Jeff Peters: Characteristics of Anesthesia Leaders: Who Can Lead Their Group Through the Anesthesia Crisis

Listen

Watch

Read

Jeff Peters (00:05):

When we talk about leadership, we can talk about it abstractly, but I thought I'd give an example that Tim Hanners in the back and I experienced last week. So last week we had the pleasure of working for the Alaska Native Medical Center where we're looking at a perioperative transformation. I've worked with them a lot over the years and it's the only level two trauma center in Alaska. It has in the main hospital 10 ORs, a four room ASC and people have a lot of babies in Alaska. The winter's cold, it's dark and there's a lot of babies.

(00:58)
Last time we were there, their biggest crisis was anesthesia. No surprise. It's extremely difficult to get anesthesia providers there. And 10 years ago they had two anesthesiologists for a level two trauma center and the average Alaskan Native woman has five children and they do VBACs. And up until a couple of years ago they did VBACs without anesthesia present or an obstetrician. A nurse midwife was doing the VBACs. Not that that's the formula for disaster, but they were doing it. So they had two anesthesiologists, about 18 CRNAs. When we were there last week, they are fully staffed with no locums. They have I think 12 to 14 anesthesiologists, I may be off on the numbers, but relatively close and 18 CRNAs. And the reason they're successful is that they recruited a young, talented anesthesia chairman who was a creative problem solver. And he said, "What is it going to take to attract anesthesia providers here?" And he said, "We can't afford to pay more than market, so they pay a competitive wage, but they balance lifestyle." The anesthesiologist who's just coming gets 10 weeks PTO, two weeks CME.

(02:55)
The CRNAs get eight weeks of PTO. They're able to work eight, 10, 12 hour shifts. And when you talk to them, they're happy. He structured the job so it gives flexibility. The CRNAs practice at the top of their license. They are not supervised by physicians. In the morning they look at the schedule and assign either an anesthesiologist or a CRNA to the room. They've got leadership pass clinically. They've got leadership opportunities in terms of management. And I would argue that the way you solve the anesthesia crisis is not all the formulas and the strategies I and people in the room develop. It's finding leaders and nurturing those leaders so they can creatively solve the problems that are confronting anesthesia. And it's not paying more because that's not sustainable. There's somebody in the audience who told me, "I can raise my anesthesiologist's salaries $50,000." And he did and he knew his competition would raise at 60.

(04:24)
We've got to find different ways of doing it because the environmental challenges are just too great. The ASA has talked about the 12,500 shortage of anesthesia providers by 2033. The work that we're doing looking at retirements and looking at the growth in the Medicare population and surgery indicates that this shortage is growing by 2000 physicians every single year. I think personally the estimate of 12,000 is very much understated. 80% of all hospitals are talking about gaps in anesthesia and partly it's because we have an aging anesthesia workforce where 50% of the providers are over 55 years of age. CRNA training has expanded to an extra year. And as you get older, you have more problems, you need more procedures and there's just more demand. It's just not sustainable. This shortage of providers combined with the decline in reimbursement, it's the basic supply and demand. It's going to go up, it's going to keep on going up.

(05:51)
And until we find a different anesthesia model to provide care, we're like hamsters on the wheel and I'll talk a little bit about some of the innovative models people are thinking about today. I'm going to talk about the importance of managing payer mix. It's sort of the elephant in the room that nobody wants to talk about, but later on in the deck, I'll give an example. If you've got commercial patients that are paying anesthesia rates at 10 times government rates, why wouldn't we look at payer mix when we're allocating block or making other decisions? It's not about improving block utilization by 10%. It's finding a way to accommodate the surgeon that has a high commercial payer mix and doing it in such a way that we're still meeting needs. And I'll actually give an example from a hospital that I've worked with. The overriding issue is creating a culture and creating an environment where anesthesia providers feel valued and appreciated.

