Health care changes are coming; we all know this. However, we don’t know what these changes will look like for medicine in general or anesthesiology in particular. We don’t even know when national changes will be instituted or begin to impact practitioners and departments. Given this uncertainty, at a grassroots level, how can we prepare to maximize clinical care, as well as efficiency and fiscal responsibility, while satisfying the demands of future changes?

When health care is remodeled at the national level, departments responding rapidly will likely fare better than those that are slow to change. We suggest that successful departments in the future will be those that welcome change rather than resist it. This may sound easy, but traditions, history and a “this is the way we have always done it” mindset result in real barriers, even when change is essential to survival.

The Department of Anesthesiology and Perioperative Care at the University of California, Irvine recently underwent significant changes. Although our experience is a case study of change in an urgent situation, it may offer valuable insights into ways other departments might cope with and succeed in the face of looming national health care changes.

For our department at UC Irvine, visits by the Centers for Medicare & Medicaid Services (CMS) in 2008, and significant past problems forced us to make sweeping changes on an extremely accelerated time line. One year later, we have a clean bill of health from CMS, a commendation from the Joint Commission, five-year accreditation from the Accreditation Council for Graduate Medical Education (ACGME), and new innovative clinical programs, and we have been ranked No. 24 in funding received from the National Institutes of Health (NIH). This accomplishment took nothing less than wholesale changes to almost every program within weeks to months. We were able to do this through the principles outlined below, and we suggest that these same principles are appropriate for any department or group practice.

Clear Roadmap

It should be evident that although you need to know where you want to go in order to get there, most organizations lack a clearly defined and uniformly understood definition of success. A clear roadmap and strategic plan are essential (Figure 1). At UC Irvine, we began with a two-day faculty retreat at which we developed a strategic plan anchored by mission and vision statements with clearly articulated core goals. The entire faculty worked together to create specific steps to accomplish those core goals. This process laid the foundation and gave us a unified direction, as well as the plan to get there. The next step was assigning priorities to the various parts of the plan.

Clinical care is the obvious top priority for anesthesiologists and anesthesia departments; clinical care is why we exist and why we come to work each day. However, in determining priorities for building a department or preparing for change, the pyramid concept is good to keep in mind (Figure 2). To create a stable department that can withstand and flourish in the face of an uncertain and changing environment, a reliable administrative base is necessary. In the pyramid, administration supports the clinical, educational and research components. If, for example, during the building or change process the focus is on research before establishing a solid administration, the pyramid is turned upside down and the whole structure collapses. Once the administrative base is set, focus then can shift to the next most important departmental concern, and so on.

Too often, once the strategic plan and priorities are established they sit on a shelf gathering dust. We view our strategic plan as a living, breathing document that is a real guide or blueprint for how to get from where we were to where we want to go. The plan is meant to evolve in response to changes, challenges and opportunities. The plan also is meant to be used. Indeed, through the summer and fall of 2009, the department has been hosting strategic planning mini-retreats. Each core goal in our strategic plan is being revisited by the faculty, residents, certified registered nurse anesthetists (CRNAs) and staff involved in that specific area with an eye to improve, update and refine the core goals, objectives, strategic initiatives and action steps. With such a roadmap, the department will be well positioned to achieve its long-term goals. Moreover, the flexibility of the process allows us to alter course and shift priorities, should the need arise (Figure 2).

Courageous, Cohesive and Competent Leadership

To move the strategic plan forward and build strong clinical, educational and research programs on a solid administrative base, a willing and flexible leadership team is essential. Teamwork is emphasized because many hands, skill sets and personalities are needed to address the myriad components of an administration. Our leadership team has roles for clinical care, education and financial management. Our team also has someone who works in all areas, providing a common thread, weaving together the various parts into a cohesive whole. The chairman’s graduate training in business was a definite help in the process. As the leader of our team, and chair of the department, he understood the need for the principles outlined here and had the vision and persistence to carry them out.

The leadership team also has to be willing to work long hours while executing the mission, vision and the core goals of the strategic plan. Throughout this first year of building, sleep became an expensive commodity and the families of all members of the leadership team became an integral part of the support system that was so much needed for the success of the transformation.

