Amidst rising costs of operations and declining reimbursement rates; increasing Accounts Receivable (AR) days is a major concern with physicians as partly paid, late or denied payments can significantly impact a practice’s bottom line.

Minimum payment days: On filing a clean claim the minimum time a physician will be paid differs on the payer: Federal payers – (Medicare/ Medicaid) – pay clean claims within 13-15 days and other commercial payers – pay clean claims within 27 to 30 days 

Industry standards: Claims generally take anywhere between 40 – 169 days to be paid, with an AR cycle of generally 60 90 days 

Why delay? 

Get It Right the First Time! -Claims are typically delayed or denied due to human error or misfiling. Additionally a variety of factors can influence why claims are not paid immediately, including:

•Claim may not be for a covered contract benefit

•Patient’s preexisting condition is not covered or patient coverage has been cancelled

•Case is under consideration as Workers’ compensation (WC) is involved

•Payer considers the physician’s procedure experimental

•Preauthorization for a procedure or for hospitalization was not obtained

•Services were provided prior patient’s health insurance contract went into effect

•Payers may ask for additional information

•Payer has requested information about another carrier for coordination of benefits

How to get paid faster?

 

Self-assessment is a vital step your practice can take to better understanding the processes used and also discover opportunities for improving the processes to help improve payments and AR. Following questions can assist Physician’s in determining cause and also do a maintenance assessment:

1.How many claims were submitted in the recent 30 day period?

2.Of those claims approximately what percent were denied and most frequent reasons for the denial?

3.Of those claims approximately what percent were delayed and most frequent reasons for the delay?

4.Does the denied or delayed percent vary between paper and electronic claims?

5.Does the billing staff track the percent of claims that are denied on the first submission?

6.Is there a policy in place for bad debt collection?

Every candidate has a unique story to tell, but most interview processes don’t effectively reveal it.

A properly structured interview can give you a window into how candidates think about their career. Some candidates think they are the victim of a long series of unfortunate events. Some candidates weave a heroic tale about their career, where they struggled mightily against their villainous bosses or doltish coworkers.

Sometimes the hero overcomes the obstacles, learns a lesson, and reaches a new level of self-awareness. But sometimes the heroes fail in their heroic quest, so they quit to find a new job … and then continue to find a new job every 18 months after that.

Funny thing about 18 months. That seems to be just about the time when people are really held accountable in many roles. The new-job honeymoon is over, problems can no longer be blamed on the predecessor, and all those easy, breezy first-year promises have come due. When people have two or three stints that last about 18 months, I become very concerned.

So how do you structure the interview conversation to tease out the patterns in someone’s background?

The normal practice of volleying interview questions back and forth will not work. Instead, at the beginning of every interview, I ask candidates to spend 20 minutes walking me through their resume. Going back to when they started working, I ask them to tell me what was best about each job and what was the worst aspect of each job. Good boss, bad company? Great experience but low pay? Great co-workers but no challenge?

I don’t comment, I just jot it down. Sometimes I have to ask a few times to pry loose the “bad” comments. Then I ask why they chose to leave each job and what they were looking for in the next job.

In about 15 or 20 minutes, the patterns emerge. Often people reveal patterns of which they are not even aware.

What answer is most frequent? Did they often just decide it was time for a change without explaining why? Did they repeatedly get recruited by a former boss? Did they often leave just to get more money? Were their coworkers terrific, or usually a bunch of losers? Did they make reference to “I did this” and” I did that” or make positive references to the team achieving something? Was the best thing the work itself, or was it the clients, the challenge, the people, or was it all about the money and recognition?

Once you know the pattern, you only need to decide how it will fit in with your organization.

Everybody fails sometimes. Everybody makes mistakes. And most people take at least one bad job that they never should have taken. But did they own their part in the problem, or did they claim to be the innocent victim of external forces?

This is a powerful concept called locus of control.

Unless you enjoy being a villain, I do not recommend hiring career victims.

Whether delivered by a boss regarding a work goal, by a coach regarding an athletic performance, or by a trusted reader regarding the quality of a rough draft, the feedback we get often powerfully influences our ability to succeed. Yet significant controversy exists in the scientific literature about which type of feedback, positive or negative, is most effective.

