Virtually every anesthesia service agreement with a facility includes a section entitled, “Medical Director.” This is nothing new. While such language has typically referred to either the chairman of the department or the head of the anesthesia group, its intent was merely to indicate that the department or group should have a clearly defined point person. Such a perfunctory definition of this role made it a rather benign and non-controversial aspect of the contract during contract negotiations but this is clearly changing. Indeed, today’s group practices should pay very close attention to the hospital’s expectations of this now critical role because this could become their Achilles’ heel. A practice with weak or indecisive leadership is a practice doomed to fail.
The Slow Reveal
What is it that hospital administrators want, and why is it so important to read between the lines of the anesthesia services agreement? A new set of requirements is slowly revealing itself. The first is not new: the anesthesia practice must speak with one voice and have the authority to make good on all its promises and representations. Second, anesthesia providers must be seen as team players in the efficient management of the O.R. suite, and the medical director must play a key role in ensuring there is a productive partnership between anesthesia and the OR staff. Third, anesthesia should help identify and propose recommendations for the enhancement and efficiency of the hospital.
A recent contract we have been reviewing for a client contains a 5-page job description for the position that includes the following:
Develop a unified culture among anesthesiologists and nurse anesthetists regarding practice style, clinical and operational objectives for the department. Assure regular department meetings to discuss clinical and operational elements of the program as well as over-arching perioperative program issues.
Each of these elements speaks to the concerns and expectations of the administration. To some extent such language represents a wish list that defines the ideal department. The language is intentionally vague, as most contracts tend to be. Lack of specificity in a contract can cut two ways. Too much specificity makes it overly punitive. Too little makes the arrangement unduly discretionary. This is exactly why the contract must reflect a deeper understanding of the administration vision for the department and the reality of a close working relationship between the department and the administration.
A Closer Look
The first phrase, “develop a unified culture among anesthesiologists,” speaks directly to the history and culture of anesthesia. There may be a group structure and legal format, but is that how the providers are actually perceived by the medical staff? Creating an anesthesia group has sometimes been described as herding cats. What makes a clinician a good anesthesia provider may not make him or her a good group member. Therein lies the first challenge of the medical director.
Then, there are the aspects of care that include style, clinical and operational objectives of the providers that may not always be consistent. By definition, a 20-provider practice with clinicians of different ages and training levels will represent a diverse collection of talents and skills. This may be a good thing to the extent that it allows the department to meet a variety of clinical requirements. It may be a bad thing if not all providers bring the same level of service and commitment to the care of patients. The reason hospitals prefer exclusive agreements with anesthesia is that the medical director is responsible for recruiting and managing the team. In the current environment, where the fundamental challenge of all practices is to generate enough revenue to recruit and retain a sufficient number of qualified providers to meet the coverage requirements of the facility, this can be a daunting challenge for the medical director.
Holding regular meetings and communicating a consistent and compelling vision for the department can be another significant obstacle. Anesthesiologists and CRNAs tend to define their value in terms of what happens in the operating room or delivery suite. The art and science of anesthesia are based on that crucible of experience that brings together the patient, the surgeon and the anesthesia provider. While good and consistent outcomes are important, they are now a given. The administration tends to be more focused on broader customer service issues and how the anesthesia staff supports the mission and vision of the facility.
The Overarching Message
What, then, are the overarching perioperative program issues? The ASA has redefined the responsibility of anesthesia, with its focus on the perioperative surgical home. The goal is for anesthesia to redefine and manage the entire perioperative continuum of care. This sounds great at a theoretical level, but to the anesthesia providers it sounds like more responsibility for no more pay. These additional responsibilities, such as staffing a pre-operative clinic, do not generate any additional revenue. Maybe they improve the quality of care and make the OR schedule more efficient, but the value of these service enhancements does not really accrue to the department.
Too often, an exclusive contract for anesthesia services is seen as a means to ensure the security of the practice, which should be the case. In the current competitive medical environment, however, it is much more. It is a commitment to partnership wherein the role of the medical director may be the most critical piece of the relationship. In the current environment, effective and inspired leadership and management trump quality of care.
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