Tag: Chief CRNA

Resolution Reality

 

Resolution Reality

(The art creating change)

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

Follow @procrnatom on Twitter

 

Santa has completed his aerial delivery, gifts are in use and empty boxes are in the recycle bin.   With the new year rapidly approaching, attention quickly shifts from Christmas to football, New Year’s Eve parties, and finally to resolutions for the new year.   Ah yes, resolutions…so easy to make and so easy to break.   The good intentions put forth as the Rose Bowl is being played are but distant memories by Superbowl Sunday.  Resolve to make this the year that you keep your resolutions.  Here are 3 tips to get you going and keep you on track.

 

Work from the positive

Our brains work best and our chances for success are the highest when we make our own decisions are in control. Self-control is empowering and is most easily achieved when it arises from a positive point of view.  When making resolutions, visualize the new desired state and the positive benefit that you will experience once your goal is achieved.   Use proactive, empowering language with your internal dialogue and think in terms of what you can and will do with available resources.  Conversely, avoid a negative approach and thoughts about what you must give up or stop doing.   In his book, The Upward Spiral, author Alex Korb discusses the brain chemistry related to establishing new habits.  Korb says that electric pathways for the old habits never truly leave the brain but fade when they are not actively used.  Replacing old habits by establishing new behavior creates new pathways in the brain and makes the old habits irrelevant. Like learning any new skill, it is necessary to repeat the desired behavior many times to establish it as the new norm.

 

Work from your personal values

The most effective resolutions are a reflection of your inner character and the things that are most important to you.  So before you make them, take time to reflect on the values that guide your decisions.  Rather than trying to create a new you, the most effective resolutions are those that put you in alignment with the character traits that you value the most.   Instead of thinking, “I need to lose 50 pounds,” tell yourself, “I value my health and, therefore, I will alter my behavior to align with my value.”   Instead of thinking, “I need to be less critical,” tell yourself, “I value collaboration so I will align my behavior to create a collaborative environment.”   If you are having problems identifying what matters the most to you, click here for a list of personal values and use them as a foundation for making resolutions.

 

Focus on today’s behavior

New Year’s resolutions tend to be global statements describing the new way of life that you imagine in your future.  Your goal may be admirable however, jumping from A to Z can be overwhelming and cause you to abandon ship somewhere between B and D.   Keep the final outcome in mind, focus on today and identify behavior that supports the goal.  Step outside yourself and view your actions through the eyes of others by asking yourself   what they see when they observe you.   If your goal is to recover your health, how would others assess the decisions you made today?   If your goal is to empower others, what would it look like to those around you?  

 

Putting it all together

Resolutions must reflect your character.  They must be well thought out, bringing your behavior into alignment with your ideal self.  Resolutions that are made to please others or that do not reflect your values will fade before the January thaw. 

 

Once meaningful resolutions have been developed, make a list of behaviors that will support achieving the goal.  State your activities in the positive and align your values with your desired future state.  Rather than, “I can’t have sweets,” a better behavior would be, “I choose to eat only things with nutritional value.”    Once you have established a list of behaviors to support your goal, commit to 2-3 things on the list and start implementing them today.  At the end of each day, take time to reflect on your success, identify areas for improvement and keep notes in a journal.  When the new behaviors become habits, select another item from the list and make it a priority, then repeat until all the items are ingrained as new habits. 

 

Here is your self-dialogue for success:  My resolution for the new year is ___ and it supports my value of _____.    To achieve the desired change, I commit to ___ and ____ for the next 60 days.   Friends and family will recognize my commitment to change when they observe me ____.

 

Whether you are building an ideal self, a desirable workplace or an empowered team, start by identifying values and then aligning behavior in order to achieve success.  Choose resolutions thoughtfully and make a commitment to the behavior that will make you successful.   By establishing new habits, you will turn your imagined future state into today’s reality.

 

Tom is an experienced clinical anesthetist, educator, speaker and teambuilding coach.    Participate in the next values-based leadership webinar and take your team to the next level.   Contact tom@procrna.com for details.

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Flight Path to Patient Safety

By Thomas Davis, CRNA

Flight Path to Patient Safety

747With reimbursement and therefore job security tied to patient safety, it is incumbent on healthcare workers to become actively involved with the process of making healthcare safe for our patients.   Since the publication of “To Err is Human” in 1999, much attention has been given to patient safety, however, statistics still show that your luggage is safer in the airline system than your grandmother is in your local hospital. What can we learn from the Airline industry?

The 1970s were a particularly tragic time for commercial aviation.  In 1977 the collision of two 747 airliners on the runway in Tenerife killing 583 people followed by the famous airline crash in Portland in 1978, both due to poor communication, triggered a change in the way that the airlines conduct their business.   Mandatory training and implementation of Crew Resource Management changed the way flight crew employees interact with one another and ushered the way to a 5 year period with zero adverse incidents.   How did they do it?

Crew Resource Management is a set of training procedures for use in environments where human error can potentially have devastating effects. The focus of CRM is on interpersonal communication, leadership and decision making.   Our patients deserve the same focus on healthcare safety that they would receive as passengers on an airline. Here are some recommendations for taking CRM from the cockpit to the hospital.

All humans are fallible and susceptible to error…period. The greatest disservice that we can do to our patients is to believe that because we have special knowledge or skills, we are infallible and cannot make mistakes.   The airline crashes of the 1970s confirmed that the senior pilot did not have all the answers. Not only can we make mistakes but others around us can do the same.   It is only when we acknowledge our fallibility, and engage with our team in vigilance, that patient safety can be ensured. Regardless of your position on the team, know that you can make a mistake, and also know that you can fend off the consequences of mistakes that others are about to make.

