Steven Fischer, MD, gave the next presentation, on how to measure the benefits and outcomes of preoperative assessment. He defined the benefits of such measurements as fewer operating room delays and cancellations, reduced preoperative diagnostic testing, decreased medical specialty consultations, and centralization of information. He also described the positive impact on prompt starting of the first surgical case of the day. The foundation of a patient's intraoperative management and potential outcome begins with a preoperative evaluation, and the primary focus of this evaluation is to determine the optimal medical preparation of patients undergoing anesthesia, especially the medically complex patients. He described the use of a preoperative clinic and alternative methods to complete the preoperative screening process.

The next presentation was by Walter Maurer, MD, who described the use of the internet to facilitate preoperative evaluation of the ambulatory patient. He began with an assessment of the problems that currently exist with the preoperative process. He emphasized that pre-admission testing is not a complete preoperative health evaluation. The preoperative evaluation process should begin when the patient makes first phone contact with the surgeon's office. Patients should be asked to bring in a recent history, physical and any recent EKG or lab tests from their primary physician. This information, with the surgeon's focused history and physical, should be used to select the pathway for further patient evaluation. The issues are: 1) to determine the need for a personal visit to the anesthesia preoperative clinic, 2) to determine the need for general internal medicine to do a complete history and physical with optimization of any unstable medical conditions, and 3) to determine the need for any focused medical subspecialty consultations. Optimally, this should be done before the patient has left the surgeon's office. Dr. Maurer then described the development of a computer-assisted history taking tool. One early tool in this field, HealthQuiz©. was developed by Dr. Michael Roizen. Recently Dr. Maurer has developed a system called HealthQuest©, which is an interactive patient history taking tool employing a touch screen personal computer. The system contains a program decision grid which determines patient risk classification employing medical status and surgical class. Necessary laboratory tests are determined from the system as well as the need for medical consultation. This triage tool aids to identify those patients who can be routed directly to the day of surgery, avoiding a personal visit to the anesthesia preoperative clinic. This computer-based system is now in the Cleveland Clinic's surgeons' offices and it compliments other major triage algorithms. Patient waiting times have improved and there has been a fourfold reduction in duplicate paper work.

Dr. Lydia Conlay presented "Human Resource Challenges for the Anesthesiologist: Hiring in a Seller's Market". Dr. Conlay identified the changing nature of work in anesthesiology, related to the changing nature of jobs and the changing nature of employees. There are "virtual markets" and workers, part-time employees and flex-time groups. She identified the major components of a successful recruiting process. First, recruiting should be an ongoing process. Second, it is necessary to understand the priorities and culture of your work group. Personnel screening should be primarily based on basic abilities and attitudes, attributes that are important but difficult to change through training. Third, it is important to keep in touch with current market trends. Traditional advertising has changed from print media to hiring on the internet. The next subject discussed by Dr. Conlay was making the most of alternative work relationships. She included a description of the advantages and pitfalls of using locum tenens agencies. Concerning the interviewing and referencing process, she commented that references are important as much for what they don't say, as for what they do. Dr. Conlay concluded by asserting that recruiting and retaining staff are challenges that should be met creatively and with enthusiasm. Optimizing hiring practices is the first step in the fruitful relationship between employer and employee or between partners and future partners.

Dr. Reuven Pasternak presented "An Economic Approach to Analyzing Operating Rooms". Operating rooms are revenue centers, and it is important to be able to appropriately identify costs and revenues. There are several types of costs. Fixed long-term costs represent an obligation that must be met independent of income, and are usually based on contractual obligations of at least six months' to a year's duration. These costs include loans to cover building expenses. There are also fixed short-term costs, which must also be met independent of volume and income, but which are subject to review on a monthly basis. The most significant example of a short-term fixed cost is staff cost. Variable costs are costs that can be managed on a daily basis due to changes in operations. Variable costs that are facility-wide include alterations of environment, such as air conditioning use, or administrative costs. There are also variable costs associated with the operating room and procedure. These are the traditional costs such as pharmaceuticals, disposables, and other discreet single use items. When assessing costs associated with operative procedures, it is important to note the cost of each component. Pharmaceuticals are often cited as the area of concern and the focus of great effort in cost reduction; however, that cost often pales in comparison to other factors. The other aspect of economic analysis is the analysis of revenue streams. A primary example of this is non-time-based payment for the procedure. In managed care markets, many customers exist on fixed charges for services plus variations in cost that can not be passed on. With bundled care, traditional separations of professional and facility fees are blurring, and professional fees and facility costs may actually be in conflict when determining the apportionment of a fixed sum that comes into a combined enterprise. Market consolidation and regulation are two additional factors in systems management. Operating room utilization must be evaluated as a balance of capacity and cost management. Each operating room is a function of the fixed and variable costs noted above. Adding to cost without achieving maximum utilization of an operating room will make for short-term friends and long-term losses.