As researcher Ayelet Fishbach explains: ”Several motivation theories attest that positive feedback is more effective for motivating goal pursuit than negative feedback because it increases outcome expectancy of the goal and perceived self-efficacy of the pursuer. According to this theoretical approach, positive feedback increases people’s confidence that they are able to pursue their goals, leading people to expect successful goal attainment. Negative feedback, in contrast, undermines people’s confidence in their ability to pursue their goals and their expectations of success.”

On the other hand, she says, “Other motivation theories make quite the opposite prediction, suggesting that negative feedback increases motivation more than positive feedback. For example, cybernetic models of self-regulation propose that positive feedback on successes provides a sense of partial goal attainment, signaling that less effort is needed to accomplish the goal. In contrast, negative feedback on lack of successes signals that more effort is needed and encourages goal pursuit.”

So which type of feedback is best? The answer is that it depends.

In general, when we succeed in behaving in a way that supports a goal (e.g., following a diet at breakfast to lose weight), we interpret that success in one of two ways: either as evidence of our commitment to that goal, or as evidence of our progress toward that goal. When our behavior (e.g., following a diet at breakfast) is taken as evidence of our commitment to our goal of losing weight, it turns out we’re more likely to repeat the same behavior again (i.e., follow our diet at lunch). If instead we take our behavior as evidence of our progress toward our goal, we’re less likely to repeat the same behavior again.

Thus, positive feedback will encourage us to repeat behaviors that lead us toward our goal when it signals our commitment, but not when it signals that we’ve made sufficient progress. So, for example, “…a math student who receives a high test score and infers that she likes math will work harder as a result, whereas a classmate who receives similar positive feedback and infers sufficient progress will relax her efforts and focus on spending time with her friends.”

Negative feedback, on the other hand, will encourage us to try again and/or harder when we at first fail if that failure signals that we’ve made insufficient progress, but discourage us from continuing to try if it signals insufficient commitment. Thus “…a math student who receives a bad test score and infers lack of commitment will subsequently reduce her efforts, whereas her classmate, who infers insufficient progress from the negative feedback, will subsequently work harder.”

Take another example: if a dieter chastises herself for her insufficient progress when she fails to follow her diet at breakfast, she’s actually more likely to follow her diet at lunch. On the other hand, if she chastises herself for her lack of commitment when she fails to follow her diet at breakfast, she’s less likely to follow her diet at lunch. In contrast, if a dieter congratulates herself for her strong commitment when she faithfully follows her diet at breakfast, she’s actually more likely to follow her diet at lunch. But if instead she congratulates herself on her outstanding progress when she faithfully follows her diet at breakfast, she’s actually less likely to follow her diet at lunch.

In other words, we should let success on the way to a desired goal mean only that we’re committed to that goal, and failure only that we’ve made insufficient progress.

But how do we take control of these interpretations? One way to increase the likelihood that we’ll focus on our commitment to a goal when we succeed in taking action toward it, according to Fishbach’s research, is by focusing not on the specific action we’ve taken but rather on the goal itself (that is, for example, on becoming healthier rather than on having completed a workout).  When the…goal is salient, it appears far from reach. Consequently, actions signal commitment to a goal more than they can provide a sense of significant progress. However, if a person focuses on the action itself, the action signals goal progress and even fulfillment.  In contrast, then, one way to increase the likelihood that we’ll focus on our insufficient progress toward a goal (rather than a lack of commitment) when we fail to take action is by focusing on the action we failed to take rather than on the goal we’re trying to achieve.

How we interpret our behaviors also changes, however, as a function of our experience in pursuing a particular goal. People often start by evaluating commitment and then shift to monitoring progress as they gain experience or expertise in a goal domain. They make this shift because novices feel uncertain about their level of commitment, whereas experts are already committed and wish to monitor their rate of progress. One consequence of this shift is that novices should increase their efforts in response to positive feedback on their successes, and experts should increase their efforts in response to negative feedback on their lack of successes. Thus when beginning a new endeavor, we should make more use of positive self-feedback (and give it to others when they’re novices as well), but as we gain expertise — or if we’re already experts — we should make more use of negative self-feedback.

To summarize:

1.When we succeed in behaving in a way that moves us toward our goal, we should commend ourselves for our commitment to our goal, but not on our progress toward our goal (which we can accomplish by focusing not on our behavior but on our goal).

