On Exceptional Experience at a Time...Every Day.®WHITE PAPER

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Effective Perioperative LeadershipThe Driving Force in Creating a High Performing OR

Day-of-cancellation rates and on-time starts are the most telling data for a quick snapshot of your OR suite’s efficiency and performance.

When an OR is underperforming, it is

rarely because members of the surgical

team aren’t up to their jobs; what’s missing

is almost always OR leadership.

TWO | EFFECTIVE PERIOPERATIVE LEADERSHIP NAPA | THREE

Day-of-cancellation rates

and on-time starts are

the most telling data for a

quick snapshot of your

OR suite’s efficiency and

performance.

Does Your OR Have a Leader?If the OR is the engine that drives thehospital, anesthesia is the engine thatdrives the OR — but who is at the wheel?On average, the operating room accountsfor up to 70% of hospital revenue; if theOR doesn't succeed as a business,neither does the hospital. You have likelydesignated a team and set goals forrecruiting surgeons and increasing surgicalvolume. More than that, you’ve madesure the correct team members are inplace and have empowered them to drivethe process they are responsible for.However, many hospitals have not takenthose same basic steps to ensure thesuccess of their OR suite.

When an OR is underperforming, it israrely because members of the surgicalteam aren't up to their jobs. What'smissing is almost always OR leadership; a competent individual with the tools,experience and authority to drive success.“Leadership” means an accountable point person who manages roles andresponsibilities, understands the greatergoals of the hospital, and creates a culturethat thrives on change/improvement.Historically, successful perioperativedirectors have come from a variety ofdisciplines including; nursing, operationsand anesthesia. Regardless of theindividuals particular path of ascension,there are common themes in excellencethat have been uncovered which will bediscussed in the following white paper.

Best Practices in Perioperative LeadershipSlow room turnover between cases, highcomplication rates, wasted disposables,growing day-of case cancellations, lowfirst case on-time start rates, high staffturnover, climbing dissatisfaction amongsurgeons and patients....

For the most part, these kinds of indicatorsare symptoms of a larger problem: poorleadership. Poor leadership can bedefined as the inability to coordinate andcapitalize on the specific surgical assetsavailable, to develop additional assets as needed, or to create a supportive andresponsive work environment whereeveryone is treated with respect andexpected to contribute to team goals.

In a study of surgical team performancewritten for Health Care ManagementReview, Leach et al conclude thatcoordination through leadership cancontribute to a successful surgical result,improve the overall process, includingerror reduction, and enhance knowledgecreation and dissemination1. The studyfurther talks about a need to integrate the technical aspects of surgery withsocial processes, that is, behaviors andattitudes. They describe a number of skillsrequired to achieve this integration, which,they point out, is complicated by the factthat many if not most surgical teams aread hoc in nature and simply don't have thetime to develop stable, interactivedynamics built on trust. The leadership

skills highlighted include resourcemanagement, coping well with pressureand fatigue, assessment of risks, mentalreadiness, decision making, flexibility, andworkload distribution.

In addition, an effective perioperativedirector should be an excellentcommunicator with a deep knowledge of OR management. To succeed, he orshe must continually seek improvementand have access to resources in thefollowing areas:

• best practices in OR management

• hospital goals and the role of theOperating Room in meeting them

• communications tactics to deal with colleagues, competitors, andsuperiors

• processes to cut through red tape to fix problems quickly

• knowledge of effective loadmanagement techniques

• proficiency in performancemeasurement and analysis

• best practices in scheduling

• understanding of revenue drivers

• understanding of surgeons' prioritiesand concerns

• ability to identify and mentorprospective leaders

• utilization of national and regionaldatabases

• familiarity with acknowledged leaders in the field

• utilization of peer connections onlocal, state, and regional levels

Putting Leadership into ActionEffective OR Leadership can help increasehospital revenues in a number of directand indirect ways that will vary dependingon the specific organization and its needs.In order to help a hospital meet its ORefficiency goals, an effective PerioperativeLeader could use the following process toassess and prioritize potential areas forimprovement:

STEP 1.Conduct a Three Part SituationAssessmentInterview all members of the surgicalteam, including the surgeons, anesthesia,and nursing / perioperative staff, toascertain their concerns, opinions, andideas. The different groups can beinterviewed together, but each individualshould have a chance to provide inputprivately, as well.

Gather and report accurate and timelyperformance data on individual staff anddepartments. The importance of datashould not be overlooked. By gathering,analyzing and managing against data, you can remove the speculative nature ofyour situation assessment and base it on actual empirical results. The moregranular your measurements, the moretargeted your solutions can be. It isimportant to report not only to executiveleadership, but also to the staff who canbe expected to respond to variances thatare presented scientifically and attached to corrective action plans.

