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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

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

To 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 surgery and major intra-abdominal procedures.

Various methods to estimate case duration can be utilized. (Table 1)

Table 1. Models to predict case duration

•             mean of historical case duration

•             surgeon estimate

•             use surgeon estimate in combination with historical data to create new estimate

•             adjust for case complexity (e.g. simple, average, or complex)

•             some combination of the above

The variance of statistical distributions of case times complicates just using the mean of historical case durations because unusually long cases (outliers) have disproportionately large effect. (Table 2)

Table 2. Possible values that can be computed from historical data

•             Median – decreases the impact of unusually long cases

•             Trimmed mean –  delete lower & upper 10% of the durations and then take the average

•            Geometric mean – At some hospitals surgeons consistently shorten their case duration estimates if they perceive they have too little OR time and need to make sure they  “fit” their cases into the OR time they have.  In contrast, other surgeons may purposely overestimate case durations to keep control/access to their OR time so that if a new case appears for them their OR time has not been given away.

Certainly, estimated case duration will only be helpful if the surgeon correctly schedules the operation they do. If this happens, how should the duration time be kept in database? We are recommending determining the mean case duration of previous cases using scheduled operations, not actual operations.

When surveying facilities many different other explanations are often heard for inaccurate scheduling besides that the surgeon estimates are incorrect. (Table 3)

Table 3. Common reasons provided for case duration inaccuracy

•             Eroded “procedure” file

For example lap chole posted under a number of different names (laparoscopic chole, lap cholecystectomy) so system can’t  aggregate

Facilities need standardized procedure dictionary

•             Multiple procedures counted as one

For example lap chole with appy, lap chole with liver bx, and lap chole all counted as same even though complexity varies

•             Accounting for setup & cleanup times that affect how late an OR runs

•             Common approach: standard amount of time booked for turnover (setup & cleanup) times

Needs to vary according to case complexity

MANAGING THE UNCERTAINTY THAT IS INTRINSIC TO CASE DURATION PREDICTION

Scheduling accuracy decreases as estimated length of time for the surgical procedure goes up. It is more difficult to know when an 8 hour expected surgery will finish than a 30 minute case.

It would be ideal to have no uncertainty in case duration prediction. Obviously, that is unrealistic. When we ask, “How long will the case last?” we are expecting a defined answer. For example, “The case will last 2 hours.” This provides an “illusion of certainty” that feeds a human emotional need for certainty when none exists.

What research in the field of OR management science has discovered is that in fact, by analyzing historical case data for the same surgeon and procedure, one can assess the uncertainty surrounding the estimate. In other words, case durations have a probability distribution, such that the expected case duration is not a point value, but rather a probability estimate. Therefore, a more informative answer to the question, “How long will this case be” might be, for example, “There is a 67% probability that the case will be finished within 90 minutes.” This is similar to the approach used in reporting weather forecasts.

We are recommending that OR management accept and manage the uncertainty in how long an individual case may last.  For example, for some decisions the OR manager needs to consider the shortest time possible that a case will last. This information may assist in deciding on whether to place an urgent case from the wait list in that OR.  For other decisions, the OR manager needs to consider the longest possible duration of a case.  There may be another OR waiting for equipment that is being utilized by the OR in question.

Best practice for case scheduling involves not having patients show up at a fixed time interval in advance of surgery. Rather, the time a patient is instructed to arrive at the hospital in advance of their surgery should vary based on the nature of the case(s) ahead of them.

For example, if patient Smith is scheduled to follow a case of predictable duration with patient Jones, then patient Smith can be told to arrive closer to her start time. On the other hand, if patient Smith is scheduled to follow a case of uncertain duration (e.g. a cancer resection around the liver), this patient’s instructions might be, “Please arrive early,” knowing that an “open and close” procedure is a possibility.

As far as the efficiency of the surgery suite is concerned, allocating the right amount of OR time to each service each day is paramount. This ensures that workload and staffing are optimally matched.  Effectively managing the associated uncertainty in case duration can minimize unnecessary overtime expenditures.

1.Gigerenzer G, Gaissmaier W, Kurz-Milcke E, Schwart L, Woloshin S. Helping doctors and patients make sense of health statistics. Psychological Science in the Public Interest 2008;8: 53-96

2. Dexter F, Epstein RH, Traub RD, Xiao Y. Making management decisions on the day of surgery based on operating room efficiency and patient waiting times. Anesthesiology, 2004; 101:1444-53.

Anesthesiology and Accountable Care Organizations: What impact will ACOs have on anesthesia delivery in hospitals and ambulatory surgical centers?

What are Accountable Care Organizations (ACOs)?

“Accountable Care Organization” (ACO) is a term attributed to Dr. Elliott Fisher of Dartmouth Medical School. An ACO is a model of healthcare delivery aimed at improving quality while decreasing costs. ACOs are a key component of the Medicare Shared Savings Program, contained within the Affordable Health Care Act passed in 2010 and upheld by the Supreme Court earlier this year. ACOs provide the mechanism for “shared savings”; if physicians organized within ACOs meet specified quality standards and decrease healthcare costs, those cost savings are ‘shared’ between the physicians and the Centers for Medicare and Medicaid Services (CMS).