2.When we fail to behave in a way that moves us toward our goal, we should criticize ourselves for our insufficient progress, but not for our lack of commitment (which we can accomplish by focusing not on our goal but on our behavior).

3.When we attempt to accomplish a goal we’ve never attempted before, one  which we have little to no experience or ability to accomplish, we should commend ourselves on our commitment by focusing on the fact that we continue to strive for it even as we make mistakes.

4.When we attempt to accomplish a goal we’ve accomplished before, one at which we have real expertise, we should look critically at our mistakes and failures in order to continually improve our ability to accomplish our goal better.

5.We should apply these same principles when offering feedback to others (especially children).

 

Here are the importance of strong leadership in business and the essential qualities a leader must have. These qualities are timeless, and they are especially important when times get tough. In the face of difficult challenges, great leaders do not retrench. Just the opposite – they step up.

In a great company, you need to institutionalize and perpetuate a great culture and excellent leaders. To do this, you must do several things well, including the training, the retention of talent and the creation of a company that is continually learning. You must have a culture of character and integrity. This comes from fostering an open environment, where people speak their minds freely, to treating people with respect – at all levels, from the CEO to clerks in the mailroom – to setting the highest standards combined with recognizing and admitting mistakes.

Leadership is an honor, a privilege and a deep obligation. When leaders make mistakes, a lot of people can get hurt. Being true to oneself and avoiding self-deception are as important to a leader as having people to turn to for thoughtful, unbiased advice. I believe social intelligence and “emotional quotient,” or EQ, matter in management. EQ can include empathy, clarity of thought, compassion and strength of character.

Good people want to work for good leaders. Bad leaders can drive out almost anyone who’s good because they are corrosive to an organization; and since many are manipulative and deceptive, it often is a challenge to find them and root them out.

At many of the best companies throughout history, the constant creation of good leaders is what has enabled the organizations to stand the true test of greatness – the test of time. Look at our great military. We love hiring veterans – more than 5,000 in the past couple years. These veterans are outstanding employees and team members.

Below are some essential hallmarks of a good leader that I have written about in my previous letters to shareholders. While we cannot be great at all of these traits – I know I’m not – to be successful, a leader needs to get most of them right.

Discipline

This means holding regular business reviews, talent reviews and team meetings and constantly striving for improvement – from having a strong work ethic to making lists and doing real, detailed follow-up. Leadership is like exercise; the effect has to be sustained for it to do any good.

Fortitude

This attribute often is missing in leaders: they need to have a fierce resolve to act. It means driving change, fighting bureaucracy and politics, and taking ownership and responsibility.

High standards

Abraham Lincoln said, “Things may come?to those who wait … but only the things left?by those who hustle.” Leaders must set high standards of performance all the time, at a detailed level and with a real sense of urgency. Leaders must compare themselves with the best. Huge institutions have a tendency toward slowing things down, which demands that leaders push forward constantly. True leaders must set the highest standards of integrity?– those standards are not embedded in the business but require conscious choices. Such standards demand that we treat customers?and employees the way we would want to be treated ourselves or the way we would want our own mother to be treated.

Ability to face facts

In a cold-blooded, honest way, leaders emphasize the negatives at management meetings and focus on what can be improved (of course, it’s okay to celebrate the successes, too). All reporting must be accurate, and all relevant facts must be reported, with full disclosure and on one set of books.

Openness

Sharing information all the time is vital –?we should debate the issues and alternative approaches, not the facts. The best leaders kill bureaucracy – it can cripple an organization ?– and watch for signs of politics, like sidebar meetings after the real meeting because people wouldn’t speak their mind at the right time.

Equally important, leaders get out in the field regularly so as not to lose touch. Anyone in a meeting should feel free to speak his or her mind without fear of offending anyone else. ?I once heard someone describe the importance of having “at least one truth-teller at the table.” Well, if there is just one truth-teller at the table, you’re in trouble – everyone should be a truth-teller.

Setup for success

An effective leader makes sure all the right people are in the room – from Legal, Systems and Operations to Human Resources, Finance and Risk. It’s also necessary to set up the right structure. When tri-heads report to co-heads, all decisions become political – a setup for failure, not success.

