CUSTOMER SERVICE – GET IT YOURSELF! . . . . . . . . . . . . . ...
Why has surgeon satisfaction become
as important to health care leaders as clin-
ical and financial outcomes? Each year,
the community, hospital administration
and surgeons. Our challenge isn’t in
understanding and accepting the ideas
and prin...
hospital with service related issues.
Humorous as it may seem, as an anesthe-
siologist have you ever been approached
by t...
If any one customer’s or constituent’s
expectations are fully satisfied (the 100
percent level) then fulfillment of other’...
tion as a customer. In general, customers’
expectations, regardless of who the cus-
tomer is, will not be met unless
The measurement of
operating room effi-
ciency used to be one
of those arcane sci-
ences r...
One school views operating room
efficiency through the absolute lens of a
Continued on page 14
Since the publication of the OIG
Compliance Guidance for Individual and
Small Group Physician Practices (here-
inafter the...
measurement tool for which each of the
perioperative disciplines will be account-
able and to encourage global participati...
We are pleased to announce that this
year’s MGMA AAA annual conference
will be held April...
current sessions include: “Modifier Magic
for Pain Management Coding,” by Marvel
J. Hamme...
approach may be viewed with great suspi-
cion by hospital administrators who do
not under...
Coding CornerCoding Corner
Speakers at anesthesia coding sem-
inars often harp on the imp...
Dec. 8-12, 2006 New York State Society of Anesthesiologists New York Mar...
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Anesthesia Business Consultants: Communique fall06


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Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.

Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.

ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.

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Anesthesia Business Consultants: Communique fall06

  1. 1. ANESTHESIAANESTHESIA BUSINESSCONSULTANTSBUSINESSCONSULTANTS CUSTOMER SERVICE – GET IT YOURSELF! . . . . . . . . . . . . . . . . . . 1 SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE . . . . . . . . . 2 ASSESSING OPERATING ROOM EFFICIENCY . . . . . . . . . . . . . . . . . 7 COMPLIANCE CORNER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2007 MGMA AAA ANNUAL CONFERENCE . . . . . . . . . . . . . . . . 12 EVENT CALENDAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Continued on page 4 FALL2006VOLUME11,ISSUE3 ➤ I N S I D E T H I S I S S U E : Customer Service – Get it yourself! That was the headline in last Sunday’s paper here in my Southwest Florida com- munity. This community is burgeoning with population growth and still recover- ing from last year’s hurricanes. There are not enough workers to meet the demand and any breathing creature can obtain a job in the service and construction industry – but what is the work ethic and profession- alism of that worker? Customer service – let’s look at our everyday lives. Whether booking a hotel reservation, questioning a bill, trying to get the TV-cable repaired, or working with your bank – just think of how difficult it is to speak to a person – typically the “cus- tomer” the guy who’s spending the money with the option of taking business else- where, is directed to voice-mail; hears, “push one for this”; “push two for that”; or best yet, must pay additional fees to speak to a person – How Do You Feel, When You the Customer are Treated That Way? In healthcare we speak a lot about “the customer and providing customer service”. Several of my hospital clients have “Customer Relations Specialists” – I think these individuals are intended to assist patients with service related issues, howev- er I’ve never really been able to understand what these specialists really do. In other instances, my hospital clients have “Physician Liaisons” – these individuals are intended to assist physicians based at a ABC offers Communiqué in electronic format Anesthesia Business Consultants, LLC (ABC) is happy to announce that Communiqué will be available through a state-of-the-art electronic format as well as the regular printed version. Communiqué continues to feature articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators. We look forward to providing you with many more years of compliance, coding and practice management news through Communiqué. Please log on to ABC’s web site at and click the link to view the electronic version of Communiqué online. CUSTOMER SERVICE – GET IT YOURSELF! By Jerry Ippolito, Vice President & Principal The Surgery Management Improvement Group, Inc. CommNEWS_Fall06v6.qxd 11/30/06 3:33 PM Page 1
  2. 2. Why has surgeon satisfaction become as important to health care leaders as clin- ical and financial outcomes? Each year, health care facilities throughout the world spend hundreds of thousands of dollars on surgeon satisfaction surveys in an attempt to arrive at the elusive answers to what truly satisfies a surgeon? The thought being that if the surgeon is satis- fied, then the patient will be satisfied and business will be good. Practically every American industry, to include healthcare and business, is brimming with thousands of articles, theories and studies about the critical importance of customer satisfac- tion in steering organizational success. The dilemma is that the act of satisfying is in as much a subjective action as it is a subjective assessment. To satisfy, and in turn be satisfied, is a personal perspective that can typically be shared and appreciat- ed, but likely not universally scripted and accepted. In many ways, customer satis- faction follows the simple Golden Rule; treat others as you want to be treated. Where the customer satisfaction waters in the health care have become muddied is that the traditional customer (the patient) has joined an ever growing list of customer stakeholders to include THE COMMUNIQUÉ FALL 2006 PAGE 2 In our competitive society we all want to know how we are doing. Few of us are so confident in our endeavors as to not want some kind of feedback or approbation, especially those of us in the service business. The challenge is know- ing what sources to trust. Too often, ulterior motives or our own naiveté cloud reality, making it hard to distin- guish the important from the trivial. How often do we only hear what we want to hear? At least in our business we have some objective measures of success. So long as we keep growing and our clients maintain their franchises we are happy. The question is, what makes for success in an anesthesia practice? The persistent dissonance and drone of life in the oper- ating room tends to dull one’s senses to everything but the matter at hand. When the case goes well all is right with the world, or so it seems. How often, though, is the rising tide a harbinger