(07:28)
The successful anesthesia leader understands the needs of his department or group and goes out of their way to establish a culture where they feel like they're contributing and they're welcome and it doesn't just come from the anesthesia leader. It's got to come from every surgeon who at the end of the case says, "Thank you. This was really a rough case. I could never have gotten through it without you. " The OR director that looks forward to our meetings with the anesthesia provider. Culture is more important in creating a stable group than compensation. Compensation has to be there. It's like Maslow's hierarchy of needs. It's the basis. But if you want to reduce turnover, if you want to have your group recruiting their friends, it's all about creating a positive culture. And part of that, I'm sure all of you have seen this, is having anesthesia either co-lead the surgical services executive committee being the medical director of the OR, establishing a collaborative body where anesthesia surgeons, nursing and hospitals come together as a board of directors to run the OR and making sure anesthesia's voice at the table is heard and they're directing what's going on.

(09:12)
It's really basic, but I've had the opportunity now of going back to hospitals that have put this model into place 15, 20 years ago and the hospitals where they've sustained this model function better. They have less of a problem with anesthesia recruitment and retention and have happier surgeons.

(09:42)
We've got to empower anesthesia leadership. They're the ones that know what's going on in the OR and they've got to use this knowledge and insight to not only co-chair but make the various decisions in terms of block. Looking at the next surgical service line, we want to expand and how to do it. We can't just focus on the anesthesia leader. The way we make a positive culture is look at the department and create opportunities within the department for people to advance clinically. Somebody might have a real interest in obstetrics. It could be an anesthesiologist or a CNRNA. We want an anesthesia service line leader who goes to the department and section meetings and understands what the needs are of that department and goes about sort of changing how anesthesia's provided. We need a personal career plan for every CRNA and every anesthesiologist in our institution and they need a mentor to help them achieve their personal and professional objectives.

(11:10)
Just sitting down regularly with every member of the department and saying, "Tell me what your needs are. How can we make this a better place for you to practice?" It goes a long way and then you've got to follow through with it, but that's what people want today because we're so technologically and IT focused. People want to work with colleagues and leaders that really care about them and organizations that do it are not only more successful with anesthesia, they don't have the same nursing problems and other problems.

(12:01)
The chair of anesthesia is really the recruiter in chief and needs to be very creative. It's not only sign-on bonuses, but Michael's wife is a first-year anesthesia resident. Organizations have already talked to her about giving her a sign-on bonus now if she'll agree to come to their group three years, three years from now. It's creating a CRNA school and if the CRNA agrees to stay with us for three years waiving the tuition sort of like the government gets physicians and nurses, we've got to be creative. If you've got an anesthesia residency program, you want to try to expand it. And one of the ways to solve the problem is to create a residency. It's a lot of work, but you can do it. Create that CRNA doctorate program. All you need is an affiliation with a school of nursing that offers doctors and nursing practice or an allied health professional school.

(13:21)
It shows your commitment and it shows that you're trying to help further the overall profession. We also need to look at coverage much, much, much, much differently.

(13:42)
A young anesthesiologist or CRNA, for some of them, it's really important every morning to drive their children to school or to let them at preschool. We've got to understand what's important to them and to try to create shifts to accommodate it. It's in some cases four hour shifts, eight hour shifts, 10 hour shifts, 12 hour shifts. And one of the things we don't leverage is half of all anesthesiologists are over 55. A lot of my friends now are in their 70s, they still want to practice, but they don't want to practice at the level that they used to. So looking at four or five senior anesthesiologists taking a position, but they're also really experienced. And if you want to accommodate the lifestyle issues of a lot of anesthesia providers that really want to take their kids to school, to be often time to go to the basketball game, that's where we can use some of our mature anesthesia providers who are very comfortable working from seven to 11 or coming in at two to five to relieve it.

(15:11)
We've got to figure out what's important and leverage our resources much differently to accommodate it and organizations that are thinking creatively like this are doing better. There's all different ratios of how you can look at ASC staffing. Increasingly because of the cost of anesthesia, you're seeing ambulatory surgery centers going to an all CRNA model or one anesthesia provider supervising one to seven rooms.

