of nature’s greatest healing powers. Introduce yourself to patients and their families and make sure they know your role.
Listen with good intent and a sincere desire to help.
Ask your patients to tell you something about themselves that is not on their medical record. Your interest in them as a person will build a foundation of trust.
Successful outcome and satisfaction arise from a daily sharing of common values with your patient.

Just as in life, building a business, a family and a good name are foundational in the healthcare industry. Our leaders must be principled, our building blocks sound, and should serve the patient and society. Our construction site must be safe and secure and the edifice we build should be a living reflection of our values – values that would make Mom proud.

The Value of Vision

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By Thomas Davis, CRNA

“You’ve got to be very careful if you don’t know where you are going because you might not get there” – Yogi Berra

On May 25^th, 1961 John F. Kennedy had a vision and shared it with the American public. “By the end of the decade we will send a man to the moon and safely return him to earth.” The race to space was launched. NASA quickly became one of the most important Government Agencies, spurring math and science to dominate higher education. Clearly, Kennedy had inspired the nation and when Neil Armstrong took the first step on the Moon in 1969 the vision was fulfilled. Creating, sharing and gaining commitment to a vision produced amazing results.

Creating a vision is the first step toward success and is all too often overlooked by emerging leaders. In his book The7 habits of highly effective people, author Stephen Covey recommends that we start with the end in mind. As a leader, having and sharing a greater goal is essential for producing collaborative teamwork and achieving the desired goal. Writing in the Harvard Business Review, Kouzes and Posner state that when workers are asked to describe the characteristics of a great boss, creating and sharing a vision are rated as very important. Across the board, leadership trainers and coaches agree on the importance of a vision when attempting to develop a highly effective team. Having a vision and implementing it is the difference between leading and managing.

What is a vision statement? A vision statement is a short sentence or tagline that defines where you want to go and describes your future state. Sharing the vision and encouraging collaboration helps to define how you will get there. The vision statement should be easy to remember and it should align with the needs and goals of your workgroup as well as the mission of the larger organization. Individuals in a workgroup may disagree on technical issues, however, everyone should be in agreement with the greater vision. The vision statement must be well known to the group, be achievable, and function as a point of reference when administrative decisions are made. Always ask, “Does this decision/policy support our vision?”

Corporations often condense their vision into a catchphrase easily remembered by both their workforce and the public.

“Where imagination meets nature” – Seaworld
“To provide access to the world’s information in one click” – Google
“People working together as a lean, global enterprise for automotive leadership” – Ford

When both employees and customers know the vision, there is common ground for aligning expectations not only about what is to be done but also how business is to be conducted.

Vision statements are equally important in healthcare to provide focus to all members of the organization, both professional and support staff. In my tenure at Baylor Scott & White Medical Center in Texas, any employee could be asked the vision of the organization – To be the most trusted and valued name in Healthcare in America – and it rolled off their lips. Every employee knew and embraced the vision. The Cleveland Clinic boasts that they have no employees, only caregivers. The tagline well known to every Cleveland Clinic employee is, “We are all caregivers.” Coincidentally, after adopting the tagline, employee engagement scores have improved throughout the organization.

Status quo is a powerful force. Vision and courage are needed to make meaningful changes. A new healthcare manager, James, was hired to be the Chief Nurse Anesthetist in a department known for low morale and recruiting problems. Clearly an opportunity for improvement existed and focus was needed to transform a dysfunctional workgroup into a collaborative team. As a new leader, James shared his vision “to be the Nurse Anesthesia employer of choice in America” and went to work communicating the vision with the group. In a subsequent meeting, each member of the group was asked to describe what would be required to achieve the vision. Discussion identified things that could be changed immediately and things that would need to change over time. The group walked away enthused and engaged with a commitment to become an employer of choice. Over the following year, results were amazing and now the group has more applicants than openings and employee satisfaction scores have improved. The success achieved by a group of Nurse Anesthetists with a shared vision is typical of what can happen in any group with a common focus.

All too often we laugh at comments like the Yogi Berra quote above and then continue to go through our daily tasks without a unifying vision or goal. Just as GE is a place where “we bring good things to life,” a leader, must have a vision and then engage the group to bring life to the stated vision.

Watch for the follow-up article for tips on how to write and implement a vision.

Thomas Davis is an experienced clinical anesthetist, leader, author, speaker and teambuilding coach.

Effective Leadership

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By Thomas Davis, CRNA

For centuries, leaders in both the Military and civilian world have attempted to identify and define the perfect leadership style. As far back as 500BC Lao-Tzu wrote in the Tao Te Ching, “The highest type of ruler is one of whose existence the people are barely aware….when the task is accomplished and things have been completed, all the people say we ourselves have achieved it.” On a grassroots level, people are empowered, engaged and have the self-satisfaction of a job well done.

Leaders in both business and healthcare are modifying their management style to encourage employee engagement. As noted by Edward Hess in the Washington Post, “leaders of the most successful companies do not have a top down style of management”. Collaborative management to encourage employee engagement is the key to success regardless of the type of business to include healthcare. In reviewing leadership literature a common thread is advocating leadership through shared responsibility. Collaborative Leadership is a sharing of power which recognizes the contributions of each individual and helps them develop and perform at their highest level.

