Douglas H. Irvine, MD, PhD, is an anesthesiologist at East Portland Surgical Center in Portland, Ore.
Q: Many spine-focused ASCs struggle to recruit well-regarded anesthesiologists. How can ASCs make themselves attractive to such practitioners?
Dr. Douglas H. Irvine: With strict attention to high standards of care, a sufficient caseload, a favorable work environment and a consistent schedule, ASCs can successfully recruit well-established anesthesiologists from the local medical community. But it's just as important for the surgeons to understand the anesthesiologist's commitment to service and clinical quality before a working relationship is established.
Speaking for myself, the experience of being personally recruited by my surgical colleagues to provide anesthesia at their ASC was a great vote of confidence in the anesthesia care I have provided to their patients over several proceeding years. It is good to be consulted professionally, to be heard and to practice collaboratively with my colleagues. The key is for anesthesiologists to feel fully part of the team, not simply as outside service providers, which is the case at many surgery centers, I believe.
Q: Strong relationships between anesthesiologists & surgeons are a hallmark of successful ASCs. Can you comment on the level of partnership at EPSC?
DI: Trust, confidence and mutual respect are the keys. Seeing the direct influence of my professional standards in enhancing overall quality of care and professionalism within the entire ASC and seeing that high quality of care attract more surgeons and patients to the ASC is a gratifying addition to my anesthesia practice. The sense of commitment and partnership extends across the entire team and our whole operation — all the surgeons, the nurses, the office staff and our business partners — share a goal to deliver outstanding care and a great patient experience.
Q: When your center added spine cases, what were the main challenges in terms of anesthesia?
DI: The challenge for anesthesia in adding outpatient spine surgery to an existing ASC is the same as the challenge for the surgeons — namely, patient selection. In addition to screening for co-existing diseases, many spine patients, especially those with failed back syndrome, are on chronic narcotic therapy.
With many orthopedic procedures, such as shoulder and knee reconstructions, specialized techniques including peripheral nerve blocks and catheters can minimize pain and discomfort and permit more extensive procedures to be performed safely and economically as outpatient procedures.
Unfortunately, the nature of spine surgery precludes the use of many of these specialized techniques. For spine surgery, we must rely on individualized titration of intravenous, intramuscular and oral narcotics coupled with additional prescription adjuncts to promote safety and comfort in the PACU and at home after patient discharge from the ASC.
Q: Can you describe the scope of the advance planning and training effort?
DI: In advance planning we must pay particular attention to screening out patients with coexisting disease that may require hospitalization for postoperative management or screening out patients that may require intravenous narcotic therapy for pain management after surgery. It is best to start with conservative selection criteria, and gradually build experience and protocols that are highly reliable and successful. Inclusion criteria can be expanded as surgeons, anesthesiologists and staff demonstrate growing proficiency. Of course, no one can reliably predict the future, and any unplanned admissions always should be used as learning opportunities to refine guidelines for future patient selection.
We also completed a fair amount of education and communication on the clinical side before taking our first spine case to ensure everyone — including schedulers and staff at the surgeons' practices — were comfortable and confident handling spine cases in an outpatient setting. In particular, the lower sedation levels dictated by shorter recovery times were an adjustment for some anesthesiologists and nurses.
Q: What are the benefits for anesthesiologists in working at an ASC?
DI: The surgeons get proven anesthesia services for their patients and the anesthesiologists get a reliable caseload with more predictable work hours than at an acute care center. Both surgeons and anesthesiologists also gain the potential for greater autonomy and professional satisfaction. In that sense, the benefits for anesthesiologists are similar to those of surgeon-owners.
And of course, the patients receive many of the benefits as well. It is good to know that my patients are getting the best surgical and anesthesia care possible at the most affordable price. It is good to see that the value that this provides our patients and the healthcare system as a whole is sustainable. It is good to contribute to a long-term solution to providing affordable, high-quality healthcare.
Q: Speaking of patients, what are the most important factors in delivering great patient experiences at your ASC?
DI: I have been asked to duplicate our success at our freestanding ASC within a large acute care hospital where I have worked extensively. But often I have had to break the bad news to these large facilities that this type of request completely misses much of the point. The very nature of being a large and often impersonal facility makes it difficult to duplicate the personal service provided at a smaller, specialized, free-standing surgery center.
Every detail and touchpoint of the entire patient experience must be considered, and it's quite a long list: ease of calling on the telephone and speaking with a friendly and helpful voice, ease of scheduling, ease of locating and driving to the ASC (location, location, location), ease of parking, length of wait for any phase of the patient's or family's experience, privacy and welcomed access to support from family and friends, appearance and cleanliness of facility and equipment, professional appearance and demeanor of staff, maximizing safety and comfort, preventing nausea and vomiting, minimizing preoperative and postoperative fasting periods, keeping patients warm, preserving modesty, providing clear postoperative instructions in verbal and written form, and facilitating the filling of postoperative prescriptions. Every detail must be examined from the perspective of a patient who has entrusted us with their health and wellbeing. That attention to detail is what will allow surgery centers like ours to fulfill their potential.
Thank you to Blue Chip Surgical Center Partners for arranging this article. From 2005 to 2009, Blue Chip served as the business partner for the profitable East Portland Surgical Center with Drs. Joseph Stapleton, Irivne and other surgeon-owners. You can learn more about Blue Chip and read more surgeon stories at www.bluechipsurgical.com/insights.
