Leadership articles – Page 8

Chief CRNA: How secure is your work group?

As Chief CRNAs, we are tasked with many roles and responsibilities. In addition to clinical case management, we are tasked with additional duties that included personnel management, scheduling, recruiting, supplies, HR issues, and much more. It is easy to become so involved in the daily work load that we lose sight of the looming threat related to survival of the work group. Across the country, large, for profit management firms are writing contracts with the hospitals and displacing long standing work groups. Market place competition is no longer between CRNA and MDA groups, but between local management versus takeover by a larger group with regional or national interests.

Tony Mira writing in the Anesthesia Insider blog makes the following statement:

“While the business of health care continues to evolve, there is perhaps no part of it changing faster than anesthesia. Numerous factors are quickly shifting the market towards an even more competitive and demanding landscape. The days of anesthesia groups simply providing clinical coverage in a hospital’s operating rooms are, for better or for worse, drawing to a close.”

He goes on to identify factors such as the expanded areas of coverage within the hospital, expanded roles of anesthesia providers, change in reimbursement levels and continued cuts in Medicare as factors that threaten the local work group. The trend is for small practices to be taken over by for profit organizations. The defense may be the merger of your group with other small work groups in your geographic area forming a larger, cohesive group.

The following are advantages of merging small groups into one organization:

One cost for management of the entire consolidated group
Single cost for billing, HR, credentialing, privileges, recruiting
Larger group generates a larger database for QA
leverage in contract negotiation for supplies
Leverage to negotiate a better benefits package
Cross coverage between hospitals within the organization for vacation / sick coverage
Larger group has increased security and is at less risk for takeover by a for profit organization

As Chief CRNAs, it is essential that we are proactive and have a positive working relationship with Hospital administration. Those in an Anesthesia Team environment must have a seat at the table when management decisions are made. Working with the Department Chair for the common good is essential. Those in an all CRNA practice must remain vigilant to the threat of takeover and form strong coalitions with other CRNA groups and even consider maintaining your own identity while merging with larger team oriented groups. The threat is real. Make sure Hospital administration knows the value you add to the organization and maintain a high level of awareness related to a potential take over by an Anesthesia corporation.

Click here to read the full article by Tony Mira

Chief CRNA: CRNA vs MDA vs Capitalism

The controversy of CRNA vs. Anesthesiologist has been ongoing for decades. Because of the overlapping clinical roles, turf battles have been ongoing with both CRNAs and Anesthesiologists in fear that the other group will one day take over. Currently, several models of practice are in place in the United States. Although groups comprised solely of CRNAs or MDAs exist, the anesthesia team is a model commonly used. Even within the team concept, disagreement continues to exist related to staffing ratios.

In an excellent online blog post, Dr William Hass, MD, MBA (Anesthesiology Reviews; CRNAs and the Elephant in the Room) suggests that there is a third factor in the ongoing dispute over Anesthesia services management. Capitalism is a driving force in the US economy and healthcare is fertile ground for venture capital. Anesthesia management companies look past professional organizations and turf battles and evaluate anesthesia services as an opportunity to make money. Remaining in business is becoming more dependent on remaining competitive in the face of capitalism, not just fighting off the other group of providers.

Venture capitalists (Anesthesia Management Companies) offer the Hospital a contract for services. According to Dr Hass, once in charge, they seek to gain return on investment and commonly:

Evaluation the process
Improve the processes
Cut costs (in anesthesia cases this almost always staff costs)
Continue to improve process and reduce costs
Provide a return to investors

The blog post goes on to state that improved technology improves safety allowing lesser credentialed providers to accomplish the same task with a lower overhead to the company. For example, using the ultrasound for central line placement reduces the need for an Anesthesiologist to be involved in the task.

Dr Hall goes on to describe the evolution of change from physician to technician practice:

anesthesiologist only practices (no CRNAs/AAs); become
anesthesia care team model practices (fewer anesthesiologists, more CRNAs/AAs); become
collaborative anesthesia practices (fewer and fewer anesthesiologists, more and more CRNAs/AAs); become
CRNA only practices (no anesthesiologists); become
anesthesia professional light practices (fewer anesthesiologists, CRNAs, AAs, and more technology)

Overall, Dr. Hass presents an excellent blog posting and a must read for anybody involved in anesthesia management. A collaborative approach with both CRNAs and MDs working at the top of their license is required if the work group is to remain solvent and viable in the era of venture capitalism.

Click here to read the original blog post by Dr Hass. Return to PROCRNA to leave a comment.

