A successful anesthetic outcome for the department of anesthesia can still be a customer service disaster for the hospital. Understanding and appreciating this distinction is the key to understanding the role of patient satisfaction in a hospital. Ideally, a medical group should provide a service that far surpasses the individual contributions of its members. Professionals have a tendency to assume the competency and professionalism of other professions.
There is no greater challenge than the need to monitor or discipline another professional. Drug diversion is just one of many problems that can haunt even the best of departments but the most common and difficult problems are attitudinal. Professionals are expected to maintain a consistent attitude and demeanor. When they decompensate under stress, the repercussions are significant and can completely undermine the credibility of the management of the practice. By the same token, unhappy providers or those whose expectations cannot be met can also have an adverse impact on the overall perception of the department.
No department can afford to have team members who are not percent committed to the success of the team. Anesthesia groups with the best reputations and most secure futures are those that have dedicated themselves to anticipating the specific customer service expectations of all their customers.
Such groups make it a point to monitor the level of satisfaction at every level of the institution. Sometimes the process takes the form of surveys and statistical analysis but more often it is the result of regular communication and inquiry. They appreciate the value of any and all feedback and know that there is no substitute for a consistently aggressive approach to customer satisfaction. They place great value in committee participation. All feedback is taken seriously and discussed at the highest levels of the organization. But this is only the beginning; environmental scanning and the triaging of customer input defines the baseline.
True value creation requires a knowledge and understanding of customer desires and expectations that exceeds that of the customers themselves. This is what defines the sizzle to the solution. Americans in general are impatient for the latest technology or the best strategy. Hospital administrators are no exception. To appreciate the importance of this concept is to understand the success of a Google or an Apple.
In both cases the companies distinguished themselves by providing services or technology that allowed their customers to do new and more things, do them faster and be more productive. Any anesthesia provider or group practice that does not believe it can significantly contribute to the growth and success of the facilities it serves has already lost the battle and probably the war. The opportunities are virtually limitless for those committed to defining and executing them, but five are worth specific consideration as starting points for a serious value added strategy.
When asked what opportunities there are for an expansion of services to a given facility, most anesthesiologists will suggest some aspect of operating room management. Few anesthesia practices actually play a major role in O. The exceptions, however, are quite notable. Years ago when Dr. Mark Rogers assumed the chair at Johns Hopkins he negotiated for Dr. Robert Donham to take over the management of the operating rooms using a scheduling program that had been designed by and paid for with department funds. Julian Gold and Ronald Wender also made a proposal to the management of Cedars-Sinai hospital in Beverly Hills that also gave the department considerable management oversight for all operating room staff and operations.
There are numerous other examples, starting with the work done by Dr. Franklin Dexter and colleagues at the University of Iowa. Michael Roizen also has written about the potential role of anesthesia in this area. The fact is that most private groups simply use this information to enhance collections and not to improve operating room efficiency or effectiveness. While this is starting to change the role of anesthesia in the management of operating rooms is still in its infancy. The irony is that by ceding responsibility for the management of the ORs to others anesthesia is foregoing an invaluable opportunity to directly manage the factors that determine provider income and lifestyle.
A commitment to playing a more active role can clearly prove to be a win-win situation for groups with the tools and commitment at avail themselves of the opportunity. But there are other possibilities as well.
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Why should the hospital pharmacy play such a significant role in drug management, for example? Is this not also an area where anesthesia brings significant expertise and experience to the table? It is probably true that few anesthesia providers have a good handle on the true economics of drug costs and usage, but this is information that should be readily available given a nominal investment in time and the formulation of some simple budget templates.
It is not uncommon for hospitals to be open to cost-sharing arrangement for savings in drug costs. An active role in this area would be consistent with the current interest in co-management options. Anesthesia also brings considerable expertise to the hospital in the area of technology management. The current focus on ultrasound is just one of many examples of a new technology that has been carefully evaluated and ultimately implemented by the anesthesia department but there are so many others.
Why should anesthesia not play an active and aggressive role in helping a facility define state of the art operating room technology? It is true that some will ask what is the financial benefit to the department or group, but often the potential value should be measured not strictly in terms of short-term return on investment, but long-term interdependence and partnership.
In other words, most businesses make certain investments intended to secure or maintain good customer relations, and to emphasize their value to the institution. Risk management is another area of increasing interest to anesthesia practices as the specialty asserts its role in defining pay for performance measure P4P. It is safe to say that with all the new programs being developed and implemented to capture clinical data throughout the entire continuum of anesthesia care that anesthesia has a significant armamentarium to offer.
