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State of the Department
Introduction The following sections provide a brief retrospective look at the Department, followed by a brief summary of our last four years with respect to the environment, the challenges, and the fundamental principles that have guided our strategic and operational plans to fulfill our specific goals and missions while supporting the goals and missions of URMC. A summary then follows of the implementation of these plans and the implications they have had in the reorganization of the Department and the implementation of our present integrated strategy working with Perioperative Services within Strong Health and URMC. Our HistoryIn 1954, Dr. Nicholas Greene founded our residency program, which continues to be the academic core of our raison d'etre. At that time, Anesthesiology was still a Division of the Department of Surgery. It became a Department in 1969 under the leadership of Dr. Alastair Gillies, who began its transformation from a private practice to an academic practice. Paradoxically, the roles of private practice models within the Department are now becoming an increasingly important component of our overall strategy with the development of career pathways that include practice in both Strong Memorial and Highland Hospitals and private practitioners working and teaching within Strong Memorial. In 1983, Dr. Ronald Gabel came to us from the Peter Bent Brigham Hospital and Harvard University, bringing unbounded energy and enthusiasm (that continues to this day) to carry out the next series of changes; enhancing the residency program, evolving the practice toward sub-specialized groups, expanding the clinical services, and establishing the foundations for research activities. After stepping down as Chair, Dr. Gabel developed and led the anesthesiology services at Lattimore Surgical Center. Dr. Denham Ward was recruited in 1992 from UCLA where he had been both Director of the Residency Program and the leader of a human physiology laboratory studying respiratory control. He brought both elements of expertise to the Department along with colleagues to continue both activities as he assumed the Chair's duties. During his tenure as Chair, the clinical service demands expanded rapidly; Highland Hospital was purchased by the University and the practice brought within the Department; an exclusive contractual arrangement to provide anesthesia services at the nearby Lattimore Community Surgicenter was established; a basic research program was begun in collaboration with the Department of Pharmacology & Physiology; sub-specialization expanded by degrees; and the administrative role of the Department in the OR established with his leadership of the Surgical Support Service. In 2001, Dr. Ward decided that it was time to spend more time with his family and focus on the academic areas that he missed. On stepstepping down as Chair, he took a yearlong sabbatical in Leiden, Holland and returned to foster clinical research within the Department and lead the Department's contributions to educating medical students. Dr. Ward has obtained funding for his research in respiratory control and now devotes much of his time to medical student educational programmatic development while maintaining a valued presence as a clinical teacher for students, residents and fellows in the OR. The present Chair, James L. Robotham, was recruited from the Imperial College School of Medicine in London where he had been Chairman of Anesthetics and Intensive Care and Deputy-Chair of Surgery, after having been 20 years at Johns Hopkins University. He assumed the post of Director of Perioperative Services for Strong Health in March 2001 and Chair of the Department of Anesthesiology in July 2001. The Present SituationThe last years have been a transition period for the Department
in a rapidly changing local and national health care scene that has included:
the financially necessary closing of our offsite Pain Center; the sudden
closure of The Genesee Hospital in May 2001; the beginnings of a reversal
in the severe reductions in reimbursement by private insurers and continued
undervalued reimbursements from governmental agencies; the worst marketplace
for the recruitment of anesthesiologists to Rochester in the past half-century
that is now being reversed; continued outstanding evaluations by the ACGME of
our resident and fellow training programs allowing us the opportunity to
increase the number of residents; the closure of the Rochester General
Hospital's Level One Trauma Unit making us the only Level One Trauma Center
in this region; unprecedented growth in the number and complexity of general
and specialized surgical cases at Strong Memorial and Highland Hospitals due
to both local events and national trends; a change in the senior leadership
of the Medical Center in May 2003; and continued URMC leadership support of
the Department's missions. The Department has put in place a continuous
evolutionary process of change in response to the need to fulfill our
goals and missions.