Morale-building

High morale is developed through fixing problems, dealing directly and honestly with issues, earning respect and winning. It does not come from overpaying people or delivering sweet talk, which permits the avoidance of hard decision making and fosters passive-aggressive behaviors.

Loyalty, meritocracy and teamwork

While I deeply believe in loyalty, it often is misused. Loyalty should be to the principles for which someone stands and to the institution: Loyalty to an individual frequently is another form of cronyism. Leaders demand a lot from their employees and should be loyal to them – but loyalty and mutual respect are two-way streets. Loyalty to employees does not mean that a manager owes them a particular job. Loyalty to employees means building a healthy, vibrant company; telling them the truth; and giving them meaningful work, training and opportunities. If employees fall down, we should get them the help they need. Meritocracy and teamwork also are critical but frequently misunderstood. Meritocracy means putting the best person in the job, which promotes a sense of justice in the organization rather than the appearance of cynicism: “here they go again, taking care of their friends.” Finally, while teamwork is important and often code for “getting along,” equally important is an individual’s ability to have the courage to stand alone and do the right thing.

Fair treatment

The best leaders treat all people properly and respectfully, from clerks to CEOs. Everyone needs to help everyone else at the company because everyone’s collective purpose is to serve clients. When strong leaders consider promoting people, they pick those who are respected and ask themselves, Would I want to work for him? Would I want my kid to report to her?

Humility

Leaders need to acknowledge those who came before them and helped shape the enterprise – it’s not all their own doing. There’s a lot of luck involved in anyone’s success, and a little humility is important. The overall goal must be to help build a great company – then we can do more for our employees, our customers and our communities.

The grey area of leadership

There are many aspects of the leadership process that are open for interpretation. This grey area contributes to the complexity of the challenges that leaders – and those who govern them – face. I would like to share with you where I stand with regard to a few of these issues.

Successful leaders are hard to find

There are examples of individuals who have been thrust, wholly unprepared, into positions of leadership and actually perform well?– I think of President Harry Truman, among others. I would submit, however, that relying on luck is a risky proposition. History shows that bad or inexperienced leaders can produce disastrous results. While there are possibly innate and genetic parts of leadership (perhaps broad intelligence and natural energy), other parts are deeply embedded in the internal values of an individual; for example, work ethic, integrity, knowledge and good judgment. Many leaders have worked their entire lives to get where they are, and while perhaps some achieved their stature through accident or politics, that is not true for most. Anyone on a sports team, in government or in virtually any other endeavor knows when he or she encounters the rare combination of emotional skill, integrity and knowledge that makes a leader.

Successful leaders are working to build something

Most leaders I know are working to build something of which they can be proud. They usually work hard, not because they must?but because they want to do so; they set high standards because as long as leaders are going to do something, they are going to do the best they can. They believe in things larger than themselves, and the highest obligation is to the team or the organization. Leaders demand loyalty, not to themselves but to the cause for which they stand.

Nonetheless, compensation does matter

While I agree that money should not be the primary motivation for leaders, it is not realistic to say that compensation should not count at any level. People have responsibilities to themselves and to their families. They also have a deep sense of “compensation justice,” which means they often are upset when they feel they are not fairly compensated against peers both within and outside the company. There are markets for talent, just like products, and a company must pay a reasonable price to compete.

Big business needs entrepreneurs, too

The popular perception is that entrepreneurs – those who believe in free enterprise – exist only in small companies and that entrepreneurs in small companies should be free to pursue happiness or monetary gain as appropriate. Free enterprise, entrepreneurship and the pursuit of happiness also exist in most large enterprises. And you, our shareholders, should insist on it. Without the capacity to innovate, respond to new and rapidly changing markets, and anticipate enormous challenges, large companies would cease to exist. The people who achieve these objectives want to be compensated fairly, just as they would be if they had built a successful start-up.

Performance isn’t always easy to judge

Managers responsible for businesses must necessarily evaluate individuals along a spectrum of factors. Did these individuals act with integrity? Did they hire and train good people? Did they build the systems and products that will strengthen the company, not just in the current year but in future years? Did they develop real management teams? In essence, are they building something with sustainable, long-term value? Making these determinations requires courage and judgment.

