How to supervise 3-4 ORs

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Job is very stressful when running the board and 1st or 2nd call. But I'm well compensated in time off, not necessarily pay. I'll take it at this point, as it's about the only thing that's currently negotiable.
 
I routinely supervise 4 rooms. I preop at least the first rounds the night before, the whole day if I anticipate quick turn overs or have the time to do so. We have a great emr which simplifies that. I dont sit around much and for sure get my steps in 🙂 but most days i manage easily.... If i get tied up with an issue in an OR my colleagues will always help out. preparation and good shoes get the job done.
 
amyl said:
I routinely supervise 4 rooms. I preop at least the first rounds the night before, the whole day if I anticipate quick turn overs or have the time to do so. We have a great emr which simplifies that. I dont sit around much and for sure get my steps in 🙂 but most days i manage easily.... If i get tied up with an issue in an OR my colleagues will always help out. preparation and good shoes get the job done.
Click to expand...


Louboutin’s?
 
There is a new creative formula that AMC is employing. It has a bunch of CRNA and few MDAs. It starts out as MDA supervision model until they get settled in the hospital. Soon they have CRNA do independently and they don’t call anesthesiologist, that way they bait and switch.
Supervising areas which are physically far apart in the same hospital, multiple rooms with non stop cases, are the ways the AMC test the resolve of the MDA.
 
Adductor canal said:
How do anesthesiologists prioritize when supervising 4 operating rooms? How to manage the flow? Are we supposed to just do prep, post ops and be readily available for critical portions of the case?. Imagine running 4 ors with quick cases and short turnover times.
what happens if there are problems in 2 operating rooms at the same time? What is legality in that situation? Will I be able to get help from anesthesia desk?
Thanks
Click to expand...

This is definitely a skill set that takes time to develop. No, not all of us that supervise make > 600K. It's not always a hellacious assignment to do 4 rooms, with some days undoubtably better than others. The same is true for solo assignments to be clear.

About 70% I start off 3:1 with increases to 4:1 to get MDs out later in the day. Recently we have had a terrible manpower crunch so it has been more frequently 4:1 to start. A lot has been posted in this thread but here are some general tips I have for going about my day:

- Careful scheduling. You don't want the open aorta, big thoracic and liver resection for the same doc. Spread around the love.
- Know your patients ahead of time. The night before I typically look up the first 2 patients in each room so I can get to work ready to go and can keep moving through the morning, particularly with quick rooms.
- Know your surgeons. Who is efficient and runs ahead of schedule? Who has a lot of complications requiring a closer eye on the room? Who treats you well and like crap?
- Know your CRNA/AAs. Not all are created equal. Go over your plan for the next case ahead of time, especially if there is anything special it requires.
- Make it clear from Day 1 if you are doing medical direction that this is a "patient-centric, physician-led" practice. Deal with clinical issues calmly, in private and in the same day (this has been a hard one for me to learn). Much easier to do if you employ them, if you do QZ/supervision more frequently then this doesn't apply as much.

As said above, very few rooms actually end up starting induction at the same time.

Problem in 2 of your cases at the same time? Call a partner for help. Don't be bashful about this. I am fortunate to be in a solid PP (equal, democratic) where we all help each other and we bounce ideas off one another all the time. It's collegial and positive. From what I understand, practices in the West can be quite different... glad I don't work at a place where I work on an island everyday.

Finally, a word about "supervision" or QZ billing. Locally, 2 of our dominant private insurers reimburse LESS (30-40%) for a case billed as QZ. As such we rarely use it, typically only for middle of the night emergencies where a backup person is on the way in and the case can't wait (e.g. trauma, emergent C/S).

Adductor canal said:
There is a new creative formula that AMC is employing. It has a bunch of CRNA and few MDAs. It starts out as MDA supervision model until they get settled in the hospital. Soon they have CRNA do independently and they don’t call anesthesiologist, that way they bait and switch.
Supervising areas which are physically far apart in the same hospital, multiple rooms with non stop cases, are the ways the AMC test the resolve of the MDA.
Click to expand...

