Unlocking Perioperative Performance Through Anesthesia Leadership

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Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Many hospitals. As they begin to think about their financial performance, or focus on creating efficiencies within the hospital, and even beyond that surgical services and what occurs in the OR, is critical to their performance. In many of the organizations that we've worked with over the, you know, probably the last 15 to 20 years. The impact of surgical services, the revenue impact is somewhere around 65% to even 70%. So it's imperative that the efficiencies of surgical services, of perioperative services, is maximized as much as possible in order for organizations to keep costs down, but also maximize the revenue potential. So, as you think about improving surgical services and perioperative performance. Leadership and governance is a critical component, and is often an area which is overlooked. A lot of times, organizations think about, really just having the directors of nursing drive a lot of the operational processes, and although that's important, leadership related to the surgeons, and particularly the integration of anesthesia, is really a driving force, and especially anesthesia. Anesthesia sees all areas of surgical services, and oftentimes their impact, their ability to influence, is really underutilized. And what we found is organizations who are the best in class, who've really optimized perioperative services Have strong integration of their anesthesiologists within all of surgical services.

Well, I'm excited today to have a strong anesthesia physician leader, Dr. Angel Martino Herrera working with us today, and a little bit of her background. She's a obstetric anesthesiologist. She worked with physicians in hospitals all over the country. She specializes in a lot of operational performance, operational excellence, and really helping organizations put in place strong perioperative and surgical governance. Angel, welcome to the program!

 

Dr. Angel:

Thank you so much, Dan. I'm really happy to be here.

 

Daniel Marino:

So, Angel, let's dive into this. I really want to dive into the whole leadership aspect of perioperative services. Why do you feel like, or what do you see in terms of the lack of, real strong surgical leadership, or really strong anesthesia leadership, driving perioperative performance? Why isn't… why hasn't it gained more attention?

 

Dr. Angel:

Well, I think that's a really interesting question to start things out with. There are some really obvious answers that are circulating right now inside of the healthcare space, but one of the things that oftentimes gets overlooked and comes up in so many conversations, but doesn't get highlighted as the main reason, is culture and mindset. And so, what we see as I talk with CEOs and CFOs and COOs, and whether it's in an anesthesia management company, or in a health system or an individual hospital, what we hear them saying so often is, it didn't used to be this way. And so there is a change that's been happening over the years that's kind of culminating in this very, very increased growth of cost with a shrinking payer reimbursement, and so you have all of these cost pressures that exist inside of an area that didn't used to be, require… didn't used to require management in the same way it does today. And that's where I think…

 

Daniel Marino:

I think a lot of times, you know, it used to be the director of nursing or the chief nursing officer that really drove a lot of leadership and perioperative services, so it was very process-driven, but. you know, as we start to think about the impact to our patients, the complexity of cases that are occurring, the integration of surgical leadership, and in particular the integration of anesthesia leadership, is just so critical. So, when you think about the culture, do you feel like there's that misalignment between maybe anesthesia and the surgical leadership to really drive that level of performance?

 

Dr. Angel:

I think in a lot of places, there still is. We see a lot of movement towards realigning those services, which I think is a really positive change in a lot of systems. However, there is still a gross misrepresentation of the value of the anesthesiologist in the perioperative space. And I think that that's where systems who are seeing really great success in moving the needle in their efficiencies are really noticing that when they put those OR governance committees together, having an anesthesiologist at the table with your surgeon, your perioperative director, that is really bringing a lot of value. And then, additionally, anesthesia services are being asked to evaluate the efficiency and the scalability of their coverage models as well, and that's not something that we really ever had to do with such great intricacy in the past. Anesthesia was frequently just a service provided to the surgeon and the hospital, they were readily available, you kind of moved things around, and now with the cost pressures that exists, we really don't have the luxury of just having people waiting on hand for cases. And so we see that the data, as it's coming through with our AI intelligence and all of our dashboards and all of these ways that we're really circulating in the OR efficiency realm, we see that leadership really becoming more and more imperative.

 

Daniel Marino:

So, to that point, a couple months ago, we did an assessment of a… for a hospital and a health system, a large surgical services evaluation. And, you know, the hospital was really struggling with inefficiencies, and, you know, they had problems with their block time, and they needed to open up capacity, and, you know, they were looking to the anesthesiologists and the anesthesia group to expand their coverage, and that sort of thing. And what we found was it wasn't necessarily a coverage issue, it was really an inefficient… inefficiency capacity issue. So when we went to the anesthesiologists, and we got their opinion. It was amazing how anesthesia and the medical director for anesthesia had a lot of great ideas and a lot of great solutions, and it was really because they're managing the pre-anesthesia testing, pre-surgical evaluation that's occurring, they're in the OR, and they're… they understand the impact in the recovery phase. So, with all of those elements in there, I mean, do you feel like, you know, maybe it's just an evolution that anesthesiologists will assume this role? Or is it more politics as to why they haven't assumed this role? The politics between the anesthesia… anesthesia and the surgical groups? Where do you think that fits in?

