Improvements in contracted outside services are oftentimes more difficult to accomplish than those made internally. Complicating issues for improving anesthesia services include the complex nature of anesthesiology, strong personalities around surgical and anesthesia services, daunting expenses, and the integrated nature of the service.

The anesthesia department is ingrained within a core competency of any facility offering surgical services. As it is usually outsourced in some manner, implementing change and improvements can be met with significant resistance, directly or indirectly. Your anesthesia service is one of the few faces of the institution many of your customers will see. As such, efforts to improve it can produce significant results—both measurable and immeasurable.

Here are five proven steps to enhance and advance anesthesia services at your facility:

1. Set Clear Goals.

In any improvement plan, such as for your facility’s anesthesia service, it is critical to first identify your goals for any changes to be made. Areas of common concern are anesthesia provider behavior, staff numbers available, call coverage, on-time procedures, and additional duties. I recommend listing specific goals and scoring them on a relative scale. Specifying goals also has the effect of challenging those involved to reach a conclusion on the matter at hand. If you are familiar with Six Sigma and/or the House of Quality, I encourage you to use either of these business management tools to identify areas requiring improvement.

It has been said that a few bad apples spoil the bunch. This can apply to behaviors in a department as well. Quite often, the bad apples are in a position of power in the anesthesia department. “Group think” can take over and lead to a negative and difficult environment to introduce change. Today’s anesthesiology environment does not leave any size practice as untouchable. In recent years, very large, established practices have been re-organized or replaced for various reasons by other competing local groups and large or small management firms.

Areas to be identified for specific need include the number of operating rooms and percent of utilization of each. According to the most recent Medical Group Management Association’s Anesthesia Cost Survey, the trend is a decline in operating room utilization. Anesthetizing locations outside of the surgery department need to be evaluated as currently in use or a possible need. At larger facilities, the anesthesia department might be unaware of moderate sedation being provided at remote locations.

The most recent Guidelines for Surveyors from the Centers for Medicare & Medicaid Services (CMS) clearly states that the sedation service being offered is under the purview of the anesthesia department. Facility managers should consider if this service is best offered by the anesthesia department. Considerations include complexity of the procedure, severity of patient co-morbidities, and ability to bill for the services provided.

2. Evaluate the Team.

The next step is to critically evaluate what is being supported by the anesthesia revenue. Identify the top three tasks being performed by the anesthesiology group at your facility. Determine what percentage of their time is spent on each activity.

Ask yourself: How well do they match with your specified goals? Do the providers support critical initiatives, such as the Joint Commission Patient Safety Goals or the CMS Surgical Care Improvement Project (SCIP)? Has a true effort been made to assist the facility or just a feigned appearance? Compare your local SCIP scores to hospitals in your area at http://www.hospitalcompare.hhs.gov.

3. Set a Process for Improvement.

At this point, incongruent practices are illuminated. If a great divide exists in the goals of the organization and history of the anesthesia service, then significant intervention might be warranted. Past history will demonstrate the likelihood of changing behavior of the department. If there is a known leader of the department, a straightforward discussion clarifying the discrepancies of goals can put the department back on track.

Sometimes outside intervention in the form of a consultant or management team might be the best approach. Advantages of a management team are noted on many websites, but for this discussion include the monitoring of quality initiatives, leverage of service agreements, compensation arrangements, and removal of disruptive providers. Through a combination of data collection and feedback, a management team can usually coach providers to effectively change to fit the corporate goals of the facility.

4. Establish Controls.

Ensure that managerial controls become part of any initiatives you establish. Quality of service, as defined in the goals you set in step one, should be monitored by the department and verified by the facility.

Does the anesthesia service provide for a single point of contact as a liaison for your facility’s quality department? Reporting on statistically significant samples should be provided to the facility decision-makers. Small to medium-sized departments are finding the administrative requirements are outpacing their capability to cost-effectively provide such service. Management firms offer the advantage here of shared expenses over multiple facilities.

5. Live Within the Budget.

While no one can predict the future of healthcare, it is clear that few resources will be available to satisfy an ever-growing need. Reduced payments for services will pressure the market to make drastic changes in the provision of those services. Furthermore, increasing competition from a variety of practice models is forcing change in the market. Facilities that find themselves paying supplements or guarantees to large anesthesiology groups have access to resources to institute change and control behaviors.

I challenge you to follow these five practical steps for quality improvement. If you – or your customers – are not highly satisfied with your facility’s anesthesia service today – there are options and actions you can take to turn things around.

This article was previously published in Executive Healthcare Management Magazine.

The CMS Conditions of Participation Section 482.52(b)(3) requires that all patient receiving anesthesia must have a postanesthesia evaluation within 48 hours surgery.  This has been the case for many years.  The most current version of the Interpretive Guidelines for Surveyors changed the requirements significantly for a “postanesthesia recovery and evaluation”.

The document specifies that surveyors should ensure that “current guidelines are utilized in establishing hospital policies on postanesthesia evaluation and recovery”.  The guidelines clearly recommend very specific items.  Credence is given to this list by referencing the ASA Practice Guidelines for Postanesthetic Care, Anesthesiology Vol. 96, No. 3, March 2002.

In reviewing the referenced article, it is clear the guidelines and list established by the authors reference the time the patient is in the Post Anesthesia Care Unit (PACU).  The authors’ recommendations for practice clearly cite their applicability for “emergence and recovery” under each item.

CMS intends for the postanesthesia evaluation to be performed and noted after the patient has recovered from anesthesia.  By strongly suggesting these criteria be documented, CMS is applying the standards for monitoring during “emergence and recovery” to a period up to 48 hours later.

CMS would have been better served by referencing the ASA Standards for Postanesthesia Care.  They have been recently updated for 2009.

The Anesthesia Patient Safety Foundation posted the results of a discussion by its Board of Directors on ventilatory depression from neuraxial opioids and patient-controlled analgesia (PCA).  The discussion highlights the inherent dangers the techniques bring to postoperative care.  Each is highly effective for treating postoperative pain.

The conference attendees and participants are noted to have recognized the “underappreciated risk” that each carries.  The recommendation is for anesthesia providers to give consideration to continuous pulse oximetry for these patients during the postoperative period.

Dr. Stoelting cautions us to remember that pulse oximetry will monitor hypoxemia but not hypoventilation.  Be mindful of hypercapnia effects which can be somewhat masked by supplemental oxygen.

Recent discussion in the Anesthesia Patient Safety Foundation newsletter led to a discussion during our recent clinical meeting. As a group we reviewed the available literature on the subject. An excellent and leading resource for information is www.lipidrescue.org. The case reports in the literature are compelling for considering the use of 20% Intralipid after standard ACLS protocol has been unsuccessful. Consider  the information at the website above.