Measuring and proving quality

[bullard]

This question is for attendings who are in private practice in a group with an exclusive contract with their hospital. I think that might just be Jet, but in any case, I'll proceed:

So let's say you are God's gift to anesthesiology. You can intubate anything with a Miller 2 and both hands tied behind your back. Your regional blocks never fail. Your CABG pts get extubated FAST. Your patients rarely get wound infections because you institute appropriate antbiotic prophylaxis at the appropriate juncture.

How do you convince your administrators that you're the man when contract negotiation time comes around? What kind of data do private practice anesthesiologists keep about their performance? Somebody on here a while back said that this field tolerates some very poor practitioners. True?

Basically, how does one prove their anesthetics are better run? I think this question is especially pertinent given the seeming inevitability (right or wrong) of pay for performance...

(This thread is not about midlevel practitioners. If you're thinking about mentioning them, please consider getting yourself a beer instead.)

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[jetproppilot]

This question is for attendings who are in private practice in a group with an exclusive contract with their hospital. I think that might just be Jet, but in any case, I'll proceed:

So let's say you are God's gift to anesthesiology. You can intubate anything with a Miller 2 and both hands tied behind your back. Your regional blocks never fail. Your CABG pts get extubated FAST. Your patients rarely get wound infections because you institute appropriate antbiotic prophylaxis at the appropriate juncture.

How do you convince your administrators that you're the man when contract negotiation time comes around? What kind of data do private practice anesthesiologists keep about their performance? Somebody on here a while back said that this field tolerates some very poor practitioners. True?

Basically, how does one prove their anesthetics are better run? I think this question is especially pertinent given the seeming inevitability (right or wrong) of pay for performance...

(This thread is not about midlevel practitioners. If you're thinking about mentioning them, please consider getting yourself a beer instead.)

Wow. Great post.

Unfortunately I dont think youre gonna like my answer, but I'll give you the answer that'll make you a three-time-successful anesthesiologist: clinically, emotionally and monetarily.

You've gotta be more than skilled to accel in this business.

First of all, Bullard, no such tracking exists in our specialty current-day, just as it doesnt in most specialties.

Certain specialties are moving in that direction, though, namely heart surgery.

If a heart surgeon is killing more than the national average, their referrals from cardiologists will slowly diminish.

No such pattern exists for anesthesiologists, nor do I think it ever will. Why? Because its rare that a board-certified anesthesiologist that finished an allopathic residency is so far off the standard-of-care that they become a risk to patients, hospitals, and anesthesia groups. Not saying that they dont exist, but they are rare. Nor am I saying that every anesthesia doc fits into every practice, but from a pure clinical standpoint, most people that have finished a residency and are board certified do not kill patients.

We are in a specialty that requires more than skill to maintain exclusive contracts. You can be God's gift to anesthesia with flawless statistics...but if you are aloof, controlling, and an overall d ickhead, you are at risk of losing your contract.

Administrators would rather have an average anesthesiologist who overall delivers good patient care, but concominantly is liked by the (client) surgeons, who works hard to minimize turnover time (read:saves hospital's $$), and truly cares about solving problems. Flexibility.

Dr X wants to move up. Can we do it?

Sure.

Would you mind putting in a central line?

No problem.

Yeah, Jet, I know its 3pm but if I dont do this gallbladder now, I'm gonna miss my kid's soccer game. Would you mind?

Not at all. (BTW, young dudes/dudettes may see this as an insult. Actually, its not. I am very catering at work, because I have partners. We share the call, so its not like I'm killing myself to be catering to a surgeon when its my turn. Believe me. I get plenty of time off, so if a surgeon wants to work when its my turn on call, I'm there, ready and willing).

This is the kind of "extra" stuff necessary above and beyond patient care.

God's gift to anesthesia? Great.

But its gonna take more than that for you to be successful in this biz.

And if that bothers you, you need to pick another specialty.

 

[militarymd]

The hospital administration listens to

1) surgeons
2) staff in the hospital
3) patients


They are all poor judges of quality of anesthesia....so guess what....it will be your personality...just like in high school.

 

[jetproppilot]

The hospital administration listens to

1) surgeons
2) staff in the hospital
3) patients


They are all poor judges of quality of anesthesia....so guess what....it will be your personality...just like in high school.

Mil has the ability to say in twenty words what it takes me twenty thousand words. Guess I like to write.

 

[bullard]

Work hard, plow through the cases, don't complain, be nice, respect everyone. Got it. If that's what it takes, then I'm there.

That said, I do have a quibble or two with your post. You wrote that there are few board-certified anesthesiologists that are actually dangerous. Understood. But then on another thread you mentioned how you handled a big vascular case with ease, noting that "...there are just as many anesthesiologists out there who are not capable of handling major vascular/CABGs". Are those guys still making bank? Do they deserve to?