The American Society of Anesthesiologists (ASA) has compiled an extensive set of frequently asked questions regarding ACOs. The ASA has expressed a number of concerns about the legislation, including “an overwhelming focus on chronic disease management [and] limited attention to the role of specialists in improving quality and controlling costs”.

What is the role of anesthesiologists in the ACO?

ACOs are vertically structured care organizations, typically consisting of primary care physicians, at least one hospital and specialists. This integrated healthcare team is responsible for working together to cost-effectively improve the health of their designated patient population. While anesthesiologists and other specialists are not expressly prohibited from forming ACOs, certain eligibility requirements make it unlikely that they would be the key players. These include the stipulationthat ACOs includea sufficient number of primary care physicians to care for a minimum of 5000 assigned. Anesthesiologists in smaller towns and more remote regions may find that no primary care practices or hospitals in their region have a large enough patient base to establish an ACO. In more populous areas, many anesthesiologists may find themselves de facto members of an ACO formed by the hospital or hospitals they serve.

However, while anesthesiologists may be unlikely to play a direct role in forming ACOs, they do have a large impact on the two essential outcome measures of ACO success: cost containment and quality of care. At a meeting in late 2010 with CMS administrator Don Berwick, MD, American Society of Anesthesiology leadership addressed the role of anesthesiologists in ACOs. First Vice President of the ASA John Zerwas, MDstated “We have a unique opportunity to lead because we care for patients through the entire peri-operative period, from admission through discharge. Eighty percent of the hospital costs come during the peri-operative period and anesthesiologists, who consistently manage the care of patients during this period, have the greatest opportunity to improve outcomes and lower costs.”

How will participation in ACOsaffect the delivery of anesthesia services in the hospital and ambulatory care setting?

• Increased responsibility for reporting on quality measures in anesthesia care

To share in the savings generated by decreased healthcare costs, the ACO must meet a number of quality measures under the broad categories of patient/caregiver experience, care coordination, patient safety, preventative health and at risk populations. Anesthesiologists have a particular role to play in the patient safety category, which includes events such as central line and catheter associated infections and postoperative sepsis. Many anesthesia practices already have mechanisms in place for documenting such occurrences and reporting them via the Medicare Physician Quality Reporting System (PQRS) and/or the National Anesthesia Clinical Outcomes Registry (NACOR) and Multicenter Perioperative Outcomes Group (MPOG). To meet the requirements of the new legislation, fully transparent reporting of all such events will be mandatory.

• Increased utilization and integration of Anesthesia Information Management Systems (AIMS)

One of the components of the ACO rule is financial incentives to groups that demonstrate meaningful use of the electronic health record. The American Society of Anesthesiologists is encouraging anesthesiologists to participate in this incentive program, typically by the utilization of anesthesia information management systems (AIMS) fully integrated with the existing hospital or group information system. An AIMS provides for automated data collection from the anesthesia machine and patient monitors, as well as manually entered data regarding medication administration, airway management and other clinical parameters. In addition to meeting requirements for the ACO, an AIMS has multiple benefits for the anesthesia group, including a streamlined interface for reporting clinical outcomes to national registries and improvements in anesthesia practice management through the tracking of procedure mix and billing efficiency.

• Increased responsibility for managing anesthesia patients throughout the entire care episode

In an ACO, anesthesiologists will need to demonstrate their value in terms of reductions in patient care costs to ensure their participation in any shared savings. In an open letter to CMS administrator Donald Berwick, MD, President of the American Society of Anesthesiologists, Mark Warner, MD delineated the means by which anesthesiologists could deliver savings throughout the entire care episode:

“shared savings would be derived… through pre-operative evaluations performed in anesthesiologist-run Pre-Anesthesia Testing (PAT) clinics, as well as reduced hospital lengths of stay and hospital readmissions arising from 1) selection of appropriate candidates for surgery, including interventions with those who are highly unlikely to benefit, 2) identification of optimal timing for surgical interventions, to avoid rescheduling, 3) reduction of complications such as surgical or catheter-related infections, poor perioperative glycemic control, and postoperative nausea and vomiting that increase length of stay or necessitate admission following outpatient surgery, and 4) improved perioperative management of pain and anxiety to ensure the best possible patient care experience.” [American Anesthesia Society Responds to Accountable Care Organization Proposed Rule]

Anesthesiologists typically interact with surgeons, who are well aware of the value anesthesiologists add to perioperative care. However, under an ACO, anesthesiologists will need to develop means of tracking and recording their contribution to healthcare savings, to better communicate the value of anesthesia services to the primary care physicians heading the ACO. The anesthesia practice’s allotment of any shared-savings bonus from Medicare will depend solely on successful negotiation with the ACO leadership.

Views expressed are the author’s and may not necessarily be shared by Xenon Health, LLC.   Nothing in the article should be construed as legal or medical advice.