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s a consultant for ASA’s Anesthesia Consultation Program for the past 17 years and a practice management consultant for a private entity for the last five years, your author has come to appreciate a recurrent series of issues that commonly cause hospitals, anesthesiology groups or both to seek outside consultation. This short vignette will describe the types of consulting services available, the process of the consultations offered, the reasons engendering a consultation and will briefly outline the challenges consultants face when arriving at a new client’s doors.

Consultation requests come from two broad categories of need: those wishing evaluation of the quality of anesthesia practice and those requesting assistance with perioperative process improvement (practice management). The ASA Anesthesia Consultation Program was established to evaluate and advise entities on matters relating only to quality of anesthesia care (and is specifically proscribed from undertaking the evaluation of practice management issues per se), while a number of private consultants (many of whom are active ASA members) undertake to assist institutions and departments with perioperative process improvement. Each type is briefly described below.

The ASA Anesthesia Consultation Program offers a single two- or three-day visit by two actively practicing anesthesiologists (either current or former members of the Committee on Quality Management and Departmental Administration [QMDA]) that produces a diagnostic report and specific recommendations for actions designed to improve anesthesia quality. The program is designed to produce a “snapshot in time” of the client’s situation, and ASA does not offer an implementation phase to its consultations.

Private consulting organizations begin their process in a manner similar to the ASA Anesthesia Consultation Program, with an extended diagnostic visit — but one that may include administrators, financial experts and nursing consultants in addition to anesthesiologists. On occasion, they employ surgeon consultants when issues appear to be significantly surgical in origin. These organizations then produce an analysis not dissimilar to the ASA report, but after their diagnostic evaluation, they offer an extended implementation phase incorporating a detailed “turnaround” plan in which the diagnostic team is intensely personally involved during the early phases, then gradually mentors and incorporates local leadership into the administration of the operating room until it is finally self-sufficient. By necessity, such a service is substantially costlier than the single-visit ASA consultation program, but it provides a wider scope of services not limited to anesthesia quality alone.

Both types of consultations base their primary information-gathering process on a series of confidential, in-depth interviews with every discipline of professional and administrator who interacts with the perioperative services. Further information is obtained from reviews of correspondence, contracts, charts, credentials files, departmental minutes, quality measures, and other pertinent documents and observations of facilities, equipment and workflow.

In the ASA consultation, the consultants then together consider the situation and construct a diagnostic report from the compilation of this information and their experience, using ASA standards, guidelines and statements for reference standards. The QMDA-produced “Manual for Anesthesia Department Organization and Management” (MADOM) is a valuable reference that contains text or links to all pertinent ASA material as well as articles written by noted experts on the various aspects of anesthesia department management. Areas of concern are highlighted and compared to these ASA publications, discrepancies are clearly stated and any areas of poor quality brought to the attention of the organization. Finally, the consultants make recommendations for improvement in accordance with ASA policy and widely accepted standards of practice.

A private consulting group will collect information in a similar manner and present a similar report to the client, often in a less detailed manner initially, with the mutually-understood intent of proposing an extended assistance program to “walk” the department and/or hospital through the steps to resolution.

Quality-limited consultations performed by the ASA Anesthesia Consultation Program are engendered by a variety of circumstances. Most often, these come from hospitals that wish to be assured that the quality of their anesthesia departments is up to standard. There may have been one or more sentinel events, questions about a specific practitioner’s capabilities, concerns that the supply of available anesthesia talent is mismatched to the demand (and having an adverse impact on quality) or a general concern about the ability to communicate with and obtain cohesion from the anesthesia department. On more than one occasion, ASA has been retained when there is simply a hospital’s desire to obtain the equivalent of a “Good Housekeeping Seal of Approval,” often occurring when all of the hospital-based physician groups are being evaluated.

Practice management consultants find a wide variety of causes of poorly functioning perioperative services. Patient flow problems can begin at surgeons’ offices and continue through hospital admission processes and cause surgeons, anesthesiologists and nurses to accept abysmally poor morning starts resulting from chronic frustration with the ability to have patients properly prepared and available for surgery. Block scheduling practices, if not carefully established and monitored, can be a major source of inefficient O.R. operation and usually need early attention by consultants because of their entrenched status and the tremendous inertia that must be overcome in order to correct them. Financial problems related to a depressed economic base in the hospital’s service area can be especially challenging and require expert reimbursement specialist analysis to see that the maximum legitimate revenue is being realized. Poor operating room or anesthesiology department leadership can be a real impediment to efficient O.R. operation.

Often, the situation may have deteriorated to the point that communications between administration, nursing, anesthesia and surgery have become so inhospitable that outside intervention is the last resort.

Sometimes, what may be perceived to be a dysfunctional anesthesia department is in fact a multifactorial problem that has its basis in economics, demographics, and hospital organization and culture. In such cases, if ASA is approached first, we suggest that private consultants be engaged who are prepared to address broad perioperative concerns that include revenue cycle management and nursing, surgical, administrative and other departments requiring anesthesia (such as out-of-O.R. anesthesia or sedation services). Although ASA does not approve or recommend any specific consultants, it does keep a list of known consultants who can be made available to members.

Although lack of leadership in any area — administration, nursing, anesthesia or surgery — is a frequent finding by consultants, there are cases in which motivated and well-intentioned leaders in each area are hamstrung by circumstance and unable to singlehandedly break free from tradition and achieve meaningful change because of poor payer mix, inadequate facilities or aberrant colleague personalities. Consultants can be effective in these engagements by breaking a chain of epidemic pessimism and constructing channels of communication between “silos,” often allowing the first real communication in months (or even years) to occur.

Concerns about an individual practitioner’s competence in the face of advancing age, extended absence from high-level clinical involvement or physical, emotional or mental disability have also engendered ASA consultations. Preoperative preparation, promptness of first-case starting times, between-case turnover times, and afternoon “cone-down” are common complaints to both quality and practice management consultants. By ASA policy, economic issues remain the exclusive venue of the private consultant.

Consulting requires the ability to listen beyond the words and sense seminal issues and latent intent. Occasionally, the “real” reason to have consultants visit does not become obvious until after the consultants arrive and the doors are closed on the first interviews. The teams must be able to accept such abrupt changes in mission and restructure their investigative processes to harvest critical information relevant to the new problem.

Nurses and other hospital staff are frequently reluctant to be candid in interviews until they are assured that their responses will not be directly attributed to them.

One pundit has described a consultant as “someone from out of town with a big briefcase who is paid to look at your watch and tell you what time it is.” In truth, consultants do have the same information available to them as do their clients, but given their knowledge of clinical standards, unbiased position and experience in managing similar problems for other institutions, they can often be the key to reversing a department’s or operating room’s downward spiral.