Butch Parker, MD
President, Columbia Anesthesia Group
Vancouver, Washington

As a representative of a small anesthesia practice, you find yourself in a hospital executive’s office discussing the anesthesia needs of your community hospital. Catching you by surprise, she asks, “Why don’t you bring in CRNAs? I’ve heard they can really cut down on anesthesia costs.” As a member of an all-MD practice, this question makes you uncomfortable as you consider why she is asking and how disruptive this would be to your practice. You come up with a few reasons why this wouldn’t be a good idea. She presses the point briefly, but eventually the conversation moves on to another topic.

You breathe a sigh of relief and think you’ve dodged a bullet—but you haven’t. This hospital executive may not understand the business of anesthesia, but she does understand what the weekly solicitations from national anesthesia staffing companies promise—better coverage and less expensive anesthesia care utilizing CRNAs.1,2

Every private practice anesthesia group must grapple with this question: Would bringing in CRNAs and an Anesthesia Care Team (ACT) model be a logistical, political, and financial benefit to my group and our customers?3,4 If the answer is yes or even maybe, then the next question is this: How would we transition to this kind of practice?

In 2013, Columbia Anesthesia Group (CAG), located in Vancouver, Washington, made the decision to hire its first group of CRNAs. As group president at the time, I found very few resources to help us make this leap. There are groups out there with CRNAs—and there is much to learn from them as they exist in their steady state—but there is little in the way of guidance on how best to create a new ACT model within a historically all-MD practice.

Today, in 2018, CAG employs 23 CRNAs and has a thriving ACT practice. Although most of the time our 45 physicians still do their own cases, bringing in CRNAs has been an overall positive experience and has given us significant flexibility and improved stability in our market.

Through this experience, we learned the key areas to emphasize and which pitfalls to avoid. Here are the nine steps to successfully introduce CRNAs into your small- to medium-sized practice.

Step 1. Understand Why

First, an all-MD group needs to develop a consensus supporting this fundamental change. There doesn’t need to be unanimity, but there needs to be a large majority that is willing to give it a try. Understanding the advantages of an ACT model for your situation and being able to articulate those advantages will aid internal discussions as well as help flesh out the talking points for your client hospital’s administrators and surgical staff. These advantages might include:

  • improved staffing flexibility,
  • call reduction,
  • improved hospital relations, and
  • better availability for out-of-operating room (OR) needs (scheduling, emergencies, consults, nerve block placements, etc).

Remember this transition will be disruptive in many respects. Almost all aspects of your anesthesia business will be affected to some degree. There will likely need to be adjustments to your reimbursement model, insurance arrangements, employment contracts, benefit packages and scheduling logistics, just to name a few.

Step 2. How Will They Work?

Before launching a search for CRNA employees, you must decide how you will use them. Are there any types of cases for which you will not schedule them? Will they do obstetrics? Will they do lines and blocks? Will they take calls? How will they interact with the partners in the group?

From the start, it is important to establish your vision for them so the hospital, surgeons, and staff know what to expect. In addition, CRNA applicants need to know exactly what the job will entail. You also must have a clear understanding of the 7 requirements for medical direction (Table).5,6

Table. Medicare’s 7 Rules for Medical Direction of CRNAs
Medicare pays anesthesiologists for medical direction of CRNAs at 50% of their normal reimbursement. Anesthesiologists can be paid for medical direction of 2 to 4 concurrent cases, with the following requirements:
1. Perform a preanesthetic examination and evaluation and document it in the medical record.
2. Prescribe an anesthesia plan.
3. Participate in and document the most demanding procedures in the anesthesia plan, including induction and emergence, if applicable.
4. Ensure that any anesthesia procedures are performed by a qualified anesthetist.
5. Monitor anesthesia administration at frequent intervals and document the monitoring.
6. Be physically present and available for immediate diagnosis and treatment of emergencies.
7. Provide postanesthesia care and document it.

Through all this, you must appreciate the culture you are setting up with your CRNAs. Animosity and lack of respect can sneak into many practices that employ CRNAs, creating a bad work environment for everyone. A successful practice with CRNAs is one in which everyone understands their role and both the physicians and CRNAs appreciate what each brings to the care of their patients. This atmosphere of mutual respect will need to be fostered constantly and will require occasional redirection by group leadership.

