ASC Focus – Team Up for Top Quality Care

How to get the best from your anesthesia provider.

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5 Essential Skills for Surgery Center Anesthesiologists From Dr. Thomas Wherry

5 Essential Skills for Surgery Center Anesthesiologists From Dr. Thomas Wherry December 16, 2011

6 Ways to Ensure Clinical Quality While Switching Anesthesia Providers

Thomas Wherry, MD, principal for Total Anesthesia Solutions and consulting medical director for Health Inventures, discusses six ways surgery center administrators can ensure clinical quality during a transition between anesthesia providers.

1. Educate your staff about the transition. Anesthesia groups and surgery centers part ways for a number of reasons, but chances are, the transition will not be entirely amicable, Dr. Wherry says. Whether the group is leaving for financial or clinical quality reasons, there may be more tension in the surgery center in the 30-90 days between the group’s decision to leave and its actual departure. For this reason, Dr. Wherry recommends that administrators communicate with surgery center staff about the transition. “These transitions don’t occur over night, and in that period of time, it’s important to do your best to educate your staff on the fact that a new group is coming,” he says. “I see so many centers that don’t clue the staff in and give them all the details.”

This doesn’t mean the administrator needs to communicate the exact reasons for the anesthesia group’s departure, Dr. Wherry says. Just make sure that staff know the dates of the transition and can come to center leadership with any problems. “The staff may feel kind of put in the middle of this,” he says. “Especially if these [providers] are their friends and they’ve worked with them for years, they need to understand that the surgeons have signed off on the change and it’s being done for the right reasons.”

2. Meet a few weeks before the start date to go over policies and procedures. Dr. Wherry says the center administrator should meet with the new anesthesia group a few weeks in advance to discuss the center’s policies and procedures. This particularly applies to pre-op screening processes and post-operative care processes. “If you’ve had trouble with the old group around pre-op screening processes, this is the opportunity to make changes,” Dr. Wherry says. “For example, the old group may have been too stringent on a type of patient or required too much information.” He says some surgery center leaders feel that their anesthesia group is not involved enough in the pre-op screening process, so this is a perfect opportunity to lay out expectations for the new providers.

The same is true for recovery care in the PACU, Dr. Wherry says. “Anesthesiologists need to clarify how patient discharge works,” he says. “What is their expectation of the recovery room, and what is their willingness to participate in helping to define the standards?” He says in the past, there may not have been clarity around when patients were ready to be discharged from the PACU. Those standards should be decided in this initial meeting.

3. Make sure the group is comfortable with all equipment, medication and disposables. Go over all the anesthesia equipment in the surgery center to make sure the new group is happy with the equipment. He says the two “big-ticket items” for anesthesia in a surgery center — the anesthesia machine and the monitors — will probably not be of concern to the anesthesiologists. “Most centers today that are fully licensed and certified have adequate equipment,” he says. He says while the anesthesia group may not be used to the monitors the surgery center uses, the providers will probably be able to adapt easily as long as the monitors have been checked and calibrated properly.

The new anesthesia group may have more requests when it comes to difficult airway equipment and equipment for peripheral nerve blocks, Dr. Wherry says. “You may have to invest in the difficult airway department,” he says. “The new group may have an expectation that a GlideScope is the standard of care, while the old group was comfortable with something a little less expensive.” Similarly, if your center performs a lot of orthopedic procedures, the new group may prefer an ultrasound technique.

The center should be confident that the group is comfortable with the anesthesia supplies on-hand and that the pharmacy formulary will meet their needs. “The center and the group should go through the anesthesia carts the evening before the transition,” Dr. Wherry says. “Avoiding any confusion the first day is of paramount importance.”

4. Do a comprehensive equipment and medication check the weekend before the start date. Dr. Wherry recommends asking your biomed provider to visit the surgery center the weekend before the group’s start date to perform a comprehensive equipment check. “That’s the time to go over everything and make sure nothing is broken, especially things that the old group was used to that [may not have been] working properly,” he says. “You want to make sure that everything is in proper working condition.”

Additionally, all open medications should be discarded and outdates checked. Dr Wherry highly recommends that tight controls on medications and processes to avoid ‘look-alike’ drugs be in place prior to the new group’s arrival.