All potential problems must be openly communicated in a positive manner that supports our coworkers.  In an environment focused on patient safety, sharing your concern with other team members should be welcomed and encouraged.   In addition, you must welcome and solicit the concerns and observations of others.   As healthcare professionals, we tend to get defensive when a co-worker points out a lapse in our delivery of a treatment.   With a focus on collaboration, we set the stage for patient safety as we reply, “Thank you,” rather than feeling threatened. Your reply sets a tone for other team members to welcome feedback.

All team members must be respected and heard.   Your knowledge and skills are respected. Your eyes and ears are open and your judgment is solid. Even so, remember that magicians make a living based on creating false perceptions.     What you see and believe may not be true. The TV program “Who wants to be a Millionaire” offers the contestants lifelines when they do not know the answer.   When statistics are reviewed “poll the audience” has the highest percentage of correct answers whereas “ask an expert” lags far behind in accuracy.   When the goal is patient safety, the collective wisdom of the group is more likely to be correct than the opinion of the expert.   Openly solicit and welcome the opinions of others regardless of their position on the team. Often, we can learn as much from people with lower status as we can from the recognized team leaders.

Problems must be anticipated and contingency plans must be in place. In his book Why Hospitals should fly: The Ultimate Flight Plan to Patient Safety and Quality, author John Nance recommends that healthcare workers view every patient as having a 50:50 chance of being harmed.   With a team committed to anticipating, detecting and preventing harm, the patient is best protected.   The team time out prior to a procedure is an opportunity for each member of the team to identify potential risk and offer a plan to prevent harm.   All too often the time out is not given the respect that it deserves and potential risk is not adequately discussed among the team members. As a patient advocate, use the time out as an opportunity to focus the team on patient safety.

Reduce distractions at critical times. Regulating the airline industry, the FAA requires the observation of “sterile cockpit” during the critical times surrounding takeoff and landing.   During this time, pilots must refrain from non-essential activities and conversation so that they can focus on the critical task at hand.   Stories of lapses in communication among distracted healthcare workers abound.   Distraction by idle conversation or use of social media during high risk times of patient care increases the risk of patient harm.   In the hospital setting it is not unusual for side bar conversations to take place while checklists are being read or timeouts are being done. As patient advocates, we must all share responsibility for the focus of the team to be on the patient at all times.

Value every member of the team.   On a recent flight, our boarding was delayed by an hour awaiting the arrival of a crew of flight attendants. Once we were on board, the pilot made an announcement. He apologized for the hour delay and said that we would be delayed a few more minutes…collective groan. He went on to say that the flight crew would be greater than 8 hours without food by the time we arrived at our destination.   He announced that he had ordered dinner for the flight crew and that we would be under way once the food arrived…collective cheer from the passengers. By looking out for the crew, the pilots believed that the passengers would be better served.   The lesson here is obvious. All too often we focus on our own needs and are not sensitive to the needs of others on our team.

As healthcare workers, our best opportunity for ensuring safety for our patients is to follow the example set by the airline industry and focus on communication and collaboration.   Hospitals across the nation hire experts to provide training on patient safety and yet the statistics often do not improve. When training is an academic exercise, nothing changes. It is only by applying the knowledge that improvement is made.   Use the lessons borrowed from the airline industry to ensure that your patients are safer your luggage.

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

Chief CRNAs are Team Builders


Chief CRNAs are Team Builders

By Thomas Davis, CRNA

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

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

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

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

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

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

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

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

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

 

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

Chief CRNA: Building a Safe OR Environment

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

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

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

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

Chief CRNA: Supervision and Billing Fraud

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

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

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

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

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

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

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

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

 

Chief CRNA: Disabled Alarms Cost Lives

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

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

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

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

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

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

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

Meeting Review: AANA Mid Year Assembly

Meeting reviewed by HP, CRNA, Texas

Meeting Date:  04/14/2013

Meeting location:  Arlington, VA / Washington, D.C.

Meeting presented by:  AANA

 

Meeting strengths / interesting topics & speakers:

Every year in April, AANA have their annual Mid-Year Assembly (MYA) in Washington D.C. I’ve had the privilege of attending MYA last year as a student and made a promise to myself and our profession that I will continue to be there every year! Experiencing the Capitol visits first-hand and seeing those in action to protect our profession — I believe whole-heartedly this is the most important AANA meeting! So what did we do??? For the “first-timers” at the nation’s Capitol, Sunday – Tuesday are full of featured speakers on prepping you on how to speak to legislators, what to expect at the Capitol, issues our profession is facing, and many more. Also, you break out to your region and speak specifically on your issues within the region. Capitol visits are scheduled on Tuesday and Wednesday. In the great state of Texas, we have 38 legislators. Out of the 38, we had 29 appointments (ladies, make sure you bring an extra pair of comfy shoes because there is a lot of walking in those stylish high heels otherwise!). The appointments were coordinated via our FDP – Jessica Appel. Most of the time you meet with the Congressman(woman) health liaison aid for about 15 minutes. You talk to them about the current issues pertaining to our profession — nondiscrimination language, SRNA education funds, etc. AANA have prepared folders to leave with them so they can review the individual topics discussed. Feel free to contact me at hpham827@hotmail.com for more information!

Overall value for the money:

Pros: 1. protecting our profession; 2. networking; 3. Cherry Blossom Festival; 4. Literally endless monuments and museums to go to; 5. Great place to bring your family

Cons: Very easy to get lost – I would suggest you hooking-up with someone who has been there before to “learn” the subway system.

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

 

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:

  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.