One resource to help you understand how you will incorporate CRNAs is by observing other anesthesia practices with CRNAs. Contact groups in your region that use an ACT model. Reach out to former classmates. Colleagues who work with CRNAs on a regular basis will have valuable insights.

As you investigate the ACT model, you will learn from good and bad examples. Pay close attention to practices that are successful and look for the common threads. You will also learn a lot from the practices that do not have the right design and culture. From all of this research, you can create your own best ACT approach that will maximize your chances for success.

Step 3. Internal Adjustments

Almost invariably, you will need to increase office workload capacity to help in the management of this new kind of employee. You may need to bring in another office employee or contractor to help manage the workload. This transition will also require some work and engagement with your local consultants, such as attorneys, pension managers, insurance brokers, billing service, the bookkeeper, and an accountant. Your benefits will need to be examined closely and likely adjusted to accommodate a new kind of employee. Furthermore, you will need to review and make necessary adjustments to your rules and regulations, company bylaws, and contracts.

As you make these adjustments, pay attention to how the nature of some physician work will change. Specifically, you will want to review your group’s internal pay structure, especially if your group has an “eat-what-you-kill” reimbursement model. You won’t need to scrap your current system, but you will need to make allowances for how you will pay your physicians when they are medically directing CRNAs, because reimbursement in this situation will be a new concept.

Step 4. Align With the Hospital

Hospital administrators will almost always welcome this move on your part and will be willing to help. They can assist you as you review and make any necessary adjustments to hospital guidelines to accommodate CRNAs. This action may include, among other things, reviewing hospital rules and regulations, medical staff bylaws, and credentialing requirements. Including key hospital administrators in this process will help you navigate any necessary changes.

If your group services more than one hospital, you should consider introducing CRNAs into only one hospital to start. Select which site makes the most sense and start there. You can always introduce CRNAs to another facility at a later date. You will have enough to manage with one hospital—there’s no need to add extra work at this point.

Step 5. Communication With Surgeons And Staff

A key to your success will be buy-in from the surgeons and staff. Prior to discussions with them, you must develop talking points to help convey your goals and to resolve any concerns about this new anesthesia model. After some preliminary groundwork with key surgeons, you will likely want to present the new model at a surgery department meeting or other venue where you have many surgeons present. Each member of your group needs to know the talking points as everyone will likely be asked questions about the ACT model once plans are revealed.

As mentioned previously, your facility will likely be on board quickly, and the OR staff, once oriented, will not pose much of a barrier. But your surgeons may need more explanation and assurance. You can anticipate some surgeons will be very hesitant to have a CRNA in their room, although most of them appreciate the need for “physician extenders.” That is a term they will understand even if the comparison to their physician assistants is not a perfect one.

Consider creating a policy by which surgeons can ask for a physician if they are concerned for whatever reason about a particular surgical case. This will allay surgeon fears considerably. Even though this will make scheduling more difficult occasionally, you will find this option rarely exercised as your surgeons become more comfortable with the good CRNAs you have hired and experience your presence during the critical points of the anesthetic.

Perioperative staff orientation to the ACT model can happen at staff meetings. They will need to understand the CRNA’s scope of practice and how they will work. They also need to understand the role of the “medically directing anesthesiologist.” Above all, they need to appreciate the culture of respect you want to foster within the ACT model.

Step 6. Find Your First Hires

Your first few CRNA hires will be crucial to ensure a solid start for your ACT model. You need to find the best CRNAs, as it is likely you will call on these first few hires to serve in leadership roles. These CRNAs will set the tone for the culture you develop. They need to have a clear understanding of their role and the job expectations. They need to be excellent anesthesia providers and have good interpersonal skills, too. These qualities will help assuage any reluctant surgeons.

Your small ACT model will evolve quickly as your practice adjusts. It is crucial that there be an open dialogue between these first few CRNA hires and group management so adjustments can be made. They need to be empowered to speak their minds about what is working and what isn’t. Remember that your CRNAs are members of a closely knit community and will serve as resources for future CRNA hires. It makes sense on all fronts to do your best to treat them well.