In addition to an effective leadership team, a willingness to bring in outside experts can greatly facilitate the process. We used consultants in multiple areas with great success, including strategic planning, billing, compliance and information technology (IT). Outside experts can jump-start the program and provide strength in areas where internal teams may be weak. In the long run, we saved a significant amount of money because of the knowledge gained through interactions with consultants.

Encourage Participation

Team members also come from our faculty, residents and staff. Community buy-in is very important to the ability to change. Almost all change—even the positive kind—is accompanied by anxiety. By including many members of the department in the change process, individuals felt that their voices were being heard and that they had some control over the direction of change. Moreover, when people are part of the process and ultimate solutions, they own it. They become more a part of and loyal to the organization, which increases satisfaction.

Moreover, anesthesiologists do not work in a vacuum—quite the contrary. We work in dynamic teams with surgeons, nurses, residents, fellows and patients. Every stakeholder in this team will be affected by the changes in national health care. Establishing flexible systems that succeed on the macro-team level will better prepare your organization for change. We actively listen to the voices of our stakeholders through surveys and committee activities. A survey of all surgeons in our hospital revealed operations issues in the OR that were specific to different disciplines, as well as gaps in communication. In response, we created a liaison group to all surgical services. Currently, each surgical service has a specific faculty member as a point person when issues arise. We have found that, in this way, most problems can be solved rapidly at the grassroots level.

Additionally, the liaisons have developed surgical briefs with information and preferences for each surgical service. Establishing communication channels and encouraging the participation of all the players on the OR macro team creates unity and a camaraderie that will facilitate change when this is required.

Flexible Thinking and Willingness To Move to New Models

Perhaps the most important requirement for successful change is flexible thinking and a willingness to move to new models. Flexible thinking allows one to see past current practices to potentially better, more efficient and more effective ways of operating. Departments, practices and people in general can be entrenched, and even when they desire change they get stuck in old ways of thinking and are unable to see alternatives. Brainstorming and examining what others are doing can open doors and encourage flexible thinking.

Our department faced an urgent situation when we were required to change almost each and every one of our programs in a very short time frame. Our leadership was open and flexible in terms of solutions, and because of that we were able to implement new models that have dramatically improved our performance.

For example, the department implemented an anesthesia information management system (AIMS) within five months after signing the purchasing agreement. While such an implementation typically takes as long as two years, we wanted to move from a paper anesthesia record system to an entirely new conceptual framework, including real-time data entry and online continuous compliance monitoring. We developed clear policies and procedures for clinical and educational programs that streamline operations while focusing on compliance. We significantly modified staffing models to optimize efficiency and maintain compliance, while providing excellent patient care. We radically changed our billing structure, bringing the front-end billing in-house, outsourcing the back end to an anesthesia billing company, and tying the billing software to the AIMS we implemented. In the process, we cut our billing costs by 50% and increased our clinical revenue significantly. We developed an innovative incentive plan for all faculty, and adopted a clinical unit system that creates efficiency and transparency in billable, administrative and research work hours.

Will the new national health care restructuring require such wholesale changes? We don’t know, but such changes are doable, and our department is in a much better place after implementing all of these changes.

Innovative conceptual frameworks can be used in all areas, including departmental research. We understood at the outset that because of our relatively small size, our research cannot be all things to all people. As such, we have decided that most research will focus on pain, behavior and neurobiology—areas in which we had some expertise and in which UC Irvine had a strong base. Indeed, within a year, the departmental ranking in federal NIH funding moved from No. 45 to 24. We are confident this trend will continue.

Maximize Infrastructure and Information Technology

It is critical to emphasize the importance of infrastructure in the implementation of some of these new models. In March 2008, our hospital administration obtained all new equipment for the operating rooms, and in March 2009, UC Irvine opened the new Douglas University Hospital, which eased the way for implementation of new processes and procedures.

IT played a huge role in transforming our department. During the past year, we have instituted six major new information systems, including Web-based scheduling software that integrated all schedules of faculty, residents and CRNAs, a resident education comprehensive management program, a Web-based billing system, and an anesthesia electronic medical record-keeping system that interfaces directly with the billing system and thus improves coding. Our coders audit each electronic record while the case is ongoing to assure adherence to our strict compliance policies.