Over the past 3 decades, I have observed many styles of leadership described with many different names. Without exception, the most efficient organizations with the highest employee engagement and morale were those in which the leaders followed the principles of Serving Leadership and shared governance. Use the principles below to establish yourself as an effective manager of an engaged workgroup.

There are no unimportant jobs or people in an organization that embraces shared governance. As a manager, develop a one on one relationship with each individual. When people are respected and their views heard, they become empowered and will seek excellence. Both managers and front line workers recognize that mistakes will be made. By treating a mistake as a learning opportunity, lessons will be learned, and the organization will become stronger because each individual is allowed to take risk. The key to success is to keep the team focused on the common goal. One of the powerful actions described by Covey is “Begin with the end in mind” where the mission and vision of the organization are known and shared by all. High functioning workgroups are founded in trust, collaboration and holding one another accountable. By affirming the common goal and using mistakes as teaching moments, effective leadership can pave the way to success.

Work is accomplished through relationships and trust is the glue that holds relationships together. Trust begins with you. Begin your journey toward becoming an effective manager by looking within. What is your capacity to trust? What would happen if you approached every interaction from a baseline of trusting that you and the other person share common goals and seek common outcomes? Because you may disagree on a step in the process does not mean that your greater goals are different. In the book Trust and Betrayal in the workplace, the Reina and Reina suggest the following for developing trust in relationships:

Share information
Tell the truth
Admit mistakes
Keep confidentiality
Give and receive feedback
Speak with good purpose
Take issues/concerns directly to the person involved

Effective communication is essential in healthcare for patient safety, efficient workflow and employee morale. Empowering Leadership upends the traditional top down leadership pyramid and makes each team member an equal participant in patient outcome. The best decisions are made when opinions are solicited from a broad base of individuals who have a common interest in a positive outcome. As a trained professional and leader, your insight and opinions are needed when decisions are being made however not all opinions are openly welcomed and received. Grenny suggests the following when confronted with a difficult conversation:

Share your facts. Let the other person know what is behind your opinion.
Tell your story. Explain how you see things and why they are seen as they are.
Ask the other’s path. Openly solicit the other person explain why they see things as they do and listen to learn. Do not argue or confront as the other person explains their position.
Talk tentatively. Ask “what if” or “what would it look like” questions to suggest your remedy and then listen as the other person responds.
Encourage testing. Come to a mutual agreement on a next step with the agreement that it will be reviewed and can be tweaked.
Being an effective manager does not require an MBA or that you were born into a family of corporate executives. Put the micromanaging aside and trust in the abilities of your team. By developing relationships, building on strengths, and communicating effectively, you too can be “the highest type of ruler” where your team achieves amazing results without your heavy hand.

Build on individual strengths to raise the collective performance of the group. Each member of your team brings different strengths to the workplace. The person with the most creative ideas is not always skilled at putting the plan into action. Teaming with others who can organize and execute the plan enables the creative genius of each individual to come to life. No individual can effectively do it all.

Hess, Edward, April 28,2013. https://www.washingtonpost.com/business/capitalbusiness/servant-leadership-a-path-to-high-performance/2013/04/26/435e58b2-a7b8-11e2-8302-3c7e0ea97057_story.html
Dennis Reina and Michelle Reina, Trust and Betrayal in the Workplace.
https://hms.harvard.edu/news/safer-patient-handoffs
Grenny, Patterson and McMillan, Crucial conversations: tools for talking when stakes are high

Thomas Davis is an experienced leader, author, speaker and teambuilding coach.

Getting the Right Match

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By Thomas Davis, CRNA

“What counts in making a happy marriage is not so much how compatible you are but how you deal with incompatibility.” ― Leo Tolstoy

Neil Clark Warren is a name that you may not know, however, when you see his face and hear his voice you will say, “Oh yeah, that guy.” Mr. Warren is a clinical psychologist, Christian Theologian, seminary professor and CEO of eHarmony.com. Most likely you know him from over a decade of TV commercials. As a marriage counselor, Neil worked with couples who, despite their love for one another, had compatibility issues. The eHarmony.com web site was designed to assess the basic character and values of each person and then match them with a partner based on compatibility. The success of this online dating plan has been impressive. Compatibility is foundational to every good relationship, including work relationships.

Compatibility is just as important in the workplace as it is to your personal life. Being in the wrong job is like being married to the wrong person…lots of work and not much fun. All too often production pressure influences a manager to hire a person primarily to get them on the job and working quickly. After months or years of frustration, the manager realizes that the employee is not compatible with his leadership style or the institution’s values. Both are unhappy and neither is as productive as each could be.

As healthcare managers, Chief CRNAs have a vested interest in ensuring that employees are fully engaged in their work. Engaged employees provide consistent, high levels of productivity. They are your problem solvers and proactively identify ways to streamline workflow and improve patient satisfaction. They embrace the vision and values of the organization and are on board with your management style.

