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Anesthesia Management – Credentialing of Anesthesiologists and Certified Registered Nurse Anesthetists

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Credentialing involves establishing the qualifications of licensed healthcare professionals and securing the appropriate and requisite documentation concerning their background, experience and licensure. The appropriate precautions are taken to ensure that the anesthesiologist or CRNA has a valid license to practice in the state where the provider will be working. In addition to licensure, the medical malpractice history of the candidate in question must be assessed. If the provider has a malpractice history, a careful assessment and analysis is made of that history. The circumstances and outcome are considered. In an ideal world, all anesthesiologists and CRNAs selected should have an exemplary practice history without any malpractice claims. However, this is not always the case. Some claims are legitimate claims by patients, some are frivolous and many are ancillary – the anesthesia provider is named in the suit but the claimed injury is not directly the result of the administration of anesthesia. The objective is to select an anesthesia provider with as few malpractice claims as possible (ideally none).

Reference checks are an essential step in the credentialing process to ensure that the anesthesiologist’s or CRNA’s qualifications are validated. One can get an assessment of the anesthesia professional’s technical skill as well as bedside manner by speaking to her fellow healthcare professionals.

Additionally, a comprehensive credentialing packet is sent to the anesthesia professional to complete. This has to be completed and shared with the surgical facility where the anesthesia provider will be rendering services. The components of the credentialing packet include:

–         State-specific license to practice

–         National license in the case of CRNAs

–         Board certifications

–         Graduate school or medical school diplomas

–         Proof of malpractice insurance

–         Continuing education certificates

–         Current ACLS certification

–         A self-query from the National Practitioner Data Bank

The National Practitioner Data Bank is a federal data bank created by the Medicare and Medicaid Patient and Program Protections Act of 1987. It was designed to collect and release information concerning the competence and conduct of physicians and other health care practitioners. The Health Insurance Portability and Accountability Act of 1996 resulted in the creation of the Healthcare Integrity and Protection Data Bank (HIPDB). It served as a system to alert users that a review of a provider’s or supplier’s history may be in order. In May of 2013, the NPDB and HIPDB were merged into one data base, the NPDB.

A background check and drug screening are mandatory elements of the credentialing process.

Once all the requisite documentation is collected, it is stored in a secured data base at corporate headquarters and transmitted through a secure mechanism to client facilities.

Maintenance of the files involves updating them periodically with current certifications and licensures as they are renewed and adding proof of continuing education credits as they are accumulated.

In addition to updating each client facility with current documentation pertinent to each credentialed provider, steps to ensure compliance with the credentialing requirements of individual accrediting bodies are taken. Surgical facilities usually choose one of several national accrediting organizations. These include the Accreditation Association of Ambulatory Health Care (AAAHC), the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) and the Joint Commission. Each organization has its own specific set of requirements for the credentialing of providers that must be met and maintained.

In summary, credentialing involves the documentation that an anesthesiologist or CRNA is qualified to render anesthesia services and patient care. That documentation needs to meet the requirements of federal and private accreditation bodies and must be appropriately maintained and updated.

Haroon W. Chaudhry MD

 

 

 

What Is Anesthesia Management?

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Anesthesia Management

Anesthesia is an integral part of any surgical procedure, for keeping the patient comfortable and stable. In addition to taking care of patients during surgery, anesthesia professionals are responsible for assessing whether the patient is healthy enough to safely tolerate the planned procedure. They are also responsible for taking care of patients immediately after the surgical procedure to ensure that they are on their way to a safe recovery.

 Anesthesia professionals in the typical community hospital are not usually employed by hospitals. Instead they frequently work as part of a private group that is contracted by the hospital. They are responsible for the clinical delivery of anesthesia care as well as the day-to-day management of the business aspects of their practice such as billing for their services. The group concept was the natural result of anesthesia professions joining forces to be able to provide effective anesthesia coverage to hospitals twenty four hours per day, seven days per week.

Anesthesia management organizations emerged shortly thereafter as a natural evolution. They assume the business and managerial aspects of an anesthesia practice such as recruiting physicians and certified registered nurse anesthetists, scheduling, billing and collections. Like most healthcare specialists, anesthesia services providers face an increasing set of economic and regulatory challenges. Not welcome by all healthcare professions, management organizations allow healthcare professionals to focus their attention on what is most important….patient care.

Haroon W. Chaudhry MD

 

Logistics and Supply Chain Management

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One of the key functions of an anesthesia management organization is supply chain management of anesthesia equipment and medications. This aspect of management can be challenging in several respects. Especially in the current healthcare climate, mitigating overhead costs is a priority for management entities, hospitals and surgical facilities. One of the mechanisms for reducing costs is to join a GPO, or group purchasing organization. GPOs leverage the collective buying power of their members in order to negotiate discounts from vendors. Some of the more prominent GPOs in the healthcare industry include MedAssets, Amerinet, Novation, Premier and HealthTrust Purchasing Group.

