anesthesia management

Core Skills for Leadership

By Thomas Davis, CRNA, MAE, Lt. Col,(ret)

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The road that a person must travel to become a fully certified/credentialed member of a profession is often long and demanding. In addition to gaining a body of knowledge, critical skills and competencies must be mastered in order to gain entry into the career field and successfully establish yourself as a qualified member of the professional community. Effective leaders in a profession must also master essential leadership skills and competencies, and, as with professional proficiency, skillful leadership expertise can be learned.

Skillful leaders have a vision. Develop the ability to formulate a picture for your workplace of the future by acknowledging where you’re at related to where you want to be. Look for areas where minor changes can produce large results moving you toward the workplace you envision. For example, in my own experience, my vision has always been to create a preferred workplace, so I am constantly seeking ways to promote collaboration and mutual respect within the team to achieve our desired future work environment.

Skillful leaders use communication to motivate. Communication is the transfer of ideas and highly effective leaders take this skill one step farther. They share information in such a way that the listener receives information AND is inspired to achieve the goal. Using good humor, warmth and civility to create a sense of imperative as you communicate, helps establish a can-do attitude within your team

Skillful leaders commit. Meaningful change takes time and having the capacity for all-in commitment is both convincing and contagious. Anything less than a commitment to achieving the vision, regardless of the amount of time it takes to get there, will be viewed by your team as a passing fad. An all-in focus on achieving your vision for the team will inspire them to commit along with you.

Skillful leaders resolve conflict. When humans interact, occasional conflict is inevitable. The best leaders aren’t the ones living in a conflict-free zone. They’re the ones who quickly and confidently address issues and achieve democratic resolution. When faced with a disagreement, assemble all the parties, listen to all sides and discuss behavior/agendas in terms of how the vision and greater goal of the group are affected. The best solutions involve compromise.

Skillful leaders acknowledge and reward success. Whether the project is big or small, determine milestones and give recognition to those whose work was important in achieving them. Plan rewards for the team as a whole as well as for individuals and take the time to celebrate. Public recognition of success is motivating and makes your team eager to take on the next project.

leaders display personal integrity. You can’t achieve your goal alone and the quickest way to kill support from your team is to compromise your integrity. Honesty, transparency and fairness every day in every interaction establishes trust. Integrity is both a value and a skill and is absolutely foundational to leadership.

Administrative authority is more than a title. It requires core competencies, and, as in any profession, requires life-long learning. The best leaders learn from every daily interaction, constantly honing their skills at establishing a vision, communicating a plan, motivating the team and celebrating success. The workplace that you create for your team of tomorrow starts with the leadership skills you employ today.

Thomas Davis is a noted leader, educator, speaker and clinical anesthetist.

Build a preferred workplace. Join Tom and a group of healthcare leaders for the values-based leadership webinar. Click here for information.

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: 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: 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

Clinical Topic: Fluid optimization improves outcome

The clinical anesthetist is frequently challenged with the critically ill patient presenting for non-cardiac surgery. Often, they are in a weakened condition with very little physiologic reserve. It is essential that fluid administration is goal directed to optimize outcome. In this patient population, hypovolemia will lead to hypotension and related complications. However, excessive fluid administration will lead to heart failure. Therefore, fluid optimization is essential in the critically ill patient.

An essay published by the Edwards Company “Using Fluid Optimization to Improve Hemodynamics : FloTrac Sensor” makes the following statement:

Successful fluid optimization has been shown in numerous clinical studies to lead to improved patient outcomes, including reduced morbidity and shorter hospital stays
The studies are typically based on the physiological principles outlined by the Frank-Starling curve, which states that an increase in preload or volume will lead to cardiac flow-related improvement (e.g., better stroke volume) up to a certain point, after which the “law of diminishing returns” applies.

The essay goes on to state that there are 3 ways to assess fluid status:

Stroke Volume Variation (SVV): For control-ventilated patients, SVV has been proven to be a highlysensitive and specific indicator for preload responsiveness. As a dynamic parameter, SVV has the advantage of predicting whether a patient will benefit from volume before the fluid is given.
Passive Leg Raising (PLR): In situations where it is not possible to use SVV (i.e., during arrhythmias, when patients are not on control-mode of ventilation, or in patients at risk of complications from fluid loading), simply raising the legs has been proven clinically to act like a “self volume challenge” to indicate the patient’s status on the Frank-Starling curve. If the patient is fluid-responsive, SV will increase substantially.
SV Fluid Challenge: In the rare case when neither SVV nor PLR is feasible, the FloTrac system provides a highly efficient method for assessing fluid responsiveness via a standard fluid challenge. The administration of a small volume of fluid (e.g., 250-500 mL) and observance of the corresponding change in SV and/or CO can indicate whether further volume will improve cardiac performance.