In contrast, disengaged employees are actively or passively against just about everything. They believe that they are right and everybody else is wrong and would rather hold on tightly to the problem than fix it. Most people reading this article can name both engaged and disengaged co-workers. As a manager, you seek to increase the number of workers carrying the load and to reduce the number of those who put a drag on the system. Your goal is to have a fully engaged workgroup, and employee engagement starts with the hiring process.

As my mother used to say, “It’s easier to avoid getting into a bad relationship than it is to get out of one.” As a manager building a team, the Chief CRNA must assess compatibility of every applicant and stay out of bad relationships. Always remember, there are highly qualified, fully capable applicants who have the work experience that you seek but still may be a terrible fit on your team. Compatibility is as important as capability when assembling your team. Building compatibility into your team begins with the application/interview process.

Competence and capability are foundational for any employee to become a valued member of your staff. Competence is evident by the applicant’s having the education and skills required in the job description, however, capability relates to the willingness to work and the quest for professional growth. When interviewed, an engaged applicant will ask about your expectations and will also ask about taking on more responsibility. The person will want to know how you define and reward excellence. When you follow up with calls to references, ask about work ethic and ask for examples of when the applicant went above and beyond the basic requirements of the job. If all the person does is show up, earn a pay check and go home, don’t expect to see an attitude change after becoming your employee.

An applicant’s Commitment to the mission, vision and values of the larger organization aligns them with others in the workgroup and provides a stable platform for future interaction. When you interview, ask the applicant why they want to work with your group. Are they committed to the group values and are they committed to a long term work relationship or are they passing through until a better option arises? Before the interview ends, get a verbal commitment that the applicant supports the values of the group. Regardless of their competence, if the applicant cannot commit to the values of the group, the person is not a good fit.

Compassion and caring about the welfare of patients and co-workers are signs of emotional health. Having a sense of happiness and a good sense of humor will elevate the mood of the entire group and make your hospital a preferred workplace. Build your team with people who appear happy, who support one another and have a desire to connect socially. The interview is your opportunity for a conversation with the applicant that is relaxed and easy. If the interview is stressful or there is not a free flow of thoughts, the applicant is not a good fit.

Compensation to include both pay and benefits is important to the institution and to the applicant. The offer should be competitive with the local market and the applicant should be satisfied with the offer. Employees who feel that your offer is too low will feel under-appreciated and may quickly become under productive. Not only do they become a drag on your system, they drag others down with them and create discord on your team. Don’t apologize for your offer. If the applicant does not gladly accept it, they will not fit in and will jump ship at the first opportunity.

Communicate with people who know the applicant and their work ethic. The applicant will provide a list of people who can be relied upon to give a glowing testimony. When you interview, ask the applicant for names and contact information for current employers/supervisors. Follow up with a phone call to validate the things told to you during the interview.

Just as Neil Clark Warren uses eHarmony to assess values and characteristics of people to increase the likelihood of compatibility, the Chief CRNA must have a working knowledge of the values of the institution, conduct a focused interview, and follow-up to assure that the applicant is a good match. A happy, healthy and engaged workgroup is founded on a compatible partnership.

Remember, it is easier to teach technical skills to the right person than it is to change the basic personality of a highly skilled but wrong person. For eHarmony in your workgroup, do your diligence and make a good match.

Tom is an experienced leader, educator, author and speaker with a passion for team building. Contact tom@procrna.com

Chief CRNAs are Team Builders

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Chief CRNAs are Team Builders

By Thomas Davis, CRNA

“Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” ― Margaret Mead

As CRNAs we live and work in a rapidly changing healthcare environment. The mandate to provide more care for more people at a lower cost combined with increased Federal regulations has introduced both stress and uncertainty into the healthcare industry. New challenges have emerged in the healthcare workplace. Value based reimbursement, systems integration, and regulatory changes are but a few of the issues that are stressing the status quo. Now more than ever, having a staff of fully engaged, cost effective workers is essential to the survival of the organization.

CRNA leadership on the local level is more important now than at any time in history as hospitals adjust to the new reality of regulation and reimbursement. With safety and outcome metrics being publicly reported and reimbursement being tied to patient safety and satisfaction, it is essential to have the right people providing patient care. As highly skilled, cost effective front line providers of anesthesia, CRNAs are regarded as leaders in the operating room. We are in a unique position to make a difference on a daily basis not only with patient outcomes but also with the overall success of the institution.

Chief CRNAs across the country play an important role at the intersection of the operating room and the larger institution. CRNA leaders are challenged with putting together a team that will provide a positive experience for the patient within the financial limitations of the Hospital. Selecting the right people and having them fully engaged is an ongoing challenge for managers. As Chief CRNAs, we must look beyond the fact that a person has a license and wants to work. We must carefully select the right people who will be fully engaged in their work and raise the bar on patient safety and satisfaction. The following are tips for selecting the right people to join your team:

Set a greater goal for your group. Have a meeting with your current CRNA group and discuss the mission, vision, and core values of the larger organization. Share your personal vision and values with your group and then listen carefully as you discuss your vision with them. Take the initiative to develop a written vision statement for your CRNA group with a list of core values. The vision and values that you share must become the foundation when interviewing applicants for a new position. Develop interview questions to determine the applicant’s alignment with your vision and values. The person may be an accomplished anesthetist however if they do not align with your vision and values they are not a good match for your group.