Q: Many spine-focused ASCs struggle to recruit well-regarded anesthesiologists. How can ASCs make themselves attractive to such practitioners?
Dr. Douglas H. Irvine: With strict attention to high standards of care, a sufficient caseload, a favorable work environment and a consistent schedule, ASCs can successfully recruit well-established anesthesiologists from the local medical community. But it's just as important for the surgeons to understand the anesthesiologist's commitment to service and clinical quality before a working relationship is established.
Speaking for myself, the experience of being personally recruited by my surgical colleagues to provide anesthesia at their ASC was a great vote of confidence in the anesthesia care I have provided to their patients over several proceeding years. It is good to be consulted professionally, to be heard and to practice collaboratively with my colleagues. The key is for anesthesiologists to feel fully part of the team, not simply as outside service providers, which is the case at many surgery centers, I believe.
Q: Strong relationships between anesthesiologists & surgeons are a hallmark of successful ASCs. Can you comment on the level of partnership at EPSC?
DI: Trust, confidence and mutual respect are the keys. Seeing the direct influence of my professional standards in enhancing overall quality of care and professionalism within the entire ASC and seeing that high quality of care attract more surgeons and patients to the ASC is a gratifying addition to my anesthesia practice. The sense of commitment and partnership extends across the entire team and our whole operation — all the surgeons, the nurses, the office staff and our business partners — share a goal to deliver outstanding care and a great patient experience.
Q: When your center added spine cases, what were the main challenges in terms of anesthesia?
DI: The challenge for anesthesia in adding outpatient spine surgery to an existing ASC is the same as the challenge for the surgeons — namely, patient selection. In addition to screening for co-existing diseases, many spine patients, especially those with failed back syndrome, are on chronic narcotic therapy.
With many orthopedic procedures, such as shoulder and knee reconstructions, specialized techniques including peripheral nerve blocks and catheters can minimize pain and discomfort and permit more extensive procedures to be performed safely and economically as outpatient procedures.
Unfortunately, the nature of spine surgery precludes the use of many of these specialized techniques. For spine surgery, we must rely on individualized titration of intravenous, intramuscular and oral narcotics coupled with additional prescription adjuncts to promote safety and comfort in the PACU and at home after patient discharge from the ASC.
Q: Can you describe the scope of the advance planning and training effort?
DI: In advance planning we must pay particular attention to screening out patients with coexisting disease that may require hospitalization for postoperative management or screening out patients that may require intravenous narcotic therapy for pain management after surgery. It is best to start with conservative selection criteria, and gradually build experience and protocols that are highly reliable and successful. Inclusion criteria can be expanded as surgeons, anesthesiologists and staff demonstrate growing proficiency. Of course, no one can reliably predict the future, and any unplanned admissions always should be used as learning opportunities to refine guidelines for future patient selection.
We also completed a fair amount of education and communication on the clinical side before taking our first spine case to ensure everyone — including schedulers and staff at the surgeons' practices — were comfortable and confident handling spine cases in an outpatient setting. In particular, the lower sedation levels dictated by shorter recovery times were an adjustment for some anesthesiologists and nurses.
Q: What are the benefits for anesthesiologists in working at an ASC?
DI: The surgeons get proven anesthesia services for their patients and the anesthesiologists get a reliable caseload with more predictable work hours than at an acute care center. Both surgeons and anesthesiologists also gain the potential for greater autonomy and professional satisfaction. In that sense, the benefits for anesthesiologists are similar to those of surgeon-owners.
And of course, the patients receive many of the benefits as well. It is good to know that my patients are getting the best surgical and anesthesia care possible at the most affordable price. It is good to see that the value that this provides our patients and the healthcare system as a whole is sustainable. It is good to contribute to a long-term solution to providing affordable, high-quality healthcare.
Q: Speaking of patients, what are the most important factors in delivering great patient experiences at your ASC?
DI: I have been asked to duplicate our success at our freestanding ASC within a large acute care hospital where I have worked extensively. But often I have had to break the bad news to these large facilities that this type of request completely misses much of the point. The very nature of being a large and often impersonal facility makes it difficult to duplicate the personal service provided at a smaller, specialized, free-standing surgery center.
Every detail and touchpoint of the entire patient experience must be considered, and it's quite a long list: ease of calling on the telephone and speaking with a friendly and helpful voice, ease of scheduling, ease of locating and driving to the ASC (location, location, location), ease of parking, length of wait for any phase of the patient's or family's experience, privacy and welcomed access to support from family and friends, appearance and cleanliness of facility and equipment, professional appearance and demeanor of staff, maximizing safety and comfort, preventing nausea and vomiting, minimizing preoperative and postoperative fasting periods, keeping patients warm, preserving modesty, providing clear postoperative instructions in verbal and written form, and facilitating the filling of postoperative prescriptions. Every detail must be examined from the perspective of a patient who has entrusted us with their health and wellbeing. That attention to detail is what will allow surgery centers like ours to fulfill their potential.
Thank you to Blue Chip Surgical Center Partners for arranging this article. From 2005 to 2009, Blue Chip served as the business partner for the profitable East Portland Surgical Center with Drs. Joseph Stapleton, Irivne and other surgeon-owners. You can learn more about Blue Chip and read more surgeon stories at www.bluechipsurgical.com/insights.