Dr. Adam Dorin presented his answer to "What is the Best Way to Market an Ambulatory Surgery Facility?" This begins with an operational assessment of the ambulatory surgery center (ASC), and this process should involve the developers, managers, and owners of the center. One major issue is staffing. The definitive variable of measurement underlying all staffing issues is "room turnover," and this should be monitored even when caseload is light. Not only will this allow good performance when the volume of cases increases, but it will also prove to be a powerful marketing tool. It may be helpful to track the clinical paid hours per case. Staff must be competent and must possess a positive team-oriented attitude and be able to multitask. Wages and benefits must be competitive with the surrounding market. Another major internal marketing tool is the evaluation of billings and collections. Top procedures should be reviewed annually, and the costs associated with each procedure should be known. A third major area is public relations. Ideally, marketing efforts are begun several months prior to the opening of an ASC. Surgeons and other providers should be approached by the medical director and the administrator of the center. Office schedulers should be courted as well, with a tour of the facility; some centers also offer in-depth tutorials to office staff on how to schedule cases. It is important to identify which managed care contracts your potential surgeons participate in, and to align with those as well. Dr. Dorin concluded with a discussion of the regulatory issues which are part of establishing a surgery center, including Medicare and state certification. Ultimately, good marketing can be crystallized into one phrase: under-promise but over-deliver.

Dr. Lee Fleisher presented the topic "How do we Measure and Prevent Morbidity in Ambulatory Surgery?". He presented a model of factors influencing perioperative morbidity and mortality, which begins with patient disease, surgical and medical, leading into surgery. Factors which affect surgery outcomes are anesthesia factors, surgical errors in judgment, and location of postoperative care. Anesthesia concerns are related to provider characteristics, errors in judgment, and mishaps. All together, postoperative outcome includes death, major morbidity, and minor morbidity. Data show that the major morbidity and mortality associated with ambulatory surgery are extremely low. Thirty-day morbidity and mortality may occur at rates similar to a group of sex, age and geographically matched individuals who did not have surgery. However, the complexity of both the procedures and the patients are steadily increasing. Although a given procedure may be associated with a low, acceptable morbidity in an outpatient setting if performed in relatively healthy individuals, these findings may not occur in patients with increased co-morbidity. While trying to perform outcome surveillance, any one center may not observe a sufficient rate of morbidity to detect major problems. One technique to address this is to review all cases of morbidity as part of a quality assurance project, and then determine if there are any patterns or systems issues which could be used to improve outcomes. An alternative approach involves a national or local multi-year survey to determine the safety of a given procedure.

Meg Rosenblatt, MD, presented a discussion on "Does Anesthetic Technique Influence Outcome in Ambulatory Anesthesia?" It is first important to determine what outcome measures are of interest. These may include time to discharge, rates of postoperative nausea and vomiting, costs, and optimal postoperative analgesia. Dissatisfaction with anesthesia has been shown to be a predictor of global dissatisfaction with ambulatory surgery. Dr. Rosenblatt presented data showing that patients continued to have cognitive dysfunction after general anesthesia into the first postoperative week. Procedures once requiring postoperative hospital admission are now being performed in ambulatory centers and this transition has required modifications in traditional anesthetic techniques and postoperative pain management. Dr. Rosenblatt discussed the use of femoral nerve block for anterior cruciate ligament reconstruction, the use of multi-modal preemptive analgesia including intradermal, subcutaneous and pre-peritoneal infiltration for laparoscopic cholecystectomy, interscalene blocks for shoulder arthroscopy, and wound infiltration for inguinal herniorraphy. In addition, postoperative analgesia for procedures which are commonly performed with general anesthesia can be augmented with local anesthetic infiltration. Outpatient laparoscopy is one such procedure, where intraperitoneal installation and mesosalpinx injection of local anesthetic can shorten the time to resumption of normal activity. Anesthesia choice can affect a variety of outcomes, but it is important to consider overall patient satisfaction.

