Incentive, Competitiveness, Transparency
If most of anesthesiologists are supervising CRNAs, the anesthesiologists’ job is to increase the amount of the CRNAs’ billable time at the facility. Have the anesthesiologists do all the pre-ops, IVs in the pre-op area, and care in the PACU while the schedule is arranged to keep the CRNAs busy in the OR rooms (most of that time is billable) or have the the CRNAs provide continuous care from the pre-op area through the end of the case (also billable).
A CRNA who refuses to help while not in an OR room is adding insult to financial injury (expense with no revenue). The anesthesiologists’ job is to keep the cases flowing quickly, and should be his principle focus whenever a CRNA can take over his other chores prepping patients for surgery. A CRNA in a room, waiting on a surgeon, is netting income. A CRNA sitting in the lounge, waiting on a surgeon, is accruing loss. A CRNA sitting in the lounge while the anesthesiologist is starting an IV is taking time away from the supervision of the case flow.
Ideally, you should have a form of incentive for billable hours, plus monitoring to ensure the competition does not sabatoge workflow. Usually, several incentivized people working together to expedite the case load is better than one. One incentive scenario is for a percentage of the total billed hours of the day to be divided among the hours worked by the CRNAs. Extra compensation could be given for each case started. Worked correctly, this would encourage quick turnover of cases while discouraging competition between the CRNAs. The anesthesiologists’ roll would be to keep the cases flowing so the CRNAs could make as much money as possible. Does this sound familiar?
The problem then would be how to incentivize an individual anesthesiologist to maximize the billable hour case flow. I’ve seen major problems with this. With an even split of the income among anesthesiologist, I worked in a group in which the CRNAs had a difficult time getting an anesthesiologist to start a case and sign the chart. When the policy was quietly changed by some of the more senior anesthesiologists so that revenue was divided among those anesthesiologists with their names on the chart, there would be 4 or 5 anesthesiologists’ signatures on every chart, but still difficulty in getting an anesthesiologist to start and supervise the case. Some of the anesthesiologists assumed others would always take up the slack. The problem was in accruing supervision hours and cases to each individual anesthesiologist (not such a big problem with CRNAs) and lack of transparency. The next paycheck made this secret change in policy apparent to the rest of the anesthesiologists and the system fell apart. This simple minded — doomed to failure — attempt was foiled by transparency. There have been much more sophisticated ruses that have gone on for long periods of time until discovered. The take-home moral is that TRANSPARENCY is a powerful means of keeping groups working together and throughput and competitiveness up. Good data keeping and easy ways to interpret it (CHARTS AND GRAPHS) is a great help in creating transparency.