Purchasing equipment and supplies external to a GPO involves ordering from a variety of re-distributors. These are often large organizations that purchase medications and equipment from the manufacturer and then sell it to healthcare facilities and practitioners. Several large re-distributors maintain regional offices and warehouses throughout the country and have an extensive system of sales representatives, online ordering and tracking platforms and rapid delivery cycles. Re-distributers are typically competitive with pricing. Research and negotiations with such companies can lead to cost savings.

Facility storage space can present another logistic challenge, especially in smaller, office-based surgical practices. Ordering frequency can vary significantly based on storage constraints. Tight inventory management and frequent ordering are common when storage space is limited. The challenge this presents is obtaining necessary equipment and supplies in time for surgical procedures. Inclement weather, backorders, and logistics complications with manufacturer, vendor or the delivery service can complicate matters significantly.

Medication supply management presents its own set of challenges secondary to a variety of factors. Over the last several years, pharmaceutical firms have dealt with manufacturing challenges in the production cycle of critical anesthetic medications such as propofol, creating lengthy back-orders.  Management companies and surgical facilities have a difficult time obtaining important anesthetics during the back order period. When they are able to obtain such anesthetics, they tend to overstock in order to avoid a shortage if another backorder period occurs. The challenge then becomes ensuring that the stored medication are utilized before their expiration date.  An appropriate inventory tracking and logging system has to be in place for medications. In addition, many anesthesia medications are controlled substances. Controlled substances have their own set of regulations issued and enforced by the federal government. Ordering, logging and storing these medications must be performed carefully in accordance with these regulations and guidelines.

Additionally, manufacturer recalls for medications occur periodically. As an example, occasional defects in the manufacturing process can result in medications with foreign substances such as pieces of glass or metal from their containers. In such an instance, the manufacturer will track the medications by their lot numbers and request that the end user return all the medications that belong to the lot number in question.

Anesthesia management companies can leverage technology to simplify the tracking of equipment and medications at remote sites. Standardized digital templates for anesthesia supplies and medications can streamline the process of inventory management. For instance, each client site can have a digitized inventory “master” list that is shared between the client site and management entity. This can assist in creating a clear understanding of exactly what is required to be kept on site to ensure the safe delivery of anesthesia and to appropriately deal with any complications. Digital transmissions through PCs, tablets and smart phones can assist the logistics team in maintaining the appropriate quantity of equipment and supplies.  These communications can be in the form of interactive PDFs or cloud based applications.

Equipment maintenance is another element of supply chain management. This is usually accomplished by forming a relationship with a competent, experienced, and cost-effective local biomedical equipment specialist. They will periodically inspect and certify that the equipment is functional and safe to use for a defined period of time.

In summary, there are a variety of facets of anesthesia supply chain management for surgical facilities. Each aspect has to be managed effectively to ensure compliance with regulations, to appropriately contain overhead costs, and to ensure the safe and efficient delivery of anesthesia care for surgical patients.

Haroon W. Chaudhry MD

Predicting Surgical Case Duration

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Predicting Surgical Case DurationTo address chronic complaints about “OR inefficiency” due to inaccurate case times and scheduling, a hospital utilizes their new surgical services computer information system to track case times. The plan is to then be able to compute a newly scheduled case’s expected duration based on analysis of previous cases’ surgical times.

However, 6 months after adoption of this new scheduling approach using historical data, the accuracy of the OR schedule has not improved.  The hospital vice president notes that approximately the same number of complaints from surgeons and patients continue.

Why has accuracy not improved using analysis of historical data? It turns out that scheduling case durations correctly is a more complex undertaking than expected and the level of certainty desired by many stakeholders is often not possible.  Best practice is to have OR management accept and manage some of the uncertainty in how long an individual case may last.

KEY MESSAGES

The take home message from this white paper is that averaging historical data for case duration predictions does not increase prediction accuracy as much as most people think it should. This is due to several key principles:

•             The combination of a great variety of procedures and the large number of surgeons on most hospitals staffs makes it such that on average half of the cases scheduled in a hospital’s surgery suite will have less than 5 previous cases of the same primary procedure type & same surgeon during the preceding year. In other words, often there are not enough similar enough cases to make a prediction regardless of whether statistics are used or how long one goes back in the system to pull out similar cases.

•             Also, if case durations for a surgeon performing a particular operative procedure vary significantly due to the nature of the surgery (cancer resection is one example as every tumor is different), then it is also intrinsically very difficult to make accurate predictions, no matter how many previous cases are examined.

•             Yet another barrier to truth in scheduling is the statistical distribution of case times which most often are not bell shaped (normal) distributions. This variance, for example, complicates using the average of historical case durations because unusually long cases (outliers) have a disproportionately large effect

 

The surgeon and the surgical procedure are the two most important determinants of surgical time.  Some case lengths are easier to predict than others. These include surgical specialties that operate on the body surface or extremities, where operations are often standardized.  On the other hand, surgery duration for many cases is intrinsically difficult to predict especially if the procedure is complex, and the operative steps are not standardized such as for ENT cancer s