 

Dr. Angel:

That's such an interesting question, because it's probably a little bit of both, depending on which system you are functioning in. But what I find so fascinating a lot of times, as a physician, anesthesiologist, and then someone who stepped into more leadership roles in the last few years, is that when…like, people describe the life that we live inside of the OR, and so when you're saying… when you come to the anesthesiologist as a consultant or an administrator, and you're asking for input, they're just telling you about their everyday life and what they see happen, and sometimes that's so… it just so easily flows in the conversation that it's… it's, like, refreshing and surprising all at the same time, and so I think that there is so much value in having those conversations from the leadership perspective, whether you are an individual hospital system, and that your C-suite is engaging with your anesthesia local providers, or whether it's a system, a health system, engaging with a nationally-based anesthesia management company. no matter the level of the conversation, the conversation needs to happen, because they are the ones living in and out in your hospital, whether it's in the OR or in the off-site locations, and they see what is happening. And so, giving them that seat at the table, with the appropriate data, with the appropriate governance and leadership structure in place to actually make something happen when things are said and observed. And then systems are set up, and then frequently challenged, because we all know what it looks like inside those perioperative spaces to make a decision, but then sometimes somebody doesn't like that decision, and so you have to have someone standing behind it. All of those things are the regular day-to-day of an anesthesiologist, and so.

 

Daniel Marino:

So… so when… with anesthesia being so involved in so many areas of perioperative services, why don't… why don't you feel like… why hasn't this been recognized? Why is it… why has it been taken so long, you know, in my mind, has it, for anesthesia to really be elevated into that… into that governance role?

 

Dr. Angel:

Yeah, I think it goes back at the beginning of the conversation. Really, it's a change in the culture and mindset of how hospitals and surgical services typically work. And then secondly, anesthesia is… is classically a behind-the-surgical drapes kind of specialty, and that's where we've lived and operated most of our life, and so there aren't very many anesthesiologists who want to take part in many of these discussions. Now, that being said, there are plenty that do, but I'm just talking about percentage-wise. This is a definite shift in the value that we see being added as anesthesiologists do step up into these leadership roles. And then hospitals also have to develop these governance systems, where it used to be a surgeon would just walk in and be like, hey, I got a case, I need to do it. And we'd be like, okay, let's find somebody to do that case, let's go. And now, as you described. When health systems are coming to the table with an increase in a subsidy request, or a high cost of running their ORs, or diminishing margins, they start to look at, why do I have so many more anesthesiologists, or CRNAs, or costs from this, management company coming through. And, of course, workforce shortages drive that. And there's obviously the payer things that we talked about at the beginning, but ultimately, when you start looking at that data, you start realizing, oh, I really need to tighten my ship in so many other areas. And so, as they develop those governances for productivity, operating room efficiencies. All of those things really play strongly into that governance structure with surgical, nursing, administrative, and anesthesia at the table.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. We are… I'm here today with Dr. Angel Martino-Horrall, and we're talking about the impact or the importance of anesthesia and anesthesia leadership and perioperative services. So, Angel, I want to kind of dive into, maybe, your thought, having to work with leaders, you know, perioperative leaders all over the country. What's the ideal anesthesia leadership? What does it look like? You know, as we start to think about moving into more of that paradigm shift, right, where anesthesia would have a seat at the table, but a stronger voice with regards to perioperative governance. What does that ideal anesthesia leadership look like?

 

Dr. Angel:

Well, there's no one-size-fits-all inside of any one health system, but ultimately, what it takes is an anesthesia leader, depending on the size of the system, either at each local facility, or if you only have one, then you have one facility. And oftentimes, in very large systems, you have leaders that sit in each area. OB anesthesia is a very common one, cardiac, your ASCs, all of these different places that oftentimes function under one health system, and often even one anesthesia group, have varying levels of leadership in each site. And so, I think establishing that, both as an anesthesiologist and a CRNA for leadership in that dyad role, and then if you add the third member of a triad into the operations. So, you have an administrative or operator, you have a CRNA leader, and you have a physician leader, and those three can really function as a cohesive unit in driving the anesthesia side of the efficiency. Then when you have those leaders meeting regularly with your perioperative nurse, your surgical services director, and then someone from your C-suite and someone that sits at the head of the surgery department, all of those are coming together to establish the guidelines with which they are going to implement your surgical services.

