Meeting the challenge of the academic mission: 3 strategies to improve efficiency in academic hospitals' ORs

NorthStar Anesthesia and Duke Department of Anesthesiology have collaborated to leverage their best in class solutions to actively manage other academic departments of anesthesiology.

Academic medical centers' three-pronged mission — education, research and patient care — makes them uniquely vulnerable to financial pressures.

"For those in the academic space, it's become increasingly more challenging to advance the goals of the academic mission and maintain a high quality surgical department," said Solomon Aronson, MD, executive vice chair of the Department of Anesthesiology at Duke University in Durham, N.C., during a webinar Feb. 16.

Hospitals and health systems affiliated with medical schools have much higher cost structures than their non-academic counterparts. They must be equipped to provide patients and the community with healthcare services for everyday needs as well as invest in scholarly research and student instruction. As such, these institutions face some of the highest fixed costs across all healthcare settings.

Traditional sources of funding for AMCs have dwindled in the last several years. Reduced government and commercial payer reimbursements and diminished government grants have made the traditional AMC operating model unsustainable for many institutions. AMC leaders looking to stay in the black are finding creative and innovative management solutions to relieve pressure on their margins.

The Duke University Department of Anesthesiology and NorthStar Anesthesia, an anesthesia management company helping hospitals improve OR efficiency, collaborated to help academic medical centers improve profitability, quality and collaboration. Dr. Aronson and Phil Eichenholz, MD, founder and president of NorthStar Anesthesia, shared insight gleaned from their successful partnership, including why anesthesiology is central to restructuring AMC operations and three strategies for achieving academic, clinical and financial optimization in AMCs.

Changing the anesthesia paradigm
"Anesthesiology is taking a leading position in redesigning perioperative programs," Dr. Aronson said.

Many anesthesiologists appreciate the need to professionally evolve under value-based payment models, which reimburse physicians, surgeons and hospitals according to overall quality outcomes. Communication and collaboration between specialties, providers and departments is key to ensuring high levels of both efficiency and clinical quality. Due to anesthesiologists' central role in patients' surgical experience, the department is uniquely positioned to facilitate a high degree of inter-departmental coordination between stakeholders.

"Anesthesia [clinicians] are in house 24/7. They know all the stakeholders, they understand their needs and they can facilitate productive conversations by bringing stakeholders to the table," Dr. Eichenholz said. "That's crucial as value-based care is about aligning the interests of all these different stakeholders."

Duke and NorthStar have focused on developing leadership skills to help change the perioperative paradigm and improve care efficiency. Select anesthesiologists attend leadership classes through NorthStar that teach best practices in communication, management and peer-to-peer relationships as well as how to listen and how to follow up, Dr. Eichenholz said. Clinicians return to the surgical environment better equipped to take on a central role in perioperative operations.

Effective surgical care management better positions AMCs to improve financial performance. "Maintaining optimal operational efficiency is crucial to managing variable costs," Dr. Eichenholz said. Anesthesiologists play an essential role in improving surgical efficiency. For instance, anesthesiologists who perform in-depth pre-operative evaluations of inpatients may discover certain medical conditions or comorbidities that require specialized care, such as diabetes or anemia. The anesthesiologist can help other physicians in the surgical team prepare accordingly, reducing the chance of complications.  

If AMCs do not develop and deploy physicians as key communicators, they risk incurring higher complication rates. This could lead to lower reimbursements due to poorer quality outcomes, exacerbating AMCs' financial challenges.  

The need for a perioperative paradigm change is clear. But changing workplace culture and deeply ingrained routines is difficult to accomplish. Dr. Aronson and Dr. Eichenholz offered three strategies AMC leaders may deploy to establish best practices in their anesthesiology department.

1. Hold faculty accountable for a service-driven culture.
The key to finding balance between academic and clinical priorities is to instill the importance of teamwork and continuous improvement into the work culture. "Promoting workplace culture is essential, and we spend a lot of time working on how to instill core values into faculty," Dr. Aronson said.

One method to achieve physician buy-in in culture change is to tie financial incentives to clinical and operational metrics. Dr. Eichenholz recommends developing performance goals based on team coordination and care quality, where compensation depends upon each physician or anesthesiologist taking accountability for their role in the surgical continuum. For instance,  NorthStar measures performance metrics like pre-operative evaluation of inpatients for surgery, on-time starts, case delays due to anesthesia, turnover times, protocol for central line placement, antibiotic administration, OR throughput and surgeon satisfaction.

At the same time, AMCs must also develop ways to ensure academic and educational advancement is also being achieved. Duke's Department of Anesthesiology designed its own set of metrics to capture academic assurance among its clinicians. Specifically, academic performance is based on metrics related to publication, research productivity, educational involvement, academic awards and mentoring and citizenship.

Tracking and managing large volumes of complex data requires a sophisticated IT system. Legacy IT systems may not have the capabilities or infrastructure to support such an endeavor. "Sophisticated algorithms are needed to translate extensive data sets into meaningful information for department supervisors, enabling them to track and monitor progress," Dr. Aronson said. Despite thin operating margins, Dr. Aronson and Dr. Eichenholz believe investing in a robust IT system designed to support faculty development generates a worthwhile return on investment.

2. Leverage mid-level providers to optimize profitability.
Utilizing student residents effectively can help AMCs optimize both the academic mission and financial efficiency.

The average annual CRNA salary is approximately $159,000 — significantly lower than anesthesiologists' average $358,000 compensation. Deploying CRNAs in place of anesthesiologists in appropriate situations can help the department and the AMC reduce labor costs and optimize operational efficiency.

Furthermore, utilizing CRNAs more extensively in the clinical space ensures academic advancement for both students and faculty. "It's really about balancing the academic experience with the clinical experience through more ample learning opportunities," Dr. Eichenholz said.  

3. Create partnerships and affiliations.
Dr. Aronson and Dr. Eichenholz stressed the importance of developing strategic partnerships and affiliations both within the AMC and with outside organizations.

Encouraging cross-departmental interactions in AMCs is a great way to break down traditional work silos and develop a team-based work culture. Collaborative initiatives between specialties and departments create opportunities for innovation — a necessity for AMCs to remain successful under value-based care.

AMCs should also look to engage in strategic partnerships with other academic, nonprofit or for-profit organizations. Sharing research and best practices between institutions can present new educational opportunities for faculty and residents, as well as advance AMC practices. In terms of advancing academic goals, Duke's anesthesiology department recently launched a perioperative medicine fellowship in collaboration with the University College of London. The English university is renowned for its work in perioperative medicine. The partnership between Duke University's Department of Anesthesiology and NorthStar Anesthesia is a prime example of a way for Academic Medical Centers to benefit from best in class OR management and academic leadership.

AMCs across the country are struggling to maintain operating margins in addition to academic excellence. The fact that half of AMCs' chairmanship positions are open illustrates the difficult leadership and operational challenges AMCs currently face. Surgical procedures, a hospital's most profitable service line, present a significant opportunity for AMCs to fulfill the academic mission and improve financial performance.

"Academic anesthesia departments that confront complex management challenges will be able to achieve better academic mission fulfillment and enhance the experience for residents, clinicians and patients through unique benefits derived from this engagement," Dr. Aronson said.

Visit to learn how NorthStar and Duke Department of Anesthesiology can help your facility.

To download a copy of the webinar, click here.
To view a recording of the webinar, click here

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