Don't use the term "MDA" please. Again, as the I guess now-banned Choco says it murkies the water between CRNA/AA/MD.
 
AdmiralChz said:
This is definitely a skill set that takes time to develop. No, not all of us that supervise make > 600K. It's not always a hellacious assignment to do 4 rooms, with some days undoubtably better than others. The same is true for solo assignments to be clear.

About 70% I start off 3:1 with increases to 4:1 to get MDs out later in the day. Recently we have had a terrible manpower crunch so it has been more frequently 4:1 to start. A lot has been posted in this thread but here are some general tips I have for going about my day:

- Careful scheduling. You don't want the open aorta, big thoracic and liver resection for the same doc. Spread around the love.
- Know your patients ahead of time. The night before I typically look up the first 2 patients in each room so I can get to work ready to go and can keep moving through the morning, particularly with quick rooms.
- Know your surgeons. Who is efficient and runs ahead of schedule? Who has a lot of complications requiring a closer eye on the room? Who treats you well and like crap?
- Know your CRNA/AAs. Not all are created equal. Go over your plan for the next case ahead of time, especially if there is anything special it requires.
- Make it clear from Day 1 if you are doing medical direction that this is a "patient-centric, physician-led" practice. Deal with clinical issues calmly, in private and in the same day (this has been a hard one for me to learn). Much easier to do if you employ them, if you do QZ/supervision more frequently then this doesn't apply as much.

As said above, very few rooms actually end up starting induction at the same time.

Problem in 2 of your cases at the same time? Call a partner for help. Don't be bashful about this. I am fortunate to be in a solid PP (equal, democratic) where we all help each other and we bounce ideas off one another all the time. It's collegial and positive. From what I understand, practices in the West can be quite different... glad I don't work at a place where I work on an island everyday.

Finally, a word about "supervision" or QZ billing. Locally, 2 of our dominant private insurers reimburse LESS (30-40%) for a case billed as QZ. As such we rarely use it, typically only for middle of the night emergencies where a backup person is on the way in and the case can't wait (e.g. trauma, emergent C/S).



Don't use the term "MDA" please. Again, as the I guess now-banned Choco says it murkies the water between CRNA/AA/MD.
Click to expand...

Choco was banned?
 
AdmiralChz said:
Finally, a word about "supervision" or QZ billing. Locally, 2 of our dominant private insurers reimburse LESS (30-40%) for a case billed as QZ. As such we rarely use it, typically only for middle of the night emergencies where a backup person is on the way in and the case can't wait (e.g. trauma, emergent C/S).
Click to expand...


This is widespread. One of AANA's priorities is legislation that would require the same payment for an anesthetic no matter the model of delivery.
 
Adductor canal said:
There is a new creative formula that AMC is employing. It has a bunch of CRNA and few MDAs. It starts out as MDA supervision model until they get settled in the hospital. Soon they have CRNA do independently and they don’t call anesthesiologist, that way they bait and switch.
Supervising areas which are physically far apart in the same hospital, multiple rooms with non stop cases, are the ways the AMC test the resolve of the MDA.
Click to expand...
Not new at all. This has been going on for YEARS.
 
AdmiralChz said:
This is definitely a skill set that takes time to develop. No, not all of us that supervise make > 600K. It's not always a hellacious assignment to do 4 rooms, with some days undoubtably better than others. The same is true for solo assignments to be clear.

