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Delivering integrated care in the operating room will become increasingly important as hospitals work to improve quality and reduce costs. Anesthesiologists play a central role in OR care and have oversight of the entire perioperative experience: preoperative patient preparation, intraoperative care and post-operative care, including pain management. By creating more effective relationships with anesthesiologists, hospitals will see gains in patient care, efficiency, profitability and integrated service delivery.
Current anesthesia models
Current models of anesthesia service leave hospitals with one of two choices: outsource to a local group or national anesthesia management company, or directly employ anesthesia providers. While the first option gives hospitals access to skilled anesthesia services, the downside can be higher overhead and misaligned incentives. Having an outside group deliver anesthesia services "is a more challenging platform for integrated OR delivery," according to Howard Greenfield, MD, principal of management and consulting firm Enhance Healthcare.
In addition, an outsourced team often distances anesthesia providers from hospital administration. "When you outsource, you are introducing an intermediary between the hospital and the providers delivering a service," says Robert Stiefel, MD, also a principal with Enhance Healthcare. "This can create a barrier to streamlined, efficient, affordable care in the OR. Outsourced groups have a business to run with their own objectives, processes, financial goals and internal margin and profit requirements."
The second option — a directly employed anesthesia model — is currently used by approximately 20 percent of hospitals in an effort to, reduce costs eliminate the intermediary and control anesthesia policies, according to Dr. Greenfield. However, in many cases "hospitals lack experienced, professional anesthesia practice management resources," he says.
New anesthesia model
Drs. Greenfield and Stiefel promote a new anesthesia co-management model they have created in which the hospital employs the anesthesiologists and engages a team of anesthesia management professionals who enhance the "in-sourced" arrangement. The model offers hospitals customized management support uniquely designed for the specialized fields of anesthesiology and OR management, they say. As anesthesiologists with extensive clinical and management experience, Drs. Greenfield and Stiefel have the ability to understand both sides of the complex relationship between the hospital and anesthesia providers. "With a co-managed anesthesia employment model, hospitals receive the best of both worlds — more control, lower expenditures and a long-term partnership assuring expert resources," Dr. Stiefel says.
Drs. Greenfield and Stiefel share six key strategies they use to integrate the anesthesia group into the hospital surgical delivery system via their co-managed employment model.
1. Support anesthesia leadership. Proper anesthesia leadership in the OR is a key element of integrated delivery of care. Dr. Stiefel 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.
Dr. Greenfield echoes this sentiment: "A proactive anesthesia physician leader will help coordinate the entire perioperative process by effectively becoming the OR's medical director. An anesthesia leader must possess excellent clinical skills as well as leadership skills to effectively work with all stakeholders — patients, administration, surgeons, OR nursing and anesthesia peers." Anesthesia leaders, however, need access to the tools, support and mentoring needed to define expectations, establish a culture of service and develop those anesthesia leaders.
2. Align incentives. Successfully integrated OR care is supported by incentives which are aligned with anesthesia providers. Metrics are important tools for hospitals to achieve this alignment in employed models. The metrics must be related to areas that anesthesiologists can directly affect, quality of care, OR throughput and customer service. By tying anesthesiologists' performance to their compensation, hospitals will begin to realize greater OR performance. The strategy motivates employed anesthesiologists to work towards common stated goals. Linking compensation to meaningful performance metrics can help hospitals move towards "a more transparent, efficient and quality-focused system in the new healthcare reform era," says Dr. Stiefel.
3. Track metrics. Gathering data on anesthesiologists' performance is useful not only as a powerful incentive, but in analyzing and developing proactive strategies to increase OR efficiency. "As the emphasis begins to shift to proof of quality, efficiency and quantifiable data, we have developed dashboards and methods to track anesthesia output and performance," Dr. Stiefel says. Some useful metrics include pre-surgical patient evaluations, first case on-time starts, as well as patient and surgeon satisfaction.
4. Encourage a customer service philosophy. Successful anesthesia programs also identify customers and develop a customer service culture, say Drs. Greenfield and Stiefel. For all anesthesia groups, patient care is their priority, but surgeons, OR nursing and the hospital are direct customers. "In employed models, the goal is to align anesthesiology services with the expectations of key customers," Dr. Stiefel says. This alignment helps the OR team deliver more integrated patient care.
Successful hospital-employed anesthesia programs incorporate procedures to ensure surgeons' needs are met. Anesthesia providers perform this role in numerous ways by evaluating all patients prior to the day of surgery, ensuring timely first case starts, facilitating quick turnover and management of postoperative pain. "Not only is it important to surgeons, but it is also a metric which payors are increasingly linking to reimbursement," says Dr. Stiefel. Additionally, clear communication about scheduling, patient care and other issues contribute to greater satisfaction among surgeons.
5. Standardize processes. Implementing standard policies is another way to establish and support a culture of customer service. By aligning processes with surgeons' expectations, hospitals are better able to provide safe, high-quality care and streamlined workflows. "Hospitals need systems where anesthesia providers, surgeons, support staff and other professionals are all following an integrated playbook rather than functioning as independent parts. At a high level, this is what integrated care strives for and anesthesia plays a central role," he adds.
Dr. Greenfield and Stiefel say standardization is easier in a co-managed hospital-employed anesthesia group than in most other anesthesia contractual relationships. A co-managed model gives the hospital more direct control and the expertise to effectively manage anesthesiologists. In many outsourced vendor groups, individual physicians "do their own thing clinically and operationally, and may differ dramatically in their approach, which contradicts the objectives of integrated care," according to Dr. Stiefel. In employed models, facilities should standardize many perioperative anesthesia processes in order to maximize performance on the day of surgery.
6. Optimize business practices. Currently, more than 80 percent of hospitals pay subsidies to support the anesthesia coverage they need, according to Drs. Greenfield and Stiefel. Drivers of these subsidies include inefficient anesthesia staffing models, a surplus of anesthesia locations, poor billing and collections practices and often lack fair-market-value compensation.
For hospitals seeking better ways to manage OR resources and performance, it is time to examine the delivery of anesthesia services to patients and surgeons. In the appropriately co-managed employment model, hospital executives and anesthesiologists can become powerful allies who, together, position the hospital for greater efficiency, improved patient care and higher profits.
Learn more about Enhance Healthcare.
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