Part 1 – Collaborative Governance
This is the first of a two-part series addressing the issues facing hospital surgical services. Part 2 will focus on Becoming the Surgeons’ Operating Room of Choice.
Dynamic changes in healthcare have made hospital/physician alignment strategies a top priority for hospitals and a more approachable subject for physicians. These changes bring the opportunity to proactively seek alignment to better meet the challenges and opportunities now facing the physicians and the hospital. One of the most rewarding areas, albeit challenging, can be found in surgical services.
Perioperative performance has historically been the responsibility of nursing directors, who are faced with the daunting and overwhelming task of keeping up with a myriad of quality issues, staffing challenges, technology needs, and physician complaints. Although Operating Room (OR) Committees exist in many hospitals, the committees lack clear direction, and meetings are poorly attended. The meetings are frequently used as a forum for personal agendas or merely serve as a place where information is disseminated but rarely acted upon. This structure prevents the OR Committee and nursing leadership from implementing change and consistently enforcing guidelines. Nursing leaders, let alone the committee, rarely have the time, the discipline, or, in some instances, the training to improve or drive perioperative performance.
Administrators have long understood that perioperative services are the financial “engine” of their hospitals. Yet administration has shied away from making changes in perioperative services and, more specifically, the OR, for fear of driving away their “customers” (the surgeons). Despite efforts to appease surgeons, the former administrative habits of “giving the surgeon whatever s/he wants” still resulted in outmigration due to a highly competitive market for profitable surgical business lines and a proliferation of practice sites. (Please refer to the February 2008 ECG aricle, “Is Your Hospital’s Surgical Service Line In a State of Emergency?” for more information about strategies involving surgical service lines.)
Due to increasing costs and declining reimbursement, surgeons are once again seeking ways to maximize efficiencies and financial performance. The economic challenges provide hospital administrators with a prime opportunity to proactively make concerted efforts to align with their surgeons and anesthesiologists. Once aligned, the focus must be on key operational and strategic performance issues such as surgeon access, utilization, throughput, staffing, and the future direction of the perioperative services. Over the past several years, hospitals of various sizes, affiliations, and locations have been successfully establishing collaborative governance models committed to optimizing the performance of perioperative services. At the core of the model is an Executive Committee made up of physicians, nurses, and hospital leaders who, together, can dramatically improve not only the OR but also the hospital’s overall financial and operational performance. Similar to most challenges in healthcare, there is no easy path to alignment – it requires several key elements and a strong commitment. However, for those that have gone through the transformation, rarely, if ever, would any of the constituents go back to doing things “the old way.”
Five Key Elements to Successfully Establishing a Physician-Led Perioperative Governance Model
The five key elements outlined below are critical to establishing a successful physician-led perioperative governance model.
1. A greater understanding of the business needs, process flows, and strategic plan of each primary constituent.
Hospitals should first evaluate their current perioperative processes and performance benchmarks. As part of this evaluation, performance indicators should be analyzed, and considerable time should be spent with the multiple disciplines (surgeons, anesthesiologists, OR staff, hospital administration) to understand each constituent’s needs and strategic plan, as well as potential barriers to achieving the collective ideal vision for the OR. An effective evaluation process can also be an opportunity to begin to build consensus on how the various constituents can collectively move forward to achieve their goals. Once the evaluation is complete, the findings, along with a well defined plan, including timelines and steps for moving forward, should be shared with all constituents.
2. Choosing the appropriate governance model.
The following are fundamental perioperative governance model components and a general overview of the nature and responsibilities of these components. It is important to note that the governance model is more than just one committee; it also includes defining the roles of key positions outside of the primary governing body that will lead to the optimal operational, financial, and strategic performance of perioperative services. Components of a successful OR governance model include:
- Surgical Executive Committee (SEC). This is a hospital committee, separate from the medical staff, that functions as the governing body for perioperative services and focuses on operational and financial performance. Appointed by the hospital, membership of the SEC should be primarily physicians, with the greatest representation from surgeons.
- Medical Director(s) of the OR. The medical director(s) chairs the SEC and functions in an operational oversight role, working directly with the OR nursing director on a daily basis. Frequently, this role is filled by an anesthesiologist since they are consistently in the OR.
- Matrix Reporting Structure for the OR Nursing Director. The OR nursing director has significant quality responsibilities as well as significant fiscal responsibilities. Therefore, a dotted-line or matrix reporting structure to hospital nursing leadership (e.g., vice president of patient care services) and hospital operational leadership (e.g., vice president of operations) is essential.
- Perioperative Business Management Focus. A dedicated perioperative business management role should be established to optimize the department’s overall financial and operational performance.
3. Administration’s commitment to the process.
Introducing a new model of collaborative perioperative operational and strategic leadership – particularly one in which the surgeons are the largest constituent – may be unnerving to some administrators. However, a firm commitment from the administrative team to the new model is essential. Administration must be willing to empower this collaborative group to make decisions and ensure that the group is supported with information – not only data, but also an understanding of the hospital’s overall strategic goals, general operating policies, and even financial constraints. Administration must be present at SEC meetings and be willing to refer issues to the committee rather than solving problems unilaterally.
4. The right agenda.
Although it may seem basic, early initiatives of the new committee should be setting committee ground rules (meeting frequency, quorum definitions, open versus closed membership, communication methods), agreeing to start and finish meetings on time, and establishing a dashboard of key performance metrics. Similar to the OR, if a lack of preparedness and organization becomes apparent, participants will begin to arrive late and will grow increasingly indifferent. Going forward, the overriding agenda of the committee should be to optimize customer (surgeon) satisfaction by monitoring OR performance via the dashboard and making required performance adjustments. The committee may need to be reminded of their agenda to remain on task.
5. Effective implementation of the committee.
Successful implementation starts with seeking out feedback on current processes from surgeons, anesthesia, the hospital, and nurses – whether through a full perioperative services evaluation or through a series of meetings with the various constituents. Effective implementation also involves selection of the appropriate committee members. Committee members need to be a diverse group, but they should also be individuals who are clinically well respected and who would be perceived by their peers as being fair versus advancing their own personal agendas.
Additionally, because of the deep-rooted OR cultures, highly contentious topics such as surgeon access and block schedules, and environments of apathy (whether regarding perioperative processes or just meeting attendance), hospitals have found it highly effective to bring in a knowledgeable outside group to facilitate implementation and minimize the political capital “burn” often experienced by hospital administration when trying to implement changes that directly impact (beneficially or adversely) the physicians’ routines. Having an experienced perioperative change agent guide the hospital through the process has frequently enabled greater buy-in, a more rapid improvement process, and greater likelihood of sustained results.
Conclusion
Implementing a collaborative governance model in the OR brings together the very diverse agendas of all of the constituents and creates a safer setting for the patients, a more efficient work environment for surgeons, and a more productive source of revenue for the hospital.
Published March 31, 2010