 

Daniel Marino:

But as you're describing that, and I agree with all of those elements, I guess the one… one piece that sort of is… seems to me that's kind of missing is that impact to the surgeons, right? So…So is it ideal to have, if we're thinking about this ideal perioperative governance structure, so to speak, I mean, are there instances where, you know, you'd have the medical director of anesthesia closely aligned with the medical director of surgery, or some type of a connectiveness there with the chief of surgery, or something that they can sort of work with their peers to push it along, or… could anesthesia fill that role?

 

Dr. Angel:

Sure, that's a great question as well. First, there's always a relationship there, because you're talking in the ORs with your surgical colleagues, and then most facilities, they have a medical executive committee where the chief of anesthesia and the chief of surgery are sitting in the same room together at the end meetings. And so, of course, the value of that relationship just goes practically with… I mean, there's so much value inside of that relationship. So, 100%. The interesting thing about these governance committees, though, when it comes to surgical leadership and anesthesia leadership, is that oftentimes. The surgeon is very focused on the cases that need to be done, where, as you described earlier, anesthesia is frequently the first in, in the pre-op area, with the testing, and then with the preparing the patients for the OR, then there's the intra-op, and then there's the PACU time, and… or wherever the patient is going in their post-operative care. And so, as a whole. Anesthesia is very well seated to lead in the perioperative throughput for efficiencies in an entire health system, even more so sometimes than the specific surgery components.

 

Daniel Marino:

Oh, I agree with you, and I think, you know, as we've worked with many different hospitals around the country, aligning ourselves with anesthesia has been critically important because of the connectedness that they have through all parts of perioperative services. I couldn't agree with you more. I'm gonna switch a little bit and talk about, kind of guiding some of the performance improvement. One of the things that's definitely impressed me about the work that you've done, is you're very data-driven. You've done a lot of work with reports, you use reports and use data to kind of drive process, which is certainly, you know, a solution that we've put in place, and I fully agree with. When you think about data and you think about reporting, you know, again, are there different views of data or different views of reporting that are more geared towards anesthesia leadership to drive perioperative services? And then some that are geared towards surgical services, and then how do you pull that together?

 

Dr. Angel:

So this is such a, like, a mission-critical question to every organization in how they are actually defining the data that they are coming in with. Because when you look purely at an OR and how it's defining its efficiencies and its productivity, that can look very different than how an anesthesia service line is. So when the anesthesiologist shows up to the C-suite with their data on operating efficiencies, which oftentimes includes all of the NORA sites, in addition to just the operating room, their numbers can look very different, even though they have the same definition up on the screen. And so, really pulling in that alignment for… and transparency. So it's alignment and it's transparency. It's a willingness to show up and say, like, hey, here's where we're seeing inefficiencies. And that takes a lot of trust in an organization on both sides of the fence. But making sure the data is good data, first of all, that whatever mechanism you're using for gleaning or overlaying or if you're getting it directly, making sure that your data is good data, and then aligning your definitions to make sure that you're all speaking the same language when you're showing up to make those discussions is critical.

 

Daniel Marino:

Yeah, I couldn't agree with you more. And especially all those indicators, you know, we've got our standard set of indicators, which I know, you know, you've put in place, the on-time starts, and block time utilization, and all of that. And a lot of time, it sort of highlights some challenges that the surgeons have, but often when you dive into it, they're not specific… they're not surgeon-related at all. It's really around process, and it's really around, or the opportunity comes out as to how anesthesia could then begin to influence that in support of the surgeons to create that level of efficiencies.

 

Dr. Angel:

Absolutely.

 

Daniel Marino:

You see, a lot of that, and, you know, so how does that wrap into some of the governance structure and the support of anesthesia, kind of driving that leadership change, if you will?

 

Dr. Angel:

So, one of the ways that you're describing and leaning towards is in, like, the pre-op testing. And so, same-day cancellations is another one of those key indicators, I think, that we are looking at for some of our success metrics. And this is where, again, an anesthesia perioperative clinic and testing is so critical as a joint service to our surgical colleagues, and then to our hospital, our nurses, our nursing leadership, our pre- and post-op care and delivery and throughput. All of those… all of those data points are critical, and without appropriate anesthesia leadership, having a seat at the table to influence those decisions, in a meaningful way that actually matters for the facility, not just that, you know, crosses or checks a box, but that actually drives a decision that can be made that actually turns a financial indicator into a positive. Like, those are the seats that you really need. And that actually takes time stepping away from the OR, and it circles back a little bit to your question earlier about why doesn't this happen? A lot of times, you're so busy running the board and taking care of patients that even if the meeting does happen that you got an invite to, you're not sitting at it. And so that's on anesthesia to really step up to the plate and really take seriously, those roles, and the value that they bring to the table.