of a major storm? Perhaps more often than most of us would care to admit. Our clients used to obsess about their collections. A good month was defined simply in terms of a high deposit. Heaven forbid we came in below expectations, though. Little did I know that those were the good old days! Now, we are all so focused on the underlying factors that generate those collections that the actual numbers on the reports are almost anticlimactic. The world of anesthesia practice management has def- initely evolved from its cash-based accounting roots to an accrual-based model of cost accounting. Sometimes I feel like a stockbroker: even a hint of bad news can send clients in paroxysms of anxiety. Disaster seems ever-present. As an organization we spend more time than ever helping our clients formulate strategies that will turn adversity into opportunity. The entire vocabulary of practice management has changed in the past few years. Discussions of gross and net collections rates have given way to talk of manpower and staffing models. We hear much more about productivity and benchmarking than we do about Accounts Receivable management per- formance. But if there is one topic which defines the new era by virtue of its novelty and lack of understanding; it is customer service. As each topic unfolds across the country it is ever more clear that we must all be constantly updating our toolset if we want to succeed and thrive in the years ahead. As always, we hope you find our authors’ treatment of these new frontier topics timely and informative. We go to great lengths to tap into those industry observers who we believe have their fin- gers on the pulse of the market. May you find ways to put these invaluable ideas to effective use in your practice! Tony Mira, President & CEO WHAT MAKES FOR SUCCESS IN AN ANESTHESIA PRACTICE? SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE By Hugh Morgan, CMPE Director, AtlantiCare Anesthesiology CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 2
  3. 3. the community, hospital administration and surgeons. Our challenge isn’t in understanding and accepting the ideas and principles of customer satisfaction, but rather in defining who we are sup- posed to satisfy? In recent years, a great deal of customer satisfaction endeavors in health care have been focused around the surgeons or the “revenue producing” cus- tomers. The shift in health care from patient-centric satisfaction to what I would refer to as “macro” satisfaction has placed operational burdens and unjust expectations on the specialty of anesthesi- ology. The industry is strewn with defeated anesthesiology groups who often times are forced to succumb to adminis- tratively supported surgical expectations. How then is it possible for an anesthesiol- ogy practice to survive and thrive in an era of surgeon-centric satisfaction? First and foremost, an anesthesiology practice must define the diverse satisfac- tion stakeholders for who they are responsible to include patients, nursing, administration and surgeons. The group should seek to understand both the com- mon and unique expectations of each stakeholder group through personal meetings and feedback surveys which ulti- mately produce the satisfaction criteria and goals. Although hard to believe, patient’s seem to have become the least arduous to satisfy. Typically, patient’s simply expect to be treated with compas- sion and respect and to receive the highest quality and safest medical care with the best possible outcome. Administration is a little more challenging to satisfy in that they usually expect anesthesiology prac- tices to infallibly provide anesthesia services and meet fluctuating clinical cov- erage requirements without pause or cancellation and within the most finan- cially insolvent manner possible. Fairly straightforward expectations, right? The quandary is that administration’s satisfac- tion expectations are often directly associated, if not embedded, with that of surgeon satisfaction expectations result- ing in a tag-team of operational and financial burdens for an anesthesiology practice. The key is to concurrently address the administrative and surgical satisfaction expectations so that there is a clear understanding by each stakeholder as to how satisfaction expectations can directly impact anesthesiology’s ability to effectively satisfy at the expense of group operations. It is essential to arrive at a set of reasonable, achievable and mutually beneficial administrative and surgical expectations so that the satisfaction crite- ria are universally known and not subject to whimsical modifications. Although some satisfaction expectations are some- what broad and inherently subjective such as, “adequate coverage” and “immediately available” it is usually more evident to notice and hear about the absence rather than the presence of satisfaction. How often have we heard that if all is quiet, things must be good? An important facet in achieving sur- geon satisfaction is the ability of an anesthesiology practice to be duly recog- nized by administration and surgeons as medical colleagues of the surgical staff. Too often, anesthesiology is viewed as a hospital “service” and not as a medical practice with a critical role in the overall safety and care of the patient. Although anesthesiology touches numerous clinical environments throughout a hospital, per- haps the most important and visible involvement is within the Perioperative arena. From the preoperative assessment through post surgical recovery, anesthesi- ology plays a vital role in the customer satisfaction of the various perioperative stakeholders, most notably the surgeons. Anesthesiology is the third cog, the others being nursing and surgery, in the wheel that effectively spins perioperative/surgi- cal services. Like a tire, if any one of these preoperative “cogs” experiences problems, the tire goes flat and unfortunate acci- dents can occur. It is important then for each of the preoperative disciplines to be accountable to each other for a variety of satisfaction criteria to include patient safety, clinical competency, professional behavior and workflow efficiencies. The challenge is to develop the mutual periop- erative satisfaction criteria and THE COMMUNIQUÉ FALL 2006 PAGE 3 Continued on page 11 CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 3