One of the reasons I am so proud of our company is because of our great people, our great leaders. These past five years have been a period of turmoil, crisis and stress for our industry and sometimes for our company. What our people have accomplished during these difficult circumstances has been extraordinary – a testament to the critical importance of strong leaders.

 

The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practice Advisory Committee have realized updated guidelines for the prevention of intravascular catheter-related bloodstream infection.  

The new guidelines which replace the recommendations published in 2002, place a heavy emphasis on the education and training of health care personnel, using chlorhexidine scrubs for skin antisepsis, ensuring a maximal sterile barrier for catheter insertions and avoiding the routine replacement of central venous catheters as an infection prevention strategy. 

Central line associated bloodstream infections (CLABSIs), the most common type of nosocomial bloodstream infection, carry an estimated mortality rate of 12%-15%.  The treatment of these infections costs US hospitals an estimated $29,000 per patient and $2.3 billion annually.  These types of blood steam infections however are considered highly preventable when proper precautions are taken.

The updated guidelines included recommendations based on a five-step checklist that has been shown to be effective in preventing central line catheter infections.  The checklist stresses hand hygiene, full barrier precautions during catheter insertion, chlorhexidine antisepsis at the insertion site, avoiding veins in the arm or leg, checking catheter lines each day and removing them when they are no longer needed.  

A study of 103 ICUs in Michigan (N Engl J Med 2006; 355:2725-2732) found that the use of the checklist lead to a 66% reduction in CLABSIs after 18 months.  After the realization that these infections could be prevented the Dept of Health and Human Services set a national goal of a 50% reduction in CLABSIs by 2013.  

In 2008, the CMC designated CLABSIs a “never event” meaning hospitals will not receive additional reimbursements for treating the infections.  Several commercial insurers have adopted this practice.

In this entry I will go over how to improve communications between anesthesia providers and hospitalists which is very important in order to maximize OR efficiency.   

There has been a huge growth surge for the hospitalist profession an estimated 29% of hospitals employ the specialty including 55% of hospitals with 200 or more beds.  Therefore, the anesthesia providers are working closely and more often with the hospitalists particularly in the area of perioperative medicine. 

The first important point is to realize that anesthesia providers basically function as hospitals for surgical patients. Both specialties should have common goals or improving patent care, decreasing the risk for errors and reducing waste.  

Best practice tips for improving communications between anesthesiologists and hospitalists.  

The hospitalists, when clearing patients for surgery, need to speak directly with the anesthesiologist in detail about the pt’s readiness for surgery, and address whether there is anything else that could be optimized with the patient. 

The anesthesiologists when turning finished surgery cases back over to the hospitalist should talk directly with the hospitalist instead of relying on a nurse or the chart to explain a patient’s status.  Remember any medical transition risks a significant loss of critical information. 

There should be monthly meetings between the heads of the two specialties so they can clarify any expectations and establish goals for each practice.  

Here is another blog based on the clinical practice of anesthesia.  Taking the time to put on a gown before inserting a labor epidural may do little to prevent infections in pregnant women while they are in labor.

A study presented by Dr Siddiqui and colleagues at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.  There were 240 women in labor requesting labor epidural showed that anesthesiologist who wore gowns were less likely to have bacteria present of their forearms.  But when they did not wear the garments, bacteria mostly did not reach the catheter tip anyway.  This finding suggests that the extra time and effort of sterile gowning may not be worth it for epidurals.  The author Naveed T. Siddiqui, MD, MSc, assistant professor in the Department of Anesthesia and Pain Management at the University of Toronto, Canada stated “the message is pretty clear from the data: Gowning will not make a difference in terms of bacterial growth.”  

Infections are relatively rare occurrences in epidurals affecting approximately 1 in 10,000 pts but those that do happen are a huge source of morbidity.  An infection can lead to an epidural abscess that can cause permanent paralysis or even death.  

Physicians including anesthesiologists are fleeing private practice and there are now two more reasons why this trend is likely to continue or even accelerate: Governmental audits and breaches of protected health information (PHI).  Audits and PHI are on the rise in physician’s practices which are threatening revenue streams at levels never seen before due to fines and penalties.  