Chief CRNA: Coordinated care; Reduce Cost and Improve Care

Managing health care dollars in more important now than ever in the era of healthcare reform. Limiting the use of extra supplies and running low gas flows is helpful but a coordinated approach involving the entire peri-operative team is needed to achieve maximum results.

Tony Mira of MiraMed Global Services posted a web based article detailing the contribution that anesthesiology makes to coordinated case management in the patient receiving total knee replacement. Tony states “Coordinated care” is one of the key concepts in health system reform. It is central to the cost savings and quality improvements expected from Accountable Care Organizations, value-based purchasing and the medical home.”

He goes on to identify three areas where the anesthetist can add value and reduce cost to the patient receiving a total knee replacement. According to Tony:

Coordinated management of patients. “First, we found that the health system with the lowest in-hospital complication rate had successfully developed and implemented an outpatient preoperative approach that emphasized multi-specialty evaluation of potential arthroplasty candidates, followed by an inpatient co-management approach involving anesthesia, internal medicine, and orthopedic surgery.”
Dedicated operating room team. “The benefit of a dedicated operating room team seems logical, given that total knee replacement is a procedure that requires staff to be familiar with multiple pans of instruments, machinery, and other technologies that are used to implant the knee prostheses. The total knee replacement surgeons agreed that working with an experienced arthroplasty team led to a smoother and faster workday.” The article does not mention anesthesiologists or nurse anesthetists as part of the dedicated OR team, but it seems reasonable that familiarity across both sides of the ether screen would be beneficial.
Management of patients’ expectations. “After having examined its data, one member health care system implemented a patient expectations management process, whereby patients were activated and engaged in the process of discharge planning before admission. The result was an initial reduction in length-of-stay, without a change in complication rates.”

By becoming active participants in the patient’s overall surgical experience we not only reduce the overall cost, but we improve patient satisfaction. CRNAs have a long history of excellence at the head of the table. It is time for us to become more actively involved in the entire process.

Click here to read the original article posted by Tony Mira and return to leave a comment.

Chief CRNA: Automated Recordkeeping

Automated Anesthesia Recordkeeping (AARK) has been available for over 20 years and is being used in more and more operating rooms across America and around the world. Despite becoming mainstream technology, AARK continues to generate controversy. Is the advantage of automatic physiologic data capture offset by a loss of vigilence by the anesthesia provider? Several studies have investigated the loss of vigilence related to AARK.

J. Allard, R, D. Zwoncaky et al published the results of a study in the British Journal of Anaesthesia addressing the issue of the effects of AARK on provider vigilence.

As stated by the Authors: “Proponents of this technology profess that automated record keepers reduce record keeping time thereby leaving more time for data interpretation and patient care . Moreover, others suggest that computer-generated records are more accurate and complete than those charted manually . On the other hand, critics argue that allowing the AARK to chart the vital signs removes the anesthetist from the information feedback loop and thereby has an adverse effect on vigilance . The main intent of this study was to determine the effect of an AARK on intraoperative record keeping time and vigilance.”

“Thirty-seven cases were charted manually and the remaining 29 were charted with a commercially available AARK. In order to evaluate vigilance, a physician examiner entered the operating room unannounced once during 33 of the manually charted cases and during 22 of the automatically charted cases and asked the anesthetist to turn away from the monitors and recall the current value of eight patient physiological variables. The examiner recorded the recalled values and also the actual current monitor values of these variables. The videotapes were reviewed and the anesthetist’s intraoperative time was categorized into 15 predefined activities, including intraoperative anesthesia record keeping time. We compared recalled and actual variable values to determine if the recalled values were within clinically relevant error limits.”

The authors conclude the use of the AARK did not significantly affect vigilance. They go on to state that it appears that in using an AARK, the provider reallocates intraoperative record keeping time from manual charting to dealing with problems.

Click here to read the complete study and return to procrna.com with your comments.

Chief CRNA: HHS to Audit for HIPAA Violations

Is Big Brother watching? You bet! The Office of Civil Rights from the Department of Health and Human Services has initiated a pilot program to audit Hospitals and assure that HIPPA standards are being met. Fines of up to $50,000 per occurence are in place and the auditors are ready to search for violations.

As reported by Drinker Biddle, ” The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has begun auditing covered entities for compliance with the Health Insurance Portability and Accountability Act (HIPAA) under the HIPAA Audit Program (Audit Program). The Audit Program is funded by the Health Information Technology for Economic Clinical Health (HITECH) Act and requires HHS to conduct periodic audits to ensure both covered entities and business associates are complying with the HIPAA Privacy and Security Rules, as well as all Breach Notification standards.”