Step 7. Plan Your Launch

Prior to your first day of utilizing CRNAs, decide on the logistics of day-to-day operations. Who is writing orders? Who is consenting the patient? These things need to be spelled out so the supervising physician and the CRNAs are not stepping on each other’s toes. You should also develop a brief script for how you will explain the care team model to patients. Keep in mind the culture of respect you are fostering as you work out these logistics.

Carefully plan the first few days and weeks of your ACT model. You need to put people in positions to maximize their chances of success—for the patient, the CRNA, the surgeon, and the medically directing anesthesiologist. It is important to pay particular attention to all the players involved in this early stage because first impressions are hard to change. As time goes on, you won’t need to be so meticulous with scheduling.

Ideally you will use anesthesiologists who have supervised in the past, have a positive attitude about this model, and are confident in their skills as a physician. Start with a small group of supervising MDs and do focused training on logistics and the required elements for medical direction. Although you will likely begin with just 2 or 3 CRNAs with 1 supervising physician, as you get used to this model you will probably want to strive for higher efficiencies with a 4:1 ratio.

Step 8. Grow the Program

Now that you have started with a handful of CRNAs, have worked out the kinks in management, and have successfully introduced them in the OR, you can determine how big you want this program to get. You will be limited by natural physician attrition and growth in anesthetizing locations. Big jumps in growth (opening new ORs, acquiring a new hospital contract) are an ideal time to expand your CRNA program if it fits your needs.

As you are able to grow, you must continue to be very vigilant about hiring the CRNAs who are a good fit. Ideal candidates are clinically strong, comfortable with medical direction, and have interpersonal skills that will contribute to positive interactions with team members. You need to be just as selective in hiring CRNAs as you have been with hiring new anesthesiologists.

Growth will also allow you to give leadership opportunities to some of your CRNAs. These leaders will help tremendously in maintaining the culture and design you have put together. They will also help you navigate the more subtle aspects of CRNA management, such as morale, perceptions, and incentives.

Step 9. Track and Adjust

You need to track a few aspects of your burgeoning ACT model. First, you should track finances. Your bookkeeper can help you create an internal “CRNA department” that tracks the costs and revenues of everything pertaining to the CRNAs. This will help you evaluate how well you are doing and find areas for improvement.

Second, you need to track how efficiently you use your CRNAs. Understanding this and the financial consequences will help your group determine how to utilize the CRNAs. Note that there will be some trade-offs between maximum efficiency and lifestyle gains for your physicians.

Third, you should monitor closely how well you are doing in maintaining your culture of respect. An ACT model can become a burden if stakeholders become disillusioned or negative. Pay attention to complaints by MDs and CRNAs with regard to interactions and address them directly, quickly, and consistently. There will always be less than ideal interactions or missteps. Have a transparent, supportive process for working through any problems that may arise. Continually evaluate and be flexible. Often you can make small adjustments that go a long way to making people happy.

So should you bring CRNAs into your practice? That is a question only your group can answer. But doing it on your terms in a proactive and smart way can result in big benefits. There are great CRNAs out there who do a fantastic job and can add tremendous value to your practice. Integrating CRNAs can make your group more agile and better positioned to take on the challenges that small- to medium-sized anesthesia practices face today and in the future.


  1. Anesthesia Business Consultants. The future of the Anesthesia Care Team. Communiqué, Spring 2009;14(1):1,4-8.
  2. Cutting anesthesia costs starts with a battle. HealthLeaders Magazine. March 21, 2013.
  3. American Society of Anesthesiologists. ASA Statement on the Anesthesia Care Team. www.asahq.org/?advocacy/?state-activities/?core-issues/?supervision-of-nurse-anesthetists. Accessed June 2, 2018.
  4. American Society of Anesthesiologists. Anesthesia Care Team. www.asahq.org/?lifeline/?who%20is%20an%20anesthesiologist/?anesthesia%20care%20team. Accessed June 2, 2018.
  5. American Academy of Professional Coders. www.aapc.com/?blog/?24070-follow-7-rules-for-billing-anesthesia-medical-direction/?. Accessed June 2, 2018.
  6. Oregon Health & Science University. www.ohsu.edu/?xd/?education/?schools/?school-of-medicine/?departments/?clinical-departments/?anesthesiology/?upload/?50-Shades-of-Grey-09-24-12-Handout.pdf. Accessed June 2, 2018.