Each of these IT systems greatly enhanced the targeted process—be it administrative, education or clinical care. To streamline the implementation of these systems, being part of the hospital IT department, rather than having our own staff, was critical. Not only is this approach cost-effective, we were able to link into hospital systems to easily capitalize on economies of scale. We are now implementing a new clinical system (“Near-Miss”), and the hospital IT department will be the one that will integrate the system with our departmental needs. This Near-Miss program will complement a newly developed, continuous quality improvement program that is based on the principles of the Anesthesia Quality Institute, ongoing data mining from our AIMS and individual scorecards.

Change the Things That Are Not Working

Moving to a new model can involve making tough choices. Having the right people in the right positions is necessary both for building a new department and being ready for change. It may require a reshuffling of personnel, even having some department members move on. Our department now has more than 50% new faculty and more than 80% new administrative staff. We made the decision to search for a new chief operating officer as early as three weeks after our arrival in the department. While personnel changes can be emotionally difficult, a department cannot flourish and grow with naysayers and people who are not capable or competent in their positions.

Decisions about personnel, space and operations can take time and effort, as well as negotiations at the top levels of administration at the institution. If the vision is clear and the need is great, tough choices can be made and a better program or process implemented.

When we began in March 2008 with our strategic planning meeting, we identified where we wanted to be in three to five years. This exercise brought to light programs and practices that were less than ideal. Once they were identified, we set about changing them. With the residency program, we radically augmented our curriculum, held new workshops for our faculty to become better teachers, opened a wellness center, changed the evaluation protocol and implemented an electronic resident education management system. Our residency program had only a two-year accreditation. Following our February 2009 site visit by the residency review committee, we were awarded the maximum five-year accreditation and a four-year program that includes a PGY-1 base year. Many people were involved in changing what was not working, but the result was worth the effort.

Similarly, our chronic pain management program lacked infrastructure in terms of space and funding, as well as weak leadership, for years. The decision was made to scrap the existing program, infuse funds and rebuild from scratch. Many man-hours were dedicated to this, and not all of the people who began the project stayed to see it through, but the result is a new dynamic, multidisciplinary team in a beautiful new space—located off campus—resulting in a completely revitalized program with a good reputation that is growing daily.

Support Innovative Programs

Innovative programs with the potential to grow may provide a competitive advantage. Although we do not know what form changes in national health care will take, there are trends emerging suggesting important future directions. Simulation is an excellent example. The ACGME and American Society of Anesthesiologists are looking carefully at expanding the board process to include simulation tests. UC Irvine is investing heavily in simulation technology, and a new four-story building for medical education and simulation will open in January 2010. Our department is part of the leadership team that will direct the building and revise the medical student curriculum as well as the anesthesia residency curriculum.

Another emerging trend is regional anesthesia. Before our arrival, there was minimal use of this technique. We hired several new faculty who have trained in this area and helped establish a new clinical service that provides ample regional experience for the residents. This new service is highly profitable, both in terms of professional and technical fees.

At any of the anesthesia education meetings, “wellness” is a buzzword. In response to this, we developed two programs that focus specifically on whole-body wellness. Our Mind-Body Patient Preparation Program is designed for adults about to undergo surgery, and for their families. The program begins with an attending anesthesiologist providing basic information about what to expect before, during and after surgery, and allowing patients to ask questions. This is followed by a 45-minute session focusing on relaxation techniques, including yoga, breathing and guided imagery. Postoperative evaluations reveal that patients significantly benefit from and appreciate the program.

Our department has also instituted a wellness program for our first-year residents that is the only one of its kind in the nation. In recognition of the stresses and demands associated with residency training, CA-1 residents participate in a 16-week stress management intervention program that teaches residents behavioral, social and cognitive coping strategies to deal with problems, rethink obstacles and challenges, and manage the stress of both work and family demands. In addition to the program, the department has opened a wellness center with equipment available to residents, faculty and staff that allows easy access to stress-reducing exercise.

We have also established three new dual tracks in our residency program. A new candidate for residency can now apply to complete a master’s degree in business administration, public health or science as part of an innovative four-year residency program.