  4. 4. hospital with service related issues. Humorous as it may seem, as an anesthe- siologist have you ever been approached by the Physician Liaison at your hospital and asked, “how are we doing” – probably not. However in my world of Operating Room Management Consulting I do encourage OR Team Leaders and Directors of Surgical Services to take on that duty – “how are we doing?”. The phe- nomena however is that we talk a lot about customer service and we have cus- tomer service specialists of every species, BUT HAVE WE DEFINED WHO THE CUSTOMER IS? According to Webster the customer is: 1. one who purchases a commodity; 2. one with expectations of outcomes. Some years ago I participated in a CQI (Continuous Quality Improvement) pro- gram where the second definition was more commonly used; in fact the second defini- tion, in my mind, is the most appropriate. We all have needs and rely on performance and fulfillment of expectations by others – WE ARE ALL EACH OTHER’s CUS- TOMERS. In the world of the operating room we typically regard the surgeon as the customer. Ironic as it is, we seldom consider the patient first. As a consultant I have the opportunity to work with several dozen hospitals each year in many communities around the country – indeed the patient is the primary customer (even more ironic in today’s world is that the payor is beginning to usurp this position). As I sit in restau- rants, ride on planes, read local papers I’ll continuously hear / read about residents’ perceptions of the local hospital. I’ve had the honor of working with several very pres- tigious community medical centers around the country; if physicians are not on staff at these centers, they can not build or sustain a practice – if they are not on staff at these centers, they are not considered quality doc- tors – THE PATIENT IS HIGHLY SELECTIVE, and rightfully so! In the world of OR we often speak of the three or four legged stool – the four cus- tomers; the four constituencies with expectations; even here we forget about the patient – aren’t there really at least five cus- tomers: 1. Patient – Expectations of: Quality care; Hospitality; Affordability; Accessibility 2. Hospital Administration – Expecta- tions of: Increased business; Increased Margins; Decreased Costs; Maximized utilization of resources 3. OR Staff / Nursing – Expectations of: Ability to deliver quality patient care; Competitive compensation; Reasonable working conditions; Job satisfaction; Reliable and predictable work schedules 4. Surgeons – Expectations of: Quality patient care; Sufficient OR access to meet practice needs; Maximized / efficient use of time; Experienced OR staff who can anticipate case needs; Equipment and technology meeting procedural needs; Ability to generate a livelihood comparable to similar specialists 5. Anesthesiologists – Expectations of: Quality patient care; Optimized uti- lization of time; Competitive compensation and lifestyle; Predictability of schedules. THE COMMUNIQUÉ FALL 2006 PAGE 4 CUSTOMER SERVICE – GET IT YOURSELF! Continued from page 1 Surgeons Anesthesiology Administration NursingPatient Surgeons Anesthesiology Administration NursingPatient COMPROMISE IS KEY TO OPTIMIZING CUSTOMER SATISFACTION & MAINTAINING A PATIENT FOCUSED PROGRAM Without Compromise the Patient Stands Alone CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 4
  5. 5. If any one customer’s or constituent’s expectations are fully satisfied (the 100 percent level) then fulfillment of other’s expectations will suffer. I hope we’re now all agreed that the patient belongs in the center of our uni- verse as professionals in the field of healthcare. Let’s move on to the “nuts- and-bolts” of developing customer satisfaction in the OR. Let’s first talk about the surgeon as we always hear that the surgeon is the customer. Typically the surgeon (or medical staff in general) wants to be regarded as a patron or cus- tomer of the hospital; the customer maintains the option to shop elsewhere. The hospital-business will not survive without the physician (and patient) cus- tomer(s). As in the retail environment the physician-customer maintains an expectation that the vendor (hospital) delivers a quality product. However, unique to the hospital setting is that the product is truly a service vs. a tangible product; physician-customers place pri- mary emphasis on the hospital meeting their service oriented expectations. Physician-customers typically “Want what they want, when they want it”. The physi- cian customer typically forgets that even in the most service oriented, traditional environment (whether Ritz Carlton, Nieman Marcus or Lexus dealership) hours of operation, dress codes, pricing strategies, rules of conduct, (etc.) exist and are required to effectively and reliably meet the majority of customers’ expecta- tions. Too frequently physicians / surgeons expect the administrative team (and anesthesiology) to meet 100 percent of expectations 100 percent of the time on terms established by the physician-cus- tomer at any given point in time. This mind-set, if allowed, diminishes the abili- ty to optimize service to the other customers (patients, nursing, anesthesiol- ogy, administration). Compromise is key. Now what you’ve been waiting for – does anesthesiology ever get to be the cus- tomer and what role does anesthesiology play in meeting customer service / satis- faction requirements? Surgeons will grav- itate to those hospitals and ASCs where a superior level of anesthesiology care is provided – where there is choice. Patients are generally unaware of the level of care / expertise provided by the anesthesia serv- ice and really don’t make decisions based on this factor. Doctors, I know this is going to hurt, but I now have to drop the bomb – in my nearly thirty years in healthcare and fourteen years in consult- ing, I can not site an instance where an anesthesiologist referred a case to a hospi- tal (pain management or a personal referral aside). Indeed, quality anesthesi- ologists and CRNA (AA’s) are in short supply these days and do have numerous job / practice opportunities, but typically anesthesiology’s decision of where to“per- form / take a case: requires a career and geographic move – very different from the surgeon’s opportunities. Doctors, we just have to “bite-the-bullet” and deal with reality. I spend a sizeable amount of my time in consulting and interviewing anes- thesiologists around the country and all too frequently I’ll hear: “My income is decreasing because they (meaning hospital administration) have lost the outpatient business”. In polite terms I’ll ask, “What role did anesthesiology play in retaining that business?” Generally I’ll continue with the anesthesiologist and ask, “Do you consider yourself a consulting specialist? “ Almost universally the anesthesiologist responds “Yes” – well then, don’t consult- ing specialists need to garner referrals; develop and protect referral sources? It then begins to sink in. In the old days and still in some pockets of the country, anes- thesiologists teamed up with surgeons and followed the surgeon all around town pro- viding anesthesia for the surgeon’s case. The surgeon was treated as a customer or client of the anesthesiologist; the anesthe- siologist was expected to provide a certain level of service (I know I’m rubbing salt in the wound – sorry). Today the model has greatly changed and rightfully so due to the economics of healthcare – one sur- geon’s practice can not support an anesthesiologist at today’s reimbursement levels. So then, the anesthesiologist, all the more, needs to expand and further devel- op the practice base – the anesthesiologist requires more clients / customers to gen- erate the expected livelihood; the anesthesiologist needs to: “Market to the Customer; Build the Business”. As we wrap this up, let’s focus on anes- thesia’s role in customer service in the operating room as well as anesthesia’s posi- THE COMMUNIQUÉ FALL 2006 PAGE 5 Continued on page 6 CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 5
