A hospital's anesthesia department plays a key role in many areas of the facility's operations including operating room efficiency (on-time starts, recovery time, etc.), patient safety and clinical outcomes and patient, surgeon and surgical staff satisfaction. Despite this level of influence, it's not uncommon for hospital anesthesia departments to feel and even act slightly like outsiders. This is because in many hospitals — save academic medical centers — anesthesiology services are outsourced to a contracted anesthesiology group, rather than provided by employed physicians. Additionally, anesthesia groups may hold a number of contracts in a single market, meaning hospitals may not always have a dedicated anesthesiology team. While it's clear that anesthesiologists who are engaged and involved in hospital issues outside the OR are beneficial, it's not always the status quo. So, how do hospital executives engage their anesthesiologists in hospital leadership? It begins with selecting an anesthesiology chief and group that exhibit behaviors and characteristics that suggest a concern for the hospital's overall operations and success, not just the department's. Or, if your current group falls short, it's about giving them the impetus to change.
Despite the importance of non-clinical skills in anesthesia leadership, it often takes a back seat. "One of the resounding themes I hear from executives is I have a chief and they're clinically astute, but they don't have these other qualities or their leadership or culture is undesirable," says Dr. Koch. "It's important to understand, though, sometimes good leaders aren't born, they're made, and sometimes culture doesn't appear de novo but develops over time."
In these cases, hospitals should provide clear expectations for their anesthesia leaders, metrics to evaluate the group's progress and encourage further training and development in these non-clinical areas.
Dr. Koch recommends hospitals consider the following: "Is there a role with some of the incumbent team or leadership to transform the department to an excellent one?" He encourages hospital leaders to work closely with the anesthesia group to explore what little or big changes could move toward "an output of excellence."
"Sometimes what the hospital is looking for is someone to play Switzerland," says Dr. Koch. "Nurses often get caught in the middle, and in many cases, this can be avoided by an anesthesiologist clearly communicating with the surgeons."
Robert Cunnah, MD, chief medical officer at Desert Regional Medical Center in Palm Springs, Calif., and an anesthesiologist, concurs. "For any specialty, someone that is very skilled clinically is important, as [clinical skills] generate the respect of other clinicians," he says. However, he notes softer skills — diplomacy, conflict management and, perhaps most importantly, communication — are equally important. "There's no point of being the smartest person in the world if you can't communicate with the rest of the world."
The anesthesiology group must also extend its relationships beyond clinical department leaders and physicians to administration as well. "You have to have very good lines of communication with the hospital executive team. It's not an 'us' versus 'them' situation," says Dr. Koch. He recommends the anesthesiology chief schedule regular meetings with the hospital CEO, CFO, CMO and/or vice president of medical affairs and CNO to proactively deal with issues before they become negative.
"If a CFO needs an explanation for a line-item expense on a new anesthetic agent, these meetings can address that before it becomes a thorny issue," he says. Additionally, meetings with the CNO might uncover information from nurses about patients appearing to be in greater discomfort post-operatively, which could trigger the anesthesiology group to assess their practices. "It really gives the group a chance to fine tune the service and make it exemplary," says Dr. Koch.
"What I see a lot in the industry, is wanting to skip a meeting because it's at noon or not wanting bring in a per diem to cover the room; there's this mentality that I'll just meet with the CEO when I'm free," Dr. Koch says. "That's not a structured and formal approach that leads to positive outcomes. It's an ad hoc approach that frankly serves nobody well."
Roy Winston, MD, chief of anesthesiology at Kaweah Delta Medical Center in Visalia, Calif., agrees that successful anesthesia departments must do a lot more than just administer sedatives. "Anesthesiology is a specialty with unique needs for its leadership, even compared to other hospital-based disciplines," he says. "As physicians, you are taking care of the patient, but administration and surgeons both are customers as well. It's a unique challenge having basically three sets of responsibilities for each patient contact — that is, patient care, consultative services to other physicians and administrative duties for OR scheduling."
Dr. Cunnah believes anesthesiology's involvement in areas outside the department are critical to the department's success. "As a hospital-based specialty, hospitals are essentially [an anesthesiologist's] world. In order to be heard and represented within your world, it goes without saying you have to be part of hospital governance," he says.
