Creating a Standardized Operating Room Management Curriculum for Anesthesia Trainees

Anesthesia education has evolved over the last decade in response to clinical and research advancements, more effective teaching methodologies, technological developments, and the demands of the healthcare market. The Accreditation Council for Graduate Medical Education (ACGME) oversees all anesthesia residency programs and periodically reviews each program before it is recredentialed. The American Board of Anesthesiologists (ABA) provides oversight of anesthesia training, the certification process, and the overall curriculum content required for core education and training components. The American Society of Anesthesiologists (ASA) has been instrumental in developing new educational content for both trainees and practicing physicians. It is at the forefront of developing new models of care and tools for physicians to succeed in their practices.

The ABA has incorporated some elements of operating room (OR) and practice management training to the required training competencies, but, to date, has not included a curriculum that addresses the components that trainees will need for a solid foundation in the organizational and business aspects of anesthesia.(1)

Historically, medical education curriculum development has followed a six-step approach (see sidebar).(2) Identifying the concept to address and the needs of the target group involves delving not only into what deficits exist (for instance, knowledge or performance deficits), but also what the practitioner, as a teacher, must do to address these gaps. Goals and objectives must be fully outlined and measurable so as to track learner performance and improvement in the subject matter; implementation strategies and timelines must be fully communicated with faculty to ensure consistencies in teaching. Once the curriculum is in place, trainee evaluation should occur at set intervals and any feedback used for curriculum improvements.

Although administrative principles include a wide range of topics from leadership to quality assurance, in this article we outline a framework for a dedicated curriculum that specifically addresses OR management and the roles of anesthesiologists within OR administration. Methods for implementation and assessment of progress are also suggested.

The Problem: A Changing Workforce

The ever-changing work environment in medicine has demanded that physicians adapt to new roles and responsibilities. Anesthesiologists, in addition to providing clinical care, are now faced with an increasing amount of nonclinical duties, including managing daily OR schedules and OR staff, participating in OR committees, and working with hospital administrators.

In addition, due to changing reimbursements and payments, there is a growing emphasis on increasing efficiency and profitability.(3,4) Achieving more with fewer or similar resources is now a strategic goal for both surgery centers and hospitals. Doing so requires leadership, coordination, and communication across several disciplines,(3) including surgery, anesthesia, nursing, and ancillary staffs, along with collaboration with members of hospital administration and patient care units. For instance, a lack of bed availability in the intensive care unit can potentially postpone any elective cases that might result in patients needing admission to that unit. These bottlenecks are among the myriad management issues that arise in the perioperative arena and must be taken into account when scheduling cases and determining surgeon block times.

Adapting to these changes and addressing these issues, however, is not just about achieving the highest volume of cases and creating the most cash flow. It is also about doing as much as possible, as safely as possible.(5,6) Although hospitals and surgery centers are businesses in their own right that are concerned about the bottom line, it is important to keep in mind that their “services” affect human life. In fact, the “assembly line” of the operating room involves evaluating medically complex patients, making the best, sometimes last-minute, decisions regarding their health, and managing their anesthetic care in a way that allows them to get through their surgery without any complications. Rushing this process, or cutting corners, can have potentially disastrous consequences. Therefore, changing or streamlining any part of the OR process requires that the individual, or team of people, making the decisions is already an integral part of the perioperative team.(1)

Basic anesthesia training already requires that anesthesiologists develop expertise in risk assessment and quality improvement. Mastery of these areas is a prerequisite for becoming effective leaders in the operating suite as well. As healthcare moves forward and perioperative care coordination becomes ever more important, anesthesiologists should be poised to make a lateral shift into the administrative realm.(4,7) While those who have been in practice for many years will have their experience to draw upon, those just graduating from residency will have significant knowledge gaps and be unprepared to adjust to these ongoing changes.

Many residents currently view OR management as simply “running the board.”

Although some anesthesia training programs across the United States have recognized this need for additional teaching, no standardized approach has yet been established. Many residents currently view OR management as simply “running the board.” They do not recognize that an effective OR manager must be responsible for a plethora of other management issues. Ideally, creating and implementing an administrative curriculum will increase a resident’s knowledge and understanding of OR management, and concomitantly provide practical management experience in operational processes.

The Solution: Upgrade the Residency Curriculum

Bridging the knowledge gap in OR management should occur in the same manner that other anesthesia specialties have utilized: prepared lectures, assigned readings, and practical experience in the form of a management rotation. Within this rotation, the overall specific goals and objectives should include providing excellent, safe patient care; developing communication and leadership skills; applying management frameworks to perioperative situations; and honing a systems-based approach across all disciplines. In addition, they should be able to view the OR, and the hospital, from a manager’s perspective, and develop a fiduciary understanding of the resources involved in perioperative processes.

Table 1 shows a sample of curriculum topics that should be addressed. There are several focus areas, including basic OR management principles (e.g., OR efficiency, OR block allocations, staff scheduling); human resource issues surrounding the management of human behavior; maintenance of workplace morale and ways to incentivize physicians and staff; the advantages and limitations of information technology, especially as it pertains to data gathering and analysis; and legal considerations (e.g., contract negotiations, liability insurance), particularly important for graduating residents.