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Why should those who have been so well trained to assess individual patient risk factors not step up to the plate to share their experience and insights? Ultimately, anesthesia plays the definitive role in creating a positive surgical experience. The sad truth is that all the hard work and discipline that goes into managing patients safely through the trauma and abuse of surgery with such consistent outcomes goes unnoticed.
Rare is the hospital with a strong reputation for advanced surgery that does not rely on sub-specialty trained anesthesiologists and in many cases nurse anesthetists to achieve the results they do. Again the role of anesthesia is just starting to be defined, but the potential would appear to be nearly unlimited. Perhaps it is time for anesthesia to step out form behind the curtain and take some of the credit for material improvements in surgical morbidity and mortality.
This short list of opportunities will no doubt inspire consideration of others. The core issue is not what services anesthesia groups are qualified to offer but rather the commitment to redefine the role of anesthesia in the hospital. As in so many businesses outside medicine the market for medical care is impatient for new solutions to long-standing historical problems.
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The tide is clearly starting to turn with the aggressive role of so many large anesthesia groups across the country. It has been said that there are three ways to play any game. One can choose not to play; one can play not to lose or one can play to win. There is a reason anesthesia is seeing a resurgence of practice aggregation: Leverage is the name of the game. Small practices will find themselves challenged to provide the kind of value added services that their larger competitors are offering. Some might be skeptical of the ability of a larger entity to provide a better and more customized service, and they might be right but being right is no longer good enough.
They are less concerned with being right than being better. The impact on anesthesia is already clear. Everyone wants to partner with a team that is being willing to take risks, create value and distinguish itself in the market. He will be a key executive contact for the group should it enter into a contract for services with ABC. He can be reached at Jody. There are many forces affecting anesthesia groups today such as the pending Supreme Court ruling on the Patient Protection and Affordable Care Act, high unemployment, pending cuts in Medicare, and a very slow economy.
Regardless of what one believes, strategically addressing these issues is paramount in providing the necessary road map for the future. Otherwise, a group may find itself in an unfavorable position. This article seeks to explore the benefits of strategy for anesthesia groups. The general who loses a battle makes but few calculations beforehand.
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Thus do many calculations lead to victory, and few calculations to defeat: It is by attention to this point that I can foresee who is likely to win or lose. It is important to note that a strategic plan is just that, a strategic plan. It is not set in stone. It is also not a detailed business plan. Business plans, however, are borne out of strategic objectives from a strategic plan. The strategic planning process is an appropriate venue to address issues for three specific reasons.
The group will have open and honest discussions about the strategic direction given a variety of issues. The group will also begin to form strategic objectives during this process. Finally, the group will focus on the development of the strategic objectives. Since this is the venue for open and honest discussions, appropriate rules and etiquette are in order for the duration of the conversations.
An informal use of Roberts Rules of Order is always applicable.
Depending upon how a group interacts, it may be necessary to have an experienced facilitator who can help guide a group through these discussions. This leads to the next point of developing strategic objectives. The discussions will need to converge on a set of strategic objectives for the group. Whether a group does it on its own or through a facilitator is not the point. The point is that the outcome from the discussions needs to be a set of strategic objectives. Strategic objectives are not specific business plans.
They are objectives that a group will use to focus their practice toward in the future. These objectives may be offensive or defensive in nature. The objectives will have some parameters around them, which includes various factors. For example, a group may develop a strategic objective to address the issue of a very slow economy by taking both defensive and offensive approaches. The defensive approach may include a hiring freeze as an example. The offensive approach may include aggressively growing the practice through additional practice opportunities at other hospitals and ambulatory surgery centers.
There certainly would be several factors involved including cash flow to take into consideration. Another benefit is that strategic planning will help a group to coalesce around the strategic objectives. The strategic planning process sharpens the vision for the group; clearly delineates the benefits of each strategic objective; and prioritizes those same objectives. Instead of looking at a landscape filled with issues and no clear direction, the process helps to sharpen the vision for the group.
The group identifies its vision through the discussions. An example of the vision may be to remain an economically viable and independent group. Using this example, the group will develop a set of strategic objectives that support that vision. An example of a strategic objective for this vision might be to mitigate a hostile take over by the hospital. A group might perceive the benefits of this strategic objective as greater autonomy and control as an example.
