Calculating institutional support that benefits both the Anesthesia group and hospital

Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, IA 52242, USA.
Anesthesia and analgesia (Impact Factor: 3.47). 03/2008; 106(2):544-53, table of contents. DOI: 10.1213/ane.0b013e31815efb18
Source: PubMed


Institutional support to anesthesia groups for clinical care is very common, particularly when compensation for certified registered nurse anesthetists and anesthesiology residents is considered. Poor contracts can reduce incentives for good operating room (OR) management. We show that two types of agreements for institutional support are rational, and that alternatives to those models increase profit for either the hospital or anesthesia group at the expense of the other. For both agreements, costs are based on survey data, not actual costs. Terms in equations are not recalculated regularly, thereby preventing undesirable incentives such as the anesthesia group profiting from reduced OR workload. Support is not based on hours worked late, because such an agreement would ignore the underutilized OR time sustained by the group. The support would create a disincentive to decision-making that would reduce overutilized OR time such as decreasing turnovers and starting add-on cases expeditiously. For groups with uncommonly low net collections, group profit is higher if the hospital provides support expected to assure a reasonable (fair) income for the group to recruit and retain members. For what is likely the majority of groups, with average net collections per anesthesia hour exceeding the hospital's compensation per scheduled hour, expected profit is higher if institutional support is payment at a reasonable rate (fair market value) for the expected incremental hours of underutilized OR time (i.e., nonbillable idle time) caused by the specialty-specific staffing (i.e., OR allocations). Such an agreement creates incentives whereby the hospital and anesthesia group both profit from increased OR workload and from more accurate specialty-specific staffing.

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    • "In this article, we describe the use of 1 hr structured meetings during which sufficient knowledge is elicited to assess the quality of OR management decisions influencing OR efficiency [1,7,11]. Approximately 45 scenarios (Table 2) from scientific articles are adapted (Table 3) automatically so that their cues are appropriate for each facility [2,12-14] (Table 4, 5). To clarify the organization of this article, conclusions from each section are listed in Table 6. "
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    ABSTRACT: No systematic process has previously been described for a needs assessment that identifies the operating room (OR) management decisions made by the anesthesiologists and nurse managers at a facility that do not maximize the efficiency of use of OR time. We evaluated whether event-based knowledge elicitation can be used practically for rapid assessment of OR management decision-making at facilities, whether scenarios can be adapted automatically from information systems data, and the usefulness of the approach. A process of event-based knowledge elicitation was developed to assess OR management decision-making that may reduce the efficiency of use of OR time. Hypothetical scenarios addressing every OR management decision influencing OR efficiency were created from published examples. Scenarios are adapted, so that cues about conditions are accurate and appropriate for each facility (e.g., if OR 1 is used as an example in a scenario, the listed procedure is a type of procedure performed at the facility in OR 1). Adaptation is performed automatically using the facility's OR information system or anesthesia information management system (AIMS) data for most scenarios (43 of 45). Performing the needs assessment takes approximately 1 hour of local managers' time while they decide if their decisions are consistent with the described scenarios. A table of contents of the indexed scenarios is created automatically, providing a simple version of problem solving using case-based reasoning. For example, a new OR manager wanting to know the best way to decide whether to move a case can look in the chapter on "Moving Cases on the Day of Surgery" to find a scenario that describes the situation being encountered. Scenarios have been adapted and used at 22 hospitals. Few changes in decisions were needed to increase the efficiency of use of OR time. The few changes were heterogeneous among hospitals, showing the usefulness of individualized assessments. Our technical advance is the development and use of automated event-based knowledge elicitation to identify suboptimal OR management decisions that decrease the efficiency of use of OR time. The adapted scenarios can be used in future decision-making.
    BMC Medical Informatics and Decision Making 01/2011; 11(1):2. DOI:10.1186/1472-6947-11-2 · 1.83 Impact Factor
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    ABSTRACT: Implementation of initiatives to increase anesthesia group productivity depends not just on anesthesia groups, but on operating room (OR) nursing administration. OR nursing directors may encourage organizational change based on the needs of their hospitals and nurses. These changes may differ from those that would increase the anesthesia group's productivity. We assessed reward structures using (A) letters of nomination for the "OR Manager of the Year" award offered annually by the publication OR Manager, and (B) data from a salary/career survey of OR directors by the same publication. (A) There were 164 nomination letters submitted from 2004 through 2007 for 45 nominees. The letters contained n = 2659 full sentences and n = 50,821 words. We systematically created a list of 36 terms related to finance, profit, and productivity. We also analyzed the frequency of use of these terms relative to the use of the 15 most common relationship-oriented terms (e.g., compassion, encourage, mentor, and respect). (B) The salary/career survey's questions relevant to anesthesia group productivity had responses from 303 US OR directors, 97% of whom were nurses. We tested the strength of the relationship between the budget responsibility of the OR nursing director and his or her annual salary. (A) 2.6% of sentences in the nomination letters included at least one term related to profit and productivity (95% confidence interval 2.0%-3.2%). Relationship-oriented terms were 9.0 times more prevalent (95% confidence interval 7.1-11.4). (B) There was statistically significant positive proportionality between the OR nursing director's operational budget (including personnel) and his or her salary (Pearson r = 0.64, P < 0.001). The 10th percentile of the operational budget was $1 million and the 90th percentile was $36 million. The budget of $1 million was associated with a salary 22% less than the median and the budget of $36 million was associated with a salary 22% larger than the median. Through (A) organizational constituencies, and (B) compensation, many US OR nursing directors likely are encouraged to enhance relations with nursing staff, not to champion organizational initiatives that would reduce under-utilized OR time and OR nursing labor costs. Resulting decisions can differ from those that would increase the productivity (profit) of the anesthesia group. Anesthesia groups need to champion initiatives to increase anesthesia productivity, while being sensitive to institutional expectations of nursing directors.
    Anesthesia and analgesia 12/2008; 107(6):1989-96. DOI:10.1213/ane.0b013e31818874a8 · 3.47 Impact Factor
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