Anesthesiologist involvement can range from participation on the governing board, if the opportunity becomes available, to contribution to various committees. "For anesthesia leadership to show interest to serve on the governing board, or to serve if asked, is a significant opportunity and responsibility because it gives them the opportunity to speak on behalf of the department to the whole medical staff and to employees and serve as an advocate for patient care," explains Dr. Cunnah.
On the committee level, anesthesiologists should get involved in committees that most directly impact quality and patient outcomes, or "picking out the venues best leverage to improve quality and outcomes," as Dr. Koch describes it. Hospitals, then, should insist the anesthesiology chief either serve on or thoughtfully delegate a colleague (perhaps another anesthesiologist, a certified registered nurse anesthetist or business office employee) to serve on the following committees: pharmaceutical and therapeutics, peer review, quality assurance, credentialing, pain management and trauma.
"The anesthesia group has to be willing to make a commitment to this, so there is non-clinical time to participate in these committees," explains Dr. Koch. "If you add up the number of hours anesthesiologists might spend participating in committees or meetings with hospital leaders, you may come up with a .25 to .5 FTE. The anesthesia department has to make the commitment to fund that, which involves the group recognizing that it adds value to the patient and to the hospital." Once the commitment is made, a group may need to bring in a per-diem or part time staff member to cover for the other providers.
So, how should anesthesiologists contribute once they join a committee? "Actively sit on those committees and listen to various stakeholders, and contribute to the strategic and tactical initiatives that flow from it," says Dr. Koch. "This engagement gives the anesthesia department a voice, not just in PACU but in the hospital proper, and often. Having that visibility and impacting the overall strategy and tactical direction demonstrates to hospital leadership and staff [the anesthesiology group's] commitment."
Dr. Koch believes that the importance of anesthesia taking an active role in hospital operations is underscored by the fact that many hospitals pay a subsidy for anesthesia services. "Like anything else, if you pay something you expect to get something for it," he says.
For example, an anesthesiologist might offer the labor and delivery service staff an in-service on the latest advances for intra- and post-partum pain management. And, the anesthesiologist must take the event seriously. "The educational efforts need to be highly structured, put on a calendar, professionally prepared with a PowerPoint or other deliverables," says Dr. Koch. "This is something that will have a resonating impact on the department and how it's perceived and will underscore it's a critical role across different areas of the hospital."
"In the old days, an anesthesiologist could show up, take care of the patient and be okay," explains Dr. Winston. "Today, if you don't ensure the position of the anesthesia department within the healthcare facility, you're falling short. Even though you may not be in the GI lab with those physicians or with the cardiologists in the cath lab [who both often administer sedation], you are charged with the overall responsibility for sedation throughout the hospital. In the past it was overlooked; today it must be actively managed."
Educational opportunities also exist outside the hospital walls and beyond clinical issues. "Hospitals are also part of the community, and depending on the talents and interests of the anesthesia group, there are many opportunities within the
community to have a voice and a presence,” says Dr. Cunnah. “Be part of the voice that helps mold healthcare in your local community, state or nationally. There are no limits or boundaries that confine people within anesthesia from breaking out and contributing to the larger picture of healthcare."
Involvement within the hospital and outside it will become increasingly important to success, predicts Dr. Winston. "We practice in an ever challenging and complicated environment where it's really important to have things well defined," he says. "It’s a huge mistake to have people who are building silos versus building bridges. Being a consultative anesthesiologist in the 21st century requires a full and wide range of presence."
"Anesthesiologists can greatly impact quality, not just clinical quality but the overall quality of the experience which is transmitted from the surgeon and staff to the patient,” says Dr. Koch.
Beyond clinical acumen
Hospitals should look for an anesthesia chief with clinical acumen who also understands the business side of medicine — accounting, management, marketing, technology, etc. — as well as the role of the department in the overall success of the hospital, says Marc Koch, MD, MBA, president and CEO of Somnia Anesthesia.Despite the importance of non-clinical skills in anesthesia leadership, it often takes a back seat. "One of the resounding themes I hear from executives is I have a chief and they're clinically astute, but they don't have these other qualities or their leadership or culture is undesirable," says Dr. Koch. "It's important to understand, though, sometimes good leaders aren't born, they're made, and sometimes culture doesn't appear de novo but develops over time."