About 70% I start off 3:1 with increases to 4:1 to get MDs out later in the day. Recently we have had a terrible manpower crunch so it has been more frequently 4:1 to start. A lot has been posted in this thread but here are some general tips I have for going about my day:

- Careful scheduling. You don't want the open aorta, big thoracic and liver resection for the same doc. Spread around the love.
- Know your patients ahead of time. The night before I typically look up the first 2 patients in each room so I can get to work ready to go and can keep moving through the morning, particularly with quick rooms.
- Know your surgeons. Who is efficient and runs ahead of schedule? Who has a lot of complications requiring a closer eye on the room? Who treats you well and like crap?
- Know your CRNA/AAs. Not all are created equal. Go over your plan for the next case ahead of time, especially if there is anything special it requires.
- Make it clear from Day 1 if you are doing medical direction that this is a "patient-centric, physician-led" practice. Deal with clinical issues calmly, in private and in the same day (this has been a hard one for me to learn). Much easier to do if you employ them, if you do QZ/supervision more frequently then this doesn't apply as much.

As said above, very few rooms actually end up starting induction at the same time.

Problem in 2 of your cases at the same time? Call a partner for help. Don't be bashful about this. I am fortunate to be in a solid PP (equal, democratic) where we all help each other and we bounce ideas off one another all the time. It's collegial and positive. From what I understand, practices in the West can be quite different... glad I don't work at a place where I work on an island everyday.

Finally, a word about "supervision" or QZ billing. Locally, 2 of our dominant private insurers reimburse LESS (30-40%) for a case billed as QZ. As such we rarely use it, typically only for middle of the night emergencies where a backup person is on the way in and the case can't wait (e.g. trauma, emergent C/S).



Don't use the term "MDA" please. Again, as the I guess now-banned Choco says it murkies the water between CRNA/AA/MD.
Click to expand...

Ugh man how do you supervision guys do it... Every time I read these posts about the headless chicken dance job I'm so thankful for being able to fly solo job. The only crap I deal with is whatever mess I cause lol.
 
2Fast2Des said:
Ugh man how do you supervision guys do it... Every time I read these posts about the headless chicken dance job I'm so thankful for being able to fly solo job. The only crap I deal with is whatever mess I cause lol.
Click to expand...

You do the math and pick your poison at each stage in your career. Adapt, leave, suck it up whatever. I do lament skill loss though. Not much else.
 
2Fast2Des said:
Ugh man how do you supervision guys do it... Every time I read these posts about the headless chicken dance job I'm so thankful for being able to fly solo job. The only crap I deal with is whatever mess I cause lol.
Click to expand...

Most anesthesiologists don’t have a choice. If you want to live out west, good probability you better be ready to do your own cases. Or at least be open to it.

If you want to live in most places on the east coast, especially the south, get ready for supervision.

No one told me that as a medical student. Not. One. Person. It would’ve been useful info. As it stands, we all make the best of it. And while it wouldn’t be the end of the world to pick up and move across the country, it perhaps has not been what you’ve been telling your spouse all along and it may very well go over extremely poorly if that’s what you decide for the sake of the desired model.
 
Southpaw said:
Most anesthesiologists don’t have a choice. If you want to live out west, good probability you better be ready to do your own cases. Or at least be open to it.

If you want to live in most places on the east coast, especially the south, get ready for supervision.

No one told me that as a medical student. Not. One. Person. It would’ve been useful info. As it stands, we all make the best of it. And while it wouldn’t be the end of the world to pick up and move across the country, it perhaps has not been what you’ve been telling your spouse all along and it may very well go over extremely poorly if that’s what you decide for the sake of the desired model.
Click to expand...

I think there are still pockets for each. If you really really really look within a state. But will you or your family move to the BFE of your desired state?

Still boil down to location, money, lifestyle. I chug this into the lifestyle bucket. Do you want to take calls and manage crnas or do you want to be up in the middle of the night?

Choices choices. I choose to make less, ****tier location, just not to deal with 12:1 or even 4:1 daily grind.
 
Adductor canal said:
What is QZ billing? Had no clue till now. Anesthesia is constantly changing bussiness.

What Does the QZ Modifier Really Mean? | Anesthesia Business Consultants

Communiqué is a professional quarterly publication dedicated to providing resourceful articles and advice to the anesthesia and pain management community.
www.anesthesiallc.com www.anesthesiallc.com
Click to expand...