The department of HHS has released information regarding the audit plan. The information provided by HHS includes information about who will be audited, how the program works and the timeline for auditing. Click here to review the information provided by HHS.

Share this information with your Chief CRNA colleagues and return to this page to make a comment and share your opinions.

Chief CRNA: CRNAs as OR Leaders

Across the Nation, Chief CRNAs are probably among the most under utilized group of talented health care providers. In addition to developing the work schedule and assuring that providers are present to support the posted schedule, Chief CRNAs know the strengths and weaknesses of the staff members and are in a unique position to guide the work flow to optimize patient care.

An original article Written by Sabrina Rodak details why Anesthesia providers are well positioned to guide the work flow in the operating room. Click here to read the original article.

Three experts on anesthesia services explain why anesthesia providers are best positioned to lead the operating room of a hospital.

1. “The perioperative leader should be an excellent communicator with a deep knowledge of OR management in order to successfully make the necessary changes required in carrying out the hospital’s overall goals. As anesthesiologists are present in the OR every single day, it is important that the anesthesia chair takes on this role to promote consistency across the board through this time of change,” says Leo Penzi, MD, executive vice chair of the department of anesthesia at North Shore University Hospital in Manhasset, N.Y., a member of the board of directors of North American Partners in Anesthesia and assistant professor in the department of anesthesiology at Hofstra North Shore-Long Island Jewish School of Medicine.

2. In a case study presented by Surgical Directions, a hospital recruited anesthesia providers to drive perioperative performance by granting them leadership positions and aligning incentives. The anesthesiologists received financial rewards for increasing patient volume and a stipend for fulfilling certain service standards, including increasing the availability of regional blocks, accommodating add-ons and participating in the OR’s daily huddle, a process in which the OR team discusses issues from recent cases and prepares for the next day’s schedule. Anesthesia leadership was an important element of the hospital’s success in perioperative services.

3. Proper anesthesia leadership in the OR is a key element of integrated delivery of care. Robert Stiefel, MD, a principal with Enhance Healthcare, defines this as “healthcare professionals and supporting facilities working towards one goal: optimized patient care that is more efficient and cost effective.” Integrated care in the OR depends on the coordination of hospital administration, OR staff, surgeons and anesthesiologists. Anesthesia providers’ involvement in all aspects of the OR makes them prime candidates to oversee this coordination. “Anesthesia providers are the most consistent component of the entire perioperative experience,” Dr. Stiefel says.

Chief CRNA: Delivering value

As Anesthetists, delivering quality anesthesia care is foudational to our work. As Chief CRNAs, we must ensure that developing and delivering value also includes delivering value to our Hospitals / organizations as well as our patients. The following information was Posted by William Hass, MD, MBA in Anesthesiareviews. Read the work below or click here to go to the original posting by Dr. Hass.

Developing and delivering value is part of business strategy. This concept can be used for an entire organization or any of its parts or functions. Usually the focus of the value proposition is externally toward customers, but a locally owned and operated anesthesia service cannot provide external value unless its support functions are providing internal value to the group.

Support services for a community anesthesia services can be incestuous. In-laws, family friends, and childhood acquaintances may be providing some or all of its support services including billing, benefits, accounting, and legal services. These inbred services are quite variable in cost and quality ranging from well-priced high quality services to high priced poorly functioning pseudo-payoffs. The value proposition of a group’s support service becomes important when there is subsidy request.

Why should a facility pay for your poor management?
Can you produce superior clinical services without adequate support?

This is where anesthesia management companies (“AMCs”) and physician practice management companies (“PPMCs”) have an advantage because they’re supposed to have a well-oiled administrative “engine.” Some do and some do not.

Their management may be centralized, but can provide excellent on-site management?
Can they get the “little things” and the not so “little things” right at a distant site?
Do they understand the culture of the facility from somewhere over the horizon?

Some PPMCs never really get anesthesia billing right because their experience is in other specialties. (Believe it or not, PPMC anesthesia billing can be significantly better than the billing services provided by the lowest bidder to a facility or multi-facility corporation.) Diligent review is required when selecting an AMC or PPMC.

There is an important problem. The progress and development of management service organizations (“MSOs”) are being slowed by nepotism. While an MSO’s advantages of lowering the overhead costs and expanding services are easy to understand, ending a combined friendship/business relationship with an in-law, family friend, and childhood buddy can be difficult, if not traumatic. If attention is not paid to the business aspects of its practice, the choices for an anesthesia group may be between amputation (of nepotism) to join an MSO or execution/extinction by an AMC or PPMC.

