ASA April 2003 Newsletter

Anesthesiologists are occasionally challenged by surgeons, operating room (O.R.) managers and hospital administrators to “improve O.R. efficiency and productivity.” Often these challenges include comments similar to the following:

1. “You don’t work fast because you get paid by time.”

2. “If turnover time was shorter, we’d do more cases.”

3. “According to benchmarks, you don’t need more people to cover more O.R.s.”

This article provides logical and evidence-based responses demonstrating that it is also in the interests of anesthesiologists and anesthesiology groups to improve O.R. productivity.

“You Don’t Work Fast Because You Get Paid by Time”
Charges for anesthesia care differ from those of other medical specialties in that time directly influences the amount charged. For instance, surgeons bill for cholecystectomies using relative value units (RVUs) independent of case duration of the surgery. In contrast, anesthesiologists bill using ASA units, which are composed of basic units (based on the surgical procedure performed) and time units (based on the amount of time anesthesia care is provided). Thus, anesthesiologists do bill more for longer cases than shorter ones.

At first glance, it would appear to be in the best financial interests of an anesthesiologist to have longer cases because he or she could bill more per case. Upon further analysis, it becomes clear that longer cases are not financially beneficial. Anesthesiologists actually bill more providing care for many short cases than for a few long cases. Instead of examining billed units per case, one should evaluate the hourly billing productivity (defined as total ASA units billed per hour of care = tASA/h).^1,2 This measurement is calculated by dividing the sum of total base units and total time units by the total hours of care (for 15-minute time units, hours of care will equal time units divided by 4). For instance, if one assumes that eight billed hours of care are provided to two different surgeons, then the difference in hourly productivity (tASA/h) is dependent solely on the basic units billed. The basic units billed for these eight hours is related to the number of cases done and the base units per case. Therefore, for similar cases, a greater number of cases that can be done in eight hours will result in more billed units. In other words, the shorter the case duration, the more advantageous it is for an anesthesiologist. Hence, there is actually an incentive to work faster!

“If Turnover Time Was Shorter, We’d Do More Cases.”
My first response to this statement is “Stop beating a dead horse!” Research has established the fact that further reducing reasonable turnover times will not increase the number of cases that can be done in a work day.³ For instance, for an O.R. in a nonambulatory surgical center hospital, a reasonable maximum turnover time between procedures might be 35 minutes. Reducing this number by 20 percent would only result in a seven-minute time saving between cases. If three cases were done per O.R., this would mean a 14-minute saving. Compared to the average surgical duration of one’s hospital, reducing turnover time by 20 percent will not allow for one more surgical case to be done. Obviously, in an O.R. where more cases are being done in a day (e.g., seven to 10 cataract or pediatric otolaryngology surgeries), reducing turnover time by seven minutes per case may be significant. But in these specific O.R.s, the turnover time will already be much lower than in the rest of the O.R.s (e.g., 15-20 minutes), and further reduction may not be possible.

In contrast, focusing on reducing any delays — defined as a turnover time greater than the reasonable maximum turnover time — will result in large time savings. For instance, if a turnover time is 90 minutes in an O.R. with a maximum time set at 35 minutes, then a 55-minute delay has occurred. Focusing on the etiologies of this type of delay could result in a reduction of 55 minutes per occurrence.

Finally, anesthesiologists should point out that they cannot bill for turnover time and therefore also are interested in decreasing it. Although decreasing the downtime will not allow an anesthesiologist to bill more per O.R. for that day (because of the previously mentioned inability to perform even one more case in a regular day), such efforts may result in the anesthesia provider(s) going home earlier, which can reduce overtime payments.

“According to Benchmarks, You Don’t Need More People to Cover More O.R.s.”
Hospital administrators or medical school deans who make this statement are mistakenly trying to apply outpatient clinic logic to anesthesia staffing. For instance, the administrator might use 30 patients a day as a benchmark for how many patients a pediatrician should see in one day. Thus, if there are 300 patients to be seen each day, then one needs 10 pediatricians to staff the clinic each day.

Unfortunately, as anesthesiologists well know, this logic does not work for determining staffing needs for operating rooms. The primary determinants of the number of anesthesia providers needed each day for a particular department are 1) the number of clinical sites or O.R.s to be staffed, 2) the staffing ratio (i.e., concurrency) and 3) the numbers of persons both on-call and post-call.⁴ What is not a direct determinant of anesthesia staffing is any type of productivity benchmark. Simply put, if the administrator wants the anesthesiology group to cover 20 O.R.s, then the group will need the same number of providers whether the cases finish at noon or 3 p.m.

In addition, the logic applied by the administrator in this situation compares anesthesiology group productivity using “per-anesthesiologist” (i.e., per-FTE, or full-time equivalent) measurements. However, using “per-FTE” measurements to compare anesthesiology groups with different staffing ratios leads to inaccurate conclusions.⁵ Administrators can more meaningfully compare anesthesia care done by groups (or by hospitals in which they work) by using tASA/hr and “per-O.R. site” measurements.^1,2,5

In summary, anesthesiologists can use evidence-based logic to answer questions about the efficiency and productivity of their groups. In doing so, they also can demonstrate the interests of anesthesiologists in improving O.R. efficiency.

References:

1. Abouleish AE, Prough DS, Whitten CW, et al. Comparing clinical productivity of anesthesiology departments. Anesthesiology. 2002; 97:608-616.

2. Abouleish AE, Prough DS, Barker SJ, et al. Organizational factors affect comparisons of clinical productivity of academic anesthesiology departments. Anesth Analg. 2002; (in press). [For the original abstract of this study, please see Anesthesiology. 2002; 97:A1135.]

3. Dexter F, Macario A. Decrease in case duration required to complete an additional case during regularly scheduled hours in an operating room suite: A computer simulation study. Anesth Analg. 1999; 88:72-76.

4. Abouleish AE, Zornow MH. Estimating staffing requirements: How many anesthesia providers does our group need? ASA Newsl. 2001; 65(8):14-16. <www.ASAhq.org/NEWSLETTERS/2001/8_01/abouleish.htm>

5. Abouleish AE, Prough DS, Zornow MH, et al. Designing meaningful industry metrics for clinical productivity for anesthesiology departments. Anesth Analg. 2001; 93:309-312.

Amr E. Abouleish, M.D., is Associate Professor, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas.

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