Category: Leadership articles

Timely and powerful articles to enhance leadership and build an empowered team.

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.

Chief CRNA: Are your Electronic Records Secure?

Patient privacy and the security of protected health information is a hot issue throughout healthcare from the primary physician’s office through diagnostic testing and including  records of hospitalization.  The Federal Government is urging health care workers to move to total electronic records and have initiated bonus money to encourage compliance.  However, the move to electronic records presents the challenge of security.

Writing for the on line blog The Anesthesiology Insider, Tony Mira states:

“Collecting, analyzing, reporting and storing electronic patient information present perhaps even greater HIPAA challenges than does the use of paper records, however.  Data entered on a computer can be copied more easily, more cheaply, more prolifically and even passively.  Once unsecured data are moved from the computer on which they are created to other media, manually or wirelessly, controlling the information becomes nearly impossible. “

A recent case settled with the Phoenix Cardiac Surgery Center demonstrates the cost of not securing protected patient information.  In this case, the center was fined $100,000 for their breach of security related to protected health information.

The Department of Health and Human Services Office of Civil Rights is actively investigating breaches of security related to protected health information.   A recent post on procrna.com discussed the HHS/OCR pilot program to investigate 20 health care institutions looking specifically for breaches in security.   Patients are being made aware of their rights to security of their records and the Office of Civil Rights has a web page with instructions for patients to file a complaint related to unsecured records.

As Chief CRNAs working in departments that either have automated record keeping or are moving in that direction, we must ask “where are the records stored and how are they secured?”  Any breach of security can be costly.

Chief CRNA: “Sterile Cockpit” and distracted workers.

Despite what the name suggests, a sterile cockpit is not an excessively clean area of an airplane. Rather it is a distraction-free cockpit–a time when the captain and crew engage only in flight-related conversation.

“The Sterile Cockpit Rule is an FAA regulation requiring pilots to refrain from non-essential activities during critical phases of flight, normally below 10,000 feet. The FAA imposed the rule in 1981 after reviewing a series of accidents that were caused by flight crews who were distracted from their flying duties by engaging in non-essential conversations and activities during critical parts of the flight. One such notable accident was Eastern Air Lines Flight 212, which crashed just short of the runway at Charlotte/Douglas International Airport in 1974 while conducting an instrument approach in dense fog. The National Transportation Safety Board (NTSB) concluded that a probable cause of the accident was distraction due to idle chatter among the flight crew during the approach phase of the flight.”    Wikipedia.

The Sterile cockpit philosophy has been applied to conversation in the operating room by several specialties. David J. Rosinski, MPS, LCP writes in J Thorac Cardiovasc Surg about the importance of protocol-driven communication between cardiothoracic surgeons and perfusionists noting that eliminating idle chatter improves safety.

Anesthetists, like pilots, are the busiest and need the most focus during take-off (induction) and landing (emergence).  Unfortunately, those are times when the room is full of commotion and idle chatter.  Gillian Campbell writing in Anaesthesia reported a study where video surveillance was assessed for distractions during critical times and found that distractions during emergence were common.

The following statement comes from the Oregon Patient Safety Commission; “While the sterile cockpit concept is associated with specific times in the flight process, in healthcare the concept is not only applied to specific times in a process (e.g., patient emergence from anesthesia), but also to specific activities (e.g., critical events in cardiovascular surgery) and specific places (e.g., a “no interruption” zone during medication preparation in an intensive care unit). According to Wadhera et al. (2010), “…effective communication can be structured around critical events rather than defined intervals analogous to the sterile cockpit, with reduction in communication breakdowns.”

As Health care professionals and anesthesia providers, we have an obligation to patient safety.  There is a clear need for us to take the lead in eliminating distractions in the operating room during critical times related to anesthesia.

What are your thoughts and experiences?