Other perioperative topics include post-anesthesia care unit (PACU) staffing issues and the reasons surrounding delays, and the importance and management of preoperative clinics. Off-site anesthesia delivery and management concerns, and the concept of the perioperative surgical home and development of care pathways also will be explored, especially as it pertains to the future of healthcare.

Along with lectures, residents would complete reading assignments, assist the anesthesia scheduler in managing the OR, manage the postanesthesia care unit, and participate in quality assurance/quality improvement committees. It is also vital to provide some exercises on the practical application of management concepts to daily workflow. For example, after reading a financial statement or accounting spreadsheet regarding staffing costs or revenue streams, residents should be able to identify areas that need improvement and make well-informed decisions and changes that would help alleviate any problems.

Management is not only about knowing the facts—it is also about being an effective leader and taking the time to build good relationships with colleagues and gain their trust. The myriad personalities inherent in any large department and the generational differences that may exist between those leading and those being led can create difficulties, especially for those physicians who have just finished training. Appreciating these issues, developing a high level of self-awareness, and learning to approach any potential interaction in a diplomatic and professional manner can make it easier for a new graduate to navigate relationships as he or she enters the workforce.

The Strategy: Gather Your Resources

Many programs may find it difficult to institute a new OR management rotation in a tightly packed curriculum. For instance, one approach could involve a one-month experience during each of the three years of training. However, taking residents out of the OR completely for a four-week rotation on a yearly basis may create conflicts with ensuring case numbers and other required case exposure. Another option might be a rotation that is a longitudinal experience integrated into the three-year residency. Here, residents would need to demonstrate the ability to handle increasing levels of responsibility by the time they enter their senior years of training. However, integration into other training experiences may be difficult given a multitude of other responsibilities trainees have during any particular month.

As a compromise, we suggest a four-week general OR/management rotation. In this model, during each week two or three days are dedicated to maintaining OR time, and the other two or three days are dedicated to the management experience. Days not spent in the OR would be filled with lectures, participation in OR committees, attendance at departmental operational or quality improvement meetings, assistance with tactical or operational OR scheduling, and management of the preoperative or PACU units. This time could also be used to work on personal, resident-driven OR management projects. More senior-level rotations may involve taking on management roles during subspecialty rotations, such as managing the labor and delivery floor. Again, there should be dedicated nonclinical, administrative time each week. Lectures and reading material would be tailored to the specific rotation and its management issues.

Teaching residents these concepts can be done in a number of ways. A conventional approach would be to have a dedicated lecture series,(1) using the concepts outlined in Table 1. In addition, faculty could organize a corresponding journal club that explores different management articles. Similarly, online learning modules focused on basic OR management concepts, accounting and finance topics, and an overview of hospital operations and IT could be included as part of the didactic series.(1,8) Resources for lecture materials, curriculum development, and faculty development in the topics required can be found online using websites related to the field or topic of interest.(2) In this case, for instance, the websites for the ABA, the American College of Healthcare Executives, and Harvard Business Review are all potential sources for management articles, cases studies and lecture topics. A more novel approach would include creating a simulation lab session, wherein different leadership skills are tested and then discussed afterwards.

One-on-one learning should also occur between the resident and the anesthesiologist-in-charge while “running the board” and overseeing the day-to-day activities of the operating room. Faculty members should develop a management framework whereby they arrive at their tactical and operational decisions. Additionally, various approaches to medical education have been explored in the past that could be utilized in the one-on-one setting. Grasha(9) put forth alternative teaching learning styles. For instance, teaching as a facilitator involves formulating various questions for the learner and exploring the merits of different answers/options; a delegator encourages learner responsibility of the topic and autonomous learning.(10) Evaluating resident learning styles, and empowering individual residents to create their own learning objectives,(11) can help facilitate teaching as well. For example, some trainees may prefer independent learning, whereas others may be drawn to group projects and collaborative efforts.

Standards and benchmarks for OR management knowledge and skills should be established using the six core ACGME competencies(1,12) and a set of milestones to guide assessment of learner progress.(13,14) Faculty members and program directors should use these guidelines when assessing resident knowledge and understanding. These assessments can be done in the form of pre- and post-tests using both multiple choice and essay questions. Alternatively, specific assignments to test decision-making processes can be utilized. As previously mentioned, one assignment may ask the resident to review an accounting statement, identify any problems, and devise a solution. Online resources are another option for learning and assessment. For example, the National Patient Safety Foundation provides certification in patient safety. Table 2 summarizes implementation and assessment strategies.