This process continues on a
daily basis but in general the last four years can be characterized as:
Leadership and management theory has frequently focused on defining organizations as either centralized or decentralized. A principle that has defined the evolution of the Department during the past four years has been that a complex organization works best if there is centralized strategic vision and decentralized implementation of operational activities on the ground level. A second guiding principle has been that success of the Department of Anesthesiology depends on the success of the Strong Health system's ORs, and conversely that success for Strong Health and its surgical programs in all areas related to the OR depends on the success of the Department of Anesthesiology in all of its missions. One cannot overemphasize the importance these principles in order to understand what we are doing now and where we need to go. The following paragraphs provide an overview and specifics regarding these activities. Departmental Administrative Reorganization
Program Administrative Staffing The opportunity arose to apply the principle that senior
administrative expertise in the business world provides numerous elements
needed for a modern academic medical practice. With this principle in mind,
Ms. Debra Bulter MBA, CPA with prior experience as an auditor for KPMG,
within Wegman's (one of Rochester's best run businesses), and with a local
entrepreneurial start up company, was recruited to be our Program Director/COO.
Ms. Bulter then recruited, Ms. Jaime Ciavarri CPA, to be our CFO. This brought
an enormous degree of financial and organizational expertise to focus on all
activities within the Department. Ms. Bulter also provides the financial
expertise as Program Administrator of Perioperative Services within Strong
Health that allowed the creation of the Perioperative Services Financial
Oversight Committee that has been fundamental to an extensive reorganization
of operating room activities at Strong Memorial Hospital under the Executive
Committee of Perioperative Services and is presently being translated in
applications for Highland Hospital. Working with the major service units
within the University and the Medical Center (e.g. Information Technology
Services, Facilities, Purchasing, Finance, Human Resources, and Housekeeping),
the Department has established new and productive relationships as results of
Ms. Bulter's efforts. Ms. Ciavarri has provided in depth analyses of the
Department's financial status along with detailed projections for the future
and was at the center of rebuilding a financially viable Pain Center at Strong
Memorial Hospital. Together, Ms. Bulter and Ms. Ciavarri have substantially
reorganized and provided in depth training for our Billing section under
Ms. Paula Stephen-Flores, which is our financial lifeline. The results of
this process are evident by the marked improvement in our long-term financial
viability. Development and implementation of a consistent, yearly budget
according to accepted accounting procedures and formats with detailed auditing
and monthly surveillance is now an integral component of our administrative
core activities and competence. The budget process that has evolved from our
first year of data, has produced predictions accurate to less than 1% over
the entire year for the past three financial years. The application of financial
management information to informing strategic analysis and decision making has
been crucial in the overall operational and financial success of the Department
in moving from the red to the black by the end of our first financial year with
continued generation of a positive margin in each subsequent year.
The administrative staff duties were reorganized along the principles of:
A substantial reduction in overhead was obtained and has been sustained with this reorganization. While the change provoked by this "real world business" approach was initially subject to skepticism by some, it has produced a tremendously positive team spirit of cooperation, individual initiative to fix problems, and an appreciation that permanently fixing a problem with a long term strategy for successful operational activity is usually better than the "quick fix" with the same problem recurring. These principles have been applied throughout the Department and Perioperative Services substantively influencing the organization and governance of both the Department of Anesthesiology and Perioperative Services. The reorganization of operational activities has been important in the coordinated and increasingly complex regulatory processes needed to carry out credentialing, reappointment and promotion, along with continuous recruitment activities for anesthesiologists, CRNAs and basic scientists. Departmental Faculty Administrative Governance Structure and Function The focus on the development of leadership within the
Department in order to develop and implement a strategic vision has been
crucial to the evolution of the present administrative structure of the Faculty.
The administrative organization is designed to transfer a substantial portion
of governance to the individual Division Chiefs and a small number of individuals
taking responsibility for critical Departmental functions. The Vice-Chair for
Clinical Affairs, the Director of Clinical Operations/Senior Clinical Coordinator,
the Residency Program Director and the Department's Program Administrator meet
with the Chair on a weekly formal and frequent informal basis. The Division
Chiefs meet with the Chair on a bi-monthly basis. The Departmental Executive
Committee meets monthly and is composed of all of the above plus all the
Division Chiefs and the Chief of Service at Highland Hospital, Director of Basic
Science Research, Director of QA, Chair of the Clinical Competency Committee,
and Chair of Resident Recruitment. The Executive Committee approves all
changes in Departmental Policy, acts in an advisory capacity to the Chair,
and provides the forum for a report each month by one of the Division/Program
Chiefs of their group's present status and plans for the future.
