The following Value-Based Enterprise (VBE) compensation model examples were developed by the Center for Anesthesia and Perioperative Economics (CAPE). The examples are based on real-life physician experiences and are intended to demonstrate how anesthesiologists and facility leaders might partner on mutually beneficial goals and outcomes. The examples cite related performance metric(s) that could be incorporated into a value-based enterprise (VBE) service contract. Readers should also consult the companion dashboards to understand how clinical actions and workflow changes can be included as performance metrics in their contracts.
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Patient Experience
Performance Metric: OAH-CAHPS Scores
At a meeting with hospital leadership, the Chief Medical Officer (CMO) raised concerns about anesthesiology Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS-CAHPS) scores. She was concerned that the group’s top box scores in the Hospital-based Outpatient Department were consistently lower than national average on both questions:
- Did your anesthesia team explain the process of giving anesthesia in a way that was easy to understand?
- Did your anesthesia team explain the possible side effects of anesthesia in a way that was easy to understand?
She also mentioned that a few surgeons had received feedback from patients that their interactions with the anesthesiologists and members of the Anesthesia Care Team seemed rushed and, at times, confusing. The Chair of Anesthesiology reviewed the data and agreed with the CMO that the scores were low and could be improved. He promised to get back to her with an assessment and plan at their next monthly meeting.
Key Stakeholders and Team Formation
The Chair of Anesthesia brainstormed with his leadership team. He quietly observed how his clinicians interacted with patients. He also solicited input from surgeons, proceduralists, perioperative staff, and his own clinicians.
Assessment and Root Cause Analysis
The Chair of Anesthesiology identified the following issues:
- Training: Most of the anesthesiologists had never received any training in communication skills.
- Lack of Prioritization: Patient experience was hardly discussed and there were no staff accountable for ensuring positive patient experience.
- Lack of Feedback: Anesthesiologists were not aware of their low OAS-CAHPS scores and had never received individualized feedback on how to improve patient experience.
Intervention
The Chair of Anesthesia and leadership team developed a plan to improve the OAS-CAHPS scores.
- He discussed the importance of patient experience with both his leadership team and his department. He stated that this initiative was a high priority for the team.
- He charged a staff member with creating a department presentation about patient experience and anesthesiology: what is it, why is it important, and how clinicians can develop skills. He appointed—and compensated—this clinician in a new role: Director of Patient Experience.
- He partnered with the hospital to enlist a nurse navigator to shadow the clinicians. The nurse navigator created a standard template that was used to record her observations. She then provided individual feedback to the clinicians, identifying areas for improvement.
- He prioritized patient experience as a recurring agenda item at department meetings. He took time to recognize clinicians who received positive comments.
- He explained the initiative at surgery department meetings, ensuring that no surgeons complained about ‘extra time being wasted.’
- He made efforts to ensure buy-in. He encouraged questions as well as open discussion and explained why improving patient experience was important. When necessary, he was clear about reprioritizing other focus areas to ensure that patient experience remained a priority for everyone.
Results
Within four months, the departmental OAS-CAHPS scores had increased to just above the national benchmark. The CMO thanked the group for their partnership and effort The clinicians were appreciative of the training and knowledge they had received.
Sustained Results
Training was periodically repeated and patient experience remained a priority. At 24-month follow-up, OAS-CAHPS scores demonstrated sustained improvement.
Obstetric Anesthesiology Coverage
Performance Metric: Labor Epidural Response Time
A Chair of Anesthesiology at a large medical center was asked by the Chief Medical Officer to lead a multidisciplinary quality improvement initiative to reduce the time from epidural request to placement in a busy labor and delivery (L&D) unit. Through systematic process analysis, stakeholder engagement, and implementation of evidence-based interventions, the team achieved sustained improvement while enhancing patient satisfaction and safety outcomes.
Key Stakeholders and Team Formation
The Chair of Anesthesiology recognized that addressing this challenge would require more than simply adding personnel—it demanded a systematic approach to understanding and redesigning workflows. She assembled a core team including the Chief of Obstetric Anesthesiology, Obstetrics and Gynecology (OB/GYN) Department Chair, L&D Unit Nurse Manager, Pharmacy Director, and a Quality Management Analyst.
Assessment and Root Cause Analysis
The team identified multiple contributing factors:
- Communication Delays: Epidural requests were communicated through multiple channels (e.g. pager, phone call, or in-person) with no standardized process. Nurses often waited for anesthesia to call back before preparing patients.
- Patient Preparation Variability: No standard protocol existed for pre-epidural preparation. IV access, consent forms, fluid bolus administration, and positioning varied widely among nurses.
- Anesthesia Provider Availability: Anesthesia providers were frequently managing emergencies, cases in the main operating room (OR), or other floor requests with minimal coordination.
- Geographic Challenges: The L&D unit and main OR were located on different floors, contributing to communication barriers between call teams.
- Documentation and Medication Management: Paper documentation and charting created delays and occasionally required repeat patient interactions without yielding added value.
Intervention
Based on the root cause analysis, the Chair of Anesthesiology worked with the team to develop a multifaceted intervention, securing buy-in through individual meetings and joint planning sessions.