Describe your leadership style and how it aligns with organizational leadership. Literature from business management states that the traditional top down “captain of the ship” leadership style blocks creativity and engagement. In healthcare as in the private sector, shared governance “serving leader” style of management promotes creativity and engagement. Take the initiative to learn about serving leadership and develop a one on one relationship with each member of your group. A sincere desire to promote the career of each person will lead to CRNA engagement which translates into improved patient safety and satisfaction. An applicant who views you as a serving leader and a person who will promote his/her individual career will be eager to share your vision and will give 100% on the job.

Discuss all of the positives and negatives related to the job. It is unfair to both you and the new employee for surprises to emerge after they start working. The applicant should walk away from the interview with a clear knowledge of your expectations. If there are less desirable assignments or shifts, the applicant should know before they agree to join your group.

Communication is essential. In this era of instant messaging and 24/7 access to texting, email and internet, it is possible to avoid basic one on one communication. As a manager, you need open and honest, face to face, two way dialogue with each employee. If you have problems communicating with the applicant at interview, you will also have problems later. Patient satisfaction is founded on connecting with healthcare providers. Your new employee must have the communication skills needed to connect with each and every patient. In addition, conflict is inherent within any healthcare team. It is equally important that your new hire have the skills to have constructive conversations with difficult physicians. At interview, ask the applicant about times when they have connected with patients as well as times that they have disagreed with physicians. If they can not have positive interactions in difficult situations, they may not be a match for your group.

Not every skilled CRNA is a good match for your team. When you have a clear vision of your goals, have an empowering leadership style, and clearly communicate your expectations, you will be able to determine the right candidate for your position. At the end of the interview, the applicant will know your expectations and will be able to commit to your vision before accepting the position. When both the manager and the new hire agree on the greater goal up front, the road to success has been paved.

Let me help you excel as a Chief CRNA. Consultation service available related to team building and serving leadership. Contact tom@procrna.com

The strategy that will fix healthcare

As healthcare workers, CRNAs have an interest in the future of healthcare. In an era where the healthcare industry is tasked with producing better patient outcomes at a lower cost, it is becoming more apparent that the status quo is not working. In the October 2013 issue of the Harvard Business Review, Authors Michael Porter and Thomas Lee discuss changes that are intended to address the challenges of faced by our current healthcare system. Below is a brief review of the major points. Click here to review the original article.

Both healthcare consumers and payers are not happy with our current model for healthcare delivery. They agree that it is now time for a new strategy that maximizes value for patients. The authors foresee the future of healthcare being organized around the patients’ medical condition rather than Physician medical specialties. The future of healthcare will move away from supply driven healthcare based on what physicians do and move to a consumer driven system based on what patients need. This change in has been termed the “value agenda”. With this agenda, the overreaching goal for medical providers as well as all stakeholders must be improving value for the patients. To do this, the healthcare system must either improve outcomes without increasing cost or it must lower cost without compromising outcomes.

This excellent article continues with a description of areas that need to be addressed in the move from the current state to the future state of healthcare. The Authors identify 6 essential components:

Organize into integrated practice units: This changes the way healthcare workers are organized to deliver care. In this model, care teams are organized around the needs of the patient. Dedicated teams of clinical and non-clinical workers come together to provide everything that is needed to treat a specific medical condition. In this model, the patient could go to one location and receive medical care, therapy and other support by an integrated team who work together to ensure optimal outcome for the patient.
Measure outcomes and cost for every patient: Current quality metrics do not measure quality but rather processes. In the future state, patient outcome and the cost to achieve it will measure the value received. Rather than assessing how many treatments were given, providers will be measured by whether or not optimal results were achieved. In this model, all providers must work together with the common goal of improving outcomes. Physicians, nurses, therapists, and others must all work as a unified team focused on the patient.
Move to bundled payment for care cycles: Fee for service rewards the volume of care delivered but not the outcome achieved. Bundled payment encourages teamwork and high value care. Wallmart recently introduced a program which identified centers of excellence for specific medical conditions. A single bundled payment is made for all the care necessary and the provider team must work together to deliver an excellent outcome within parameter of the bundled payment. In this system, teamwork and focus on patient outcome are essential.
Integrate care delivery systems: As the healthcare system moves to bundled payments, care for specific conditions will be concentrated into fewer locations with healthcare teams who specialize in that condition. Integrating healthcare delivery offers the patient a “one stop shopping” experience at a place known for excellence. Having highly skilled professionals working as a team with a high volume of patients with a specific condition encourages excellence. Patients may need to travel farther but will receive the best possible care.
Expand the geographic reach: Once a team of healthcare providers has achieved a level of excellence treating a certain medical condition, the system must leverage their expertise by increasing the volume of patients they treat. Rather than duplicating efforts at every clinic in the system, referring patients to a high excellence/high volume location will both improve outcome and reduce cost.
Build an enabling information technology platform:
A supporting information technology system is required to support all of the elements described above. The current model of silos of healthcare delivery has allowed technology to develop within each silo. Moving to the future state of integrated care, one data platform that can be accessed by all members of the team is essential.