Observe processes and workflows toidentify redundancies, inefficiencies,logjams, and conflicts.

An effective Perioperative

Director needs to

understand how each

function within the

hospital impacts the

other functions.

1 Leach, LS et al. Assessing the Performance of Surgical Teams. Health Care Management Review, 34(1), 29-41; January-March 2009.

FOUR | EFFECTIVE PERIOPERATIVE LEADERSHIP NAPA | FIVE

Targets might include:

• patient flow and throughput,specifically in PACU and dischargefrom PACU to floor

• patient preparation (e.g., does thepatient have all appropriate medicalclearances in place prior to the day of surgery)

• case time effectiveness (e.g., time-sensitive steps: patient in holdingarea/induction area, induction toincision, incision to closure, closure topatient out of room, room turnover)

• materials management (e.g.,inventory control, materialsdistribution, physician preferences,standardization, vendor relationships,storage and locator system)

• management structure and staffing(e.g., case coverage, skill sets,scheduling, reporting structure,assignment of responsibilities)

• governance (e.g., medical leadership,surgeon relations: development and enforcement of policies andprocedures; credentialing; qualitymonitoring; introduction of newtechnologies)

• surgeon relations

STEP 2. Analyze and BenchmarkWhat does it mean that post-operativenausea and vomiting (PONV) rates are7%? Is this higher or lower than the rate ofa year ago? Is it more or less than otherhospitals are experiencing? Is it allassociated with one anesthesiologist orseveral? What are the causes and howcan these be eliminated?

Measuring and benchmarking teamperformance against organizational, local,regional, and national standards is mosteffective when you are comparing applesto apples, that is, looking most closely at indicators from hospitals with similartypes of procedures and case mixes. You should also investigate the precisedefinitions of your benchmark data. Is yourdefinition of case state the same as yourbenchmarks?

The importance of quality data comes tothe forefront of your process at this point.You must be certain that the informationyou are compiling is accurate andinterpreted according to consistentparameters. Keep in mind the old axiom“Garbage In = Garbage Out.”

STEP 3. Set Goals in Sync with Hospital Needs The goals of the Perioperative Director and their management of the OperatingRoom should always reflect the largerpriorities of the hospital as a whole and the realities of both operating and capitalbudgets. Some of the most commongoals include:

Expansion of services to coveradditional surgical volume – ThePerioperative Director should takeresponsibility for procedural areas outsidethe “four walls” of the OR suite as well asmanaging surgical demands for additionalOR capacity. As the areas of the hospitalbeing utilized to deliver care expand, theneed to provide proper and efficientperioperative oversight also grows.

The Perioperative Director should beprepared to address scheduling andstaffing concerns of nursing andanesthesia while concurrently balancingthe desires of the hospital’s surgical staff.Working with nursing and anesthesia tocreate a more efficient scheduling andstaffing model can help to cost effectivelycover increased surgical volume insideand outside of the OR and provide theflexibility that these important constituentsneed. Flexibility also must be addressed.An efficient staffing model can flex toaccommodate additional case volume andprovide enhanced patient care.

Quality assurance program – Devise arobust program that enables tracking andtrending of both facility and individualclinician performance relative to clinicaloutcomes. Hospitals want detailedreports available for real-time review andpresented on a quarterly basis to proveresults and drive improvement. Again, the

utilization of data can take a discussionbased on conjecture and turn it to onebased on actual outcomes and results.

Customer Service – The PerioperativeDirector must recognize the needs of hisor her most important customers — thesurgeons and patients.

Several factors which drive surgicalsatisfaction are:

• On time first case starts

• Speedy room turnover time

• Readily available and properlyfunctioning supplies and equipment

• A friendly and efficient environment

In order to increase patient satisfaction,the Perioperative Director should:

• Provide a patient-centric experiencethat clearly communicates to all thatthe patients safety and comfort arethe top priority of the organization

• Ensure the hospital’s Pre-SurgicalTesting program is working correctly –leading to a reduction in day-of-casecancellation rates

• Facilitating communication among thepatient, the OR staff and the patient’sfamily to ensure all parties areinformed as to the patients statusduring surgery

Metrics are a critical

component to managing

a hospital’s business —

you can’t improve what is

not being measured.

The Perioperative

Director should involve

the physicians and

nursing staff in the

identification and

prioritization of key

operational strategies

that drive the change

process.

The Perioperative Director must

recognize the needs of his or

her most important customers —

the surgeons and patients.

Leadership means an accountable point person who manages roles and

responsibilities, understands the greater goals of the hospital, and creates a culture

that thrives on change/improvement.