5. Ask anesthesia to review the first week’s schedule. Prior to starting at the surgery center, the anesthesia group should review the first week’s schedule, Dr. Wherry says. At that point, go over how you will communicate about add-on cases and cancellations, and assign a point person from the group to answer any last-minute scheduling questions. You can also go over when the anesthesia providers are expected to arrive at the surgery center for each case.

6. Identify a lead anesthesiologist who can serve as a liaison. The anesthesia group should appoint one anesthesiologist to serve as a go-between for the group and the surgery center. “It would be really nice to identify a lead anesthesiologist who will be on-site most of the time and who would be willing to go with the administrator to surgeons’ offices and answer any questions they have,” Dr. Wherry says. The surgeons may have had problems with the previous anesthesia group’s techniques, and the anesthesiologist can address those concerns during the office visits.

Ins and Outs of 4 Anesthesia Provider Models: Thoughts From Dr. Thomas Wherry

Surgery centers have several options for anesthesia provider models, depending on surgeon preference, local anesthesia market conditions, surgery center size and revenue and federal or state regulatory requirements. Thomas Wherry, MD, founder of Total Anesthesia Solutions and medical director with Health Inventures, discusses the details of several anesthesia models — all-MD, all-CRNA, the anesthesia care team and the MD/CRNA model.

“When it comes to staffing an ASC, there is really no one perfect model,” Dr. Wherry says. “There is no cookie cutter approach. Each situation is unique and one must weigh all the pros and cons.”

All-MD model: Dr. Wherry says the all-MD anesthesia model is often seen in one- or two-room surgery centers. The small size of one- or two-room ASC makes it inefficient to staff with both MDs and CRNAs. However, he says the all-MD model is less common in larger ASCs because of the cost required to staff the center with multiple anesthesiologists. “An all-MD model can be cost-prohibitive in a larger surgery center, especially if the group is expected to provide a ‘floating’ anesthesiologist to cover pre-op and PACU,” Dr. Wherry says. “If you have four rooms, it’s really hard to have five MDs there.”

Clear-cut policies for patient handoff are important in any model, but particularly important when using a model that does not have a ‘floating provider.’ Surgery center leaders should also explore how the staff handles problems in pre-op or the recovery room. If there is any question about the patient’s condition, the anesthesiologist must remain with the patient in the recovery room, precluding him or her from starting another case.

This can be a source of frustration if there are frequent case delays. If any patient suddenly becomes unstable, the nurses in the recovery room must be fully trained to handle such problems. Dr. Wherry says all PACU nurses should be ACLS-trained for this reason.

All-CRNA model: An all-CRNA model allows certified registered nurse anesthetists to function independently without the assistance of an anesthesiologist. Certain states require CRNAs to be supervised a physician, but not by an anesthesiologist. “The surgeon could be considered the supervising physician,” Dr. Wherry says. “There are CRNAs that function independently in the ASC setting. This is a broad level of supervision and there is little to no risk of the supervising physician being vicariously liable. This model will run in to the same problem as the all-MD model: no ‘floating provider.’” Thus, the ASC must have all the proper protocols in place to handle any emergencies if the CRNA is tied up in the operating room.

Furthermore, Dr. Wherry says ASCs that use an all-CRNA model should be sure to discuss emergency care and transfer procedures, including what will happen if the patient has a “life or death” issue. Dr. Wherry adds that these issues should be discussed during the quality review process, and any complications should be tracked and analyzed.

Care team model: The “anesthesia care team model” or “ACT”  is a term coined by the American Society of Anesthesiologists to describe “anesthesiologists supervising resident physicians in training and/or directing qualified non-physician anesthesia providers in the provision of anesthesia care wherein the physician may delegate monitoring and appropriate tasks while retaining overall responsibility for the patient.”

According to Dr. Wherry, the care team involves the anesthesiologist in all key elements of anesthetic provision but allows CRNAs to administer the anesthetic themselves. “The anesthesia care team model is a highly supervised environment where the MD is involved in all aspects of the care,” he says. This means the anesthesiologist is present for pre-, intra- and post-operative processes and must be available at all times to consult with the CRNAs.