  6. 6. tion as a customer. In general, customers’ expectations, regardless of who the cus- tomer is, will not be met unless expectations are reasonable and clearly defined. Most frequently for anesthesia this is defining how many sites are staffed by hour of day and day of week; this CAN NOT be a moving target if customer serv- ice is to be effectively delivered. Only as a few examples, as a customer, anesthesia should be able to rely on: • Development of clearly defined and agreed to expectations with regard to sites staffed; • Competitive compensation and lifestyle for services rendered deliver- ing to expectations (potentially requiring a hospital stipend); • An OR committee (or governance body) having developed effective scheduling policies and procedures and further, consistently enforcing them; • Surgeons’ offices effectively commu- nicating with OR scheduling; • Surgeons effectively communicating with anesthesia with regard to diffi- cult cases or sick patients; • Nursing effectively implementing preadmission screening protocols that have been developed jointly with anesthesia; • Charts being complete on the day of surgery; • Patients being appropriately prepared for surgery in either a Day-surgery unit or on the hospital floor; • Ability to transport the patient to the OR in a timely manner in order to have on-time case starts; • Surgeons reporting to the OR on time for on-time case starts; • Experienced OR staff and appropri- ately set-up cases in order to reduce case times; • Experienced charge nurses working with anesthesia to run the day’s schedule; • Experienced PACU staff who can function with relative independence; • Lots of other stuff... In providing customer services anesthesia should be expected to: • Be current in state-of-the art anesthe- sia care with an emphasis on ambulatory anesthesia; • Maintain reasonable flexibility with regard to agreed expectations – main- tain an attitude of meeting or exceeding expectations; • Assure consistent and reliable staffing for all anesthesia sites agreed to; • Collaborate with nursing to develop state-of-the-art preadmission guide- lines; agree as a group to established guidelines; • Screen all ASA III and above patients and visit with all inpatients prior to the day of surgery; • Develop processes to administer anesthesia consults for the preadmis- sion unit; • Call patients on the evening prior to surgery; • Be as familiar as possible with patients’ conditions prior to the day of surgery; • Review patient charts at least the day prior to surgery; • Proactively work with nursing in schedule planning and management; • Begin reviewing the schedule with nursing several days prior to surgery; • Facilitate getting patients into the OR for on-time case starts; • Facilitate expediting turnaround time; • Maintain an effective medical direc- tion model where CRNA direction is based on case complexity, patient acuity and CRNA skill level; • Be promptly available to CRNAs dur- ing on-going cases; • Be promptly available to CRNAs cases to expedite induction and emergence; • Develop a staffing model and service agreement model whereby anesthesia staffing requirements of OR-periph- eral sites does not disrupt OR staffing; • Develop a Q/I and education model for all anesthesiologists, CRNAs and hospital staff (RNs; RTs) where appropriate; • Assign lead individuals to foster skills and business development in key services such as cardiac / vascular,OB, ambulatory, pain (potentially neuro, trauma, pediatrics); • Play a key role in developing and sus- taining YOUR OWN BUSINESS by focusing on what is required to devel- op a marketable and financially viable surgical program with increasing case volume; • Focus on delivering the highest level of patient care with respect for the patient’s time; provide hospitality; • Focus on defining expectations and then exceeding those client / customer expectations and your business / anes- thesia practice will flourish (1). (1) Depending on expectations, payor mix and OR efficiencies / case times there may always be a need to approach hospital administration for a subsidy payment to deliver on expectations. THE COMMUNIQUÉ FALL 2006 PAGE 6 Continued from page 5 CUSTOMER SERVICE – GET IT YOURSELF! CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 6
  7. 7. THE COMMUNIQUÉ FALL 2006 PAGE 7 The measurement of operating room effi- ciency used to be one of those arcane sci- ences reserved for a special breed of con- sultant with experience in balancing the political and practical requirements of the daily management of a suite of operating rooms, but not any more. Given the impact of inefficient operating room management on anesthe- sia coverage and call requirements, O.R. utilization is rapidly becoming a key factor in an anesthesia practice’s need for finan- cial support. While the causes of inefficient operating room utilization tend to be complex and directly related to a hospital’s need to compete for surgeon allegiance in increasingly competitive markets, it is not uncommon for anesthe- siologists to be invited to join the fray. The concept of an anesthesiologist or an anes- thesia department designee playing some role in O.R. management is not new. Many practices have had a “floor person,” “Clinical Day Director,” or “Captain of the Ship” for years. Typically, these have been ombudsmen providing a customer service rather than aggressive managers empow- ered to actively modify surgeon behavior. The problem is simply that for all their experience in the arena, most anesthesiol- ogists have yet to develop the necessary tools and strategies to make them effective agents of change. From an anesthesia perspective all discussions of operating efficiency ulti- mately hinge on the economics of coverage and call. This takes some over- eager practitioners right to a discussion of profitability. From a management per- spective, however, an exploration of benchmarks and metrics may be more useful in the strategic positioning of anes- thesia as a contributor to the solution of declining productivity. Establishing a common vocabulary of performance uti- lization is deceptively complex. It is not uncommon to hospital administrations to view any data from