Karin Bierstein, JD, who is the ASA's Practice Management Coordinator, discussed changes in Medicare regulations that will affect ambulatory anesthesiologists. 1) Her presentation first addressed the proposed Medicare regulations that will alter payment policies for ambulatory surgical centers. One issue is the facility payment for pain treatment procedures. For surgical operations, if the new payment rates do not cover the ASCs' costs, these facilities will not be an option for Medicare patients and the surgeries will be performed elsewhere. The Medicare ASC procedure list will also be updated. The criteria for inclusion on the ASC procedure list now state that procedures will be eligible for an ASC facility payment if they: require surgical facilities and services of the kind that are typically provided in a hospital setting; require a dedicated procedure room or recovery room; and would not be expected to necessitate inpatient admission. 2) In addition, HCFA has published a proposal that would change payments for hospital outpatient department services from a "reasonable cost" to a fixed amount prospectively set for each CPT code. Again, the portion of the prospective payment amount intended to cover the cost of providing anesthesia supplies and equipment is not likely to affect the availability of anesthesia for surgical procedures. As with the ASC rules, the hospital outpatient proposed rule would limit payment for pain management. Another new element of HCFA's prospective HOPD payment proposal is the concept of setting an expenditure target for the totality of services billed by HOPD. This mechanism would limit future payment updates if spending in a given year exceeded the target set for that year. 3) Physician payment - there is a proposed 8% reduction for anesthesiology services based on practice costs. Medicare payment to physicians is based on the Resource Based Relative Value Scale, which consists of distinct relative value units for physician work, practice expenses, and professional liability insurance costs. Until this year, only the physician work component was fully resource based. Starting on January 1, HCFA began to implement the results of its efforts to develop resource based practice expense relative value units. The proposed changes project an 8% decrease in total payments to anesthesiologists over a three-year transition period.

Dr. Alex Macario discussed measuring patient satisfaction in ambulatory healthcare. He began with the problem of defining quality in healthcare. Patient satisfaction is being used as an index of quality. However, patient satisfaction scales may not be sensitive enough to detect changes in the quality of clinical care by an anesthesia group. The difference between the patient's perceptions and the patient's a priori expectations is another way to think of quality. Patient satisfaction relies on a standard or expectation against which care is compared. Satisfaction may not be a reliable or valid way of detecting change in quality of care. Other confounding variables which can influence patient satisfaction relate to the appearance of the physical plant and circumstances out of the anesthesiologist's control, such as delays. Also, research has shown that patients typically do not distinguish between technical aspects of care and interpersonal skills. Quality of patient satisfaction and clinical outcomes can be improved by listening to patient preferences. Since for any single patient it is difficult to know which clinical anesthesia outcomes are of most concern, it may be useful to actively engage patients to identify their most important clinical outcomes and then design the anesthetics to optimize these outcomes. Unnecessary variability in how physicians care for patients with similar conditions also needs to be addressed to increase quality. Dr. Macario spoke about developing report cards for anesthesiologists. This is difficult, in part, because there are multiple customers: surgeons, hospitals, insurance companies, and patients. Monitoring of key clinical outcomes may be a useful measure of clinical quality. He concluded by stating that to adequately measure levels of satisfaction requires an investment in computer technology and information systems.

The final presentation of the day was by Charles McLeskey, MD, who presented "Where are we Today and Where are we Going?" He believes that the future of anesthesiology will involve management, and he addressed the management of several specific areas. These included management of processes, management of costs, management of complications, management of patients/consumers, management of information, management of new technology, management of training tools, management of new dimensions of medical therapy, and management of ourselves, by expanding our traditional intraoperative role.