SIX | EFFECTIVE PERIOPERATIVE LEADERSHIP NAPA | SEVEN

STEP 4. Develop an Action Plan Input from surgeons and staff,performance measurements and the list of priorities provide ample data to developa plan of action that will create a clearoperational infrastructure that engages allparties. This plan must:

1. Be realistic

2. Win the support of department andhospital leadership

3. Introduce best practices

4. Represent real, measurableimprovement in efficiency and cost-effectiveness.

Each project should include specificperformance goals, tactics to achievegoals, project assignments, budgets, andtimelines.

STEP 5. Implement Your Action Plan Leadership is especially important duringplan implementation. Change is almostalways resisted at first. Consistent andtransparent communication is essentialduring the transition. A culture that is unableto constantly change and adapt will neverfoster high performance; this inability tochange is one of the top reasons ORs fail.

STEP 6. Monitor Progress and ReassessA true leader is never satisfied with thestatus quo, but is constantly watching to see that gains are not lost over time and seeking to identify where furtherimprovements can be made.

The perioperative leader may not handleeach of these tasks personally in theirentirety, but he or she will be accountable.The leader sets each step in motion anddetermines when it has been accomplishedsatisfactorily, identifies and engages theright team members in the appropriateparts of the process, and is alwaysavailable to inspire, consult, help, and, asnecessary, reset course.

At the start of this cycle is Superior Patient Care, the core function of anyhospital. If every other point of the cycle is executed consistently, the final point is accomplished – Greater HospitalRevenue. This increase of revenue allowsthe hospital and its staff to invest inadditional competencies that again lead to an increase in patient care.

At the center of this cycle is theAnesthesia & Perioperative Alliance which drives OR performance. Thatperformance supports surgeons toimprove outcomes, increase patient andsurgeon satisfaction, enhance the hospitalreputation, improve surgeon recruitment,increase case volume, etc. While the OR, is not the only part of the hospitalworking on developing these initiatives, it is the keystone, and its leader must beconstantly striving to improve performanceand become more efficient.

The Virtuous Cycle Perioperative leadership and the anesthesia department’s ability to fuel top perioperative performance are at the center of a healthy hospital. It has been proven that an engaged and effective anesthesia leader, working in concert with the hospital’snursing, perioperative and surgical staff can help create a cycle of positive outcomeswhich is self sustaining.

SuperiorPatient Care

The Anesthesia & Perioperative

Alliance

Better ClinicalOutcomes

Increased Patient

Satisfaction

Increased Surgeon

Satisfaction

AdditionalPatientVolume

GreaterRevenue for

Hospital

EnhancedReputation for

Hospital

EnhancedSurgeon

Recruitment and Retention

EIGHT | EFFECTIVE PERIOPERATIVE LEADERSHIP NAPA | NINE

Today's OR Needs Require NextGeneration Anesthesia SolutionsOne of the challenges many hospitals faceis that the typical anesthesia group, whichin many instances has been in place formany years, if not decades, is set up forfailure in this new era of reform. While it isusually staffed by excellent physicians,they lack the management expertise andinfrastructure to provide effectiveanesthesia stewardship. According to theAmerican Society of Anesthesiologists,nearly 70% of these groups have just 1-25physicians. They often lack internalexpertise including scheduling, recruiting,billing, collections and contracting. If theyhave a QA program at all, it includesminimal data and is often solely dependentupon the data the hospital is providingthem. They can’t develop continuingtraining programs, tested policies andprocedures, or a nationwide network ofpeers for problem solving.

Smaller groups lack the infrastructure thatis required to participate in many hospitalinitiatives and many are using inefficientstaffing models that no longer meet thehospital's current goals, structure, andpatient mix. In a survey of hospitaladministrators conducted by the TarranceGroup for the American Society ofAnesthesiologists less than a decade ago,nearly half of the respondents said theyhad reduced or redirected OR proceduresdue to anesthesia staffing issues. Amonghospitals reporting shortages, 75% hadexperienced an increase in surgery waittimes and 66% had to limit access to theOR as a result.

These common results are unacceptablefor hospitals and health systems facingmassive challenges and changes to howthey do business including:

• The expected surge in patient volumeas 30 million additional Americansenter the public insurance roles

• The shift in emphasis to outpatientcare

• The increased use of other surgicalprocedure areas within the hospitalsuch as catheterization labs,interventional radiology and GI suites

• The continued competition forsurgical cases from independentambulatory surgery centers (ASCs)

• The requirements set out in PPACA,such as Accountable Care andShared Savings Models.

Regardless of its makeup, an anesthesiagroup of a dozen or two dozen clinicians issimply not in a position to drive clinical orbusiness efficiencies the way a largeregional or national group can.

As a result, a growing trend ofconsolidation has emerged as these smallgroups are increasingly joining largerorganizations so they can continue toserve the hospital and community theyhave invested themselves in — but nowwith the management infrastructure theanesthesia department needs to succeed.