The healthcare system is changing. Those who cling to the past will become dinosaurs. Patient safety and satisfaction combined with improved value (improved outcomes) will be the hallmark of the future of healthcare delivery. How will this play out for CRNAs? Rather than your value being totally at the head of the OR table, expect to become part of a collaborative team focused on patient outcome. As centers of excellence emerge, the variety of cases you do may become narrower as your team is called upon to do a higher volume of patients with similar conditions. Expect to play a larger role in the overall peri-operative experience of the patient to include postoperative care.

In the era of healthcare reform and changing expectations of patients and payers, the only thing that is certain is that changes will be made.

Click here to read the original article

Chief CRNA: Building a Safe OR Environment

The model for Healthcare delivery in the United States has evolved from a paternalistic, volume based approach through an era of shared responsibility and now into a consumer driven value based model. To remain competitive in today’s healthcare market, hospitals and providers must strive for patient safety and satisfaction in the delivery of patient care. Creating and maintaining a safe environment is foundational to patient safety.

Writing in the Healinghealth.com blog, Susan Mazer writes about the importance of a clean and safe hospital environment. She notes “The patient environment of care plays a vital role in the discipline of patient safety for every hospital. Demonstrating that the hospital is a safe place for patients and for those that work there should be of the utmost importance for all health care personnel.” She goes on to list 5 steps for improving patient safety by improving the environment. Below, are the 5 points from the original article modified to the anesthesia environment.

Remove Equipment from Public areas: As anesthetists, we are well aware of equipment that is stored in the hallways . Not only does this extra equipment block the walkways, but it also increases the risk of tripping and makes cleaning more difficult. Work with others in the OR suite to return excess equipment to the proper place and keep the halls free from clutter
Minimize clutter within the operating room: Extra monitors, pumps, warmers etc stored behind the anesthesia machine or cart limits your ability to move within the room and increases the risk for tripping. Excess equipment also reduces your ability to clean between cases and increases the infection risk. As above, return all excess equipment to the proper place before starting your case.
Organize your cart and machine work space: Everything needs to be seen and immediately available before starting the case. Organize your work space the same way for every case so you know where to look for any drug or piece of equipment. Have a place for drugs, airway equipment and paperwork so that each is readily available.
Inspect your workspace and monitors for cleanliness: Don’t rely on housekeeping to get it right. Look for residual blood or body fluids on your equipment and re-clean them if necessary. Patients expect and deserve a clean environment that protects them from infection
Minimize auditory clutter: OK, music is great but it’s not the main event in the operating room. Patient centered care requires the provider to be able to hear monitors, alarms and be able to communicate with the surgeon. Keep the noise low and develop a “sterile cockpit” attitude during induction and emergence.

Developing and maintaining a safe environment involves more than the anesthetist. The entire operating room crew must be on board and work together to ensure a clean, clutter free environment that promotes patient safety.

Chief CRNA: Supervision and Billing Fraud

CRNAs work in many practice settings. Those working in an office, clinic or small hospital often work as independent providers and work in collaboration with their surgeon. CRNAs working in larger hospitals often work in an anesthesia team model and charges are made based on “supervision” by an anesthesiologist who is “immediately available”. The definition of immediately available remains a topic of debate.

Writing in the blog The Anesthesia Insider, Tony Mira addresses the topics of immediately available and billing fraud. He notes that there has never been a numerical definition for distance or amount of time allowable for an anesthesiologist to respond to a call to the room and states that the HHS Inspector General has visited hospitals, put on scrub clothes and observed the participation and availability of the anesthesiologist during a case.

Addressing this issue, last year the ASA House of Delegates approved this definition of “immediately available”

A medically directing anesthesiologist is immediately available if s/he is in physical proximity that allows the anesthesiologist to return to re-establish direct contact with the patient to meet medical needs and address any urgent or emergent clinical problems. These responsibilities may also be met through coordination among anesthesiologists of the same group or department.

Differences in the design and size of various facilities and demands of the particular surgical procedures make it impossible to define a specific time or distance for physical proximity.

In addition to observing the level of participation and availability of the anesthesiologist, the IG also does record audits looking for the following:

Errors in billing medically directed (modifier QK) cases as personally performed (modifier AA);
Missing documentation of any post-anesthesia care; and
Missing physician initials on the anesthesia records.

The clear implication for the CRNA at the head of the table is that if the anesthesiologist is billing for supervising the case they must be present and must also participate. In addition, the participation must be documented. Failure of the Anesthesiologist to be present and participate constitutes billing fraud.