The implementation of an OR management rotation is not without financial and structural barriers. For instance, taking a resident out of the OR for a couple of days per week will result in less staffing capacity and a tighter daily schedule. Unfortunately, some attending anesthesiologists may perceive this reassignment as an imposed workday or a loss of administrative/academic time. In addition, lectures have to be staffed, and experienced individuals must be willing to serve as mentors for residents as they work on their assignments and projects. In short, cooperation and support is required from the whole department and the hospital. In fact, integration of an OR management rotation requires a multidisciplinary effort, with collaboration from nurses and surgeons as well. If surgeons and nurses are aware that a resident manager exists, then they will be more likely to use that person as a resource when addressing daily OR scheduling issues. This not only gives the resident a better work experience, but also can provide the perioperative staff with a different management perspective.

This nonclinical rotation should be treated like any other educational rotation.

Above all, it is imperative that residents are not seen as just another “pair of hands” to help start cases, place IVs, give breaks, or do preoperative assessments. Although these tasks are important to maintain OR workflow and should always be part of the purview of an effective OR manager, the primary role of the resident should be of a manager, and this should be taken seriously by both the attending staff and other residents. This nonclinical rotation should be treated like any other educational rotation.

The Result: A New Gene ration of Physician Managers

Imagine a world where doctors manage doctors, where physicians make medical decisions based not only on the financial bottom line, but also on the impact on patient care. Most residents have no interest in participating in the business aspects of medicine. Similarly, most residents also do not specialize in cardiac, obstetrical, pediatric or neurosurgical anesthesia. However, all of them are exposed to these areas of anesthetic practice so that they have a broad-based clinical understanding of these critical subspecialties. Likewise, most anesthesiologists will not be heavily involved in the management of their operating suites. However, they should be able to communicate intelligently and develop rudimentary tactical and operational plans with their colleagues and hospital administrators.(15)

Anesthesiologists are indoctrinated in the cultural and operational aspects of the perioperative services from the first day of residency. Anesthesiologists learn to work collaboratively with nurses, surgeons, and anesthesia healthcare providers in an intimate, intensive environment. The reality of medicine today demands that all anesthesiologists have a basic toolkit of managerial information. If we do not help future physicians adapt to these changes and take charge, then someone else will. Keeping up with these shifts requires exposure and training early on. Implementing a specific, standardized OR management curriculum would provide a means of preparing residents for the future practice of our specialty.

References

1. Wachtel RE, Dexter F. Curriculum providing cognitive knowledge and problem-solving skills for anesthesia systems-based practice. J Grad Med Educ. 2010;2:624-632.

2. Thomas PA, Kern DE. Internet resources for curriculum development in medical education. J Gen Intern Med. 2004;19:599-605.

3. Ornstein GD, Kaye AD, Fox CJ, Urman RD. Maximizing collections from patient services billing. J Med Pract Manage. 2014;30: 24-27.

4. Tsai MH. Ten tips in providing value in operating room management. Anesthesiol Clin. 2008;26:765-783. doi:10.1016/j.anclin.2008.07.009.

5. Gabriel RA, Gimlich R, Ehrenfeld JM, Urman RD. Operating room metrics score card—creating a prototype for individualized feedback. J Med Syst. 2014;38:144.

6. Gaulton T, Shapiro F, Urman R. Administrative issues to ensure safe anesthesia care in the office-based setting. Curr Opin Anaesthesiol. 2013;26:692-697.

7. Dexter F, Epstein R. Associated roles of perioperative medical directors and anesthesia: hospital agreements for operating room management. Anesth Analg. 2015;121:1469-1478.

8. Tsai MH, Haddad DJ, Friend AF, Bender SP, Davidson MD. A web-based operating room management educational tool. Anesth Analg Case Reports. 2016 (in press).

9. Grasha AT. Teaching with Style: A Practical Guide to Enhancing Learning by Understanding Teaching and Learning Styles. Pittsburgh: Alliance, 1996.

10. Vaughn L, Baker R. Teaching in the medical setting: balancing teaching styles, learning styles and teaching methods. Medical Teacher. 2001;23:610-612.

11. Smith D, Kohlwes R. Teaching strategies used by internal medicine residents on the wards. Medical Teacher. 2011;33(12)::e697-703. doi: 10.3109/0142159X.2011.611838.

12. Swing SR, Clyman SG, Holmboe ES, Williams RG. Advancing resident assessment in graduate medical education. J Grad Med Educ. 2009;1:278-286.

13. Ling L, Derstine P, Cohen N. Implementing milestones and clinical competency committees. JAMA. 2002;287:2153.

14. Kaye AD, Okanlawon OJ, Urman RD. Clinical performance feedback and quality improvement opportunities for perioperative physicians. Adv Med Educ Pract. 2014;5:115-123.

15. Marjamaa R, Vakkuri A, Kirvelä O. Operating room management: why, how and by whom? Acta Anaesthesiol Scand. 2008;52:596–600.

Hierarchical Six-Step Approach to Curriculum Development

1. Identify the problem to solve/concept to address.

2. Assess needs of the target group.

3. Identify specific curriculum goals/objectives.

4. Choose education tactics.

5. Set implementation strategy/timeline.

6. Obtain evaluation/feedback.

Source: Reference 2.