In these cases, hospitals should provide clear expectations for their anesthesia leaders, metrics to evaluate the group's progress and encourage further training and development in these non-clinical areas.
Dr. Koch recommends hospitals consider the following: "Is there a role with some of the incumbent team or leadership to transform the department to an excellent one?" He encourages hospital leaders to work closely with the anesthesia group to explore what little or big changes could move toward "an output of excellence."
"Play Switzerland"
One important characteristic of strong anesthesiology leaders is good communication skills. This is particularly important in the sometimes hostile OR environment. If two surgeons are upset about a case being rescheduled, a proactive anesthesiologist can talk to them and explain why the change was made. If surgeons have all the information —perhaps the cancellation was due to an extremely urgent case — and receive this communication with respect, they are often understanding."Sometimes what the hospital is looking for is someone to play Switzerland," says Dr. Koch. "Nurses often get caught in the middle, and in many cases, this can be avoided by an anesthesiologist clearly communicating with the surgeons."
Robert Cunnah, MD, chief medical officer at Desert Regional Medical Center in Palm Springs, Calif., and an anesthesiologist, concurs. "For any specialty, someone that is very skilled clinically is important, as [clinical skills] generate the respect of other clinicians," he says. However, he notes softer skills — diplomacy, conflict management and, perhaps most importantly, communication — are equally important. "There's no point of being the smartest person in the world if you can't communicate with the rest of the world."
Proactive relationships
"Any good anesthesia chief has to be involved with all disciplines," says Dr. Koch. "If he or she does not have good relations with other departments that are closely linked to the OR — such as radiology and the emergency department, for example — it's a disservice to the patient and the situation." After all, strong care coordination can improve outcomes.The anesthesiology group must also extend its relationships beyond clinical department leaders and physicians to administration as well. "You have to have very good lines of communication with the hospital executive team. It's not an 'us' versus 'them' situation," says Dr. Koch. He recommends the anesthesiology chief schedule regular meetings with the hospital CEO, CFO, CMO and/or vice president of medical affairs and CNO to proactively deal with issues before they become negative.
"If a CFO needs an explanation for a line-item expense on a new anesthetic agent, these meetings can address that before it becomes a thorny issue," he says. Additionally, meetings with the CNO might uncover information from nurses about patients appearing to be in greater discomfort post-operatively, which could trigger the anesthesiology group to assess their practices. "It really gives the group a chance to fine tune the service and make it exemplary," says Dr. Koch.
"What I see a lot in the industry, is wanting to skip a meeting because it's at noon or not wanting bring in a per diem to cover the room; there's this mentality that I'll just meet with the CEO when I'm free," Dr. Koch says. "That's not a structured and formal approach that leads to positive outcomes. It's an ad hoc approach that frankly serves nobody well."
Roy Winston, MD, chief of anesthesiology at Kaweah Delta Medical Center in Visalia, Calif., agrees that successful anesthesia departments must do a lot more than just administer sedatives. "Anesthesiology is a specialty with unique needs for its leadership, even compared to other hospital-based disciplines," he says. "As physicians, you are taking care of the patient, but administration and surgeons both are customers as well. It's a unique challenge having basically three sets of responsibilities for each patient contact — that is, patient care, consultative services to other physicians and administrative duties for OR scheduling."
Committee involvement
Beyond working closely with other departments and administration, anesthesiologists should be proactively involved in hospital leadership through committees or other avenues. "Being proactive requires taking initiative [to serve the hospital]; it involves more than lip service and requires time, energy and effort," explains Dr. Koch.Dr. Cunnah believes anesthesiology's involvement in areas outside the department are critical to the department's success. "As a hospital-based specialty, hospitals are essentially [an anesthesiologist's] world. In order to be heard and represented within your world, it goes without saying you have to be part of hospital governance," he says.
Anesthesiologist involvement can range from participation on the governing board, if the opportunity becomes available, to contribution to various committees. "For anesthesia leadership to show interest to serve on the governing board, or to serve if asked, is a significant opportunity and responsibility because it gives them the opportunity to speak on behalf of the department to the whole medical staff and to employees and serve as an advocate for patient care," explains Dr. Cunnah.