Chief CRNA: Disabled Alarms Cost Lives

Do you ever get tired of listening to monitor alarms? Many anesthesia providers who are confident in their vigilance and their ability to “know when something is wrong” mute the alarms when they feel that they are needlessly alarming. Unfortunately, patients are injured or killed every years in anesthesia related mishaps which could have been prevented had the alarms been fully functional.

According to Ana McKee, MD from the Joint Commission “Alarm fatigue and management of alarms are important safety issues that we must confront”. Between January 2009 and June 2012, the commission received 98 voluntary reports of alarm-related events, 80 of which resulted in patient deaths and 13 in serious injuries. (The Dangers of Alarm Fatigue)

An article published in Outpatient Surgery describes one such case in which a 17 year old female was given Fentanyl in the recovery room in a bay where the monitor had been silenced. The narcotic caused a respiratory arrest which went unnoticed due to the curtain pulled around the bed. The patient suffered severe brain damage and died a few weeks later. The settlement in the case was 6 million dollars and the CRNA was named in the suit along with the PACU staff because the anesthetist had left the patient with a monitor that had been muted. Click here to read about the case.

The Joint Commission has named alarm fatigue as one of the top healthcare technology hazards and makes the following recommendations:

standard operating procedures for alarm management and response
an inventory of devices that sound alarms
guidelines for alarm settings and situations when alarm signals are not clinically necessary
regular training on alarm management and inspection of alarm-equipped devices
discussions to determine how to reduce nuisance alarms

Click here to read more from The Joint Commission regarding alarm fatigue

Monitor alarms are an important tool in the quest for patient safety and should not be disabled or muted.

Chief CRNA: Collecting Compensation Information

A Chief CRNA is seeking help from others across the country. Specifically, the Chief is gathering information related to how CRNAs are compensated when taking call. Please use the reply area on this web site or contact the Chief CRNA directly at the email address listed below.

Please provide the following information:

Are CRNAs at your institution exempt or non-exempt employees?

Do your CRNAs take beeper call from home and, if so, how are they compensated for this call?

Please use the reply area at the bottom of this posting or contact the Chief CRNA Directly at marty.henley@camc.org

Chief CRNA: Are Smartphones safe in the Operating Room?

We live in the age of instant access to information literally in the palm of your hand. As more and more information becomes available on smartphones, notebooks and pads, their ligitimate use by healthcare workers has increased. However, the device that delivers information can also create distractions.

Lawyers know that distracted healthcare workers are more likely to make errors and frequently examine phone records when investigating an injury to a patient. The following come from the leagal blog “FindLaw KnowledgeBase”

Medical errors and other adverse events in hospitals claim nearly 180,000 lives every year. This is an astonishing number, and it implicates all types of medical professionals providing care in a hospital setting.
More comprehensively, anesthesiologists are responsible for monitoring the condition of the patient throughout the surgical procedure. This includes paying close attention to oxygen levels and temperature.

An article published in Anaesth Intensive Care. 2012 Jan;40(1):71-8 By Jorm CM, O’Sullivan G. made the following points

Experienced anaesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anaesthetists.
While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting

When preparing for legal action, lawyers commonly apply the standards set forth by the professional organization. Non compliance with established guidelines strengthens the case against the anesthetist. The AANA does not have a formal policy statement, however they have a position statement 2.18 regarding the use of mobile devices. The following is from the AANA position statement 2.18

Mobile Devices may:

Aid communication
Cause a contamination risk
May distract anesthetists / reduce vigilance
Should never be used for reading, gaming or texting
Camera use violates HIPAA regulations
Use should follow institutional policy

The risks of Anesthetists distracted by mobile devices is well documented. CRNAs are advised to avoid using devices for personal entertainment and to always base decisions on patient safety.

Chief CRNA: Should You Use Social Media?

We live in a turned-on, linked-in world where instant access to information is the norm. Long gone are the days of reference books and extensive library searches. The generation who grew up using web based technology is now entering the workplace and bringing their mobile devices with them. As Chief CRNAs, it is to our advantage to use social media to enhance the flow of information within our work groups. However, the use of personal devices in the workplace is not without risk to the patient and administration must establish policies that balance the flow of information with patient privacy and safety.

In a blog by his own name, Phil Baumann makes the case that there is a place for twitter among healthcare workers. His article lists 140 uses of twitter to enhance communication and efficiency among workers. A few items on the list include:

Disaster alerting and response
Emergency response team management
Alarming silent codes (psychiatric emergencies, security incidents)
Biomedical device data capture and reporting
Triage management in emergency rooms
Publishing health-related news
Reporting hospital staff injuries
Reporting medical device malfunctions
Discussing HIPAA reform in the age of micro-sharing
Recruitment of health care staff

The blog goes to warn of dangers of using social media in the operating room:

Patient dignity and privacy
Professional oaths to do no harm (distracted workers and Infection risk)
Litigation concerns
HIPAA

Click here to read the Baumann Blog

An article by Barker, A et al published in the Journal of Clinical Anesthesia discussed the use of social media by Residency programs. The Barker group found that only 30% of residency programs have social media policies in place. They also found that 12% of the programs use a social media search as a part of the initial applicant screening.