the anesthesia practice with a healthy dose of skepticism. As in so many exercises in change, management time must be spent educating all the stake- holders so that they agree on the problem, accept the metrics and share some owner- ship for the process. Most observers would agree all met- rics should be viewed and tabulated by anesthetizing location. Let us further assume, for the sake of this discussion, that an anesthetizing location is an actual or virtual location that requires dedicated anesthesia personnel for part or all of a 24 hour period. By this definition each oper- ating room is an anesthetizing location, as is the delivery suite, the Cystoscopy room, or any other physical space where anesthe- sia services might be required. The definition becomes a little less clear when the dedicated personnel are required to provide a variety of non-operating room services. Each practice must work through its own definition of N.O.R.A. (Non- Operating Room Anesthesia) ASSESSING OPERATING ROOM EFFICIENCY By Jody Locke Continued on page 8 CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 7
  8. 8. THE COMMUNIQUÉ FALL 2006 PAGE 8 requirements. One school views operating room efficiency through the absolute lens of a particular metric such as cases, units or minutes per anesthetizing location day. There is considerable discussion across the country as to appropriate points of refer- ence. There is some data to support an optimal number of cases per location day, but as even the most casual observer of the specialty will note not all cases are of equal acuity or duration. Others prefer to focus on total ASA units billed per location per day (base, time, modifier and incidental units) and will site the magic number 50 as an ideal productivity benchmark. Still others prefer to measure and monitor minutes. Actual anesthesia time has the advantage of corresponding, more or less, to the operating room time captured by the hospital staff. Discussions of anesthe- sia time can take a number of directions depending upon how important it is to identify when activity occurs. It has been suggested that an operating room that generates 6 hours of anesthesia time between 7 AM and 3 PM is running at optimum efficiency. Obviously, all bench- marks and standards must be adjusted to meet the particular requirements and challenges of the facility. Proponents of such metrics argue that while they may not be a perfect measure- ment of every situation at least they provide a consistent frame of reference. They lend themselves to an objective com- parison of facilities. An operating room that consistently generates 40 ASA units per location day is clearly less efficient than one that generates 50 or more units. Inevitably, the question arises: Which metric is best? “Best” is a relative term because all valid data has some value if it is applied judiciously. A determination of the most appropriate metric or approach for a particular setting should hinge on two separate issues: reliability and credi- bility. Many anesthesiologists put great stock in measuring total ASA units per location day, because they know how they get paid for anesthesia, but such an Continued from page 7 ASSESSING OPERATING ROOM EFFICIENCY Hours per Location Day Versus Hours Per Location Dayshift 6.011030596 5.944845679 5.964393939 5.90016835 5.973765432 4.215288462 4.031243032 3.951185897 3.96497669 3.914597902 3.963269231 3.855992196 3.880512821 6.193117284 5.723054214 5.664907407 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Avg Hours per Location Day Avg Hours per Day Shift Location CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 8
  9. 9. THE COMMUNIQUÉ FALL 2006 PAGE 9 Continued on page 14 DAY Day of Week CASES CHARGES Units Expected Collections Anes. Locations Units/ Anesthetizi ng/ Location Day Expected Gross $ / Location Day 1 Wednesday 25 $29,113.50 447.9 $15,005 12 37.33 $1,250.39 2 Thursday 28 $22,919.00 352.6 $11,812 12 29.38 $984.34 3 Friday 40 $37,128.00 571.2 $19,135 9 63.47 $2,126.13 4 Saturday 29 $25,148.00 386.9 $12,961 4 96.72 $3,240.22 5 Sunday 7 $5,512.00 84.8 $2,841 3 28.27 $946.93 6 Monday 5 $4,160.00 64.0 $2,144 12 5.33 $178.67 7 Tuesday 32 $24,687.00 379.8 $12,723 12 31.65 $1,060.28 8 Wednesday 32 $26,344.50 405.3 $13,578 12 33.78 $1,131.46 9 Thursday 28 $22,386.00 344.4 $11,537 12 28.70 $961.45 10 Friday 47 $40,703.00 626.2 $20,978 9 69.58 $2,330.86 11 Saturday 25 $23,965.50 368.7 $12,351 4 92.18 $3,087.86 12 Sunday 10 $7,228.00 111.2 $3,725 3 37.07 $1,241.73 13 Monday 4 $3,692.00 56.8 $1,903 12 4.73 $158.57 14 Tuesday 29 $26,955.50 414.7 $13,892 12 34.56 $1,157.70 15 Wednesday 27 $26,718.00 411.0 $13,770 12 34.25 $1,147.50 Anesthetizing Location Production Metrics for Month of March 2005 (Based on DOS Data) 16 Thursday 39 $37,076.00 570.4 $19,108 12 47.53 $1,592.37 17 Friday 40 $32,922.50 506.5 $16,968 9 56.28 $1,885.31 18 Saturday 32 $29,428.00 452.7 $15,167 4 113.18 $3,791.68 19 Sunday 10 $10,991.50 169.1 $5,665 3 56.37 $1,888.28 20 Monday 8 $7,553.00 116.2 $3,893 12 9.68 $324.39 21 Tuesday 26 $24,017.50 369.5 $12,378 12 30.79 $1,031.52 22 Wednesday 32 $29,107.50 447.8 $15,002 12 37.32 $1,250.13 23 Thursday 14 $11,011.00 169.4 $5,675 12 14.12 $472.91 24 Friday 28 $21,671.00 333.4 $11,169 9 37.04 $1,240.99 25 Saturday 20 $18,359.00 282.4 $9,462 4 70.61 $2,365.49 26 Sunday 10 $8,495.50 130.7 $4,378 3 43.57 $1,459.48 CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 9
  10. 10. Since the publication of the OIG Compliance Guidance for Individual and Small Group Physician Practices (here- inafter the “OIG Guidance”) in 2000, many anesthesia practices have had some experience with compliance auditing. The first of the seven compliance pro- gram elements recommended by the OIG is conducting internal monitoring and auditing through the performance of periodic audits. What does this entail for an anesthesia practice? Although physicians may not be legally required to conduct internal audits and the fact remains that the OIG Guidance is only a set of recommendations, many experts recommend that physician practices should strive to conduct internal audit- ing at least on an annual basis. Conducting annual audits should prove beneficial in assisting the practice in identifying issues that should be addressed or corrected thereby reducing ongoing risks to the practice. By per- forming an audit on at least an annual basis, the practice should avoid messy sit- uations such as identifying a significant problem or issue that may have been occurring for a significant time period resulting in potential large overpayments received by the practice. Such circum- stances can raise significant questions for the practice related to payback and dis- closure obligations. A common question facing anesthe- sia practices when deciding to conduct an internal audit (either by internal staff or hiring an outside