Dr. Wherry says for the care team model to work, the anesthesiologists must be invested in the model’s efficacy. If the anesthesiologist believes that only MDs should treat patients, he or she may create a hostile environment for the CRNAs and the patient. This type of anesthesiologist might also be a poor CRNA supervisor.

Anesthesiologists who use the care team model may have different billing requirements than anesthesiologists who participate in a less-strict MD/CRNA model. When billing Medicare for services, anesthesiologists must determine whether they should bill for medical direction based on their level of supervision over the CRNA. “Seven steps of supervision are required to meet medical direction, making it more of a billing term than a medical term,” Dr. Wherry says.

MD/CRNA model: The MD/CRNA model functions much like the care team model but with fewer supervision requirements, and it allows the CRNAs to function according to their full scope of practice, Dr. Wherry says. In this looser supervision model, the MD is present in the surgery center to supervise the CRNAs but may leave the operating room to attend a meeting, staff another room or answer another provider’s questions. “It depends on the physician’s comfort level, as well as the local and state requirements [governing CRNA practice],” Dr. Wherry says. This model marries the advantages of anesthesiologist involvement in patient care, the skills and scope of practice of the CRNAs and the cost efficiency of CRNAs.

Dr. Wherry says the MD/CRNA model provides larger facilities with more flexibility when the center needs to cover an extra room. If the center is consistently running three rooms and occasionally needs to cover a fourth room, the MD/CRNA model is useful because the center can choose between an MD and a CRNA for coverage. “If it’s all MD, you’ve got to find another MD,” he says. “With this model, you can pull one or the other, and you have a greater chance of finding someone to cover that room.”

Total Anesthesia Solutions, LLC Partners with Danville Regional Medical Center

“We are very excited about working with Danville Regional Medical Center and Chief Operating Officer Cherie Sibley,” said Steve O’Neill and Tom Wherry, M.D., Principals of Total Anesthesia Solutions, LLC. “Our dedication to achieving the optimal results for DRMC and its talented group of Certified Registered Nurse Anesthetists (CRNAs) and Medical Doctors (MDs) are paramount.”

“Dr. Wherry brings a wealth of experience to the table and combining that with our current anesthesia providers creates a strong team,” said Sibley.  “The partnership between TAS and DRMC came naturally as both are dedicated to not only making a difference in their community, but in the medical world as well.  Both parties look forward to the future, building and maintaining a strong relationship and a creating a positive influence in the field.“

About Danville Regional Medical Center

Danville Regional is the leading medical center in the Dan River Region of Virginia and North Carolina, providing open heart surgery, spinal surgery and advanced cancer treatment.  Approximately 140 physicians are on the medical staff.  The medical center employs approximately 1,200 people.  For additional information, visit www.danvilleregional.com.

About Total Anesthesia Solutions, LLC

TAS is a clinically driven, experienced company committed to providing strategic solutions for issues relating to anesthesia care. TAS will be your partner in working out a winning resolution that will ensure long-term success for all vested parties. For more information about TAS, visit www.totalanesthesiasolutions.com, or contact Megan Whitlow, VP Client Relations & Business Development, megan@tasglobal.com, 410.455.0878

4 Tips on Difficult Airway Management

http://www.beckersasc.com/anesthesia/4-tips-on-difficult-airway-management.html

10 Steps to Prepare for and Respond to Anesthesia Subsidy Requests

It is likely only a matter of time until your hospital is asked to subsidize its anesthesia provider, if it hasn’t already faced this request. Anesthesia groups are more regularly asking hospitals for subsidies, and hospitals are taking these requests more seriously than they used to and are starting to take action around them, says Thomas Wherry, MD, principal of Total Anesthesia Solutions. Here are 10 steps from Dr. Wherry which will help your hospital prepare for this request, know how to respond to this request and ensure your hospital maximizes the benefits of this financial arrangement. Editor’s note: Please assist Dr. Wherry’s research of hospital anesthesia stipends by taking a short survey found here.