On the committee level, anesthesiologists should get involved in committees that most directly impact quality and patient outcomes, or "picking out the venues best leverage to improve quality and outcomes," as Dr. Koch describes it. Hospitals, then, should insist the anesthesiology chief either serve on or thoughtfully delegate a colleague (perhaps another anesthesiologist, a certified registered nurse anesthetist or business office employee) to serve on the following committees: pharmaceutical and therapeutics, peer review, quality assurance, credentialing, pain management and trauma.
"The anesthesia group has to be willing to make a commitment to this, so there is non-clinical time to participate in these committees," explains Dr. Koch. "If you add up the number of hours anesthesiologists might spend participating in committees or meetings with hospital leaders, you may come up with a .25 to .5 FTE. The anesthesia department has to make the commitment to fund that, which involves the group recognizing that it adds value to the patient and to the hospital." Once the commitment is made, a group may need to bring in a per-diem or part time staff member to cover for the other providers.
So, how should anesthesiologists contribute once they join a committee? "Actively sit on those committees and listen to various stakeholders, and contribute to the strategic and tactical initiatives that flow from it," says Dr. Koch. "This engagement gives the anesthesia department a voice, not just in PACU but in the hospital proper, and often. Having that visibility and impacting the overall strategy and tactical direction demonstrates to hospital leadership and staff [the anesthesiology group's] commitment."
Dr. Koch believes that the importance of anesthesia taking an active role in hospital operations is underscored by the fact that many hospitals pay a subsidy for anesthesia services. "Like anything else, if you pay something you expect to get something for it," he says.
Educational efforts
Another way anesthesiologists can encourage cross-disciplinary relationships and communication is to offer education to other departments that work closely with anesthesia. "Education [within hospitals] often occurs in silos. Labor and delivery has in-services, ER and OR have their respective in-services," explains Dr. Koch. "Because anesthesia is so closely connected with all these groups, they should join or offer in-services. This, in a sense, helps increase the profile of the anesthesia department."For example, an anesthesiologist might offer the labor and delivery service staff an in-service on the latest advances for intra- and post-partum pain management. And, the anesthesiologist must take the event seriously. "The educational efforts need to be highly structured, put on a calendar, professionally prepared with a PowerPoint or other deliverables," says Dr. Koch. "This is something that will have a resonating impact on the department and how it's perceived and will underscore it's a critical role across different areas of the hospital."
"In the old days, an anesthesiologist could show up, take care of the patient and be okay," explains Dr. Winston. "Today, if you don't ensure the position of the anesthesia department within the healthcare facility, you're falling short. Even though you may not be in the GI lab with those physicians or with the cardiologists in the cath lab [who both often administer sedation], you are charged with the overall responsibility for sedation throughout the hospital. In the past it was overlooked; today it must be actively managed."
Educational opportunities also exist outside the hospital walls and beyond clinical issues. "Hospitals are also part of the community, and depending on the talents and interests of the anesthesia group, there are many opportunities within the
community to have a voice and a presence,” says Dr. Cunnah. “Be part of the voice that helps mold healthcare in your local community, state or nationally. There are no limits or boundaries that confine people within anesthesia from breaking out and contributing to the larger picture of healthcare."
Involvement within the hospital and outside it will become increasingly important to success, predicts Dr. Winston. "We practice in an ever challenging and complicated environment where it's really important to have things well defined," he says. "It’s a huge mistake to have people who are building silos versus building bridges. Being a consultative anesthesiologist in the 21st century requires a full and wide range of presence."
Big impact
In fact, as healthcare shifts from a paradigm of volume to one of value, it is almost necessary that anesthesiologists — and truly all providers — reach beyond their clinical duties (e.g., administering anesthetics) and even their administrative ones (e.g., managing OR throughput) and take part in helping move healthcare in a new, better direction. Anesthesiologists who provide this additional influence, and do so proactively, present a great opportunity to hospital leaders, especially those of organizations that are actively working to better coordinate and integrate care. Accordingly, hospital leaders should work with their anesthesia providers to ensure the group works with hospital leadership, other disciplines and impacts hospital strategy to the greatest extent possible."Anesthesiologists can greatly impact quality, not just clinical quality but the overall quality of the experience which is transmitted from the surgeon and staff to the patient,” says Dr. Koch.
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