Departmental Growth, Retention and Recruitment A focus on recruitment for both SMH and HH has been a major
activity of the Chair's office. The first four years have witnessed a 27%
increase in surgical volume at Strong Memorial, the opening of 12 state of
the art ORs at Strong Memorial, 4 new ORs at Highland Hospital signifying a 50%
increase in OR capacity at HH over two years along with increased surgical
volume at the Lattimore Surgical Center. This past year resulted in an
incremental 4% growth in surgical volume at SMH but a 3% decrease in surgical
volume at HH due to movement in surgical practices within Rochester that should
be reversed next year.
Indeed, we also seen long term academic faculty at Strong Memorial fulfill a desire for a change of pace and life style by staying within the Department and practicing at Highland Hospital. The national marketplace for anesthesiologists and CRNAs has been for five years, and is predicted to continue for some time, the worst in anyone's memory. Our success in recruitment is a testament to the quality of the professional and family life styles that the University of Rochester and the Rochester community offers. In the last 4 years we have recruited 16 anesthesiologists and 11 CRNAs. Eight of the 16 anesthesiologist recruitments have come from residents and fellows within our own training program. Additionally, we have recruited three pain physicians (two from our own training program), one psychologist, and three basic scientists (two with NIH funding). Redefining Relationships of the Department of Anesthesiology (DA), the School of Medicine (SOM), and Strong Health Missions We have redefined the goals of DA to fulfill the missions of DA and Strong Health from being considered in conflict for the same resources, to being those goals necessary to develop needed resource support for both institutional missions in a complementary fashion. In brief, a well-run OR will result in resources needed to fulfill our academic teaching and research missions while a well-run academic and clinical program by the Department is necessary for the ORs in Strong Health to function optimally. This has resulted in a highly successful integration of resources, information, communication, strategic planning, and operational activities in the governance of the Department and Perioperative Services. Redefining Relationships and Process Within the Department of Anesthesiology The relationships between the Departmental faculty at the
Highland Hospital (private practice model) and Strong Memorial Hospital
(traditional academic practice model) have evolved during the past four years
to address the changing healthcare environment nationally and locally. To this
end, a transition on both sites from an "us" and "them" relationship that
initially existed between the faculties of each site is converging towards a
single "us" as part of the most flexible recruiting and retention strategy for
anesthesiologists in the US. We have moved from separate recruiting process and
goals for HH and SMH to an appreciation of the need for clinicians on both
sites to meet the phenomenal rate of compounded surgical growth year on year
that cannot be addressed solely by seeking "triple threat, academic"
anesthesiologists to SMH. Conversely the association of a
"private practice model" within DA without conventional private
practice partnership status adversely affected recruitment to HH alone.
The obvious solution was to find a recruiting strategy that would allow the
best aspects of each hospital site within Strong Health to be utilized to
facilitate recruitment to a single department governing both sites.
Triple Threat Department rather than Triple Threat Individuals The unrelenting growth of surgical volume and the problematic
national marketplace for anesthesiologists combined with the lack of unlimited
resources provides a logical rationale in concluding that it is far better to
focus on developing a Triple Threat Department in which individuals excel in
one or two of the three classical missions, i.e. clinical skills, teaching
abilities, or research potential. It is from the amalgam of these skills
present within the Department that individual patients, residents, and fellows
will be able to find the expertise expected in a first-class department.
Redefining the Relationships between the Department of Anesthesiology and Strong Health Systems In order to integrate and coordinate the missions and functions
of the Department and Strong Health, the Department has extended its prior role
in managing the operational activities and governance of the ORs within Strong
Health. The previous nomenclature of Surgical Support Services has been changed
to reflect the broader role of Perioperative Services (PS) within Strong Health.
The PS Executive Committee has as its Director, the Chair of the Department of
Anesthesiology while the Vice-Chair of the Department is the Medical Director
of PS, and the Program Administrator of the Department has assumed the post of
the same title for PS. Most importantly, the governance of PS Executive
Committee includes the three nurse managers (Strong Surgical Center -SSC,
PreAnesthesia/PACU, and the OR) and senior Chairs of surgical departments
who have demonstrated leadership and commitment to the institutional mission at
hand. The heads of key UR services, (e.g. Information Systems, Facilities)
are active members of the Executive Committee. This Committee meets monthly
and as needed to coordinate strategic and operational planning for all
activities related to the integrated function of patient care within the
operating rooms at SMH.
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