Audits are on the rise in regards to governmental and other third party payers, pre-payment reviews by Medicare Administrative Contractors (MACs) are the dominant activity in practices thus far.  The second audit risk comes from Recovery Area Contractors (RACs) who are ramping up their presence for anesthesia practices especially in the hospital setting.  While both threaten the anesthesia practice revenue stream, the MACs pose a greater revenue cycle issue.  MACs pend claims upon submission.  Reimbursement to the practice is held while the case is reviewed.  MACs also have no limit to the number of cases they can audit, whereas RACs have a legally mandated limit.  

There are two “best” practices for dealing with all audits.  The first is an automated tracking system that manages timelines and status of all audits.  Most practices are either handling this manually or in an Excel spreadsheet.  The second best practice is to bolster clinical documentation improvement efforts.  Improving documentation minimizes auditor red flags and provides quick justification for medical necessity and payment.  

The cost of a PHI breach is going up.  Statistically, breaches of PHI are going to happen to every practice.  However the risk of breach shows considerable variance due to some practices have the technology, policy and procedures and education to mitigate their risk while others pay lip service to the issue.   The enforcement of breach reporting with fines and disclosure notification is becoming much more onerous with the possibility of up to $1.5 million fines per incident.  Most breaches are caused by human error through staff carelessness and forgetfulness.  Best practice is full encryption at the drive level-not the file level.  If electronic PHI is lost or stolen in an encrypted format, it is not considered a reportable breach.  Encryption is just part of the full policy and procedure program that practices must train their staffs to implement.   This is not a situation where practices can write policy and procedure manuals and keep them on the shelf collecting dust.  They must be  living documents, which are regularly updated and presented to staff in an educational setting. The costs of breaches also include patient notification, potential bill write-off, credit monitoring/identity theft monitoring and legal fees, as well as time and effort of staff and management.  

If there is a breach and practices can demonstrate they took the necessary steps to prevent disclosures, the penalty can be mitigated-perhaps even avoided.  Efforts should include: 

1)Detailed policy and procedures

2)Regular staff training

3)Ongoing internal audits

4)A plan for response to incidents

5)Detailed risk assessments

6)Detail record kept of the facts surrounding disclosures, particularly dates of events  

As audits and breaches increase they will become a much great thereat to the practice’s profitability.

Staff and resources should be bolstered now before the auditors and attorneys come knocking.

Published in Br J Anaesth. 2013;111(3):331-333. 

Authors: C. J. L. McCartney, S. Choi

Total knee arthroplasty (TKA) is a common, painful surgical procedure requiring good quality anaesthesia and postoperative analgesia to provide best patient care and facilitate effective rehabilitation. More than 70 000 knee replacements are performed in the UK each year and this is projected to increase as the population ages and osteoarthritis, the most common reason for TKA, becomes more prevalent. Given ever increasing pressure on resource utilization the quality and the type of anaesthesia and postoperative pain relief can have a significant impact on ability to meet rehabilitation goals. Studies have also demonstrated that poor pain control after knee replacement is associated with development of chronic pain[4] although our understanding of this area is only starting to develop. 

The anaesthetic management of patients undergoing TKA has undergone several refinements and transitions. In the past, general anaesthesia (GA) with systemic opioid analgesia alone was commonly used. Spinal anaesthesia, uniquely suited to lower extremity orthopaedic procedures, has gained prominence with several landmark studies demonstrating the superiority of spinal anaesthesia over GA in terms of morbidity and mortality. Contemporary studies have continued to reinforce these data with recent epidemiological studies using large databases indicating a reduction in risk of morbidity and mortality with the use of neuraxial anaesthesia. The mechanisms underlying these benefits remain to be fully understood but may include improvements in blood flow, cardiorespiratory benefits and a possible reduction in surgical stress response. Outcomes such as pain relief, opioid consumption, and length of hospital stay (LOS) also favour spinal anaesthesia. However, neuraxial anaesthesia is not without risk, and although rare, does have potential for spinal haematoma, infection, or abscess in contemporary practice. Therefore, despite the perceived benefits of neuraxial anaesthesia, newer methods of providing anaesthesia for knee replacement need to be evaluated and existing techniques challenged.