The larger anesthesia group can:

• Take advantage of economies ofscale, which means its costs aregoing to be lower

• Devote specialized resources to thebusiness — to billing, collections,contracting — resulting in improvedresults and allowing clinicians todevote their time to patient care

• Build a comprehensive QA programwith seasoned, up-to-date QAexperts

• Collect, analyze and utilize data toassess the effectiveness of individualclinicians against their peers and thelarger entity. This function also allowsintegration with a local RHIO and/orACO

• Drive the development of non-clinicalcompetencies among its leadershipphysicians through involvement oncommittees such as RiskManagement, QA, Equipment andothers

• Allow the operations of the practice tobe run by dedicated experts andalleviate some of the managementburden that the clinicians in a smallpractice face

All of these advantages give the hospitalan edge when it comes to recruiting andretaining top surgeons, who are needed toexpand surgical capacity in and beyondthe OR and to bring in more patients to fillthe complete range of facilities.

The OR is the engine that drives thehospital, and anesthesia is the fuel thatpowers the OR.

By combining effective perioperative

and anesthesia leadership, hospitals

are provided the tools required to

successfully compete in today’s new

post reform reality.

The OR is the engine

that drives the hospital,

and anesthesia is the

fuel that powers the OR.

TEN | EFFECTIVE PERIOPERATIVE LEADERSHIP NAPA | ELEVEN

Hospital Overview• Member NY Presbyterian Health

System

• 9,000 admissions/year

• 12,000 surgical operations/year

• 15 ORs/anesthetizing locations

Situation Hospital was experiencing declining ORperformance which lead to decliningrevenues from surgical procedures. At thesame time, its costs to run the OR wereincreasing as an inefficient and expensiveanesthesia staffing model was in place.

Reason for IssueLacked anesthesia leadership andmanagement infrastructure

SolutionDevelop a new anesthesia staffing modelto ensure optimal coverage and designatean OR leader responsible for maintainingOR performance, efficiency andsatisfaction from all constituents includingpatients, surgeons and hospital leadership.

Implemented Solution1. Fix Staffing: a fast and thorough

situation assessment revealed a needfor a MD/CRNA staffing modelconsisting of 14 MDs and 6 CRNAs.This decision was based on thedepartment’s ability to:

a. cover all anesthetizing locations

b. cover vacation demands

c. cover call schedule

d. provide capacity for serviceexpansion for labor epidurals, GIcases, acute and chronic painservice

2. Provide OR PerformanceMeasurement: the hospital did nothave an OR/anesthesia specificquality assurance program tomeasure and manage performance.The new program:

a. Tracks 31 different indicators of ORperformance

b. Measures results against peers andnational (ABG) benchmarks

c. Results analyzed by NAPA andpresented to hospital managementon a quarterly basis

Our Unmatched Anesthesia Experience. Your OR’s Advantage.

How Anesthesia Leadership Turned Around the ORThe Brooklyn Hospital Center, NYPresbyterian Health System

CASE STUDY3.Designate an OR Leader: There

was no person in the OR designatedto function as a perioperative leader.NAPA, and its anesthesia chief, tookon the responsibility and immediatelyimplemented:

a. A refined pre-surgical testingprocess

b. Communication and coordinationwith nursing and surgeons

c. Integration with hospitalcommittees and management

d. Building a strong relationship withsurgical staff

4.Improve Revenue: there were noset procedures to make sure everycase was billed and collected. Newprocedures and by implementingNAPA’s well developed managementprotocols, department revenue wasimproved by:

a. Reducing days in A/R to under 35days (top quartile of MGMA results)

b. Working all charges to an ultimateresolution of 99.6% of collectibledollars

c. Ensuring that each case andprocedure were captured andsubsequently billed

d. Implementing correct and up-to-date case coding

RESULTS IN 2010

1. Surgical Volume increased 7%, to 12,000 cases a year

2. Anesthesia Subsidy decreased 50%

3. OR Utilization improved 6%

4. 99.6% of allowable claims resolved

5. Days in A/R reduced to under 35 days

Baseline Year 1 Current0%

20%

40%

60%

80%

100%

Anesthesia Subsidy

Operating RoomUtilization

After

Before

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North American Partners in Anesthesia

About North American Partners in AnesthesiaFounded in 1986, North American Partners in Anesthesia (NAPA) is thelargest single specialty anesthesia management company in the UnitedStates. With over 800 clinicians nationwide, the company is known forhaving the most respected clinical staff, management leadership, andevidence-based quality initiatives in the industry – resulting in maximized ORperformance, reduced costs and consistent surgeon and patient satisfaction.

NAPAanesthesia.com

© 2012 North American Partners in Anesthesia. All rights reserved.