consulting group) is “how many records should we review?” While there is no exact right or wrong number, it is reasonable for the practice to limit the record review to a manage- able and practical number for several reasons including costs. In the OIG Guidance, the OIG suggests that an appropriate sample size may be five (5) to ten (10) records per physician in the practice. In many situations, a group’s decision to audit between 5 and 10 records per physician would be reason- able. Some outside consultants that have an economic interest in reviewing many records, may suggest too large of a sam- ple size. The practice must keep this in mind when hiring and coordinating an audit with outside help. Outside con- sultants can and do provide valuable assistance and expertise for many prac- tices, however, the practice should maintain control of the process and not simply allow the consultants to direct and select the sample size. Given that the auditors will typically identify problem areas, it is also important for the practice to conduct the internal audit under the attorney/client privilege. This process is not complicated and involves the prac- tice’s attorney directing the auditors to perform the audit under the THE COMMUNIQUÉ FALL 2006 PAGE 10 As part of our desire to keep both clients and readers up to date, the Communiqué has been printing compliance information since its inception. In the Compliance Corner, we will now formally keep you abreast of the various compliance issues and/or pick out a topic that would be of interest to most of our readers. COMPLIANCE AUDITING: HOW MANY RECORDS SHOULD YOU REVIEW? By Abby Pendleton Wachler & Associates, P.C. CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 10
  11. 11. measurement tool for which each of the perioperative disciplines will be account- able and to encourage global participation as a means to achieving higher levels of performance and satisfaction. Earlier this year, with input from my perioperative leadership colleagues at AtlantiCare, I initiated the development of a 360 degree Perioperative Satisfaction Survey to purposefully achieve higher lev- els of mutual perioperative satisfaction and drive higher levels of perioperative performance. The 360 degree approach for survey and evaluation purposes is not a new concept as business leaders have suc- cessfully used 360 surveys as a means of assessing leadership at every organization- al level. Although surgeon specific satisfaction surveys had previously been attempted at AtlantiCare, the thought was that a comprehensive 360 degree survey would likely surface common satisfaction and dissatisfaction themes affecting all of the perioperative disciplines to include the surgeons. The intent was to obtain defini- tive feedback on the common satisfaction and dissatisfaction themes so that the lead- ership of each perioperative discipline could address the universal issues of the discipline rather than issues of isolated dis- satisfaction. A set of mutually inclusive satisfaction criteria with basic effective scoring was developed and scoring that fell above or below acceptable targets required supportive elaboration so that dissatisfac- tion could be effectively addressed. The leaders of each perioperative discipline were tasked with distributing the 360 degree survey to their respective col- leagues. Each perioperative discipline had the opportunity to survey each of the other disciplines as well as their own discipline. As with any feedback survey, it was impor- tant to establish deadlines for survey submission dates so that feedback is timely and action plans for improvement can be efficiently developed. The survey success is completely dependant on the level of par- ticipation or you will have developed the best satisfaction survey with no feedback to improve satisfaction or performance. The key point is that to achieve higher levels of surgeon satisfaction is to concur- rently achieve higher levels of nursing and anesthesiology satisfaction. Within the perioperative arena, none of the disciplines can achieve high levels of satisfaction with- out the other disciplines also being effectively satisfied. It comes down to a mutual respect and understanding of the critical roles that each discipline plays in determining the performance, culture and overall success of perioperative and surgi- cal services. In the end, it becomes an exercise in futility to attempt to satisfy one discipline, namely surgeons, at the expense of the other two perioperative disciplines, nursing and anesthesiology. THE COMMUNIQUÉ FALL 2006 PAGE 11 Continued from page 3 SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE attorney/client privilege. In addition to the cost issues, if the goal of the audit is early identification of issues or patterns, a large volume of records is typically not necessary. In fact, many auditors will begin to identify issues/patterns in the first 10 to 20 records. For example, in auditing anes- thesia records, it usually does not take many records to identify whether the physicians are fully documenting med- ical direction requirements or whether anesthesia time is being rounded. In the anesthesia setting, many auditors suggest a review of a full day of cases in order to perform a concurrency review in con- nection with the audit. The practice will have to make a determination as to whether an independent check of con- currency is necessary. Accordingly, while there may not be one “magic” number for compliance auditing, your practice should take a rea- sonable approach by selecting enough records to accomplish the goal of the audit, which in many routine compli- ance audit situations is to identify areas needing attention. For many practices, selecting a minimum of 5 records per physician will accomplish this goal. Of course, once issues are identified, the practice should perform specific focused follow-up audits to oversee that correc- tive action measures that were put into place (e.g., educating providers or estab- lishing new policies) are working. CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 11