(15:56)
The outcomes in an ASC, it's very hard to argue that this wider staffing model has affected clinical outcomes, but we just can't afford the cost anymore and we've got to look at new models. One of the models that some organizations are looking at is a zone model where you allow the CRNAs to practice on the top of their license. It's very, very protocol driven. So there's an anesthesiologist in same day to look at the admission and to evaluate the chart. There's one or two anesthesiologists in the ORs that might be up to 15, 18 ORs, one to two. They're monitoring centrally what's going on in each room and there's one anesthesia provider looking at staffing recovery. It dramatically reduces the cost. It's being used very successfully with a tertiary hospital outside of Ohio and it's reduced the cost. It's increased RNA satisfaction because they're practicing on the top of the license and it's reduced their anesthesia subsidy annually by five or six million.

(17:27)
This is the type of creative things we need to think through. It's not going to work if we just tweak our blocks and go to four to one versus three to one. I'm sorry, sir. You had a question? How does that hospital done with the surgeons accepting liability when they typically don't ... They have to soft on the chart, they take responsibility for the CRNA. Yeah, you don't do it without the buy-in of the surgeons, but it's having that difficult conversation that we can't sustain this financially so we'd like to give it a try. Is it going to work in all organizations? It's not, but it's worth having the conversation to just begin to look at the reality. And I think the surgeon signing the chart is part of the reason hasn't been adopted more broadly. So I think you raise a really good point.

(18:42)
I think the old way of scheduling is not going to work. I'll talk about this a little later. When somebody was reviewing the deck, they said, "Oh, Jeff, you must be talking about ASCs, not hospitals." But increasingly, what we're seeing is even in level one trauma centers, hospital for joint disease in New York, other really complex big organizations, there's no such thing as a four-hour block and the utilization to maintain your eight or 10-hour block has to exceed 80%. And depending upon your payer mix, and I'll talk about this in a chart a little bit later, we can't afford to pay our anesthesia providers eight hours a shift, but only get six hours of revenue. The economics don't work. We're seeing economic credentialing going into the discussion, where when you're allocating block, you talk about the percentage of commercial cases, and you have physician scorecards to do it.

(20:06)
Managing is basic, it's tactical, but having the surgeons talk to us six months in advance when they're going to a conference all helps. And then constantly knowing what surgeons and offices have a backlog and how to accommodate it. At the Alaska Native Medical Center, they have 3000 case backlog. That means patients have seen their surgeon and the decision was made to have surgery, but they're just trying to accommodate it. When they get a cancellation or something goes on with travel, they have a computerized list of who they contact so they don't lose that opportunity to serve them. As I've talked about before, you can't continue to pay eight hours of pay for 6.5 hours of revenue. That's not how the Toyota factory works. Toyota, if they're paying their workers for eight hours, the line is going for eight hours. So it's just this historical tradition that you have to maintain 75% utilization to maintain your block.

(21:40)
That's great when we weren't paying anesthesia subsidies, but it doesn't work today when we've got the crisis now. We've got to look at utilization not on the basis of average utilization, but the heat maps that Michael has created. And again, the elephant in the OR is payer mix. This is an East Coast hospital with $120 reimbursement for commercial pay. Their Medicare is 18, no margin, no mission. It's very clear you can't afford to give up that $100 every 15 minutes. The benchmarks need to change. The old benchmarks don't work. The cost of coverage has increased. So in our scorecards, we've got to create benchmarks. We've got to look at a level of efficiency.

(22:50)
In most markets, it requires over 10,000 anesthesia units to cover our physician cost. Those are the types of benchmarks we need to look at to drive it. So I think in summary, what we're seeing is that the market is changing. Because the market is changing, we really need to empower and engage anesthesia leaders to look at new ways of motivating their staff, getting involved in how we manage procedural services, sitting down with the people negotiating the anesthesia contracts in the PHO and making them aware of the fact that in most markets we need an average reimbursement of about $110 a unit to cover our cost. If you want to reduce the anesthesia stipend, you need to focus on this. So I think I'm going to take a break now and then we're going to have a panel.

Be Our Guest

Do you have an anesthesia perspective to share? We’re always looking for healthcare leaders to discuss the industry's most pressing challenges. Apply below for a chance to be featured.