In this issue of the British Journal of Anaesthesia, Harsten and colleagues compare recovery from TKA after GA [specifically with total-i.v. anaesthesia using target-controlled infusions (TCI) of propofol and remifentanil] with spinal anaesthesia with bupivacaine in a randomized study of 120 patients. The authors demonstrate that patients in the GA group had a shorter time to meet discharge criteria (46 vs 52 h), less nausea and vomiting, better pain control (except for the first two postoperative hours), and less dizziness compared with the spinal anaesthesia group. The findings of this paper appear to contradict previous recommendations regarding spinal anaesthesia for TKA and prompt an assessment of the reasons for disparity with previous results.

A closer examination of the study reveals both strengths and limitations. A major strength of this study is the comparison of a state-of-the-art general anaesthetic technique including multimodal analgesia with a basic spinal technique. Both of these relatively straightforward and common methods of anaesthesia would be feasible in all hospitals where total knee replacement procedures are currently performed. Many institutions across the world are unable to provide consistent, high-quality regional anaesthesia for their patients and in this regard demonstration of the effectiveness of a GA with multimodal analgesia technique is timely. The recovery time and time to reach discharge criteria are impressive in both groups and is currently faster than that achieved in many centres.

Some criticisms and observations with the techniques used in this study should be noted. First, the authors use a spinal anaesthetic technique without additional adjuvant and it is therefore not surprising that the spinal group had severe pain on block resolution. Most practitioners using spinal anaesthesia for TKA would institute adequate opioid-related analgesia before spinal resolution either by adding a dose of intrathecal hydrophilic opioid such as morphine, diamorphine, or hydromorphone, or by giving opioid analgesics by another effective route. Although the use of intrathecal opioids is associated with adverse effects such as pruritis, urinary retention, and respiratory depression, their addition will provide long lasting analgesia after resolution of the local anaesthetic effect. The post-surgical pain that the patient experiences with the rapid regression of spinal anaesthesia can be intense, particularly when limited provisions for analgesia are made such as omitting peripheral nerve blocks, neuraxial opioids, or other systemic analgesia and this certainly contributed significantly to the poor pain control that the spinal group reported in this study.

Secondly, the duration of effectiveness of the local infiltration analgesia (LIA) technique was surprisingly short. Given the recent excitement for the potential of LIA as a simple method of pain relief after knee replacement[14] it was disappointing to see how poorly it performed in this study. Personal clinical experience of using LIA has given the impression of an effective but short-lasting effect. The study by Harsten and colleagues reinforces our impression because although the LIA appeared to provide good early analgesia in the GA group by the time the sensory block had resolved in the spinal group, the analgesic effectiveness of LIA appears to have disappeared.

It is also interesting to note that despite availability of rescue analgesia, the spinal group continued to experience significantly more pain for 2 days after surgery. The landmark editorial by Wall who coined the term preoperative pre-emptive analgesia and more recent work on preventive analgesia also note the ‘protective’ effect of opioids and other analgesics such as N-methyl D-aspartate receptor antagonists on pain control well beyond the clinically expected duration of these drugs. The seemingly prolonged analgesic effect of an intraoperative dose of oxycodone appears also to have provided some ‘preventive’ analgesic effect in the GA group. Conversely, there is no evidence of a hyperalgesic effect from remifentanil infusion that has previously been demonstrated. Finally, although a significant difference in LOS was demonstrated between the GA and spinal group, a 6 h differential may be of limited clinical or practical significance in most institutions and might not actually influence the day of discharge.

Several important messages can be taken from this paper. First, despite current beliefs, it appears that a good quality GA technique such as the TCI method can in fact provide effective anaesthesia and transition to reasonable postoperative analgesia after knee replacement. This may be a very useful option in centres that are currently unable to provide consistent high-quality regional anaesthesia such as neuraxial anaesthesia, continuous peripheral nerve blocks, or both. Secondly, the importance of multimodal analgesia in facilitating good pain control is underscored by the fact that all patients were given acetaminophen and celecoxib. The better pain control in the GA group reflects the important role that long-acting opioids continue to play in the context of multimodal postoperative analgesia especially when given before recovery of anaesthesia. Finally, the transient and disappointing effect of the LIA technique was especially evident in the spinal anaesthesia group and continues to call into question the overall utility of this method[20] especially when used alone without systemic or spinal opioids.