  12. 12. THE COMMUNIQUÉ FALL 2006 PAGE 12 We are pleased to announce that this year’s MGMA AAA annual conference will be held April 29 – May 2, 2007 at the spectacular Four Diamond Sheraton Hotel and Towers in Seattle, WA. For those who have never attended this anes- thesia practice management conference, it is one of the best in the industry. This year, due to popular member demand, we added two half-days of pain management specific practice management informa- tion as a pre-conference on Saturday afternoon and Sunday morning, in addi- tion to offering a pain track throughout the concurrent sessions of the main con- ference. Typically attended by approximately 300 administrators, physi- cians, practice managers, billing service owners, consultants and others involved in advanced level anesthesiology and pain practice administration, it also provides an exceptional forum for networking and information exchange. Early in the con- ference we offer roundtable discussions on specific issues of interest that allow people to meet others in comparable practices or with similar concerns. We include a number of social events to pro- vide further networking opportunities. People who have attended this meeting for many years develop friendships that provide continuing networking support throughout the year. Once again, we have an exceptional group of speakers lined up for this year’s conference and pain management pre- conference. The pain pre-conference is scheduled to begin on Saturday, April 28th from 1:00 to 5:00 p.m. and Sunday, April 29th from 8:00 a.m. to 12:00 p.m. The keynote speaker is Doug Merrill, MD from Virginia Mason Clinic located in Seattle. Dr. Merrill, a leading physician in the chronic pain management field, will share his vision in “The Future of Pain.” Other speakers include nationally renowned healthcare attorneys Vicki Myckowiak, Esq., and Jennifer Bolen, J.D., who will address fraud and abuse risk areas and compliance concepts for the pain management provider, respectively. Also, nationally known speakers, Devona Slater, CHC and Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO will dis- cuss pain management coding, billing, and appeals. In response to member requests, this information-packed pre- conference was designed to meet the specific needs of our members with pain- management practices. On Monday morning, physicians who attend the conference are invited to join Dr. Craig Johnson, ASA liaison to MGMA AAA, and other colleagues for breakfast. As in past years, this “physician only” informal networking event gives physicians an opportunity to discuss cur- rent topics and exchange information pertinent to their practices. Our keynote speaker (special thanks to Tony Mira and Anesthesia Business Consultants, LLC for their generous sponsorship of this event) is Jim Bergquist, president, BizFutures. This Seattle-based consulting company has been featured on National Public Radio and has an impressive list of clients, including Microsoft and Boeing. The high energy and high impact presentation – designed to inspire and motivate employ- ees – is fun and educational. Other general session speakers include Mark J. Lema, MD, president, American Society of Anesthesiologists, Norman A Cohen, MD, American Society of Anesthesiologists’ Committee on Economics, and Alexander Hannenberg, MD, Vice-President Professional Affairs, ASA. Back by popular demand, national- ly known health care futurist James E. Orlikoff, Orlikoff & Associates, Inc., Chicago, will discuss “The Impact of Technology on the Healthcare System.” As usual, the concurrent sessions will include many experienced speakers cover- ing a great variety of new and timely topics. This year we will be adding a fourth option to the concurrent sessions to provide a specific pain track in the main conference as well as the pre-conference offerings. Topics to be covered in the con- 2007 MGMA AAA ANNUAL CONFERENCE PROVIDES EXCEPTIONAL EDUCATION AND NETWORKING OPPORTUNITY By Kelly Dennis MBA, ACS-AP, CPC, President-Elect, MGMA AAA, Leesburg, FL CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 12
  13. 13. THE COMMUNIQUÉ FALL 2006 PAGE 13 current sessions include: “Modifier Magic for Pain Management Coding,” by Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO; “General Competency – Communication Skills,” by Sara M. Larch, MSHA, FACMPE, chief operating officer, University Physicians, Inc.; “To EAR or not to EAR - What you Need to Hear Before Implementing an Electronic Anesthesia Record,”by Phil Mesisca, MBA, CMPE, CEO, University of Pennsylvania Health System; “Pain Clinic Operations and Profitability,” by Devona J. Slater, CHC, CMCP; “Achieving Optimum Back Office Productivity,” by Jody Locke, vice president of anesthesia and pain manage- ment services, Anesthesia Business Consultants, LLC. In addition to these excellent speak- ers, many who are members of MGMA AAA, roundtables will be moderated by members, who facilitate discussion and share their experiences on a variety of issues of interest. Social events run the gamut from breakfast, lunch and networking recep- tions to a golf tournament and casual get-togethers by members. Each year, an introductory session is held for new administrators and a special reception is held prior to the opening reception for first-time attendees to help them meet people and start networking right away. Most of the key anesthesiology and pain management vendors are “on hand” as sponsors and exhibitors during the breaks to demonstrate their products and servic- es, answer questions and solicit feedback. It provides a great forum to comparison shop and evaluate products your practice may need. The Sheraton Seattle Hotel and Towers, the location of our 2007 meeting, is located in the city’s vibrant core and has recently undergone a 14 million dollar ren- ovation of the lobby, restaurants, guest rooms and suites. Sheraton Seattle has been the recipient of Meetings and Conventions Gold Key Award for five con- secutive years. It is conveniently located next to the sights, sounds, and experiences of one of the greatest cities in the northwest and just steps from world-famous Pike Place Market and the world-class shopping, exciting nightlife and gourmet restaurants that surround this magnificent hotel. The hotel is located at 1400 Sixth Avenue in downtown Seattle. For more information, visit seattle/ To learn more about the conference, view the brochure or to sign up yourself and/or your administrator, visit, find the appropriate dates and click on the MGMA AAA annual conference. Or you can call 1-877-ASK-MGMA and request to have a hard copy brochure mailed to you. ASA members who sign up with their administrator who is an MGMA AAA member may attend at the member rate. There is also a special rate available for non-members to include purchase of their initial membership and obtain the membership price for the conference. Please do not hesitate to contact me, kelly- or MGMA AAA president Jack Beecher,, should you have questions or need more information about the conference or any aspect of MGMA AAA membership. We hope to see you in April, 2007!! CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 13