Click here to read the essay

Maxime Cannesson MD, University of California, Irvine has published a full lecture complete with slides detailing the importance of goal directed fluid therapy during the intraoperative period. The lecture may be viewed on Youtube and will give the viewer a foundational understanding of optimizing fluid therapy. Click here to view the video.

To assist the anesthetist with goal directed fluid therapy, the Edwards Lifesciences Corporation has introduced the FloTrac Sensor and Vigileo monitor to clinical practice. These devices help the anesthetist to evaluate the patient’s fluid status with respect to the Frank Starling curve and make appropriate goal directed decisions with relation to fluid administration

Click here to go to the Edwards web site and learn about the FloTrac sensor and Vigileo monitor.

PROCRNA.COM would like to hear from anesthetists with experience using the Vigileo monitor. Please read the articles, view the video and return to share your comments with your colleagues.

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.

Clinical Topic: Predicting Sleep Apnea, the STOP-BANG scale

A foundational skill required of all anesthetists is airway management. With the obesity epidemic in our nation, obstructive sleep apnea (OSA) is becoming more common and presenting challenges to the anesthetist. Predicting which patients are at increased risk for OSA is an important part of the preoperative assessment. In a recent report published in the british J Anaesth, 2012; 108:5: 768-75, Chung F et all evaluated the correlation of the STOP-Bang scale to the occurrence of sleep apnea.

The STOP-BANG evaluation scale is simple to use. It consists of asking the patient yes or no questions regarding the following 8 items:

Snoring. Do you snore?
Tired. Are you frequently tired during the day?
Obstruction. Have you ever been told that you stop breathing when you are asleep?
Pressure. Do you have high blood pressure
BMI Is your BMI over 35?
Age. Are you over age 50?
Neck Circumference. Is your neck circumference over 40 cm?
Gender. Are you male? (should be obvious)

If the answer is yes to 3 or more of these questions, the patient is at increased risk for obstructive sleep apnea. The higher the number, the greater the risk. Of interest, a male over 50 starts with a score of 2 regardless of the other risk factors.

Click here to review the on line assessment tool published by thesleepmd.com

Click here to review the article by Chung et al. as presented by the Virginia Assn of Nurse Anesthetists.

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.

Clinical Topic: Ipad APP for Anesthesia Patient Teaching

Are you still trying to justify whether or not to break down and buy and iPad? As the use of technology continues to grow and develop, devices such as the Ipad are becoming important tools for the anesthetist. Writing for the on-line Barton Blog, author Ben Amirault describes a newly developed APP for the iPad which enables the provider to better educate patients in the pre-op environment. According to Mr. Amiralut, “An informed patient is a happy patient. Providers who can effectively communicate with their patients can expect high patient satisfaction scores and improved outcomes.”

The drawMD APP has diagrams and descriptions of common anesthesia related procedures and enables the provider to better explain the planned anesthetic to the patient and the family. The APP is currently free and can be obtained through the iTunes store. As described by the vendor “drawMD Anesthesia & Critical Care enhances doctor-patient communication by offering a new paradigm for explaining the complex issues surrounding the intensive monitoring and care provided by anesthesiologists and critical care physicians. In order to improve patient understanding of medical problems, drawMD utilizes the iPad’s unique interface to allow anyone to sketch, stamp, or type directly on the detailed anatomic images included in the application.”

Click here to read the blog post by Mr Amirault

Click here to view the APP at the iTunes store

Download it, try it, and return to PROCRNA.COM and leave a comment.

Clinical Topic: CRNA liable for poor communication

Despite the requirement for all health care workers to have annual training related to fire safety, hospital fires continue to occur. Operating rooms have an ample supply of each of the elements required to ignite a fire and the anesthetist must be vigilant to the threat of fire at all times.

Ann Latner, JD, writing for the online blog clinicaladvisor.com describes an interesting scenario in which a fire occurred on a patient during a procedure. To summarize:

Routine case (facial area) with patient receiving Monitored Anesthesia Care
Patient’s Oxygen sat drops and CRNA applies supplemental oxygen
Oxygen buildup under the drapes
Surgeon uses cautery
prep solution ignites and patient receives a facial burn

In addition to the burns, the patient required psychiatric follow-up and filed a law suit against the CRNA, the surgeon and the Hospital. At trial, each of the defendants had separate lawyers and each gave testimony. The Hospital affirmed that they had provided the required fire safety training. The surgeon testified that had he known oxygen was in use, he never would have used cautery. The CRNA was the only one of the three found to be liable for damages.