Considered yourself lucky.
It’s how people get away with 1:12 supervision.
Some people say you’re only allowed to bill ~80% of the whole thing. But I haven’t seen the exact number on paper.
 
Adductor canal said:
What is QZ billing? Had no clue till now. Anesthesia is constantly changing bussiness.

What Does the QZ Modifier Really Mean? | Anesthesia Business Consultants

Communiqué is a professional quarterly publication dedicated to providing resourceful articles and advice to the anesthesia and pain management community.
www.anesthesiallc.com www.anesthesiallc.com
Click to expand...

Well from your article QZ is an unsupervised (AKA independent) CRNA billing code. It seems like more anesthesia departments are moving to this no matter their care model to avoid legal issues relating to TEFRA regulations. A side effect that may come around in the long run is that payors and bean-counters only see increased CRNA independence by this metric through financial records.

And yes, as IMGASMD pointed out, it allows anesthesiologists to be spread even thinner. I'm not sure about the ~80% billing thing though.
 
2.0% said:
Well from your article QZ is an unsupervised (AKA independent) CRNA billing code. It seems like more anesthesia departments are moving to this no matter their care model to avoid legal issues relating to TEFRA regulations. A side effect that may come around in the long run is that payors and bean-counters only see increased CRNA independence by this metric through financial records.

And yes, as IMGASMD pointed out, it allows anesthesiologists to be spread even thinner. I'm not sure about the ~80% billing thing though.
Click to expand...

Correct. 15+ years ago groups started billing everything as QZ. The reimbursement was the same, and this was a gift in that it almost completely did away with compliance violation concerns, and whistleblower lawsuits. Many/most groups still operated as a medical direction model (or near medical direction). Two things followed. The payors came up with a variety of excuses to lower reimbursement. E.g., "The standard for your community is medical direction. We are going to regard QZ as medical supervision which has a significant cut in reimbursement". Another one is the ever popular, "you need less resources to provide QZ therefore you should be reimbursed less".

Also, it gave ammo to the CRNAs who claimed that all QZ billing was evidence of widespread CRNA independence when in fact the CRNAs were supervised by anesthesiologists. There was in fact at least one study that looked at patient outcomes of billing QZ vs other modifiers. The AANA tried to run with this to show no difference in CRNA only outcomes.

The AANA is lobbying hard to make it law that all modifiers be reimbursed the same way. The likely consequence is less medical direction, more medical supervision practices with higher supervisory ratios with a lesser bump in true CRNA independence.
 
How do you protect yourself from companies that have all your information and bill and collect on your behalf for clinical services. What if they over bill , up code etc and cause Medicare fraud? These companies can get away with all kinds of frauds and you the anesthesiologist is stuck with the consequences of their greed.
 
Adductor canal said:
What if they over bill , up code etc and cause Medicare fraud?
Click to expand...

Can you give some examples? Anesthesia billing is very different from the rest of medicine - it’s unit based. as such you can’t really “up code” like an internal medicine visit or outpatient specialty consult - level 3, 4 and 5 visits aren’t as translatable for our field. Either you did X case for Y amount of time or you didn’t.

Our experience has been if the insurance companies start to “sniff” something off, they’ll ask for documentation. Typically it’s easy stuff like ultrasound pictures. But other than billing for procedures you aren’t doing, I don’t fully understand the question.
 
AdmiralChz said:
This is definitely a skill set that takes time to develop. No, not all of us that supervise make > 600K. It's not always a hellacious assignment to do 4 rooms, with some days undoubtably better than others. The same is true for solo assignments to be clear.