  14. 14. THE COMMUNIQUÉ FALL 2006 PAGE 14 approach may be viewed with great suspi- cion by hospital administrators who do not understand how anesthesia basic val- ues and time units are determined. In other words, if a particular metric does not serve the goal of providing common coinage for a discussion of management options it will serve no practical purpose. Another school of thought is more concerned with the relationship between coverage commitments and actual pro- duction patterns. In this variation on the theme actual hours of anesthesia time are divided by total hours of staff coverage. Such an approach factors in such issues as call and distinctions between short and long rooms. The advantage of such a per- spective is that it can be customized to any particular configuration of anesthetizing locations. The disadvantage is that all applications become relative. Included below are examples of each of the two approaches to the measuring of operating room productivity. Not every anesthesia practice will want to develop the tools to generate such reports, although more practices should probably be exploring the possibilities than are cur- rently doing so because too often it is the initiation of a serious subsidy discussion that triggers the need to look at productiv- ity. Practices that have been monitoring O.R. metrics over time have much greater conversance with their applicability and relevance. The fact is that as is true of the administration of anesthesia, it is difficult to manage what one does not measure. While anesthesia practices have tradition- ally focused on the measurement and management of billings and collections, more and more are beginning to realize that the one piece of the equation they did not choose to monitor is the one that has the greatest impact on the income and lifestyle of the members. It has been said that you cannot man- age what you do not measure. Anesthesiologists know this intuitively, because the availability of reliable physio- logic data about a patient’s response to the trauma of surgery and anesthesia plays such a critical role in the consistent out- comes of today’s practitioners. The converse is also true: what you do not measure, you cannot manage. Anecdotal discussions tend not to support serious change. If O.R. productivity is an issue for your practice then an investment in the tools and resources to capture the data and monitor it closely is a small price to pay for the opportunity to be part of the solution rather than a victim of the problem. ASSESSING OPERATING ROOM EFFICIENCY Continued from page 9 27 Monday 6 $4,927.00 75.8 $2,539 12 6.32 $211.61 28 Tuesday 27 $28,073.50 431.9 $14,469 13 33.22 $1,112.97 29 Wednesday 35 $36,305.50 558.5 $18,711 14 39.90 $1,336.52 30 Thursday 38 $38,389.00 590.6 $19,785 15 39.37 $1,319.01 31 Friday 39 $37,050.00 570.0 $19,095 12 47.50 $1,591.25 Totals 772 $702,038 10,800.6 $361,819 298 629 $572,910 8,814.0 $295,269 270 143 $129,128 1,986.6 $66,550 28 24.90 22,646.37 348.41 8.76 36.24 $1,524.31 29.95 27,281.43 419.71 12.86 32.64 $1,064.33 Weekends Overall Averages Weekday Averages Weekdays CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 14
  15. 15. THE COMMUNIQUÉ FALL 2006 PAGE 15 Coding CornerCoding Corner Speakers at anesthesia coding sem- inars often harp on the importance of indicating the use of hardware when documenting spinal surgery. The argu- ment is that failure to indicate the use of hardware will result in the loss of five billable units. While it is useful to keep this in mind when reporting spinal pro- cedures, this is hardly the end of the story. New surgical techniques make it imperative that not only is the surgical approach and location clearly indicat- ed, but that the coders understand the significance of each indication. A case in point is a practice that routinely reported a spinal procedure indicated as “TLIF.” The indication obviously made sense to the anesthesi- ologists, but was not at all clear to the coders. A review of various reference materials indicated the following options for which the corresponding anesthesia basic values are indicated. Another physician reported a pro- cedure as“ACDF,”which was interpreted as Anterior Diskectomy with fusion and the coder selected CPT code 22554. A review of a standard coder’s reference indicated such a procedure does not typically involve instrumentation. A review of the surgical operative report, however, clearly indicated the use of plates and screws. This clarification resulted in a base value of 13 instead of 10. The bottom line is that the place- ment or removal of plates, screws, rods, cages or dowels during spine surgery should be clearly noted together with the level of the procedure. It is always a good habit when providing anesthesia for a procedure that is new to your practice to confirm the best way to doc- ument the surgery so that the coders will be able to code it appropriately. For ABC clients this is a standard part of the service. DOCUMENTING SPINAL SURGERY By Jody Locke,Vice President Anesthesia Business Consultants, LLC Thoracic Lumbar 8 units Interbody Fusion Transforaminal Lumbar 8 units Interbody Fusion Translaminar Instrumentation 13 units with Fusion CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 15
  16. 16. PROFESSIONAL EVENTS DATE EVENT PLACE CONTACT INFO Dec. 8-12, 2006 New York State Society of Anesthesiologists New York Marriott Marquis, Postgraduate Assembly in Anesthesiology New York, NY Dec. 13, 2006 “Pain Managment 2007 Coding Update and Live Webcast and Audio Conference Common Coding Pitfalls to Avoid!” 2:00 p.m. to 3:30 p.m. EST Speaker: Linda Van Horn, MBA Sponsored by MGMA Jan. 18, 2007 Anesthesia Coding Updates Live Webcast and Audio Conference Speaker: Debbie Farmer Sponsored by MGMA Jan. 26-28, 2007 Arizona Society of Anesthesiologists Scottsdale Resort and Conference Annual Mtg. Center, Scottsdale, Arizona Jan. 26-28, 2007 ASA Conference on Practice Management Pointe Hilton-Tapatio Cliffs Resort, Phoenix, AZ Feb. 7-10, 2007 American Academy of Pain Medicine Ernest N. Morial Convention Center, Annual Meeting New Orleans March 8-11, 2007 Society of Pediatric Anesthesia Pointe Hilton Squaw Peak, Winter Meeting Phoenix, Arizona April 19-22, 2007 32nd Annual Regional Anesthesia The Westin Bayshore Hotel, Meeting and Workshops Vancouver, British Columbia, Canada April 21-25, 2007 Society of Cardiovascular Anesthesiologists Palais des Congres de Montreal Annual Meeting and Workshops Montreal, Quebec, Canada April 26-28, 2007 AUA 54th Annual Meeting Sheraton Hotel and Towers, Chicago, IL April 29-May 2,2007 MGMA AAA Annual Conference Sheraton Seattle Hotel & Towers, Seattle, WA May 16-19, 2007 Society of Obstetric Anesthesia and Perinatology Fairmont Banff Springs, Annual Meeting Alberta, Canada May 31- Jun 3, 2007 CSA/UCSD Annual Meeting & Clinical Sheraton San Diego Hotel & Marina, Anesthesia Update San Diego, CA, Sept. 28-30, 2007 South Carolina Society of Anesthesiologists Grove Park Inn, Asheville, Annual Meeting North Carolina 255 W. MICHIGAN AVE. P.O. BOX 1123 JACKSON, MI 49204 PHONE: (800) 242-1131 FAX: (517) 787-0529 WEB SITE: PRSRT STD US Postage PAID Holland, MI Permit No. 45 ANESTHESIAANESTHESIA BUSINESS CONSULTANTSBUSINESS CONSULTANTS CommNEWS_Fall06v6.qxd 11/30/06 3:16 PM Page 16