This issue of the NEWSLETTER addresses non-operating room anesthesia (NORA) and all the challenges and rewards of this rapidly growing aspect of your specialty. As I thought about this special issue, two experiences in my early career reminded me of the potential of this trend for our members.
First, during my tenure at the Clinical Laboratory Management Association (CLMA) in the early to mid-1990s, many of the association’s 5,000 members were in a bit of a crisis. By way of background, CLMA represented lab managers from multiple backgrounds, including pathology, clinical chemistry and medical technology. Clinical laboratories were being transformed – moving from big, centralized locations to smaller, decentralized areas, including the emergency department and doctors’ offices. Many clinical laboratory managers and their staffs were worried about losing their authority and leadership roles. Alternatively, others saw this as an opportunity to expand the reach of the laboratory and to play an ever more integral role in the health system.
Ultimately, this transformation provided great opportunities for many laboratory managers. By leveraging their leadership roles through all aspects of the delivery system, they were able to enhance their profile by bringing their services closer to patients. Laboratory executives played key roles in the regulatory and accreditation processes through the Clinical Laboratory Improvement Amendments, College of American Pathologists and the Commission on Office Laboratory Accreditation. These actions helped ensure a foundation for safe practices and an important role for laboratory professionals.
Plastic surgery is another case where, in the 1980s and ’90s, the vast majority of procedures rapidly moved outside the hospital setting to ambulatory surgery centers and doctor’s offices. In the beginning, the office-based settings were largely unregulated and there were significant reports of safety issues and poor outcomes. The Society worked very closely with the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for the Accreditation of Ambulatory Surgery Facilities and state governments to provide for standards of care.
This experience, coupled from what I am learning at ASA, is that the transformation overtaking health care will continue to push the locus of care closer to the patient and non-traditional settings. Anesthesiology is a hospital-based specialty, but today, hospitals have changed, encompassing doctors’ offices, satellite locations and often sophisticated information technology that links doctors and patients across this network. In this new world, what is the hospital? And if the locus of patient care is shifting, how will it affect the role of the physician anesthesiologist, not only today, but in the next generation?
A recent article in the Harvard Business Review, “The Strategy That Will Fix Health Care” (October 2013) by Michael Porter and Thomas Lee, speaks to several characteristics of the emerging health system. Among the observations made is that less complex and routine procedures should be shifted out of hospitals and into satellite facilities. According to the authors, senior management at MD Anderson estimate that around 50 percent of care still performed in hospitals could move to off-site locations, offering huge value to patients and facilities.
Of particular concern for us is that often medical personnel untrained in anesthesia are delivering sedation and putting safety at risk. ASA, through its House of Delegates and Board of Directors, has seen this evolution and has prepared to equip the specialty to provide leadership in an age of decentralized care. There are several ways that ASA can help support this transformation. Last year, ASA’s House of Delegates approved creation of a deep sedation training program for non-anesthesiologist physicians, and development is well under way, with launch expected in late 2014. This initiative is an important step in addressing safety and quality, while reinforcing the “Director of Anesthesia Services” for all sedation procedures.
Secondly, the Anesthesia Quality Institute has recently published a set of sedation measures to help assist the Director of Anesthesia Service with their oversight responsibilities. Finally, we continue to work with CMS and accrediting organizations such as the Joint Commission and the AAAHC to promote anesthesiology oversight of sedation in NORA settings.
As the role of the anesthesiologist transforms through the Perioperative Surgical Home model to provide greater oversight to the pre-, peri- and post-procedural processes, there is no doubt that the trends described in this issue will be an opportunity. We know there is much to do ... and we are eager to learn from you how we can help.
Paul Pomerantz is ASA Chief Executive Officer.