1. Engage the anesthesia group
Anesthesia providers ask for subsidies when they are struggling financially. Unfortunately, as Dr. Wherry notes, many hospitals do not have a good understanding of the success or struggles of their anesthesia providers, so the hospital does not explore ways to ensure that their anesthesiologists are seeing strong returns on their work.

“I would strongly recommend that the administration of any hospital should develop a relationship with the anesthesia group,” he says. “It sounds obvious, but many are not doing it, which is surprising since anesthesia is such an important component of the hospital.”

Management should identify a point person within the anesthesia group and start a regular dialogue on how the group is performing and its experience at the hospital. Include your anesthesia provider in on discussions about scheduling efficiency and allocation of block times, for example, as these components of your operation can have an effect on the anesthesiologist’s financial performance.

More and more hospitals are looking more closely at their own efficiencies in the OR to help anesthesiologists, Dr. Wherry says. One of the biggest problems for anesthesia groups at the hospital is downtime. Many hospital ORs do not run efficiently, and groups are often asked to cover many more rooms than are needed for actual cases.

“In the past, the hospital wasn’t paying for the group to cover those extra rooms, the group was,” he says. “The only thing they were paying for was nurses but they could be assigned to other tasks. Once you start paying anesthesiologists to cover those rooms, you need to really look at efficiencies. Many hospitals are bringing consultants and experts to help deal with underutilized block time and developing a more vertical schedule.”

2. Reward your anesthesiologists
Hospitals can make a number of inexpensive gestures to show appreciation for their anesthesiologists, according to Dr. Wherry.

“Little things, like providing an office with Internet access, can go a long way,” he says. “I’ve never understood why hospitals don’t provide some sort of incentive or bonus program for the group for hitting certain performance measures, such as patient or staff satisfaction.”

A hospital may want to consider naming one of its anesthesiologists as the operating room’s medical director and paying a small stipend for the work. This is likely to help develop a closer relationship with the anesthesiologists, which may encourage discussions on important issues such as financial challenges before problems turn into crises.

3. Require full disclosure
It is perfectly reasonable to ask an anesthesia group requesting a subsidy to fully disclose its financial records so you can understand why the subsidy is necessary.

“I’ve seen stipend subsidies given when the group hasn’t really disclosed what the problem is — they don’t want to show their finances,” Dr. Wherry says. “I don’t know how you can ask for hundreds of thousands of dollars without that.” Hospitals should expect more transparency and force the anesthesiologists to demonstrate the need by opening their books.

It is critical that your hospital involve its accounting team or find a third party who understands anesthesia billing and management to review the group’s financial records. This will put you in a place where you can truly understand the group’s position.

4. Consider a third-party representative
With hundreds of thousands of dollars potentially tied to a stipend, it is very easy for emotions to run high and the relationship between the facility and anesthesia group to become strained. One option to help prevent this is to find a third-party representative to come in and help determine a fair stipend and any parameters the group must meet to receive the stipend (see step 8).

5. Understand the factors that should influence stipends
The subsidy that is provided should not just be based upon the group’s revenue. If the group is failing to capture the reimbursement it deserves or is overspending, it is not the facility’s responsibility to make up the group’s shortcomings.

A third-party representative — or someone within the facility with knowledge of providing anesthesia and perhaps running a group — should assess whether the anesthesia group’s subsidy request is appropriate based on the group’s internal efforts to maximize its revenue and minimize costs. Some questions Dr. Wherry suggests assessing about the group include:

  • Is the group’s productivity appropriate?
  • Is the group being asked to cover underutilized locations?
  • Is the group staffing efficiently?
  • Is the billing appropriate?
  • How aggressive is the group at pursuing good third-party contracts?
  • Is the call (for hospitals) appropriate?

“All of that information should impact the subsidy; all of those questions need to be answered in determining the subsidies. I think sometimes organizations don’t look at that the full picture,” Dr. Wherry says. “[Some groups] say, ‘here is our budget, here’s how much we’re making and you need to make up any difference.’ That’s a really dangerous approach because then it almost becomes an entitlement. To avoid the entitlement mentality being adopted by your group, consider labeling the financial support mission support versus a subsidy or stipend. Mission support implies a collegial partnership.”