The article concluded: “residency programs should have a written policy related to social media use. Residency program directors should be encouraged to become familiar with the professionalism issues related to social media use in order to serve as adequate resident mentors within this new and problematic aspect of medical ethics and professionalism.”

Click here to read an abstract of the Barker article.

Here is the question for PROCRNA.COM readers: Does your department have a social media policy and, if so, is it known by front line workers and enforced by administration? Please leave your comments below.

Chief CRNA: How to Motivate your Staff

Being an effective Chief CRNA involves multitasking to meet the needs of the patient, the institution, the regulatory agencies and the needs of your staff. Staff engagement is a buzz word in corporate America. According to Wikipedia, An “engaged employee” is one who is fully involved in, and enthusiastic about their work, and thus will act in a way that furthers their organization’s interests. As Chief CRNAs, it is easy to become so focused on the daily grind that we often ignore things that will promote engagement within our staff.

An interesting article by Martin Dewhurst et al and published in the McKinsey Quarterly addresses the issue of staff engagement. All too often, administration relies on financial recognition for motivation of employees. Dewhurst et al point out that there are more effective non-financial motivators of your staff. According to the report, the top 3 non-financial motivators are:

Praise, commendation and interaction with the supervisor
Attention from leaders
Opportunities to lead projects or task forces

“The survey’s top three nonfinancial motivators play critical roles in making employees feel that their companies value them, take their well-being seriously, and strive to create opportunities for career growth. These themes recur constantly in most studies on ways to motivate and engage employees.”

“One-on-one meetings between staff and leaders are hugely motivational,” explained an HR director from a mining and basic-materials company—“they make people feel valued during these difficult times.” By contrast, our survey’s respondents rated large-scale communications events, such as the town hall meetings common during the economic crisis, as one of the least effective nonfinancial motivators”

“A chance to lead projects is a motivator that only half of the companies in our survey use frequently, although this is a particularly powerful way of inspiring employees to make a strong contribution at a challenging time. Such opportunities also develop their leadership capabilities, with long-term benefits for the organization.”

Click here to read the original article posted in the McKinsey Quarterly

As Chief CRNAs we need to not only ensure that patients receive the highest quality of care but also that they receive the care from a motivated and engaged staff. Finding ways to involve and value individual staff members will pay high dividends in the long run.

Chief CRNA: Patient Safety and the Aging CRNA

We have all heard the stories of the super star who played one season too many leaving the sport at the bottom of his game rather than at the top. The physical effects of aging are well documented in the literature and we are reminded of those changes every time we pre-op a geriatric patient. As the baby boomers reach retirement age, many super star CRNAs who carried our professional torch for the past several decades are experiencing many of the physical changes that they see in their aging patient. The question arises, does the aging healthcare provider pose a safety risk to the patient? How can the skills of the aging CRNA be fairly assessed to ensure patient safety? Is aging really a problem anyway?

Canadian researcher Michael J. Tessler M.D. writing in Anesthesiology and published in the on line blog Community Health Network (Older Anesthesiologists have Higher Litigation Rates) notes:

“We found a higher frequency of litigation and a greater severity of injury in patients treated by anesthesiologists in the 65+ group. The reasons for these findings should become an active field of research.”

Click here to read the blog

An editorial published by the ASA addressed the issue of the aging Anesthesiologist. The editorial reminds the reader that the older provider brings years of experience to the job and has valuable insight to be shared with the younger providers. From the editorial:

“Older physicians, including anesthesiologists, have developed a wealth of experiences during their years in practice that regularly benefit patients,” said Dr. Warner. “The study’s findings remind all physicians that they need to understand their practices, the changes that they personally will experience as they age and the value of working with colleagues to gain continuous feedback about their personal performance in patient care.”

Dr. Warner added, “All physicians should know their personal limits and adjust their practices as they get older to best serve patients. For example, older physicians may choose to reduce the number of hours they work during the nighttime to ensure that they are well rested and alert when caring for patients.”

Click here to read the editorial

CRNAs tend to be at the front line of patient care and are found at the head of the table providing hands on care. We need to respect the knowledge and skills of our “experienced” CRNAs while, at the same time, protecting the safety of the patient.

Here is the question for procrna.com readers: How do we assess the continued competency of the aging CRNA? Use the comments box below.

Chief CRNA: New HIPAA rules released

On January 17th, HHS Office for Civil Rights Director Leon Rodriguez issued a press release announcing the new HIPAA rules being published by the HHS Office of Civil Rights. The 563 page document strengthen the requirements placed on providers and institutions to protect the privacy and health care information of the patient. According to Rodriguez “These changes not only greatly enhance a patient’s privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a health care provider, or one of their business associates.”