- She restructured anesthesia staffing to enhance coverage during peak and off-peak hours. She hired additional staff and developed clear escalation protocols for when multiple concurrent requests occurred.
- She implemented a new epidural workflow integrated with the hospital's communication platform. Nurses entered epidural requests directly into the electronic system. Automatic notifications were sent to dedicated anesthesia pager and real-time dashboards showed pending requests and estimated wait times.
- She developed a standardized nurse-driven protocol that would be initiated immediately upon patient request and before anesthesia arrival. This included verifying adequate IV access (18-gauge or larger) prior to epidural request, administering crystalloid fluid bolus (unless contraindicated), as well as positioning the patient and preparing the room.
- She implemented team-building initiatives because she recognized that process changes alone wouldn't succeed without cultural transformation, She implemented joint monthly meetings between anesthesiology and OB/GYN teams, interdisciplinary education sessions, a recognition program for teams achieving rapid response times, and transparent data sharing with collaborative problem-solving.
Results
- Improvement: 34% reduction in epidural wait times.
- Target achievement: 87% of epidurals placed within 30 minutes.
- Patient satisfaction scores improved from 67th to 92nd percentile nationally.
- Maternal pain scores during epidural wait time decreased by 32%.
- Nursing satisfaction with anesthesia collaboration increased from 64% to 91%.
- Unplanned general anesthesia for urgent cesarean sections decreased by 18%.
Sustained Results
At a 24-month follow-up, all key performance indicators demonstrated sustained improvement. The Chair of Anesthesiology ensured that there was continued education about the new workflows.
Coordinating OR and NORA Scheduling
Performance Metrics: Same Day Case Cancellations, First Case On-Time Starts
A Chair of Anesthesiology at a large medical center was asked by the Chief Operating Officer to lead a multidisciplinary performance improvement initiative to increase access to services requesting non-operating room (OR) anesthesia.
Key Stakeholders and Team Formation
The Chair of Anesthesiology recognized that addressing this challenge would require more than simply adding anesthetizing locations—it demanded a systematic approach to understanding global non-operating room anesthetizing location (NORA) demand. He assembled a core team including the Vice Chair of Anesthesiology, VP of Perioperative Services, Associate Chief Nursing Officer, and a Business Operations Analyst.
Assessment and Root Cause Analysis
The team identified multiple opportunities:
- Case Booking Delays: There was no standard process for booking cases and many were added after the OR schedule closed, making it challenging for anesthesiology OR coordinators to staff additional locations.
- Patient Preparation Variability: No standard protocol existed for clearing patients for procedures or coordinating additional interventions (e.g. dialysis, radiological studies).
- Anesthesia Provider Support: Anesthesia providers were often caring for patients in remote locations with variable support from nurses, technicians and proceduralists.
- Scheduling and Operational Inefficiencies: First case on start (FCOTS) rates were significantly below OR FCOTS rates and order in which procedures were performed lengthened turnover times.
Intervention
Based on root cause analysis, the Chair of Anesthesiology worked with the team to develop a phased intervention, securing buy-in through individual meetings and joint planning sessions.
Phase 1: Operations
- The Chair of Anesthesiology developed a streamlined, electronic process for communicating and booking cases with input from clinicians and division administrators. Local clinical leadership reviewed and adjusted daily order of procedures prior to publication to optimize patient flow.
- The Chair of Anesthesiology developed a checklist to aid nurse handoffs and ensure that patients were cleared to undergo procedures under anesthesia.
Phase 2: Capacity-building
- The Chair of Anesthesiology developed a guide for nurses and technicians to increase their comfort in assisting anesthesia clinicians during key portions of anesthesia and during emergencies.
- The Chair of Anesthesiology mapped distance between NORA locations to optimize call and late shift coverage.
Results
- Case growth: 20% increase in case volume during first 6 months following implementation of phase I.
- Case cancellations: 40% decrease in same day case cancellations.
- FCOTS: Improvement from 30% FCOTS to 50% FCOTS (no grace period).
- TOT: 10% decrease in turn over time.
- Redesigned call/late assignments: Increased support of anesthesia staff by NORA technicians and nurses allowed OR coordinators to safely and efficiently assign coverage locations after peak hours.
Sustained Results
At 24-month follow-up, all KPIs demonstrated sustained improvement. The Chair of Anesthesiology ensured that there was continued education about the new workflows.
Operating Room (OR) Utilization
Performance Metrics: Prime Time OR Utilization, Surgeon Satisfaction, Compliance with Daily Huddle Meeting
At his monthly meeting with hospital leadership, the Anesthesiology Chief relayed ongoing recruitment challenges that necessitated ongoing use of locums tenens clinicians. He also noted that his employed CRNA compensation was lower than market for the area, and that there was a risk some would move to the competitor across town. He suggested to hospital leadership that they jointly should review operating and procedure room utilization and explore opportunities to reassess the number of sites of service, better matching demand with coverage.