Survival and success in business requires difficult decisions. Anesthesia group leaders may need to make hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them.

Take Home Points:

Nepotism can slow the development of MSOs
MSOs can lower costs and improve group management
Survival and success in business requires hard decisions
Anesthesia group leaders need to hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them

Chief CRNA: OR Efficiency

The following information was provided by Jay Horowitz, candidate for AANA Region 7 director. With the current budget restraints and emphasis on efficiency, Jay has documented the inherent inefficiency of staffing ratios and the cost to the system. Read Jay’s comments, link to the supporting articles and return to procrna.com and offer your comments.

From Jay: This week an article appears in “Anesthesiology, The Journal of the American Society of Anesthesiologists, Inc.” (!!): Supervision Ratios that gets to the heart of the inefficiencies, waste and fraud inherent in “supervision” and “medical direction” models of anesthesia delivery. With an average 22 minute delay in multiple operating rooms several times a day, and an average Medicare reimbursement rate of $1.43/minute X 250 working days a year X 1000’s of US operating rooms, the money adds up awfully fast! So do the savings with greater CRNA utilization models validated in the recent Health Affairs and Nursing Economics articles with NO compromise in quality of care. Click here to read the ASA article.

I’ve been writing about these inefficiencies for some time now: Streamlining Anesthesia Care and how we might rationally fix the problem. We need to make sure that this kind of information is available to every state and national decision maker and other stakeholders. Click here to read an article from the Herald Tribune.

Read, enjoy, and return to make a comment

Chief CRNA: How to balance your life

Life has many demands at home and at work. As CRNAs, we are expected to provide first time value to patients with each encounter and we are expected to be available 24/7. As Chief CRNAs, we add the responsibility of department management to the clinical responsibilities. After a long day at the Hospital, we often go home to a long list of “must do” items leaving little time for rest and relaxation. Over time it takes a toll. As professionals, we must balance our lives if we are to avoid burn out.

In a blog posted on Rock the post, the author presents 7 key tips for bringing your life back into balance. The author concludes, “If you don’t have a sense of harmony between your personal and professional life, things can take a toll on you mentally and physically.” Taking simple approaches, like those listed in the blog, can help you get your life back in balance so that you can be productive at work and have fun with your family and friends.

Click here to go to the blog and read the 7 tips. Return to www.procrna.com and leave your comments.

Chief CRNA: Negotiate Your Salary

In business, everything is negotiable. As a Chief CRNA, you are responsible for not only setting the Corporate climate and enforcing the standards in your work group, but you also must attend to the business of Anesthesia. Being fairly and adequately compensated is foundational to being a loyal and engaged employee. Negotiation is essential both when you are being compensated and when you are hiring new people to work in your group.

An article written by Linda Jenkins on the salary.com web site details some of the elements of successful negotiation. In a negotiation, each party should fulfill the needs of the other party. In order to do so, you must know your strengths and resources and be able to respond to the needs of the other person. She stresses preparation prior to the negotiation.

Click here to read the article in a PDF format or click here to link to the article published on salary.com.

The Chief CRNA area of procrna.com is a forum for those interested in Anesthesia Department Management to share ideas. If you are a Chief CRNA, please use the guestbook on this page to let us know who you are and where you work. Please pass this web site along to your colleagues.

Clinical Forum: Evidence Based Management

“Show me the money” “Where’s the beef?” Health care delivery has evolved over the past few decades to evidence based practice. With the emergence of new drugs, techniques, and regulations health care providers are demanding “where’s the evidence”. In our quest for evidence to guide our medical resource management, we often overlook the fact that our personnel are the most important resource that we manage.

An excellent article by Vicki Hess, RN published in Hospital and Health News (Jan 19, 2012) encourages evidence based management as a tool for increasing employee satisfaction and productivity.

In the article, Vicki states that in recent years, scholars have studied and written about evidence-based leadership and evidence-based management. A logical progression in this thinking is evidence-based employee engagement. Employees are engaged when they are satisfied (they like what they do), energized (they put effort behind it) and productive (their work contributes to organizational goals). Leaders who are effective in engaging others are facilitators of the engagement process. Because no one external source can motivate an employee, providing an environment that encourages intrinsic motivators is critical.

The article continues with the concept that employee preferences are an important but often overlooked factor in department management. Engaged managers are in touch with employee preferences and make personal contact with employees on a daily basis.

She concludes that by adopting an evidence-based employee engagement approach that combines current engagement research, leadership insights and employee preferences, leaders can positively impact important business results without subtracting from the bottom line.

Click here to read the excellent article by Vicki Hess, RN