Some of the items in the new rule:

Increase the protection and control of health information.
Especially effects health information associates, contractors and subcontractors who help healthcare workers gather and store information. Some of the largest breaches have been by associates.
Maximum penalty for violation has been increased to 1.5 million per violation
New rules also strengthen the requirement to report breaches to HHS and to notify the patient.
New rules make it easier for a patient to share their information for research purposes
Patients can ask for a copy of medical records in an electronic form
New rules regarding how information can be used for marketing and fundraising

The new rules add new regulations and stiff penalties related to gathering and storing protected information. The actual implementation and enforcement of new rules will become apparent over the upcoming months but as anesthesia providers, we can expect questions about our health information security during future CMS visits.

For those with insomnia, click here to review the entire 563 page document

Chief CRNA: “Never Events” in Anesthesia

Never events are inexcusable actions in a health care setting, the things we talk about in the lounge and just can’t believe actually happened. We wonder how somebody could have possibly made such a terrible mistake. The National Quality Forum has formulated a list of 28 never events in the hospital setting. In the Operating room, never events include things such as wrong patient, wrong operation, wrong body part, use of contaminated drugs and many other issues. Click here for a list of never events.

A recent press release from Johns Hopkins University School of Medicine states that across the country, never events occur at lease 4000 times per year. The press release refers to research done over a 10 year period to quantify the occurence rate of never events. Among other things, the study found: Of the 80,000 patients who were affected by never events, 6.6% died, 32.9 % suffered permanent injury, and 59.2% suffered temporary injury as a result of the mistake. The events also led to 9,744 paid malpractice claims over the same period with payments totaling $1.3 billion.

The press report mentions policies hospitals and healthcare centers can implement to prevent never events, including mandatory “timeouts” in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table. Other steps include surgical checklists as well as surgical instruments with electronic bar codes that allow for precise counts of materials and limit human error.

Click here to read the press release from Johns Hopkins.

As CRNAs, we are instrumental in developing a corporate culture of safety. As leaders in the perioperative area, CRNAs can make a difference.

Chief CRNA: The anesthesia team of the future

In the era of Healthcare reform, the practice of anesthesia is being redefined by both the advancement of technology and the impact of regulations. As the scope of anesthesia care emerges from the head of the table to include care across the entire perioperative course, the anesthesia team must evolve to meet the new demands.

An article by Bartels K, et al published in Curr Opin Anaesthesiol. 2011 Dec;24(6):687-92, speculates on the anesthesia team of the future.

According to Bartels, the anesthesia team of the future must provide well tolerated, efficient, and cost-effective perioperative care. Some of the points made are:

The team of the future must develop standards for simulation assuming that simulation will improve healthcare delivery
The team of the future will draw large volumes of information and generate data that is more accurate and complete related to the patient’s physiologic parameters. The providers will use smart phones and other devices to add portability to the data they compile.
Electronic resources will provide real time updates along with physilologic data and pictures to help the provider determine interventions for optimal patient care.
Merging of databases will streamline operating room utilization, hospital bed utilization and supply ordering and storage

The anesthesia team of the future will utilize all available emerging technology to provide expertise across the perioperative continuum.

Click here to review an abstract of the original work

Chief CRNA: Billing audits, Are You At Risk?

Every year the Department of Health and Human Services Office of the Inspector General conducts audits and on-site inspections of Health Care Facilities to ensure that billing and payment policies are being followed. Recovery audit contractors are utilized to make the inspections and are reimbursed by collecting a percentage of the money saved due to the inspection. In other words, the more billing discrepancies they uncover, the more they make. The office of the Inspector General has over 600 auditors, the largest number of auditors of any Federal Agency.

Writing for the on-line blog MiraMed, Tony Mira discusses the 2013 OIG work plan and the implication for hospitals. According to Mira,

“While the Work Plan sets forth the OIG’s attention for the upcoming year, it also provides insight into the attention other agencies and contractors (e.g., the Centers for Medicare and Medicaid Services (CMS), Recovery Audit Contractors (RACs), etc.) will pay, as well. When the OIG cracks down on one body (e.g., CMS), that body cracks down on bodies beneath it (e.g., Medicare Administrative Contractors (MACs)), sending a ripple downstream all the way to the provider. As such, it is important for providers to be aware of the OIG’s focal points in the upcoming year as they, too, will feel the impact.”

Click here to review the OIG 2013 work plan

According to the plan, several ongoing areas of review remain from previous work plans:

Hospitals—Same-Day Readmissions
Program Integrity—Medical Review of Part A and Part B Claims Submitted by Top Error-Prone Providers
Program Integrity—High Cumulative Part B Payments
Physicians—Error Rate for Incident-To Services Performed by Nonphysicians
Physicians—Place-of-Service Coding Errors
Evaluation and Management (E/M) Services—Potentially Inappropriate Payments in 2010

New areas of interest for review in 2013 include:

Hospitals—Inpatient Billing for Medicare Beneficiaries
Hospitals—The DRG Window
Hospitals—Non-Hospital-Owned Physician Practices Using Provider-Based Status
Hospitals—Compliance with Medicare’s Transfer Policy

The OIG has published a video discussing the priorities of the 2013 work plan. Click here to view the video.

As anesthetists, it is essential that our records and the billing for our services are accurate. Inspectors have a plan to uncover billing fraud and recover excess payment. As providers, we must be aware of the issues being audited.