These innovative programs are examples of advantages one has to establish in order to compete in the marketplace. Since our clinical volume is not large in national terms, we have developed innovative programs that do not necessary rely on patient volume in the operating rooms, but instead on “out-of-the-box” thinking.

Innovative programs need not be huge to make an impact. Something as simple as standardizing the setups of the trauma room and drug trays can dramatically increase efficiency while decreasing stress for the clinical care providers. Being open to and supportive of new programs, regardless of size, may provide a critical advantage in the face of health care changes on multiple levels.

Open and Transparent Communication

Communication is the keystone of all interactions, and poor communication is often at the root of many problems. We have spent ample resources, funds and man-hours in developing communication systems that are open and transparent. A major component of this is clearly articulating expectations and providing resources to enable success.

Our new faculty, for example, undergo a 30-day orientation that includes sessions with the vice chairs for clinical affairs and education to discuss expectations for clinical care and the residency program. In addition, during their first four weeks, every resident or CRNA who works with the new faculty completes an evaluation that is reviewed with the chair after the first month. In this way, we can identify potential issues early, provide teaching workshops and clearly establish the standards of our department.

Perhaps the most significant communication change we implemented this past year was the AIMS. AIMS has replaced our paper records and, according to the Joint Commission, puts us among the top in the nation for accurate medical records. Moreover, because of the time-stamp feature, records cannot be tampered with or falsified.

Also, in keeping with transparency, we established a new physician scheduler system that allows all practitioners to see the entire schedule and feel reassured that everyone is treated equally in terms of assignments.

With so many changes, especially those involving OR policies and procedures that affect patient care, clear communication is essential. To facilitate this, we have begun a weekly bulletin that contains all important departmental, clinical and educational information in one place. This document is available online; members of other departments can view it, again fostering open communication and transparency.

Examine Departmental Culture; Be Bold in Creating Change

Creating culture change may be difficult to address before establishing a solid administrative base and communication pipelines, but is necessary for long-term success. It is particularly important when facing looming uncertainty and the anxiety it generates. Our department worked with the Paul Merage School of Business at UC Irvine to develop a department-wide retreat that focused specifically on culture change. We asked the entire department to read two books, John P. Kotter’s “Our Iceberg Is Melting” and Tom Rath and Donald O. Clifton’s “How Full Is Your Bucket?” which echo the principles presented here. The retreat had sessions dedicated to communication skills, the Strength Deployment Inventory (personality assessment tool) and team building. In the last session, the department broke into groups and generated a list of the top five things to remember when interacting with one another. These were combined, and the departmental credo was born: Encourage communication, avoid gossiping, be professional, be a team, be positive and be the vision.

This credo rewards positive behavior, respect and teamwork. The feedback from the retreat has been very positive, and the change in the day-to-day feel of the department is remarkable. Other OR divisions are now holding similar retreats and the excitement generated by the changing dynamic in our workplace is electric.

Is Your Department Ready for Change?

The principles presented are general rules and fairly self-evident, although in crisis mode this is often not the case. Having gone through a major change in urgent circumstances, we can attest that each of these principles was essential for our success. By necessity, we changed our models, platforms, procedures and protocols in a reactionary way, responding to new pressures as they arose. Even more crucial is the fact that we chose to change our culture, without which other changes were unlikely to be sustainable. Because national health care changes have not yet been instituted, departments and medical practices have the opportunity to better prepare for the challenges that lie ahead.

The past year would have been less stressful had we stepped into a department ready for change. However, our faculty, residents and staff did an exemplary job. They were flexible and open-minded, and willing to move in a direction that led to where we now have exceptional clinical standards and practices, a top residency program, a burgeoning research program and the highest job satisfaction rate in a very long time.

Every department and practice faces a future involving change and uncertainty. Although change and uncertainty are stressful, it is our hope that this case study demonstrates that the results are more than worth the effort.

—Zeev N. Kain, MD, MBA, MA (Hon)

Dr. Kain is professor of Anesthesiology and Pediatrics and Psychiatry, chair of the Department of Anesthesiology and Perioperative Care and associate dean of clinical research at the School of Medicine at University of California, Irvine.