Also, you noted that minimizing turnover time saves the hospital $$. I've seen some attendings (in academia) working by themselves have some slow wake-ups on gen surg cases (like the surgeons are already in the lounge and the nurses are playing 20 questions). I know that's probably not tolerated in private practice, but surely some folks are faster than others, use more regional which might translate to faster discharge from the PACU, etc.

My point here is not that I want _recognition_ if I train hard and become a great anesthesiologist. Who cares? I just think if you're better than everybody else and you can prove it with data, you should get paid better too.

Wow. Great post.

Unfortunately I dont think youre gonna like my answer, but I'll give you the answer that'll make you a three-time-successful anesthesiologist: clinically, emotionally and monetarily.

You've gotta be more than skilled to accel in this business.

First of all, Bullard, no such tracking exists in our specialty current-day, just as it doesnt in most specialties.

Certain specialties are moving in that direction, though, namely heart surgery.

If a heart surgeon is killing more than the national average, their referrals from cardiologists will slowly diminish.

No such pattern exists for anesthesiologists, nor do I think it ever will. Why? Because its rare that a board-certified anesthesiologist that finished an allopathic residency is so far off the standard-of-care that they become a risk to patients, hospitals, and anesthesia groups. Not saying that they dont exist, but they are rare. Nor am I saying that every anesthesia doc fits into every practice, but from a pure clinical standpoint, most people that have finished a residency and are board certified do not kill patients.

Administrators would rather have an average anesthesiologist who overall delivers good patient care, but concominantly is liked by the (client) surgeons, who works hard to minimize turnover time (read:saves hospital's $$), and truly cares about solving problems. Flexibility.


But its gonna take more than that for you to be successful in this biz.

And if that bothers you, you need to pick another specialty.

 

[militarymd]

It will depend on the practice model.


If you are in an environment where you are one of many solo P.C.s, then your skills (clinical and non-clinical), if superior and recognized, will get you the privilege of having the "pick" of cases that are available.

If you are an employee of a hospital, then you are out of luck....but your skills may get you that job and allow you to keep it....some employee jobs are great....ala Jet.

If you are in a group/exclusive contract job (ala ..me), then your skills will get you to be partner/owner of the group....then that allows you to decide how pay everyone.....we/I pay everyone the same....that's fair....but then, I'm looking for a all star team...with the intention of letting the bench warmers becoming free agents.

 

[niceguy]

Bullard,

Great questions you pose. As a future anesthesiologist who has a business and health policy background I believe pay-for-performance will make its way to anesthesia in the future. In some aspects it already has with prophylactic antibiotic administration. Future initiatives will involve perioperative normothermia, maintenance of strict glycemic control, and issues around chronic pain management. Do I think that success with these initiatives, which will be publicly available, will help with contract negotiations with a hospital or whomever? Absolutely, but these initiatives are still in their infancy and as you can see our colleagues already in private practice have yet to feel the ramnifications. I believe success with these initiatives will indicate that you have a strong anesthesia system at your hospital and serves as a basis for continuous quality improvement. As far as delineating one provider from another I think thats a huge political battle that the ASA will not want to tackle.

 

[militarymd]

Bullard,

Great questions you pose. As a future anesthesiologist who has a business and health policy background I believe pay-for-performance will make its way to anesthesia in the future. In some aspects it already has with prophylactic antibiotic administration. Future initiatives will involve perioperative normothermia, maintenance of strict glycemic control, and issues around chronic pain management. Do I think that success with these initiatives, which will be publicly available, will help with contract negotiations with a hospital or whomever? Absolutely, but these initiatives are still in their infancy and as you can see our colleagues already in private practice have yet to feel the ramnifications. I believe success with these initiatives will indicate that you have a strong anesthesia system at your hospital and serves as a basis for continuous quality improvement. As far as delineating one provider from another I think thats a huge political battle that the ASA will not want to tackle.

I don't think so.

 

[Noyac]

As Mil said in much fewer words. If you are a stellar anesthesiologist, your surgeons will know it. Especially if they have worked with others less stellar. The ICU docs will notice, cause you bring them managable pts unlike some of your colleagues. Your complications will be few and far between, failed blocks, slow wakeups, delayed cases are just some of the things that go noticed. But happy pts immediately upon extubation, talking comfortably upon entry to the PACU (saying Doc, "YOu the MAN" and "Are we done already?") and not sitting back on the phone reading the wall street journal but standing up paying attention to the case or at least pretending to be interested. You need to pay attention and be conversive with everyone in the room whether professionally or socially. If you cover all these bases then you will be golden.
This doesn't show any performance stats but it sure makes everyone feel like you are doing a good job. While Jet is right about most board cert. anesthesiologists being very competent (its the ones that are not boarded that I notice are lacking in one way or another), it is very hard for a hospital to let a group go and quickly fine a better group. There just aren't that many out there and the ones looking for jobs tend to be young or nearing retirement or not boarded. If that makes sense?
I like MIl's example of high school. Its like your shooting for Most Popular or Mrs/Mr Congeniality. Don't worry its not that bad though.