Chief CRNA: 360 Degree Evaluations

As the regulatory requirements continue to increase, the need for 360 degree evaluations has emerged as a part of JCAHO certification.  The concept is that those who do evaluations of their staff should also be evaluated by their staff.  In the case of CRNAs it means that the anesthetist should be evaluating the supervising Anesthesiologist.  Wilma Gillis from Madison Wisconsin is facing this issue in her department and wrote the following for CRNAs who read procrna.com.  Please use the comment box below to share your thoughts and experiences.

Hey friends,
I am canvassing a few department leaders preliminarily who work in management or in large institutions to see what your place of employment does about this “new” and controversial concept for implementing 360 degree evaluation of ALL team members.  Does your institution have a way for its CRNAs to evaluate the anesthesiologists?

To give you some background on this, twice we in our group decided this would be an important contribution to our concerns.  We wrote a tool over the last years and it was shut down by our administration due to absolute fury by several anesthesiologists. The aspects of performance included in this tool had nothing to do with evaluating their medical practice.  It revolved around things that were important to harmonious, collaborative practice.

Now JCAHO is mandating the idea after several years of hinting at it.  I am very interested in learning of your various departmental evaluation processes and tools.  If any of you have given evaluations to anesthesiologists, how did it go?  Repercussions?

Wilma Gillis.

Chief CRNA: CRNA supervision requirement reviewed by CMS

Physician supervision of CRNAs has been an ongoing topic of debate within the Anesthesia community for decades.  Under current law, CRNAs are required to be supervised by a physician unless the individual State “opts out” of the requirement.   To date, 17 States (Kentucky the most recent) have opted out of the requirement.

In a post on The Anesthesia Insider, blogger Neda Mirafzali, Esq  (Anesthesiologists Targeted in CMS’ Review of Existing Rules)  states that Health and Human Services (HHS) has been directed to review all existing rules related to health care and make them more effective, efficient, flexible and streamlined.   As a part of the review, CMS is looking at the issue of CRNA supervision as a condition of participation in the care of Medicare and Medicaid patients with the possibility that the supervision requirement be removed on a Federal level.

The blog post includes a brief but excellent review of who may supervise a CRNA and what constitutes supervision.  Changing the regulations would have no effect on the states that have already opted out of the requirement for supervision.  The remaining 33 States would, in essence, be automatically opted out by virtue of the rule change

Click here to read the original blog post and return to procrna.com to make a comment.

Chief CRNA: Corporate takeover of your Department?

As Healthcare workers, we watch the reports on the evening news about corporate takeovers in the business community and are relieved that we don’t have to worry about things like that in our profession, but are we really safe?   An post on Anesthesia Reviews Blog by William Hass, MD, MBA explains why investors with venture capital investing in and profiting from the Healthcare industry. He lists the following reasons for their new interest in making profit from Healthcare:

  • The stock market as a whole has barely risen in the past decade,
  • Bond yields are unusually low
  • With the global savings glut there is just so much capital chasing too few worthwhile investments.

Among the options are anesthesia management companies who undercut your contract to provide services.  Once they have secured the contract to provide services at your hospital (your job), all staffing and equipment decisions are made based on generating a profit for investors.  Sadly, the group of people who are not actively managing the business of anesthesia and maintaining contracts are the anesthesia professionals.  Dr Hass lists the following as things that we could and should be doing to protect our jobs and the quality of care offered to our patients;

  • Be politically active at the facility, community, state, or national level
  • Spend money and time for business education
  • Develop and utilize an effective human resource program
  • Understand anesthesia service and OR management
  • Give group leaders time to lead
  • Educate and develop the next generation of leaders

This warning by Dr Hass reinforces the experience that small anesthesia departments are having across the nation.  Now is the time for CRNA leaders to be proactive and solidify the relationship between the Hospital and the anesthesia group.  Failure to maintain vigilance in the front office may cost you your job.

Click here to read the original blog post by Dr Hass and return to procrna.com to make a comment.

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:

  1. 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.”
  2. 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.
  3. 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