6. Support anesthesiologists in payor negotiations
If your anesthesiologist provider signs better contracts with payors, it will help reduce subsidy requests. More hospitals are assisting anesthesiologists in contract negotiations payors, Dr. Wherry says.

“They’re trying to work and support the group during sometimes very contentious negotiations whereas in the past they would have rarely or never got involved,” he says.

7. Avoid one-way deals
Stay away from case/volume guarantees and money guarantees, Dr. Wherry suggests.

“What’s the incentive for the anesthesia group to be aggressive in billing and not to cancel cases inappropriately?” he asks. “Guarantees become a disincentive. You don’t want to enter a situation where you agree to make the anesthesia group whole every month. That’s where I’ve seen hospitals get burned. For instance, the anesthesia group may need $200,000 to make the budget every, and if they only make $150,000, the hospital must cover the rest. Where is the incentive for the group to improve collections, lower costs or get better contracts?”

This is why it is beneficial to tie the stipend or subsidy to the group’s performance, Dr. Wherry says.

“I would strongly encourage any hospital — when entering into an arrangement — to try to get something in return, whether it is showing up on time, high satisfaction, good outcomes, participation in committees or accreditation help,” he says. “It really should be tied into performance.” Some hospitals have agreed to subsidy contracts with anesthesia providers that sets aside a portion of the subsidy and ties it to meeting performance measures.

8. Determine fair and attainable measures
If you are going to tie the subsidy to performance and meeting requirements, both parties need to agree to the performance measures the group must meet and what will happen if they are met or not met. These performance measures should be measurable, attainable and not too easy.

Reasonable performance measures may include:

  • showing up to the facility on time;
  • staying in the post anesthesia care unit until the patients are stable;
  • committee involvement;
  • providing in-service training to staff;
  • patient or staff satisfaction (with surveys that include a rating for anesthesia); and
  • surgical outcomes such as postoperative nausea and vomiting rates.

Once the measures are agreed upon, you will want to put them in a well-defined contract. Also, depending upon which performance measures are chosen, the anesthesiologists would likely appreciate an invitation to become involved with the hospital’s efforts to improve efficiency in these areas.

Editor’s note: To learn more about performance metrics for anesthesia stipends, read “Anesthesia Stipends: Performance Metrics Increasingly a Part of Stipend Agreements.”
9. Keep subsidy contracts short-term
Subsidy contract terms should run between six-month and one-year terms. If the hospital is ramping-up and adding an operating room, consider a six-month term as it will give both sides an opportunity to revisit the contract after several months of use of the new room. This term may also help serve as motivation for your surgeons.

The longest subsidy or stipend contract you will probably want to sign is one year, with a review process that starts about three months before the contract expires, says Dr. Wherry. This will allow ample time for a complete review of the hospital operating room’s and the anesthesia group’s operations and profits. If the hospital’s operating room budget is performing well, and the anesthesia group is benefiting from this growth, the hospital may want to explore whether a subsidy is still necessary.

10. Know your alternatives
Depending upon the relationship you have with your anesthesia provider, a subsidy request can come at any time — and unexpectedly. In addition, the provider may expect an answer fairly soon after informing you of the need for a subsidy. It is worthwhile to regularly research alternatives for your anesthesia provider just in case you cannot satisfy a request for a subsidy and ultimately lose the service of your current group.

“Once subsidy approaches 30-40 percent of the group’s revenue, employment arrangements begin to enter the picture,” a trend that is becoming more common, says Dr. Wherry. However, moving to an employment model can have its drawbacks and third-party involvement is highly recommended.

Editor’s note: Please assist Dr. Wherry’s research of hospital anesthesia stipends by taking a short survey found here.

Learn more about Total Anesthesia Solutions.

Original Article found at beckershosptialreview.com:
http://www.beckershospitalreview.com/hospital-physician-relationships/10-steps-to-prepare-for-and-respond-to-anesthesia-subsidy-requests2.html

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5 Reasons Anesthesiologists Will Cancel an ASC Case

Dr. Wherry describes five common reasons during these two periods when anesthesiologists may cancel a case. Click to read the November 04, 2010 interview from Becker’s ASC Review.