August 2004 Volume 68	Number 8

Performance Evaluations

Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)


Has your group developed a formal system for evaluating the performance of individual anesthesiologists? Anesthesia Administration Assembly member David Whitten, CEO of Anesthesia Medical Group in Nashville, Tennessee, describes the process used by his very large group below. Implementation of this sophisticated process would require much adaptation by smaller groups, but we hope that the basic concepts and findings will be of interest to all.

e have used a simple tool for several years now in evaluating our anesthesiologists. (We have a different system for evaluating our nurse anesthetists.) We are a large practice arrayed in five call pools of varying sizes. The evaluations are done under a peer-review blanket and thus protected. [Satisfying the statutory conditions for peer review will generally shield performance information from discovery in litigation. — K.B.]

Once a year, the anesthesiologists in a call pool evaluate each other on five questions:

• Clinical skills

• Customer service

• Work ethic

• Nurse anesthetist relationships

• Ability to work as a team member

Each question is ranked on a scale of 1-7. We use an outside firm to tabulate the results. Each anesthesiologist is profiled on each question against the call pool mean. The call pool chief visits with every physician to review that physician’s results. Any anesthesiologist falling two standard deviations or more from the call pool mean is re-evaluated in six months. Counseling (for problems of team member and nurse anesthetist relationships, for instance) and remedial courses, as appropriate, are strongly encouraged. These are on the physician’s time and at his or her expense. Failure to correct the deficiency is dealt with by a visit with the board of directors.

If a physician falls two standard deviations below the mean for two years in a row, the consequences are:

1) Visit with the board;

2) Mandatory remedial course; and

3) Formal review after six months.

In addition we believe clinical skills and customer service are the top priorities. Therefore, if an anesthesiologist falls two standard deviations below the mean in two sequential years on either or both of those questions, he or she may not be allowed to take call and thus sacrifices call pay for 90 days. Failure to correct the problem in a subsequent year will result in further penalties.

This entire effort is a work in progress and is only in its third year of use. The board and group have had to get comfortable with the process, its confidentiality, the benefit of honesty in their evaluations of each other and the need for firm, predicable and consistent consequences. This last point, the penalties, has been and is the most difficult to work our way through.

As a practice administrator, my belief is that it is our job, as the group’s conscience and manager, to make sure that the process and results are consistent with the culture and values of the group. In my group’s case, we are constantly looking for better ways to do things in terms of clinical skills, customer service, relationships with nurse anesthetists, etc. I have said to the group, “If we are not looking to make things better, things will get worse.”

Doctors have no special training in evaluating peer performance and thus are often somewhat skittish about doing it. Sometimes they have to be encouraged and shown how to do it. Eventually they come to see the value. I remind them that I evaluate all staff members who report directly to me, and all of my direct reports evaluate their staffs. There is no fanfare or magic here — just letting people know how they are doing. Even physicians need this. The board and group have now begun to see the benefits.

I have asked that the board evaluate me formally each year; this is not something that the members were necessarily eager to do (nor I necessarily to endure). I believe that it is important that the board exercise its duty to the shareholders to make sure I am doing my job.

Lessons learned:

1. Physician evaluations help to make the group better.

2. Physicians may need to be shepherded gently through the process, and it takes years for performance evaluation to become part of the culture of the group.

3. The administrator may have to drive the process for a while.

4. Confidentiality and nondiscoverability are essential.

5. The anesthesiologists did not like my seeing the results the first time we went through the process. There is less concern that I see them now, and I am very careful in my use of the results.

6. Consistent, predictable and rational consequences are crucial.

7. Objective data interpretation is important. This is why I outsourced that function (but within the United States!).

8. Keep it simple. This is really important.

9. The anesthesiologists, for the most part, are able and willing to evaluate each other.

10. There will be some people who are upset. This comes with the process.

11. Behaviors and performance will change. For some anesthesiologists, it will be permanent. For others, it will not. With this latter cohort, the group has to be willing to accept that some of its members just will not get it. We are still struggling with this piece.

2005 RVG and CROSSWALK™ Will Be Available in November

he 2005 Current Procedural Terminology-4™ codes become effective January 1, 2005. Unlike its practice in past years, the Centers for Medicare & Medicaid Services will not accept 2004 codes after that date. The 90-day grace period at the start of the year has been eliminated. Because of this, ASA is committed to publishing the 2005 editions of the Relative Value Guide (RVG) and CROSSWALK™ early so that users will be able to update their systems in order to switch over to the new codes on January 1, 2005. (Please note: you should not make this change effective before January 1. You must use the code set in effect on the date the medical service is provided.)

The 2005 editions of the RVG and CROSSWALK will be available in November. The Reverse CROSSWALK™ will be available only on CD. Order your copies from the ASA Publications Department at (847) 825-5586 or at <publications@ASAhq.org>.

Anesthesiology First Specialty to Have Own Page on CMS Site

he Centers for Medicare & Medicaid Services (CMS) has been working hard for some time to provide better and more accessible information to physicians. One of the possible innovations that CMS discussed with the specialty societies was creating specialty-specific pages on the Web site. We are the first specialty to have worked with CMS on this project, which recently launched the Web page pictured below <www.cms.hhs.gov/physicians/anesthesiologist/default.asp>.

The page on “Medicare Information for Anesthesiologists” contains the anesthesia conversion factors, Medicare’s base units for the anesthesia codes; the section from the Claims Processing Manual spelling out the rules for “Payment for Anesthesiology Services” (this is where readers will find all the rules on medical direction) and other information. It is a good portal to all published Medicare policies and regulations, many of which are important to billing staff, if deadly dull reading for anesthesiologists. We are currently working on adding material on pain medicine services.