Finally, the group then would decide what priority to assign this strategic objective. Is this strategic objective the top priority, or in the top five, or even the top ten? The group decides this as part of the process. Ultimately, the group holds the leadership accountable for implementing the strategy, guiding the group, and developing more concrete business plans from the strategic objectives. Depending upon the governance structure of the group, the leadership will execute this work in the board and various committee meetings.
The leadership is responsible to communicate with the group regarding the ongoing progress of the strategy implementation. One final point to make is the approach to completing the strategic planning process. With these benefits of strategy come several approaches to developing strategic plans. The two approaches for the purpose of this article are the McKinsey strategic problem-solving model and the decision-making model found in the book, Lead with Intent, by Arne Pedersen.
Both models help in decision-making but also guide the user through strategic decision making for the purposes of strategic plans. The McKinsey model begins with the business need that must be solved and moves through data analysis and interpreting the results to the final plan and implementation [3]. This is a time-tested model with thousands of clients. The decision-making model is similar with its seven steps: This is also time-tested by military, civilian, and business leaders alike for multiple decades.
In both models, the focus on strategic objectives is a key to success as alluded to earlier. For a group doing this exercise, it is important to know who the group is, what the underlying culture of the group is, how and where the group fits in and what you see as the strengths, weaknesses, opportunities, and threats of the group. Additional data from the billing system and the hospital system s will aid in the analysis. The strategic objectives that are developed from this process are the objectives a group will focus on.
Each objective will address a specific strategic issue such as the pending Supreme Court ruling on the Patient Protection and Affordable Care Act. The objectives form the base for the plan, which the group will approve and then look to their respective leadership to implement. In conclusion, a group can decide to do nothing with its future dictated. Conversely, a group can decide to take advantage of the benefits of strategy and dictate its own future.
His distinguished background includes serving as a former Anesthesia Group Administrator, an expert on leadership, and a Bronze Star Medal recipient from the Persian Gulf War. During the audit process, physicians are held to certain standards including, but not limited to: Having legal responsibility for all claims submitted under their billing numbers; Having legal responsibility for knowing Medicare policies regarding the services and procedures they perform, including policies on documentation.
The Social Security Act confers to patients entitlements to a range of medical services defined by broad categories. The Social Security Act also describes exclusions from coverage, most notably including payment for expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Generally speaking, a service may be covered if it is reasonable and necessary under Section a 1 A of the Social Security Act. With this in mind, we offer the following straightforward tips for consideration: Focus Considerable Effort on Documentation Improvement: The anesthesiologist performed the pre-anesthetic exam and evaluation; The anesthesiologist prescribes an anesthesia plan; The anesthesiologist participates in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence; The anesthesiologist ensures that any procedures in the plan that he or she does not perform are performed by a qualifying individual; The anesthesiologist monitors the course of the anesthesia at frequent intervals; The anesthesiologist remains physically present and available for the immediate diagnosis and treatment of emergencies; and The anesthesiologist provides post-anesthesia care, as indicated.
Specifically, according to the OIG: The record should be complete and legible; Each encounter should include the reason, relevant history, exam findings, prior test results, assessment, clinical impression or diagnosis, plan of care, date and identity of the observer.
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Records should take into account any applicable National Coverage Decision or Local Coverage decision requirements; If not documented, the rationale for ordering a test or service should be easily inferred and past and present diagnoses should be accessible. Obtain and Review Payor Policies and Guidelines: Engage In Educational Activities: Here are some examples of Federal insurance legislation passed during hard markets: Resolving federal versus state conflicts Federal laws have not been welcomed by state insurance regulators, who are understandably uneasy about companies over which they have no regulatory power.
How can these federally regulated companies help doctors? The problem with more choices, of course, is more potential for confusion. Some of the doctor owned companies are being acquired by publicly traded companies like The Doctors Company. Risk retention sponsors A risk retention group is usually formed by a sponsoring organization for a specific purpose. Some examples of hospital owned risk retention groups include: Ophthalmic Mutual Insurance Company, A Risk Retention Group Preferred Physicians Medical Risk Retention Group for Anesthesiologists Other risk retention groups are broader in scope and offer coverage to many specialties to capitalize on the insurance principles of large numbers and spread of risk.
What is the difference between all these companies? Companies vary widely and doctors need to look at more than price. Here are some examples of issues to watch for: If a hospital offers cheap coverage it may be looking to push liability on to the doctors avoiding their responsibility to provide an independent defense. Doctors do not like receiving letters in the mail informing them of a claim settlement to which they did not agree. The insurance company may offer risk management so insubstantial that it has little impact on the practice and provides less protection.