In the words of Ann Latner, the author, “Good communication is one of the best ways to avoid being a party to a lawsuit. Whether it is talking with your patient or a colleague, when making referrals, or even in chart notes (an important form of medical communication), having clear, direct, and open lines of communication can prevent unfortunate results. Mrs. H would have never been injured had Mr. D simply notified the surgeon of the oxygen use. No amount of testimony could make up for those few missing words during the procedure. Communication is key to better patient outcomes and to protecting yourself.”

Click here to read the full article and return with your comments.

Clinical Topic: Ultrasound Guidance in Anesthesia

For nearly 60 years ultrasonography has been in use in clinical medicine. Over the past few decades the use of ultrasonography in anesthesia has increased. As imaging machines improve in technology and the use of ultrasonography becomes everyday practice, patients are benefiting in terms of safety, comfort and cost. The number of hands on workshops to teach anesthesia providers the proper use of ultrasonography is an indication of the importance and popularity of the technique.

An excellent article by Jonathan P. Kline, CRNA, MSNA titled “Ultrasound Guidance in Anesthesia” and published in the AANA Journal (AANA Journal, June 2011, Vol. 79, No. 3) gives a comprehensive overview of ultrasonography in Anesthesia. The author describes the history of imaging, scanning techniques and use of the Doppler mode. Most important, the author describes the use of the technique for the following specific procedures:

Central line placement
Spinal and epidural placement
Regional blocks
Perivascular injections

This comprehensive review reinforces the knowledge of those already experienced in the use of the ultrasound and tweaks the interest of those who have yet to learn the technique. As ultrasonography becomes main stream in anesthesia practice, patient expect their provider to be skilled with the technique.

Click here to read the original articles and view the pictures.

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.

Clinical Topic: SSEP Not required for Cervical Spine surgery

As anesthetists, we are frequently called upon to administer safe and effective anesthesia to patients with cervical spine disease. Patients with symptomatic spondylosis or stenosis have symptoms of myelopathy and/or radiculopathy. The goal for the surgeon and the anesthetist is for the patient to be free of neurologic symptoms postoperatively.

Somatosensory evoked potential (SSEP) monitoring has been used to detect adverse surgical effects on nerve roots during scoliosis surgery. In recent years, SSEP monitoring has been used increasingly for other types of spine surgery, including decompression. This study was done to evaluate the value of the use of SSEP for Cervical Decompression surgery.

Dr. VINCENT C. TRAYNELIS, MD a Neurosurgeon from Rush University did a comprehensive record review of cases involving decompression of the Cervical Spine between 2000 and 2009. The results were published in J Neurosurg Spine. (2012 Feb;16(2):107-13. Epub 2011 Nov 11.) The records of 720 patients who had a total of 1,534 levels decompressed without the use of SSEP were reviewed. Specifically, the authors were seeking new neurological symptoms related to the surgery. They found 3 patients with new neurologic symptoms after surgery, 1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy. The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment.

The authors concluded that decompression of the cervical spine without intraoperative monitors is not only safe but offers a significant savings. In this case, the authors speculated that the cost of monitoring the patients who were reviewed would have been 1,024,754.

Click here to read the original abstract and return to procrna.com to leave 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

Feature SRNA: Judith Arrington

Name: Judith A. Arrington

Email address: judy.arrington79@gmail.com

Anesthesia School: NorthShore University School of Nurse Anesthesia

Graduation Date: August 24, 2012

CV: Click here to view CV

Preferred geographic region: Central TX

Major work as SRNA: Perceived Anxiety of the Nurse Anesthetist of
Parent Presence during Induction of Anesthesia.

Parent presence during induction of anesthesia (PPIA) is a fairly new concept that is being implemented in order to incorporate family involvement with the pediatric patient in the operating room. Previous studies have not researched PPIA’s effect on the anesthetic provider, specifically nurse anesthetists.

Objectives: This study examined the nurse anesthetist’s perceptions, attitudes, and emotions regarding PPIA; and possibly past experiences which can affect the anesthetic provider’s peri-operative anxiety possibly impacting the outcome.

Click here to read the abstract of this original SRNA work.

Special Interests: boating-that’s why I need to move so I can actually get some use out of our boat!

SRNAs…The future of our profession.
Available to join your group in the Fall of 2012.

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: 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: 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

SRNAs…The future of our profession. Available to join your group in the Fall of 2012.

SRNAs…The future of our profession.
Available to join your group in the Fall of 2012.