TKA is a common and painful surgical procedure that requires effective, safe anaesthesia and good postoperative pain control to facilitate best outcomes including reduction in LOS and chronic pain after surgery. Harsten and colleagues demonstrate that the TCI GA technique used compares favourably with a very limited spinal anaesthesia technique. However, better regional anaesthesia methods are available in centres that have the expertise and resources to provide them. Regional anaesthesia including neuraxial techniques continue to provide short-, medium-, and long-term outcome benefits for patients having TKA. Although Harsten and colleagues provide thought provoking data they do not really compare their GA technique with the standard of care for spinal anaesthesia not to mention peripheral nerve block techniques. Further studies are required to continue to investigate the best method of anaesthesia and postoperative analgesia for patients undergoing TKA (including GA techniques) before significant change in guidance can be advised.

Every good manager will tell you that conflict is part and parcel of the job.  Whether it’s an issue within the team, or whether an external source is disrupting your progress, conflict happens.

Dealing with the conflict will determine whether your project succeeds or ends up as a failure.

Here are seven tips to addressing and resolving conflict on the job.

1. Keep your cool

As a manager, you will find yourself at the center of the cross fire.  You need to make sure that you stay calm and you do not get worked up.  In environments with lots of stress, everyone else is already angry; getting angry yourself will just make the situation worse.  If you feel you are getting tense: step back mentally, breathe and relax.  You need to remain rational and demonstrate your leadership.  Think through your responses before reacting, whether it is verbally or sending an e-mail, and display a calm even demeanor.

2. Deal with conflict when it arises, don’t wait

Conflict is part of everyday life.  It happens all around us, in different forms, but it’s important to act on it as soon as you notice it’s there.  Don’t let conflict fester, assuming it will “blow over”.  In most cases, conflict will arise because of something which was said, or in the case of dealing with project stakeholders, something which was not said.  Miscommunication among project stakeholders can be a nuclear bomb.  If you suspect something is wrong, speak to your team; and if there is an issue, deal with it transparently.

3. Don’t play the blame game 

People get defensive when they are blamed for something, it’s a natural reaction.  When you are sitting two people down to mitigate a conflict, encourage them to you use “I feel that” or “I think that” instead of pointing fingers and saying “You do” or “You are”.  The latter is placing blame on somebody while the former is simply conveying a feeling, and this can greatly reduce defensive reactions among both parties.

4. Accept that somebody has to be wrong and it might be you

People make mistakes, its part of life.  It doesn’t make you a bad person, or a bad manager (most of the time); and it doesn’t mean that your team is not suited for the job.  It simply means that you are human.  Once you have identified the cause of a problem, accept it if it is your fault. Apologize and correct it.  If the problem rests with the other party, accept their mistake, forgive them and move on.  Accepting that mistakes happen, and accepting responsibility for mistakes when they are yours, is the cornerstones of ensuring a project stays on track after it hits a wobble.  It also demonstrates a high level of leadership maturity to those around you.

5. Compromise, but don’t limit yourself (SWOT)

Conflict requires compromise, but don’t limit yourself to the options presented.  Thinking creatively about a solution might be your best chance of saving a project, enforcing client expectations, or ensuring team members are not overworked.  Similarly, the first solution you come up with might not be the best one.  List all the solutions, as well as their pros and cons, using a “SWOT” format.  Using the SWOT format, list the Strengths, Weaknesses, Opportunities, and Threats (SWOT) of critical project conflicts to mutually arrive at a compromise.

6. Keep the big picture in mind

Whatever solutions you come up with, and whatever recourse you take to get there, keep in mind that you still have one ultimate goal: the success of your department.  Don’t lose momentum, identify the source of the conflict and address it immediately.   

7. Listen carefully, find the facts, ditch the rest

As a manager, it’s up to you to not only manage the project, but also the relationship between all involved.  It’s therefore imperative that you are a good listener.  If somebody has an issue, listen to them, but make sure you listen to the other side of the story, too.  Gather the facts of the situation and discard any irrelevant personal agendas which might be making the situation worse.  Confront the facts and resolve the issues that way.

Managers must be expert diffusers.  Think of your role as a bomb technician – somebody who has to very carefully get rid of a potentially explosive device.  One wrong move and you could blow everything sky high.  Communicating clearly, keeping calm, and sticking to a diplomatic approach is the best way to move forward and ensure the success of your department.