The insurance company may not offer additional services like asset preservation plans, which can be of great value in providing a litigation proof defensive shield. What are the weaknesses of risk retention groups? How can risk retention groups protect doctors from litigation? Should you consider a risk retention group for your insurance?
Greater flexibility in participation eligibility; Multiple start dates in and longer agreement period for those starting in ; Greater flexibility in the governance and legal structure of an ACO; Simpler quality performance standards; Adjustments to the financial model to increase financial incentives and decrease in disincentives for participation; and Greater flexibility in timing for the evaluation of sharing savings and the repayment of losses This article will examine each of these significant modifications in more depth, comparing the provisions of the Final Rule to the provisions of the Proposed Rule and setting forth the impact this will have on the anesthesia community, as a whole.
Conclusion As a result of the MSSP and similar programs adopted by Medicare and other third party payors, anesthesiologists today find themselves facing a new health care payment regime, which increasingly pays them for value i. Customer Service Everywhere Conventional wisdom holds that all surgeons care about is availability of anesthesia staff so that they can operate instantly when there are patients requiring surgery. New Roles for Anesthesia Any anesthesia provider or group practice that does not believe it can significantly contribute to the growth and success of the facilities it serves has already lost the battle and probably the war.
The point is that a department of anesthesia should have more and better data about what actually happens in the operating rooms than even the hospital. With that said, a strategic plan provides various benefits for anesthesia groups including: Appropriate venue to address issues A set of strategic objectives as part of the road map An avenue to coalesce a group around the strategic objectives An accountability tool for a group to see how the leadership is guiding for the future It is important to note that a strategic plan is just that, a strategic plan.
Appropriate Venue The strategic planning process is an appropriate venue to address issues for three specific reasons. Which is the best vehicle, given the ultimate objective of being able to bench mark practices and identify common risks and challenges? Since the objectives of both organizations are the same it would appear inevitable that they will come together and work in a unified or, at least, a coordinated manner.
Security and the integrity of clinical details is an issue, to be sure. If a practice shares information about reportable events and these are shown to be outliers what might the consequences be? Attachments are a serious issue. No alternative is without some risk. Important precedents were established with the implementation of the Health Insurance Portability and Protection Act HIPPA in for the protection of individually identifiable health care information.
If the intent of quality indicators is to identify and prosecute individual providers is will never succeed. The goal must be a feedback loop of quality trends for the advancement of all. Self-reporting is another challenge. What is to motivate providers to report honestly? Legal precedent has been so punitive in this area. This is where the leadership of the practice must take a stand and reframe the issues. Anesthesiology has a long history of independence and autonomy.
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Its practitioners believe that the consistent quality of care they provide is a function of good training, timely and reliable monitoring data and the sound judgment that comes from years of practical experience. The time has come to demonstrate just why and how anesthesia morbidity and mortality have fallen so dramatically in the past few decades.
The database will eventually contain both basic demographic data about the population of patients who undergo anesthesia across the country and the kinds of complications they may experience under anesthesia. Encouraging participation has become a priority of the ASA, which has supported its development. The ABG began collecting data from its member groups but is now encouraging other non-member practices to contribute.
Like the AQI, it has paid staff who are dedicated to data evaluation and statistical analysis. The organization has dedicated considerable time and resources to ensuring the accuracy and reliability of all its data elements. ABC has made this a special priority. These efforts will give all practices that outsource their billing a tactical advantage with regard to these national clinical initiatives but it is certainly not to say that those which chose to do their billing themselves cannot find other ways to participate. In other words, concerns about how to capture data can be readily addressed by a variety of options currently available to all groups.
The real question each practice must come to terms with is their appreciation of what is at stake here. This is one of those longer term strategic questions, the kind that has more to do with how members see the role of their specialty in the future and what they are prepared to do to redefine their practice value proposition. Change is never easy and the requirement that individual anesthesia providers start sharing more details about the care they provide is being viewed in many quarters with great concern and no small amount of skepticism; the Orwellian overtones of such initiatives can often lead to considerable paranoia, especially among those not willing to change the way they practice.
As is so often the case, in anesthesiology the real challenge may have less to do with contributing data and more to do with convincing partners that the business of healthcare really has changed the specialty that much. To those who think effective anesthesia practice management is just about effective billing and accounts receivable management, welcome to a future in which you must be able to sell your services to get paid for your services.
He will be a key executive contact for the group should it enter into a contract for services with ABC. He can be reached at Jody.