Key Stakeholders and Team Formation
With hospital leadership’s support, the Chief convened a workgroup including surgical, nursing, IT, and anesthesiology leadership. At the project’s start, anesthesiology coverage consisted of a total of eighteen sites: twelve operating rooms (OR), two endoscopy rooms, two urology rooms, one electrophysiology (EP) room, and a labor and delivery (L&D) room.
Assessment and Root Cause Analysis
- The group agreed upon a standard definition of utilization: (Total OR Time Used/Total OR Time Available) X 100%. Analysis of primetime (7am-3pm) OR utilization revealed operating room and urology room utilization of 45-50%, well below the ideal target of 75%.
- Lack of Communication: There was no regular communication between OR, nursing, and anesthesiology leadership throughout the day. Schedule changes often were made by one person or group without collaborating with the others.
Based upon this analysis, the workgroup developed the following recommendations for hospital leadership:
- Reduce the number of operating rooms from twelve to ten (7am-3pm). Data strongly suggested that this change could be made without impacting surgical access.
- Change urology coverage from two rooms (7am-3pm) to one room (7am-7pm)
- Require a daily huddle at the start of each workday involving the OR Nurse Manager, Anesthesiologist Board Runner, Lead Anesthetist, L&D Nurse Manager, and External Site (urology, endoscopy, EP) Nurse Manager. This huddle would ensure each site leader was aware of existing and potential constraints on room coverage and that the group proactively would collaborate to address potential coverage issues.
The workgroup presented its finding to hospital leadership and with its support, delivered the plan to their own groups and key surgical leaders. The group set a date for implementing the new coverage, working with individual surgeons and their schedulers as needed to reallocate block time. The Anesthesiology Chief solicited surgeon feedback before and during the implementation.
Results
Six months following plan implementation, hospital leadership and the Anesthesiology Chief identified the following changes:
- OR utilization increased to 64%, with no change in access.
- Urology utilization increased to 70%, with no change in access.
- The Anesthesiology Chief was able to reduce staffing costs by eliminating locums CRNAs coverage. With the resulting annual cost savings of $680,000, he was able to provide compensation increases to his employed CRNAs totaling $350,000, retaining all of his employed CRNAS while resulting in a net savings of $330,000.
- OR and anesthesiology leadership reported improved collaboration and communication since implementation of the daily huddle.
- The annual Surgeon Satisfaction survey increased from 3.5/5 to 4.3/5 (3=average, 4=good, 5=excellent).
- OR, procedural site, and anesthesiology leadership established a monthly meeting to jointly review data, processes, and future growth needs. They set a goal for the following year to establish a formal OR Utilization Committee that will include key surgeon leaders as well.
Sustained Results
At 24-month follow-up, all retention and utilization metrics demonstrated sustained improvement. The formalized OR Utilization Committee continues to monitor all relevant metrics.
Peripheral Nerve Blocks in Ambulatory Surgical Centers
Performance Metrics: Pain Scores, Block Placement Times
At an Ambulatory Surgical Center (ASC) Board meeting, a high-volume orthopedic surgeon asked how the anesthesiology practice ensured its clinicians were well trained in placement of peripheral nerve blocks. This surgeon was relatively new to the center and routinely performed a high volume of arthroscopic surgery procedures. He stated that since his arrival, he has observed some variability in both placement (e.g. time, ease) and success of peripheral nerve blocks. In his anecdotal view, the blocks too often did not provide pain relief to his patients, requiring supplemental narcotics before and after discharge.
Key Stakeholders and Team Formation
The Director of Anesthesia Services (DAS) stated he would investigate the concerns and return with an update in one month, at the next ASC Board meeting. With the assistance of the ASC Manager, the DAS reviewed the cases for patients who had received a peripheral nerve block.
Assessment and Root Cause Analysis
He learned that the majority of the anesthesiologists placed blocks quickly and that postoperative patient pain scores were generally low. Yet for two of his anesthesiologists, block placement times and patient pain scores varied greatly.
- Methods: One anesthesiologist rarely used ultrasound (U/S) and his block medication doses varied as well.
- Scheduling: The other anesthesiologist routinely did not schedule his workday in a way that would allow for timely block placements.
- Lack of Feedback: Both anesthesiologists were unaware they were falling short on metrics related to peripheral nerve blocks.
Intervention
The DAS then met individually with each of the clinicians. He explained the concerns and information learned. He showed each the data around block placement times and patient pain scores. While he acknowledged that both were excellent anesthesiologists, he also stated that their performance on this key clinical skill needed to improve. Once he had their buy-in, he worked with them to develop an improvement plan.
- Each anesthesiologist would be proctored for twenty-five block placements by a colleague.
- Each anesthesiologist would schedule their workflow to ensure a minimum of fifteen minutes time for block placement, before scheduled surgery start times.
- The DAS would continue to track block placement times and patient pain scores with each anesthesiologist as they went through this process.
Results
Within two months of plan implementation, both anesthesiologists had improved on every metric. The orthopedic surgeon and ASC leadership complimented the anesthesiology group for its leadership and dedication to patient care.
Sustained Results
At 24-month follow-up, block placement time and patient pain scores demonstrated sustained improvement. The DAS continued to track patient pain scores and blocks patient times, and he developed improvement plans for any anesthesiologists that were falling short.
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