About 70% I start off 3:1 with increases to 4:1 to get MDs out later in the day. Recently we have had a terrible manpower crunch so it has been more frequently 4:1 to start. A lot has been posted in this thread but here are some general tips I have for going about my day:

- Careful scheduling. You don't want the open aorta, big thoracic and liver resection for the same doc. Spread around the love.
- Know your patients ahead of time. The night before I typically look up the first 2 patients in each room so I can get to work ready to go and can keep moving through the morning, particularly with quick rooms.
- Know your surgeons. Who is efficient and runs ahead of schedule? Who has a lot of complications requiring a closer eye on the room? Who treats you well and like crap?
- Know your CRNA/AAs. Not all are created equal. Go over your plan for the next case ahead of time, especially if there is anything special it requires.
- Make it clear from Day 1 if you are doing medical direction that this is a "patient-centric, physician-led" practice. Deal with clinical issues calmly, in private and in the same day (this has been a hard one for me to learn). Much easier to do if you employ them, if you do QZ/supervision more frequently then this doesn't apply as much.

As said above, very few rooms actually end up starting induction at the same time.

Problem in 2 of your cases at the same time? Call a partner for help. Don't be bashful about this. I am fortunate to be in a solid PP (equal, democratic) where we all help each other and we bounce ideas off one another all the time. It's collegial and positive. From what I understand, practices in the West can be quite different... glad I don't work at a place where I work on an island everyday.

Finally, a word about "supervision" or QZ billing. Locally, 2 of our dominant private insurers reimburse LESS (30-40%) for a case billed as QZ. As such we rarely use it, typically only for middle of the night emergencies where a backup person is on the way in and the case can't wait (e.g. trauma, emergent C/S).



Don't use the term "MDA" please. Again, as the I guess now-banned Choco says it murkies the water between CRNA/AA/MD.
Click to expand...
Not banned yet! But close. Teaches me to not venture anywhere outside this forum.
They are sensitive out there!
And I am “good” now🙂.
Yup. Reformed. Nice. Lol
 
AdmiralChz said:
Screen name is crossed out and says “account on hold” - so maybe temporary? She definitely needed a break from here, though.
Click to expand...
Aww man. You hurt my feelings:-(
I thought you loved and missed me!

Well, good thing for you, I am back!!!
They can’t get rid of a sister!
Not yet anyway, but I am sure it’s coming.
 
chocomorsel said:
Not banned yet! But close. Teaches me to not venture anywhere outside this forum.
They are sensitive out there!
And I am “good” now🙂.
Yup. Reformed. Nice. Lol
Click to expand...

I used to wonder why no physician would post in the premed and medical student sections. I don't wonder anymore. What a wasteland of sensitivity and victim mentality. They will report you and chase you out for trying to help them.
 
2Fast2Des said:
Ugh man how do you supervision guys do it... Every time I read these posts about the headless chicken dance job I'm so thankful for being able to fly solo job. The only crap I deal with is whatever mess I cause lol.
Click to expand...

and I wonder how somebody can sit in a room and do their own cases day after day. When I do it I am literally bored out of my mind.

Different strokes for different folks.
 
As a new attending, I'm doing almost all MD only cases, but every now and then I get put in 3:1 ratio directing. I've found it frustrating because even when they're nice, it's hard to tell them they're doing so many things suboptimally while not frustrating them no matter how nicely I address things. I either see the cases done suboptimally or I annoy the **** out of my CRNA coworkers, who are often pretty nice people with whom I want to maintain good relationships.
 
zizzer said:
As a new attending, I'm doing almost all MD only cases, but every now and then I get put in 3:1 ratio directing. I've found it frustrating because even when they're nice, it's hard to tell them they're doing so many things suboptimally while not frustrating them no matter how nicely I address things. I either see the cases done suboptimally or I annoy the **** out of my CRNA coworkers, who are often pretty nice people with whom I want to maintain good relationships.
Click to expand...
This is exactly what I dread about supervising. Physician-only PP is my dream.
 
Mman said:
and I wonder how somebody can sit in a room and do their own cases day after day. When I do it I am literally bored out of my mind.

Different strokes for different folks.
Click to expand...