 

[bullard]

I'm aware of those future initiatives, and they're important considering those tasks don't always get done consistently. But let's face it, how hard it is to turn on the damn Bair Hugger and give insulin? Those initiatives will hopefully bring all practitioners up to some minimum level of quality. Keeping track of failed blocks (or something to that effect) is a whole different ballgame and would actually differentiate excellent quality from merely good.

Guess we're not there yet though.

Thanks for the replies everyone; very educational.

Bullard,

Great questions you pose. As a future anesthesiologist who has a business and health policy background I believe pay-for-performance will make its way to anesthesia in the future. In some aspects it already has with prophylactic antibiotic administration. Future initiatives will involve perioperative normothermia, maintenance of strict glycemic control, and issues around chronic pain management. Do I think that success with these initiatives, which will be publicly available, will help with contract negotiations with a hospital or whomever? Absolutely, but these initiatives are still in their infancy and as you can see our colleagues already in private practice have yet to feel the ramnifications. I believe success with these initiatives will indicate that you have a strong anesthesia system at your hospital and serves as a basis for continuous quality improvement. As far as delineating one provider from another I think thats a huge political battle that the ASA will not want to tackle.

 

[jetproppilot]

...there are just as many anesthesiologists out there who are not capable of handling major vascular/CABGs". Are those guys still making bank? Do they deserve to?

Probably more due to certain anesthesiologists working in practices that dont do these cases...surgery centers, hospitals that do all bread n butter stuff...then after years of doing all ASA 1s and 2s, you lose the ability.

Not that they couldnt relearn, but most of them probably prefer not to do the big cases.

Dont really blame them.

 

[jetproppilot]

Probably more due to certain anesthesiologists working in practices that dont do these cases...surgery centers, hospitals that do all bread n butter stuff...then after years of doing all ASA 1s and 2s, you lose the ability.

Not that they couldnt relearn, but most of them probably prefer not to do the big cases.

Dont really blame them.

And as far as bank, you can do 2-3 insurance tonsillectomies on healthy kids that'll take about one hour (for all three cases) and make more than a 4 hour medicare ASA4-E leaky AAA.

Explain that to me.

 

[bullard]

Haha I forgot about that. The system is so broken.

And as far as bank, you can do 2-3 insurance tonsillectomies on healthy kids that'll take about one hour (for all three cases) and make more than a 4 hour medicare ASA4-E leaky AAA.

Explain that to me.

 

[supahfresh]

As Mil said in much fewer words. If you are a stellar anesthesiologist, your surgeons will know it. Especially if they have worked with others less stellar. The ICU docs will notice, cause you bring them managable pts unlike some of your colleagues. Your complications will be few and far between, failed blocks, slow wakeups, delayed cases are just some of the things that go noticed. But happy pts immediately upon extubation, talking comfortably upon entry to the PACU (saying Doc, "YOu the MAN" and "Are we done already?") and not sitting back on the phone reading the wall street journal but standing up paying attention to the case or at least pretending to be interested. You need to pay attention and be conversive with everyone in the room whether professionally or socially. If you cover all these bases then you will be golden.
This doesn't show any performance stats but it sure makes everyone feel like you are doing a good job. While Jet is right about most board cert. anesthesiologists being very competent (its the ones that are not boarded that I notice are lacking in one way or another), it is very hard for a hospital to let a group go and quickly fine a better group. There just aren't that many out there and the ones looking for jobs tend to be young or nearing retirement or not boarded. If that makes sense?
I like MIl's example of high school. Its like your shooting for Most Popular or Mrs/Mr Congeniality. Don't worry its not that bad though.

this thread depresses me. I want to do the best job I can, but I sure as hell dont want to play in some f'ing popularity contest.

 

[Noyac]

this thread depresses me. I want to do the best job I can, but I sure as hell dont want to play in some f'ing popularity contest.

Don't worry, if you can get along with others well and do good anesthesia then you will do fine. But it does feel like a popularity contest from time to time. It takes me a little while to get to know people, so I am not the most outgoing social person in the OR but I find it to be a very pleasant and welcoming environment non the less.

 

[militarymd]

this thread depresses me. I want to do the best job I can, but I sure as hell dont want to play in some f'ing popularity contest.

In a competitive environment, every little bit counts....so assuming everyone is competent....."popularity contest" becomes the next benchmark.

And anesthesia has become or will become a competitive environment with all these new people wanting to do anesthesia.