 

Daniel Marino:

But I agree with you. I think as anesthesia starts to not only take the lead on pre-surgical evaluation and expanding the value of pre-anesthesia testing, but to really talk through how that's going to influence the efficiencies in the OR, and then the post-recovery, I mean, they're helping the surgeons right then and there. So, I think as a starting point the more anesthesia can really drive that change becomes critically important, especially when you talk about value-based care and the performance outcomes related to it. It all starts with what occurs from pre-surgical evaluation, pre-anesthesia testing, how you're using that information to drive the change.

 

Dr. Angel:

100%, and anesthesia is and always will be a service-oriented profession, and so I think that that's where we can really shine. One of the things that I have loved seeing in some of the places that I've been able to work is allowing them to see that when they're making these positive changes and positive decisions, if they're not doing it in the right time frame, you're actually not driving cost efficiencies. And so we've seen so many times where they will cancel the case the day before, and you're like, great, I paid my locums person, and they have a 72-hour, you know, a term in order to be able to… you still have to pay them. I'm like, so you have to know the timing of making these decisions is just as important as the fact that you're making them in the first place. And that's where, again, having someone that can sit at the table, whether you're bringing in an outside consultant, or whether you have the privilege of having someone in-house that can do that for you. No matter how it's being made, all of those aspects come into play when you're actually trying to drive the bottom line.

 

Daniel Marino:

For many hospitals around the country, they are focusing on improving their perioperative services, surgical services, make it more efficient, you know, reduce costs, improve revenue. For our listeners today, what advice would you give them on where to start on looking at leadership on surgical service governance to really bringing together, or maybe creating more of an influence from anesthesia and better aligning it with the surgeons? Any thoughts?

 

Dr. Angel:

Oh, yes, I have tons of thoughts. I'm trying to think of how to start that conversation. One of the things that I think is really important, if we just step back for one… one brief moment from that question, is that a lot of times, healthcare systems lose people chasing efficiency. And that's where I do think that culture and emotional intelligence paired with that operational discipline is really critical. And so having the right people at the table is just as important as the fact that you're developing your leadership and governance structure in the first place. And so many times, I have seen organizations change anesthesia leadership, and ultimately, it's just the same things happening inside of the OR with a different name on it, and so you really have to have the right people in place, and the right support system backing it from the C-suite to know that this is not just a facelift. It's actually, we're making transformational change, and it's gonna get stood behind by… Right.

 

Daniel Marino:

Great point. I mean, clearly that transformational change, as you mentioned, coming from the C-suite and really providing that right level of support with the right individual is absolutely key. Well, Angel, thank you so much for coming on today. This is a great discussion. I'd love to dive into this a little bit more. I think, you know, the attributes of leadership and in surgical services governance, in perioperative governance, the role of anesthesia, you know, I think we've just… just scratched the tip of the iceberg there. You know, any final piece of advice for any of our listeners?

 

Dr. Angel:

I would say that as you are looking towards your anesthesia governance and your perioperative governance, transparency in the data and in the shared goals behind every system is really critical. And then also showing the value for your clinicians and the clinician engagement, coming alongside of the operations. Just goes a long way inside of building whatever kind of governance structure for your perioperative services that you're looking for.

 

Daniel Marino:

Well, great point. I mean, that becomes a foundation of your culture transformation, right?

 

Dr. Angel:

Absolutely.

 

Daniel Marino:

It does. Well, Angel, thank you very much. If any of our listeners today are interested in maybe following up with you, asking some more questions, you clearly have a lot of experience with perioperative governance, can you share your email or maybe your LinkedIn address?

 

Dr. Angel:

Absolutely. I am available at Dr. AngelMartinoHorrell at linked… on LinkedIn. Dr. Angel Martino will get you there. I do understand that's a pretty long name, but I'm the only one out there, so you'll find me on LinkedIn. And then, I have a website, Halo-consultants.com. It's healthcare and anesthesia Leadership and Operations. And so, you are welcome to contact me there as well.

 

Daniel Marino:

Great. Well, thank you again, Angel, for coming on. Love the conversation, really appreciate all your insights.

 

Dr. Angel:

Thank you so much, Dan.

 

Daniel Marino:

And for any of our listeners tuning in, if you're interested in learning a little bit more about this topic or other topics, please visit luminaHP.com or eCGMC.com. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Thank you. Take care 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners