Author: Tony Mira
Summary: Managing expectations in the business environment can be a bit tricky. Anesthesia groups have certain expectations that have always been placed upon them. The problem comes when these expectations are increased in number and intensified in detail. Today’s alert reviews the continual mission creep being experienced by many of our anesthesia clients.
Traditionally, hospital administrators have had three kinds of expectations of anesthesia providers. Many used to refer to them as the three A’s: ability, affability and availability. Providers were assumed to be competent to perform any kind of surgical or obstetric case. Quality of care was considered a given. With regard to the relationship with the OR staff and surgeons, anesthesia providers are expected to be affable and accommodating even when surgeons are being unreasonable. Most important of all, though, someone from anesthesia should always be available for every case the staff wants to book. As if this weren’t a tall enough order, there is now a fourth A: affordability. In this era of hospital subsidies and financial support, what used to be a free good now has a serious cost, and this has changed everything.
Meeting the Expectations
There was a time when anesthesia providers were simply grateful to have a job in a busy facility with a positive payer mix. Now things have become much more complicated. If they could generate at least 50 billable units per clinical day, they would make a good living and there would be no need for financial support from the facility. How things have changed. Now more than 75 percent of anesthesia practices that work at hospitals get some form of financial support. The calculation of the amount of support required to recruit and retain an appropriate team of qualified providers has become one of the most contentious aspects of a contract renewal. It is not uncommon for practices to have to hire outside consultants to validate fair market value (FMV) assessments.
As is true in so many disciplines, money changes everything. Professional anesthesia services used to be a free good to the hospital—as distinct from outpatient facilities where there is almost never any form of subsidy or support. The fact that money now changes hands casts all the service requirements in a different light. What used to be assumed now usually needs to be quantified and validated. This has resulted in numerous specific contract criteria and performance metrics.
Ready, Willing and Able
With regard to the clinical qualifications and specific requirements of an anesthesia department, hospitals are now enumerating qualification requirements. Board certification has long since been a requirement, but now specific sub-specialty qualifications may be required for pediatrics, chronic and acute pain management. TEE qualification may be required for cardiac cases. In addition to these basic items, departments are also required to report their quality metrics. It is not uncommon for part of a subsidy to be withheld for satisfaction of certain quality metrics.
Affability is a rather general term that implies a positive working relationship with all members of the O.R. and OB teams and practicing surgeons. In the current environment, it has come to be defined as customer service. In other words, how and in what ways do anesthesia providers not only support their customers but enhance the overall surgical and obstetric experience of the patient?
On the one hand, anesthesia has always been focused on a safe and comfortable surgical experience for the patient. In other words, each provider should know how to manage what happens in the operating room. Now, they are being asked to play a much larger role in managing the whole peri-operative continuum. The need to set up pre-anesthesia clinics is just one aspect of a pre-occupation with O.R. productivity and a more collaborative approach to patient care.
An Open Schedule
The availability of anesthesiologists and anesthetists to provide services when surgeons want to do their cases has become an especially contentious issue. Three factors have contributed to what is now a significant challenge for virtually all practices. The migration of surgical cases from inpatient venues to outpatient venues and ASCs has dramatically changed the staffing requirements of most practices. The call requirements of hospitals and declining revenue potential due to increasing public payer populations has become the number one reason why most group practices require financial support. The gradual erosion of operating room productivity has then been further exacerbated by a national anesthesia manpower shortage.
Sage advice to parents is to never permit today what you will regret tomorrow. In many ways, today is the tomorrow anesthesia practices should have planned for yesterday. Today’s practices have become victims of scope creep. Vaguely defined service criteria have been expanded. What was once reasonable has now become unreasonable. Whatever surgeons want, surgeons tend to get. The set of requirements keeps expanding, while the revenue potential remains stagnant or decreases. The problem is that resetting customer expectations is challenging in any business, but especially in medicine. However, that is where we are. This is the new reality. Anesthesia practices must learn how to under-promise and overdeliver. Good customer service is now the key to success and survival.