But the main part of supervising is doing all the hard work of supervising running around making sure CRNAs are breaked, lunched, ego massaged or managed, keep your sanity alive and making sure they are relieved on time, despite your own needs fulfilled, with the spattering of actual patient care
 
Mman said:
and I wonder how somebody can sit in a room and do their own cases day after day. When I do it I am literally bored out of my mind.

Different strokes for different folks.
Click to expand...

Doing your own cases is great. I get a lot of reading done. But it sucks when **** goes down and you're the guy that has to fix it alone. It's real nice when you're in a jam and your partner just strolls in for a visit.
 
GassYous said:
But it sucks when **** goes down and you're the guy that has to fix it alone.
Click to expand...

Sucks worse when you fix a mess you didn’t create.

Also, sometimes I appreciate the help in fixing a mess. But sometimes that help isn’t really helping at all, and I’d prefer to be left alone.
 
2Fast2Des said:
But the main part of supervising is doing all the hard work of supervising running around making sure CRNAs are breaked, lunched, ego massaged or managed, keep your sanity alive and making sure they are relieved on time, despite your own needs fulfilled, with the spattering of actual patient care
Click to expand...

Yes when you employ them. No to all of the above when they are hospital employees and they are responsible for figuring it out on their own.
 
2Fast2Des said:
But the main part of supervising is doing all the hard work of supervising running around making sure CRNAs are breaked, lunched, ego massaged or managed, keep your sanity alive and making sure they are relieved on time, despite your own needs fulfilled, with the spattering of actual patient care
Click to expand...

I don't give breaks or lunches or massage egos. I simply go about my day evaluating patients, picking out appropriate anesthetic plans, and helping implement them.

I am glad there are physicians out there that like doing their own cases. I occasionally have to do it and while easier than my normal day it also bores me. I do not think I could do it full time.
 
Mman said:
I don't give breaks or lunches or massage egos. I simply go about my day evaluating patients, picking out appropriate anesthetic plans, and helping implement them.

I am glad there are physicians out there that like doing their own cases. I occasionally have to do it and while easier than my normal day it also bores me. I do not think I could do it full time.
Click to expand...

I like working solo days. More sanity.
 
Mman said:
I don't give breaks or lunches or massage egos. I simply go about my day evaluating patients, picking out appropriate anesthetic plans, and helping implement them.

I am glad there are physicians out there that like doing their own cases. I occasionally have to do it and while easier than my normal day it also bores me. I do not think I could do it full time.
Click to expand...

In a system like that it would be much easier to supervise if you don't have to worry about non clinical care like lunch\breaks. That does take a load off. Except, being a pre\post-op chart monkey and standing there while CRNA is doing everything in the room is not mentally exciting. Only benefit of those days is getting my steps in lol
 
2Fast2Des said:
In a system like that it would be much easier to supervise if you don't have to worry about non clinical care like lunch\breaks. That does take a load off. Except, being a pre\post-op chart monkey and standing there while CRNA is doing everything in the room is not mentally exciting. Only benefit of those days is getting my steps in lol
Click to expand...

I usually occupy my time in the room with starting IVs, art lines, central lines, spinals, etc.
 
Mman said:
I usually occupy my time in the room with starting IVs, art lines, central lines, spinals, etc.
Click to expand...
Really? Because you always have patients that require any and all of the above?
No appys, choles, hernias, toes, ORIFs, for you?
Always something that requires a second IV, a line, spinal and CVC?
 
chocomorsel said:
Really? Because you always have patients that require any and all of the above?
No appys, choles, hernias, toes, ORIFs, for you?
Always something that requires a second IV, a line, spinal and CVC?
Click to expand...

no, but I assure you I don't lose any sleep over not putting the tube in an ASA 1 lap chole or adjusting the nasal cannula on a MAC patient that I put a block in preop. While supervising 2-4 rooms I generally have enough things to do to keep my occupied. Let's be honest, it isn't exactly mentally stimulating to be personally providing the care in those simple cases either.
 
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